Complications of rhytidectomy (facelift surgery)

• Hematoma

The most common complication of rhytidectomy is hematoma formation, which occurs in 2-15% of patients. A large hematoma requiring re-intervention usually develops within the first 12 hours after surgery. Hematoma formation is accompanied by pain and increasing facial edema. Interestingly, there is no correlation between the volume of intraoperative blood loss and hematoma development. On the contrary, hypertension predisposes to this, increasing the incidence of hematoma by 2.6 times. The importance of blood pressure control cannot be overestimated; it should be regularly monitored both intraoperatively and in the postoperative period. Particular attention should be paid to a smooth recovery from anesthesia and the prevention of postoperative nausea, vomiting, and anxiety. Other factors that predispose to hematoma development include taking medications containing acetylsalicylic acid, nonsteroidal anti-inflammatory drugs, high doses of vitamin E, and dominantly inherited Ehlers-Danlos syndrome. It is necessary to have a detailed list of medications containing acetylsalicylic acid. All these medications must be discontinued at least 2 weeks before surgery and not resumed for about 1 week after surgery.

Of course, the management of a patient taking anticoagulants should be done in collaboration with the appropriate specialist. We routinely perform prothrombin time, partial thromboplastin time, and platelet count on all patients, with further testing if the results are abnormal by two times. Special care should be taken when working with men, as most plastic surgeons agree that men are more susceptible to bruising. Although not proven, it appears that the greater risk in men is related to the increased blood supply to the skin and hair follicles of the beard.

Delay in treatment may result in necrosis of the skin flap, especially in patients with extremely rapidly enlarging hematomas. In addition, the fluid accumulation may be an ideal environment for the growth of microorganisms, increasing the risk of infection. Often, during evacuation of the hematoma, it is difficult to see the single vessel that caused it; rather, diffuse bleeding is common. Treatment should consist of clot removal, irrigation, exploration, and electrocoagulation of suspicious areas and vessels. Drainage should be reinserted and a pressure dressing applied.

Small hematomas are common and probably contribute to the overall incidence of hematoma recognition. Small hematomas are usually recognized in the first week after surgery and are small collections of fluid, usually in the retroauricular area. Once liquefied, these fluid collections can be removed by aspiration with an 18-gauge needle under sterile conditions. If there is a tendency to organize, a small incision may be required to drain the hematoma. These patients are treated with a pressure dressing and a course of antibiotics. Unrecognized hematomas lead to fibrosis, wrinkling, and discoloration that may take months to resolve. In these cases, a course of steroid injections (triamcinolone acetonide - Kenalog, 10 mg/ml or 40 mg/ml) may be helpful.

• Flap necrosis

Skin flap necrosis occurs due to impaired blood supply to its distal ends. Predisposing factors include improper flap planning, excessive subcutaneous flap isolation, damage to the subcutaneous plexus, excessive tension during suturing, some systemic diseases, and smoking. Necrosis is most likely in the postauricular and then in the anterior auricular region. Deep rhytidectomy with SMAS displacement is associated with a lower risk of necrosis, as it allows for the creation of a more powerfully blood-supplied flap and reduces tension during suturing. The toxic effect of nicotine and smoking has long been considered the most preventable cause of impaired blood supply in skin flaps. The risk of flap necrosis increases by 12.6 times in smokers. Patients should abstain from smoking for at least 2 weeks before and after surgery. Systemic diseases such as diabetes mellitus, peripheral vascular disease and connective tissue disease may predispose to circulatory compromise and require careful discussion prior to surgery.

Necrosis of the flap is preceded by venous congestion and discoloration. Frequent massage of the area and a long course of antibiotic therapy are prescribed. Necrosis is often accompanied by the formation of a scab. The area of impaired circulation should be treated conservatively, with daily treatment with hydrogen peroxide solution, toilet, and application of antibacterial ointment. Fortunately, most such areas heal well by secondary intention, but frequent postoperative visits and persuasive talks with the patient are required.

• Nerve damage

The most common cervical sensory branch injured during facelift surgery is the great auricular nerve, which occurs in 1-7% of patients. This nerve can be found at the anterior margin of the sternocleidomastoid muscle. The skin flap becomes thinner as it approaches the postauricular and mastoid region. Care must be taken to avoid damaging the muscle and nerve during dissection. Increased bleeding is a common sign of muscle injury. Injury to the great auricular nerve is often detected intraoperatively. The nerve ends must be sutured with an epineural suture of 9/0 nylon. Failure to restore the nerve will result in local hypoesthesia and possible formation of a painful neuroma.

