Complications of rhytidectomy (facelift)

• Hematoma

The most common complication of rhytidectomy is the formation of a hematoma, which occurs in 2-15% of patients. A large hematoma requiring repeated intervention usually develops within the first 12 hours after the operation. The formation of a hematoma is accompanied by pain and swelling of the face. It is interesting that there is no correlation between the volume of intraoperative blood loss and the development of hematoma. On the contrary, hypertension predisposes to this, which increases the incidence of hematoma by 2.6 times. The importance of controlling blood pressure is difficult to overestimate; It should be regularly monitored both during the operation and in the postoperative period. Particular attention should be paid to a smooth exit from anesthesia and the prevention of postoperative nausea, vomiting and anxiety. Other factors predisposing to the development of hematoma include the use of agents containing acetylsalicylic acid, nonsteroidal anti-inflammatory drugs, high doses of vitamin E, the dominantly inherited Ehlers-Danlos syndrome. It is necessary to have a detailed list of drugs containing acetylsalicylic acid. All these funds must be discontinued at least 2 weeks prior to surgery and not renewed approximately 1 week after surgery.

Certainly, the management of a patient taking anti-coagulant drugs should be carried out in cooperation with the appropriate specialist. We usually determine prothrombin time, partial thromboplastin time and platelet count in all patients, subjecting them to further examination in the case of double deviations in the results of the analysis. Special precautions should be observed when working with men, as most plastic surgeons agree that men are more prone to hematoma formation. Although this is not proven, it seems that a greater risk for men is associated with increased blood supply to the skin and hair follicles of the beard.

Delay in treatment can lead to necrosis of the skin flap, especially in patients with an extremely rapidly increasing hematoma. In addition, fluid accumulation can be an ideal medium for growth of microorganisms, increasing the risk of infection. Often during the evacuation of the hematoma, it is difficult to discern a single vessel, which was the cause of its occurrence; more common is diffuse bleeding. Treatment should consist in removal of clots, washing, revision and electrocoagulation of suspicious places and vessels. It is necessary to re-enter the drainage and apply a pressure bandage.

Often there are small hematomas, which probably increase the overall frequency of hematomas. Small hematomas are usually detected in the first week after surgery and represent small accumulations of fluid, usually in the behind-the-ear area. After liquefaction, these fluid accumulations can be eliminated by aspirating with a 18 G needle under sterile conditions. If there is a tendency to organize, a small incision may be required to remove the hematoma. These patients are given a pressure bandage and a course of antibiotics is prescribed. Unrecognized hematomas lead to fibrosis, wrinkling of the skin and discoloration, which may take months to resolve. In these cases, a course of steroid injections may help (triamcinolone acetonide-Kenalog, 10 mg / ml or 40 mg / ml).

• Necrosis of the graft

Necrosis of the skin flap occurs due to a violation of the blood supply to its distal ends. Predicting factors are improper flap planning, excessive subcutaneous secretion, damage to the subcutaneous plexus, excessive tension in the application of sutures, certain systemic diseases and smoking. The most likely necrosis is in the BTE, and then in the anterior region. Rhytidectomy in the deep plane, with SMAS displacement, is accompanied by a lower risk of necrosis, since it allows you to create a more powerful blood-supply flap and reduce the tension when suturing. The toxic effect of nicotine and smoking has long been considered the most preventable cause of circulatory disorders in skin flaps. The risk of developing a flap necrosis is increased in smokers by 12.6 times. It is necessary that patients refrain from smoking at least 2 weeks before and after the operation. Systemic diseases, such as diabetes mellitus, peripheral vascular and connective tissue diseases, can predispose to blood flow disorders and require serious discussion before surgery.

Necrosis of the flap is preceded by venous stasis and discoloration. Prescribed frequent massage of this area and a long course of antibiotic therapy. Necrosis is often accompanied by the formation of a scab. The zone of the disturbed blood circulation should be kept conservatively, daily treating with a solution of hydrogen peroxide, producing a toilet and applying antibacterial ointment. Fortunately, most such areas are well healed by secondary tension, but frequent post-operative visits and persuasive conversations with the patient are required.

• Nerve damage

Most often, with a surgical facelift, the cervical, sensitive branch, the large auricular nerve, is damaged in 1-7% of patients. This nerve can be found at the anterior edge of the sternocleid-but-mastoid muscle. When approaching the bovine and mastoid areas, the skin flap becomes thinner. It is necessary to act cautiously, so that in the process of dissection, there is no harm to the muscle and nerve. Increased bleeding is a common symptom of muscle damage. Damage to the large ear nerve is often found intraoperatively. At the same time, the ends of the nerve should be sewn with an epineural seam with a nylon thread 9/0. Failure to restore the nerve will lead to local hypostasias and the possible formation of a painful neuroma.

