1
Rhytidectomy: Complications
An unhappy patient is
particularly in your
This remains true no
you think the result
therefore to take the
full pre-operative
not to operate on
you believe are not
red flags are
remember when
patients:
1. insatiable
surgery
candidates
(“cosmetic
junkies”)
2. transient,
interpersonal
relationships
suggesting
personality
3. disturbed
image
4. unclear about desired result
5. perceived deformity greater than actual deformity
6. history of dissatisfaction / multiple revisions
7. psychotic and depressive illness
a complication waiting room.
matter how good
is. It is wise
time needed for a
assessment and
candidates that
suitable. Rees’
important to
evaluating your
aesthetic
surgery
volatile
unstable
body
The wise surgeon never says that a patient ‘needs’ a face-lift, nor does he promise that
the patient will look younger. Rather, a rhytidectomy ... often produces a ‘refreshed’ or
‘rested’ look, but certainly it is not the fountain of youth. (Courtiss)
Patients must be warned about the possibility of surgical complications such as
haematoma, skin slough, hair loss - temporary or permanent, sensory or motor nerve
damage and poor scarring. Should a complication occur the surgeon must acknowledge
this to both the patient and him/herself. Appropriate measures must be taken to remedy
the problem and the surgeon must be available to see the patient as often as is necessary
to alleviate the associated anxiety.
Surgical complications can be placed in 2 broad categories:
2

minor complications

major complications
Minor complications
Infection
Infection following facelift procedures is rare with a reported incidence of <1%.
Prophylactic shampoo and face-wash the night before and on the day of the operation are
advised, but there is no evidence to support the use of prophylactic antibiotics. Minor
localized infections around sutures are easily treated by suture removal and evacuation.
Suppurative infection beneath the flaps is usually the result of untreated haematoma, and
management consists of suture removal, drainage and specific antibiotics. Acute
chondritis may occur when postauricular sutures are placed through the perichondrium
and cartilage; prompt therapy must be instituted to minimize cartilage destruction.
Small haematomas
This is the most common complication following rhytidectomy. They are usually small,
localized collections varying from 2 - 30ml in size with a reported incidence of
approximately 15%. Very small haematomas usually absorb spontaneously within a few
weeks and leave no trace. Collections may often not be detected until the oedema has
subsided - they will then appear as an area of firmness, ecchymosis or skin surface
irregularity. They will liquefy between the seventh and fourteenth days when every
effort should be made to evacuate or aspirate them. If the haematoma is far from a suture
line, it is sometimes possible to evacuate it by placing a small stab incision in a natural
skin crease overlying the haematoma and then expressing it. After the 14th day the
haematoma becomes firm again and a puckering or minor contour deformity of the
overlying skin may occur; this could take several months to resolve. Some recommend
small doses of intralesional steroid during this organizational phase of clot formation to
minimize the deformity.
Smokers have an increased risk of hematoma ?related to smoking
Extensive ecchymosis and pigmentation
Following a rhytidectomy some localized ecchymosis is usually seen which resolves
within 1 - 2 weeks. Patients with thin, transparent skin and hypopigmentation, and those
with a history of unusual bruising are prone to severe, extensive ecchymosis. This may
extend down to the lower aspect of the sternum and require many months to resolve.
Resolution is usually complete, but patients with darker skins may have a residual brown
3
pigmentation due to haemosiderin deposition. (Usually, hyperpigmentation from
haemosiderin deposits resolves within 6 - 8 months.)
Patients with small telangiectasias preoperatively may develop new lesions following the
procedure and they should be forewarned of this possibility. A permanent reddish
discoloration of the neck and cheeks may occur. This is usually best managed with the
use of cosmetics, although large telangiectatic lesions may be electrocoagulated.
Oedema
Oedema secondary to venous stasis is usual and normally resolves by the 2nd
postoperative week. Oedema lasting >3 weeks is unusual and thought to be due to
lymphatic stasis. This, too, usually subsides with no residual sequelae. Gentle tissue
handling will help to minimize postoperative oedema. Diuretics are NOT recommended.
Local disfigurements
Ear deformities
1. pixie ear
2. loss of pretragal pit
3. tragal distortions
4. hair growth in pinna with pretragal incisions
Most rhytidectomy incisions require a 75% or more circumscription of the pinna. If
excessive tension is applied to it during closure, the ear may become dislocated or twisted
on its axis. The pixie ear is the most common type of ear deformity - this results from
adherence of the lobe to the skin of the cheek. One must take care when trimming the
pre- and postauricular skin to ensure that an exact fit of the lobe is attained without
tension. Furthermore, the first suture of the postauricular flap should never be hung on
the fascia of the earlobe, but tension and fixation should be at the peak of the
postauricular incision through the mastoid fascia.
Pre-auricular incisions carried behind the tragus in an attempt to minimize visible scars
may result in unsightly distortion of the tragus when wound contraction occurs. A
significant ear deformity may require a complete wound revision as a secondary
procedure.
Dog-ears
Small dog-ears may persist in the temporal region or nape of the neck despite all
precautionary measures taken at the time of surgery. Although most will resolve over a
few months, they are frequently annoying to the patient and excision and correction may
need to be done as an outpatient procedure.
4
Submental depression
Removal of all submental fat may result in adhesions with fixation of skin to the
underlying muscle, causing unsightly contour irregularities that are very prominent
during swallowing or neck motion. It is therefore important to leave a small adipose
layer attached to the skin.
Small dog-ears usually remain at the ends of the submental incision and must be carefully
trimmed or unsightly bumps will remain.
Excessive excision of skin and fat - especially in patients with microgenia or mandibular
retrusion - may result in webbing in the vertical dimension of the neck.
Wound dehiscence




