TITLE: The Aging Face and Complications of Rhytidectomy<=
br>
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: October 3, 2007
RESIDENT PHYSICIAN:
FACULTY PHYSICIAN: Francis B. Quinn, Jr., MD
SERIES EDITORS: Francis B. Quinn, Jr., MD
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties, eit=
her
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Introduction
Aging is a normal and ubiquitous process of life= . The effects of aging on the face m= ay carry the persona of being unattractive, undesirable, and helpless. Within a society which values yout= h and a youthful appearance, many desire to restore a younger form to disconnect = from the connotations associated with aging.&nb= sp; For these reasons, facial cosmetic surgery and facial rejuvenation procedures have become popularized. With an aging population, procedures that aim to restore a youthful appearance will increase in demand. The purpose of this review is to understand the process of aging upon the face and the complications associated with rhytidectomy.
Aging Face
Facial anatomy is composed of three essential
elements. The skin serves as a
protective barrier and varies by pigmentation, texture, elasticity, thickne=
ss,
and hair distribution. The
underlying soft tissue and fascia contains the musculature and neurovascular
supply. The bony and cartilag=
inous
skeletal elements provide the basic shape of the face. In aging, elasticity of skin becom=
es
weakened and its texture and pigmentation changes due to inherent and
environmental effects. Over t=
ime,
the distribution of collagen loses its organized pattern. Additionally, there is resorption =
and
remodeling of the underlying skeletal elements of the face with aging which
replace the softer curves in youth.
Age is the most significant factor determining facial structures.
From a histologic perspective, the epidermis and subcutaneous fat thins and redistributes during the aging process which contribute to rhytid formation. Additionally, there is effacement of dermal-epidermal junction which leads to a flattened rete ridge pattern.&n= bsp; Elastosis is the progressive loss of organization of elastic fibers = and collagen and is another finding during aging. Finally, there is weakening of the underlying facial mimetic muscles which may result in the sagging appearanc= e of skin folds.
The appearance of aging upon the face begins from
youth and there are distinct changes that may be identified as one ages.
Aging of the nose may be exhibited by thinning a= nd weakening of the nasal skin, bone, muscle, fibrous tissue and cartilage with visible underlying nasal skeleton and tip ptosis. There may be separation of the upp= er and lower lateral cartilages resulting from splaying of the fibrous attachments= at the scroll. Narrowing of the = nasal valve from weakened cartilage is not uncommon. Midfacial aging results in l= oss of orbicularis oculi muscle tone and descent of malar soft tissue. This results in an illusion of exc= ess fat in the lower eyelid. Additionally, the nasolabial crease deepens.
The lower third of the face also has prominent age-related changes. There is= chin ptosis, resorption of mandibular height, thinning of subcutaneous fat with excess skin resulting in jowl formation.&n= bsp; There is platysmal banding, and loss of the youthful cervicomental angle, and submental fullness. Laxity of the platysma accounts for the formation of paramedian vert= ical bands in the neck, and ptosis of the platysma leads to enhancement of jowli= ng.
SMAS
The Superficial Musculoaponeurotic System is a fibromuscular fascial extension of the platysmal muscle that arises superio= rly from the fascia over the zygomatic arch and is continuous in the inferior c= heek with the platysma. It was des= cribed in 1976 by Mitz and Pyronie in a landmark paper. The branches of the facial nerve l= ie deep to the SMAS. The functio= n of the SMAS is to transmit the activity of the facial mimetic muscles to the facial skin. Posteriorly, the= SMAS fuses with the fascia overlying the sternocleidomastoid muscle, but it is a distinct layer superficial to the parotid fascia. Anterosuperiorly, the SMAS invests= the facial mimetic muscles of the mid-face (i.e., orbicularis oculi, zygomatic major/minor, levator labii superioris).&nb= sp; Anteriorly, the SMAS invests the superficial portions of the orbicul= aris oris and gives off fibrous septae that insert into the dermis along the melolabial crease and upper lip.