Fortunately, damage to the motor branches occurs much less often, in 0.53-2.6% of cases. The most often damaged two branches of the facial nerve - the temporal branch and the marginal branch of the lower jaw. More frequent damage to the two branches depends on the method of operation and the particular situation. However, both of these injuries can lead to an unsuccessful outcome for the patient and the doctor. A perfect knowledge of the anatomy of the facial nerve is necessary for everyone who plans to engage in surgical facelifts. The temporal branch of the facial nerve is superficially located from the level of the zygomatic arch. Dissection in this area, to prevent damage, must be directly subcutaneous or sub-periosteal. The temporal branch is not a single nerve, as is often drawn in manuals, but several branches. Anatomical studies identified branches that cross the middle part of the lower arc. Dissection within 10 mm in front of the ear along the arc and within the distal 19 mm arc is safe. Unfortunately, damage to the facial nerve is usually not recognized during surgery, but if this occurs, you should try to impose a primary anastomosis. The use of a microscope can help. If paralysis or paresis of a part of the face develops immediately after the operation, do not panic. First, wait 4-8 hours until the local anesthetic has passed. If it turns out that there has been a damage to the motor branch, the revision of the wound for the purpose of finding and anastomosing the nerve does not make sense. Calm down, clinical practice shows that most of these injuries (85%) will eventually recover. The high frequency of recovery may be due to the fact that the violation occurred not because of the intersection, but because of local nerve injury. Other researchers theorize that in the case of damage to the temporal nerve, multiple branches provide reinnervation, even in the case of crossing. However, if the recovery does not occur within 1 year, it may be necessary to reconstruct the facial tissues, including raising the eyebrow, neurolysis of the frontal branch from the opposite side, and procedures aimed at revitalizing the eyelid.

Dissection under the subcutaneous muscle is dangerous in terms of damage to the branch of the mandible edge. Dis-section directly under the muscle with scissors with rounded ends, while limiting vertical movements protects the nerve from damage. The nerve, which first goes behind and below the lower jaw, leaves more superficially, above the jaw, 2 cm lateral to the core of the cochlea of the ear. Dissection in the subcutaneous plane is unsuccessful and full of dangers. The cheek and cheek branches run along the surface of the anterior edge of the parotid gland and are rarely detected with the standard technique of suspenders. However, these branches are often affected by dissection in the deep plane. Damage in this area can remain unnoticed due to the large number of branches and anastomoses.

Reported a relapse of peripheral paralysis of the facial nerve after a facelift. Therefore, patients with a history of paralysis should discuss this possibility. Patients with complete paralysis of the facial nerve should be sent for consultation to the appropriate specialist. Electrical testing of the nerve can clarify the prognosis in such patients, as well as in those who have had damage to the motor branch.

• Hypertrophic scarring

Hypertrophic scarring can occur when the flap is hemmed with a significant tension and is most often associated with an insufficient allocation of a subcutaneous flap. Hypertrophic scarring can occur within 2 weeks after surgery, but usually occurs within the first 12 weeks. Here, periodic local injections of steroids can help. The excision of the hypertrophic scar with primary plasty should be delayed for no less than 6 months.

• Unevenness of the cut line

Poor planning of lines of incisions can lead to the loss of temporal bundles of hair, alopecia, the formation of "dog ears" along the edges of the incisions and the ladder of hair growth. The temporal bundle of hair can be restored by transplanting a microtransplant or working creatively with local grafts. Hair loss is usually secondary to damage to the hair follicles and is reversible. However, if the hair follicles have been crossed or the flap is sutured with excessive tension, the loss of hair can be permanent. If, after 3-6 months of waiting, the hair is not restored, the areas of alopecia can be excised and closed primarily. Microtransplants can also help to hide defects.

The impossibility of interleaving and rotating the BTE flap can lead to the formation of a ladder-like border for hair growth. Fortunately, in most patients this area is easily concealed. However, if this becomes a problem, those who want to wear hair back may need a flap revision.

• Infection

In patients who underwent facelift, infection develops rarely. The mild cases of cellulite respond well to a long course of antibiotic therapy, acting on the most frequent varieties of Stap-hylococcus and Streptococcus. Wounds in these patients usually heal without consequences. In rare cases of abscessing, tissue dissection, drainage and sowing of the wounded are required. In such cases, you need to choose an intravenous route of administration of antibiotics.

• Deformation of the auricle

The ear of the satyr (diabolical ear) can turn out if the auricle is located incorrectly. During the healing period, the ear drops down. The poor location of the auricle can lead to gossip about surgical facelift. Restoring an unnaturally looking ear can be deceptively complex. The best way to create a lower furrow of the auricle is VY plastic; However, this can be done no earlier than 6 months after the first operation.

• Damage of the parotid glands

Damage to the parenchyma of the parotid glands, leading to sialoceles or fistula formation, is extremely rare. The intraoperationally recognized damage must be repaired by an accessible part of the SMAS. Postoperative fluid accumulation can be treated by aspiration with a needle and a pressure bandage. Persistent fluid accumulation may require drainage.

The consequences of telangiectasias, hypertrichosis and temporary hypostases over the excreted flap decrease with time. However, with persistent vascular formations and excessive problematic hair can be effectively controlled with a laser.

[1], [2], [3], [4], [5], [6], [7], [8], [9]