This is usually due to excessive tension on the wound or secondary to trauma.
There must be NO tension on the pre- and postauricular incisions.
D Baker and Rees recommend that 6.0 Nylon sutures be used for the pre- and
postauricular lines and removed at 5 days to prevent suture marks; 4.0 Nylon is used
for the temporal scalp and mastoid skin (most tension) and removed on the 10th to
12th postoperative days.
Wound dehiscence may be treated with Steri-strips or resuturing.
Scars and keloids







Fortunately, hypertrophic scars and keloids seldom occur following rhytidectomy.
Hypertrophic scars, if they occur, usually occur in the postauricular area where the
greatest tension exists, and not in the preauricular region.
Incisions closed under tension in the nape of the neck or temporal areas may result in
wide or hypertrophied scars, made more noticeable if there is associated hair loss.
Wound closure without tension is the best prevention.
Should they occur, hypertrophic scars must be treated with patience and possibly
intralesional steroids.
Re-excision should only be considered after maturation is complete.
Keloids should be treated by intralesional steroids and silicone gel, and if necessary,
excision, intralesional steroids and possibly radiation.
Hair loss

Causes
1. superficial undermining with injury to the hair follicles
2. excessive tension on the skin flaps
3. interference with the blood supply to the hair follicles
5




incidence ranges from 0 - 3%, most commonly in the temporal region.
Fortunately, most hair loss is temporary and the hair will regrow within several
months
An obvious hair-loss may be noted in the postauricular scalp as a “stair-step” if the
hairline has not been accurately approximated.
Male patients should be warned that the hairless preauricular area will be narrowed,
and the beard area will alter, possibly necessitating shaving behind the ear. If hair
loss is unusually extensive, a dermatological consult should be requested.
Sensory nerve injury and paraesthesias
Temporary numbness and paraesthesias over the earlobes and cheeks are common in the
early postoperative period. This is usually due to transection of the small sensory nerves,
and full sensation returns in weeks to months.
Permanent injury to the great auricular nerve (the most common significant nerve injury)
may occur if dissection is too deep over the midportion of the sternocleidomastoid
muscle. This causes a permanent loss of sensation over the lower portion of the ear, and
the immediate pre- and postauricular areas. With the head turned 450 toward the
contralateral side, the great auricular nerve consistently crosses the midportion of the
sternocleidomastoid muscle at a level 6.5cm below the caudal edge of the bony external
auditory canal. It then courses cephalad just beneath the SMAS, 0.5cm posterior and
parallel to the external jugular vein. Mckinney and Gottlieb recommend that the safest
place to incise the SMAS-platysma during rhytidectomy is at a point anterior to the
sternocleidomastoid muscle. Should one recognize injury to the great auricular nerve
intraoperatively, an immediate, meticulous repair should be performed in an attempt to
restore as much sensory function as possible and to prevent the development of a painful
neuroma. Patients with earlobe anaesthesia should be cautioned against wearing
compressive jewelry.
Pain
Significant post-operative pain is not usual - it should arouse suspicion of haematoma
which will need investigation.
Plication of the platysma often leads to patients complaining of a tightness in the neck for
the first few days to weeks postoperatively. Reassurance that this is normal and will
subside with time is all that is required. Chronic, intractable pain is rare, and thought to
be due to injury to branches of the cervical sensory nerves as they emerge from the
posterior border of the sternocleidomastoid muscle. Even this will usually subside within
6 months, but regional sensory nerve blocks or muscle relaxants may be required for
temporary relief.
Major Complications
6
Large haematomas