Facial Nerve
The anatomy of the extracranial facial nerve (FN=
) is
important when considering surgery upon the face. The facial nerve is protected by t=
he
parotid after it exits the stylomastoid foramen. Its lower divisions are deep to the
masseter fascia and there is a potential space between the SMAS and masseter
fascia in the inferior cheek. This
is an important factor when considering deep/composite rhytidectory techniq=
ues. The temporal branch is the most
superficial division of the FN. It
crosses the junction of the anterior 1/3rd and posterior 2/3
Complication of Rhytidectomy: Hematoma
Although there are multiple approaches to rhytid= ectomy that are beyond the scope of this Grand Rounds, the surgeon must understand= the complications which may result from this operation. Hematoma formation is the most com= mon complication and has an incidence from 1-15%. Its consequences may be partial sk= in flap loss, infection, pigmentary changes, persistent facial edema, prolonged convalescence, and scarring. = Major expanding hematomas occur within 24 hours of the operation and early signs = may include sudden sharp pain followed by swelling and ecchymosis. There may be hardening or tightnes= s of the skin, trismus, anxiety and dyspnea.&nb= sp; Late signs include swelling and discoloration of the lips and buccal mucosa. 1.9%-3.6% of large hematomas require an operative intervention. Prevention and early recognition a= re keys to the management of hematomas. A compression dressing may provide = the pressure needed to prevent the development of a hematoma. Aspiration and evacuation of hemat= omas when they are detected is essential to prevent the sequelae of this complication. Persistent ecch= ymosis and prolonged edema usually resolves after treatment of the hematoma without compromise to aesthetic result.
Complication of Rhytidectomy: Hematoma
Risk factors to the development of hematomas fol= lowing rhytidectomy have been studied. The detection and management of preoperative and postoperative hypertension has been found be an effective measure to prevent hematomas. In a study by Berner et al. in 197= 6, preoperative and postoperative BP within the first 2 hours of operation were found to be similar, but reactive hypertension was found in the subsequent 3 hours and medications were less effective in this period, and pain and anxi= ety had an affect on BP. Striath = et al. in 1977 found a 9.2% hematoma rate in 500 rhytidectomies when systolic BP preoperatively was greater than 150 mm Hg.= Recently, Grover et al. in 2001 conducted a multivariate analysis of 1078 rhytidectomies and found a strong association of hematoma formation wh= en preoperative SBP was greater than 150 mm Hg.
Several retrospective studies have found a great= er incidence of hematomas in males. Baker et al. in 1977 found a major hematoma rate of 8.7% in males an= d an overall rate of 3.26% in 137 men who underwent rhytidectomy. Lawson et al. in 1993 found a hema= toma rate of 9.6% in 115 males. Gr= over et al. in 2001 found a 12.9% incidence in males and 3.6% in females. This finding may be related to inc= reased blood supply to bearded skin and greater sebaceous glands in males.
The use of aspirin or other non-steroidal anti-inflammatory is also associated to the development of hematomas. Grover et al. found a higher hemat= oma rate in individuals that used ASA/NSAID within 2 weeks of rhytidectomy. Other agents that may increase ris= k for hematoma formation include Vitamin E, Ginkgo, ginger, ginseng, and garlic.<= /p>
The deep-plane technique was studied by Kamer et= al. in 2000. In 451 rhytidectomie= s, there was an incidence of 2.2% of major hematomas and 6.65% incidence of mi= nor hematomas. These all occurred= in the subcutaneous plane.
The use of general anesthetic was studied by Ree= s et al. in 1994 in 1236 rhytidectomies. This study concluded that general anesthetic is not a risk factor for the formation of hematomas as there was a 1.1% rate of hematomas in the gen= eral anesthetic group and 0.9% in the conscious sedation group. The use of a suction drain prevent= s the formation of seromas, but has minimal impact on the formation of hematomas according to a study by Perkins et al.&nbs= p; The use of fibrin glue has also been studied by several studies. These studies by Marchac et al., G= rover et al., and Fezza et al. do not provide evidence that fibrin glue prevents = the formation of hematomas.
Complication of Rhytidectomy: Nerve Dysfunction
There is risk of injury to sensory and motor ner= ves from rhytidectomy. The most c= ommon nerve injury is to the great auricular nerve with an incidence of 1-7%. When transected, it should be repa= ired with 10-0 nylon perineural sutures. Injury to the lesser occipital nerve may also be encountered. For this reason, dissection poster= iorly should remain in a subcutaneous plane.