Fortunately, damage to the motor branches occurs much less frequently, in 0.53-2.6% of cases. The two branches of the facial nerve that are most often damaged are the temporal branch and the marginal branch of the mandible. More frequent damage to the two branches depends on the surgical technique and the specific situation. However, both of these injuries can lead to an unsuccessful outcome for the patient and the surgeon. A thorough knowledge of the anatomy of the facial nerve is essential for anyone planning to perform facelift surgery. The temporal branch of the facial nerve is located superficial to the level of the zygomatic arch. Dissection in this area, to prevent damage, should be directly subcutaneous or subperiosteal. The temporal branch is not a single nerve, as often depicted in textbooks, but several branches. Anatomical studies have identified branches crossing the middle part of the inferior arch. Dissection within 10 mm in front of the ear along the arch and within the distal 19 mm of the arch is safe. Unfortunately, facial nerve injury is usually not recognized intraoperatively, but if it occurs, an attempt should be made to perform a primary anastomosis. Use of a microscope may be helpful. If paralysis or paresis of part of the face develops immediately after surgery, do not panic. First, wait 4-8 hours for the local anesthetic to wear off. If it turns out that a motor branch has been injured, there is no point in exploring the wound to find and anastomose the nerve. Relax, clinical experience shows that most of these injuries (85%) recover over time. The high recovery rate may be due to the fact that the injury was not due to transection, but to local trauma to the nerve. Other researchers theorize that in the case of temporal nerve injury, multiple branches provide reinnervation, even in the case of transection. However, if recovery does not occur within 1 year, facial tissue reconstruction may be required, including brow lift, contralateral frontal branch neurolysis, and procedures to revitalize the eyelid.

Dissection under the platysma muscle is dangerous from the point of view of damage to the branch of the edge of the mandible. Dissection directly under the muscle with scissors with rounded ends and limited vertical movements will protect the nerve from injury. The nerve, initially running posteriorly and inferiorly to the mandible, emerges more superficially above the mandible, 2 cm lateral to the shaft of the cochlea. Dissection in the subcutaneous plane is unsuccessful and full of dangers. The zygomatic and buccal branches run along the surface of the anterior border of the parotid gland and are rarely identified with the standard lifting technique. However, these branches are often affected by dissection in the deep plane. Injuries in this area may remain unnoticed due to the large number of branches and anastomoses.

Recurrence of peripheral facial nerve palsy after facelift has been reported. Therefore, this possibility should be discussed with patients with a history of such palsy. Patients with complete facial nerve palsy should be referred to an appropriate specialist. Electrical testing of the nerve may clarify the prognosis in such patients, as well as in those who have sustained motor branch injury.

• Hypertrophic scarring

Hypertrophic scarring may occur when the flap is sutured with significant tension and is most often associated with inadequate subcutaneous flap exposure. Hypertrophic scarring may become apparent as early as 2 weeks after surgery but usually occurs within the first 12 weeks. Intermittent local steroid injections may be helpful. Excision of the hypertrophic scar with primary reconstruction should be delayed for at least 6 months.

• Unevenness of the cutting line

Poor planning of incision lines can result in loss of temporal hair bundles, alopecia, dog ears at incision margins, and scalloped hairline. The temporal hair bundle can be restored by micrograft transfer or creative manipulation of local flaps. Hair loss is usually secondary to follicular damage and is reversible. However, if follicles were transected or flaps were sutured with excessive tension, hair loss may be permanent. If hair does not regrow after 3-6 months of waiting, the alopecic areas can be excised and closed primarily. Micrografts can also help conceal defects.

Failure to interleave and rotate the postauricular flap may result in a scalloped hairline. Fortunately, this area is easily concealed in most patients. However, if it becomes a problem, flap revision may be necessary in those who wish to wear their hair back.

• Infection

Patients who have had a facelift rarely develop infection. Mild cases of cellulitis respond well to long-term antibiotic therapy that covers the most common types of Staphylococcus and Streptococcus. The wounds in these patients usually heal without sequelae. In rare cases of abscess formation, tissue dissection, drainage, and wound culture are required. In such cases, the intravenous route of antibiotic administration should be chosen.

• Deformation of the auricle

A satyr ear (devil's ear) can occur if the pinna is not positioned correctly. During the healing period, the ear droops downwards. Poor pinna positioning can lead to gossip about facelift surgery. Reconstructing an unnatural-looking ear can be deceptively difficult. The best way to create a lower pinna sulcus is a VY plasty; however, this cannot be done until at least 6 months after the initial surgery.

• Damage to the parotid glands

Parotid parenchymal injury resulting in sialocele or fistula formation is extremely rare. Intraoperatively recognized injury should be sutured with accessible SMAS. Postoperative fluid collection can be treated with needle aspiration and pressure dressing. Persistent fluid collection may require drainage.

The effects of telangiectasias, hypertrichosis and temporary hypoesthesias over the allocated flap decrease over time. However, persistent vascular formations and excess problematic hair can be effectively treated with a laser.

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