Large expanding haematomas that cause pain, swelling and ecchymosis demand
immediate attention and should be evacuated as an emergency procedure.
usually manifest within the 1st 24 hours but may occur as late as 10 - 14 days.
excessive pain after facelift is unusual, and it warrants an examination and removal of
the dressing. This in turn may result in venous engorgement and circulatory
compromise of the flap, and eventual flap necrosis.
On identification of a large haematoma, sutures should be removed immediately at
the bedside, and the clots evacuated to relieve tension on the skin flaps. Thereafter
the patient is returned to the operating theatre where the rest of the blood is evacuated
and the source bleeding stopped. Following successful management of this,
ecchymosis and oedema will be prolonged but the final result is usually not
compromised.
Incidence of large haematomas requiring surgical evacuation varies from 0.9 - 8.0%,
with an overall average incidence of 3.7% in 9352 patients.
Most plastic surgeons agree that men tend to bleed more at the time of the procedure,
and have a higher incidence of post-operative haematomas. Two studies confirm this
- that by Pitanguy and colleagues revealed a 7.7% incidence in men undergoing
facelift procedures (n=52), and Baker and colleagues showed an 8.8% incidence
(n=137). Baker and colleagues suggested that this may be related to the increased
blood supply to the beard but this has not been proven.
Numerous reports have analyzed the causes of haematoma - essentially the more
extensive the undermining the higher the incidence of post-operative haematoma.
The most meticulous haemostasis, various drainage methods, use of dressings versus
no dressings, and immobilization have all been tried but failed to show a decrease in
the incidence of haematoma formation.
General anaesthesia or hypotensive anaesthesia also does not reduce the incidence of
post-operative haematoma.
One factor that does appear to play a role is post-operative hypertension. Berner and
colleagues studied the pre- and postoperative blood pressures of 202 facelift patients.
During the first 2 hours postoperatively the blood pressure levels were similar to the
preoperative recordings. However, during the succeeding 3 hours most patients
demonstrated blood pressures well in excess of their preoperative level. The authors
pointed out that this was at the point when the pre- and intra-operative drugs lose
their effect and the adrenergic response to pain and anxiety manifests itself. They
recommended the use of chlorpromazine in the intra- and early postoperative period
to reduce the reactive hypertension.
Straith and colleagues looked at 500 consecutive face-lift patients and found a strong
correlation with the admission blood pressure and the incidence of haematoma;
patients with a blood pressure > 150/100 had a 2.6 X greater risk of developing a
major haematoma postoperatively.
Imperative that aspirin and aspirin-containing compounds are stopped two weeks
before the procedure and not taken for one week thereafter. Aspirin irreversibly
inhibits the adherence mechanism of platelets and as little as 10g a day can prevent
7

normal platelet aggregation. This effect lasts for the lifetime of the platelet which is
approximately 10 days
Important to ensure that anti-hypertensive medications are taken in the morning of the
operation
Motor nerve injuries
The most commonly injured motor nerve is the frontal branch of the facial nerve(2.64%). Other branches of the facial nerve are also at risk but far less so. The anatomy of
the facial nerve and the danger points during rhytidectomy have been well documented:
1. over the mandibular body, at the point where the facial artery crosses the
mandibular branch of VII and this nerve becomes superficial
a. distinguish from marginal mandibular nerve pseudo-paralysis (PRS 2003)
i. cervical branch may innervate depressor anguli oris – may get
asymmetrical smile in these cases
ii. a
v
o
i
d
a
g
g
r
e
s
s
i
v
e
s
h
a
r
p
d
i
s
s
8
ection in the lateral danger zone near the angle of the mandible in
an effort to prevent cervical branch injury.
iii. Mandibular branch function can be demonstrated by intact
mentalis protrusion of the lower lip in a symmetrical fashion
2. over the malar eminence, where the frontal branch is superficial as it passes over
the zygoma
3. at the midpoint of the temporal skin between the lateral canthus and the superior
auricular angle
4. buccal nerve in buccal fat pad
Extensive dissection in these areas should be avoided, particularly in patients with thin,
atrophic skin and subcutaneous tissue. The facial nerve will not be endangered if the
plane of dissection is kept superficial. Dissecting as far anteriorly as the oral commissure
or the nasolabial fold is not recommended as the branches lie very superficial this far
anteriorly. Nerve regeneration does often occur here, but it may be accompanied by
dissociated muscle fasciculations, resulting in annoying, involuntary twitching.
The various causes of VII paresis / paralysis include:
1. transient paresis from local anaesthesia infiltration
2. stretching of the nerve during blunt dissection
3. pinching of the nerve with forceps
4. thermal injury during electrocoagulation
5. compression of the nerve by a plication suture
6. partial or complete transection
7. inflammation and infection
8. coincidental Bell’s palsy or other neurological pathology
9. distorted anatomy from subcutaneous fibrosis in 20 or 30 face-lifts
9
The nerve branches most frequently injured are the frontal, buccal and marginal
mandibular (1.7%). Permanent paralysis is fortunately rare, and full function usually
returns within weeks to months. Treatment is therefore expectant unless it is obvious that
10
a branch has been transected. If this is the case, the best chance for recovery of function
is immediate microsurgical approximation of the cut ends.
Injury to the spinal accessory nerve with resultant loss of movement of the trapezius
muscle has also been reported. This is presumably due to dissection that is too deep
along the posterior border of the sternocleidomastoid muscle. Dissection must remain
superficial to the fascia of the sternocleidomastoid; muscle fibres must not be exposed.
Salivary fistula/Sialocele
Facial nerve injuries in rhytidectomy