Facial nerve deficits from paresis to complete paralysis have an incidence of 0.3%-2.6%.&= nbsp; In a study by Baker of 7000 rhytidectomies, there was a 0.7% inciden= ce of paralysis with 0.1% of permanent paralysis. The marginal mandibular division w= as found to be most commonly affected followed by the temporal branch. Neuropraxia, heat injury, needle i= njury, and inadvertent transaction are the main causes of FN injury.
The region from the mandibular angle to the faci= al artery is where injury may occur during dissection, and it is more commonly injured when dissection is performed to correct platysmal laxity. Presence of platysmal atrophy or hypoplasia may increase the risk of potential injury, as well as in revision rhytidectomy procedures. The temporal branch of the FN is at risk when a forehead or brow procedure is combined with rhytidectomy. F= or this reason, forehead procedures should remain subgaleal at the level of the superficial layer of the deep temporal fascia to avoid injury. The buccal division of the FN is a= t risk of injury from subperiosteal dissection for midface-lift. During this procedure, the dissect= ion from periosteum along the inferior border of the zygoma requires transition over the masseter tendon near the buccal branch. A sub-SMAS dissection over the che= ek also places the buccal branch at higher risk than a more superficial dissection.
Complication of Rhytidectomy: Skin Flap Necrosis
Compromise to the vascular supply to the skin and ischemia from vascular congestion may result in necrosis of the elevated sk= in flap. This may result from an unrecognized and untreated hematoma. The use of tobacco has been associated with a 12 time greater risk of skin flap necrosis. For this reason, smokers should be counseled for smoking cessation for several weeks prior to and after the procedure. Other causes of skin flap necrosis include an underlying vasculitis, injury to the subdermal vascular plexus and excessive tension at the closure. The incidence of ski= n flap necrosis is 1.1%-3%. The most common region of skin flap necrosis is in the postauricular region where the flap is the thinnest and closure is under tension with the most distal arte= rial supply. Conservative manageme= nt for partial-thickness skin flap necrosis is appropriate with local wound care.<= span style=3D'mso-spacerun:yes'> This usually heals with little or = no visible scarring or with hypopigmented scar.
Complication of Rhytidectomy: Scars
Scarring from rhytidectomy usually occurs in the postauricular region. This ma= y also occur in regions where the skin closure is under the greatest tension. Scars are usually evident at 12 we= eks postoperatively and serial local steroid injections may diminish their appearance. The use of approp= riate incisions in regions to camouflage the surgery also minimize the appearance= of scarring.
Complication of Rhytidectomy: Hair Loss
Alopecia may occur along poorly placed incisions= or in regions where the skin flap elevation is too superficial. Hair loss has an incidence of up to 8.4%, and 1%-3% require surgical revision.= This most commonly occurs the temporal region of the hair-bearing scalp. Heat injury due to cau= tery and excess tension also contribute to hair loss from rhytidectomy. This complication may be prevented= with carefully planned incisions respecting the hair follicles and minimizing the use of cautery with appropriate closure technique.
Minoxidil is an agent used for alopecia and has = been studied as a preventative medication following rhytidectomy. Eremia et al. conducted a restrosp= ective review of 60 rhytidectomies in 2002 and found that there was no incidence of permanent alopecia and temporary alopecia was found in 1.7% of cases.
Complication of Rhytidectomy: Pixie Ear Deformity
Excessive skin excision at the earlobe or excess= ive tension across the skin incision may result in the pixie ear deformity. This form of deformity may also oc= cur from inappropriate closure technique following parotid surgery. This may be avoided by incising th= e flap prior to the SMAS dissection or placement of suspension sutures.
Complication of Rhytidectomy: Infection
Postoperative infection following rhytidectomy is relatively uncommon with incidence of about 1%. Leroy et al. reviewed 6166 rhytidectomies and found an incidence of 0.18% of postoperative infections = that required hospitalization. The infections usually occurred within the first postoperative week and the most common organisms cultured were Staphylococcus and Streptococcus. These infections improved with intravenous antibiotics and incision and drainage. Of note, the majority of these infections had been prescribed postoperative antibiotics empirically.
Complication of Rhytidectomy: Parotid Injury
Parotid injury from rhytidectomy procedures is r= are with appropriate dissection. = It is more common in sub-SMAS dissection techniques and may delar healing with possible formation of a salivary pseudocyst. This may be prevented by cauteriza= tion of exposed ductules if noted during the dissection. Serial aspirations and compression= dressings with use of anti-sialogogues or Botox injections may be used when appropria= te.
Complication of Rhytidectomy: Pigmentary Changes
Individuals with darker complexions (Fitzpatrick= types IV-VI) have a higher risk of hyperpigmentation postoperatively. This may persist for months, but gradually fades. For this rea= son, appropriate preoperative counseling is important along with avoidance of sun exposure and use of sun block and cosmetics. Telangectasias may develop in prone individuals in areas of dissection.
Complication of Rhytidectomy: Depression
An important postoperative complication that mus= t be considered in individuals with either a pre-existing mood disorder or chang= e in mood postoperatively is depression. Short term situational depression occurs in 30% of women following rhytidectomy. Onset of depres= sion occurs within the first postoperative month and is related to the individual’s unnatural appearance.&n= bsp; Management of depression includes reassurance and possibly a short course of an antidepressant. Consultation with a psychiatrist may be required for some patients.<= /p>
Complication of Rhytidectomy: Deep Vein Thrombosis and Pulmonary Embolism
DVT and PE account for up to 5% of postoperative morbidities. Reinisch et al. conducted a review of 9937 rhytidectomies and found a 0.49% incidence of thromboembolic complications (0.35% DVT and 0.14% PE). 83.7% of all patients had general anesthesia. A decreased incid= ence was found in patients in whom sequential compression devices were used.
Sources
Moyer JS, Baker SR. Complications of rhytidectomy. Facial Plast Su= rg Clin NA 2005;13:469-78.
Baker TJ, Gordon HL, Mosienko P. Rhytidectom= y: a statistical analysis. Plast Reconstr Surg 1977;59(1):24–30.
Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg 1983;10(3):543–62.
Grover R, Jones M, Waterhouse N. The prevent= ion of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. B= r J Plast Surg 2001;54:481–6.
Rees TD, Barone CM, Valauri FA, et al. Hemat= omas requiring surgical evacuation following face lift surgery. Plast Reconstr S= urg 1994;93(6): 1185–90.
Perkins SW, Williams JD, Macdonald K, et al. Prevention of seromas and hematomas after face-lift surgery with the use of postoperative vacuum drains. Arch Otolaryngol Head Neck Surg 1997;123(7):743–5.
Kamer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast Surg 2000;2(4):240–2.
Jones BM, Grover R. Avoiding hematoma in cer= vicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Recons= tr Surg 2004;13(1):381–7.
Straith RE,
Berner RE, Morain WD, Noe JM. Postoperative = hypertension as an etiological factor in hematoma after rhytidectomy: prevention with chlorpromazine. Plast Reconstr Surg 1976;57:314–9.
Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast Reconstr Surg 1977;60: 514–22.
Lawson W, Naidu RK. The male facelift: an an= alysis of 155 cases. Arch Otolaryngol Head Neck Surg 1993;119(5):535–9.
Marchac D, Sandor G. Face lifts and sprayed = fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg 1994;47:306̵= 1;9.
Fezza JP, Cartwright M, Mack W, et al. The u= se of aerosolized fibrin glue in face-lift surgery. Plast Reconstr Surg 2002;110(2):658–= ;64.
Pantaloni M, Sullivan P. Relevance of the le= sser occipital nerve in facial rejuvenation surgery. Plast Reconstr Surg 2000;105(7):2594–9.
Baker DC, Conley J. Avoiding facial nerve in= juries in rhytidectomy. Plast Reconstr Surg 1979; 64:781–95.
Daane SP, Owsley JQ. Incidence of cervical b= ranch injury with ‘‘marginal mandibular nerve pseudo-paralysis’= ’ in patients undergoing face lift. Plast Reconstr Surg 2003;111(7):2414̵= 1;8.
Pitanguy I,
Blackwell KE, Landman MD, Calcaterra TC. Spi= nal accessory nerve palsy: an unusual complication of rhytidectomy. Head Neck 1994;16:181–5.
MacGregor MW, Greenberg RL. Rhytidectomy. In:
Goldwyn RM, editor. The unfavorable result in plastic surgery.
Nason RW, Abdulrauf BM, Stranc MF. The anato= my of the accessory nerve and cervical lymph node biopsy. Am J Surg 2000;180:241–3.
Vecchione TR. Rhytidectomy flap necrosis in = Raynaud’s disease. Plast Reconstr Surg 1983; 72(5):713–9. Complications of Rhytidectomy 477