swelling or discharge increases during meals and only partially subsides, slowly,
several hours after food intake.
Occurs due to damage to the gland or stretching of Stensons duct during subSMAS
lift
Fistulas may drain down externally through a skin wound if the parotid cyst is located
lateral to the buccinator muscle and into the buccal mucosa if it is located medial to
the buccinator muscle.
Treatment
o Antibiotics
o Compression dressing
o Anticholinergic drugs
o Sialoendoscopy of Stenson’s gland to relieve the obstruction and to distend
the salivary duct  stent
o Botox
Skin slough and necrosis
11
The incidence of skin slough has been reported as being between 1.1 and 3.0%. Major
skin slough is on a par with injury to the facial nerve as concerns feared complications.
The vascular compromise resulting in flap necrosis can be caused by several factors:
1. delayed recognition of a haematoma (most common cause)
2. excessive superficial dissection of the flap
3. excessive trauma to the flap from retractors or “raking” with the scissors
4. excessive tension from too much pulling or tightening of the skin
5. excessive pressure from tight dressings
6. excessive undermining
7. impaired circulation from previous scars eg thyroidectomy
8. infection
9. smoking
Skin flap necrosis is usually heralded by pallor (or a bluish tinge) of the skin over the
mastoid area - it is here that the skin flap is thinnest, tension is greatest, and blood supply
farthest away from the tip of the flap. Skin flap necrosis is fortunately rarely extensive
and the resulting scar is usually behind the ear where it can be easily hidden by hair
styling.
All sloughs should be treated conservatively and expectantly (once the aetiology eg
haematoma has been removed). If a small area they will normally heal with minimal
scarring. Healing of full thickness loss should be allowed to occur by 20 intention in
which time period the patient will require much reassurance. Partial thickness loss will
generally heal satisfactorily, but may leave residual pigmentation, coarseness or
superficial scarring of the skin.
Major full-thickness losses are very rare and usually the result of a neglected massive
haematoma. In these cases the resulting scarring may be unsightly and require excision
and repair, or even skin-grafting.
The best treatment of skin flap necrosis is prevention:

gentle tissue handling

meticulous haemostasis
12
Rees (1984) showed that smokers (7.5 percent) had a significantly higher chance of
developing wound healing problems than nonsmokers (2.5 percent) after undergoing a
face lift. Furthermore, he showed that smokers had a 12.5-fold chance of suffering skin
slough than nonsmoking patients. Caused by a combination of decreased skin flow
into the skin flaps caused by nicotine and decreased skin oxygen levels caused by
carbon monoxide.
Recommend to stop smoking 1 month prior and 1 month post surgery.
Riefkohl (1986) reported an incidence of wound slough in nonsmokers of 5 percent and
in active smokers, 19.4 percent. They also found high-grade microvascular occlusion in
the dermal capillaries in smokers and ex-smokers.
DVT/PE (John Reinisch PRS 2001)




Rates: DVT 0.35% and PE 0.14%
Deep venous thrombosis/pulmonary embolus is more likely to occur when the
procedure is performed under general anesthesia.
Intermittent compression devices were associated with significantly fewer
thromboembolic complications
TED stockings afforded no protection against deep venous thrombosis/pulmonary
embolus when used alone.
Causes of failure and unfavorable results
1.
Poor patient selection
2.
Improper surgical technique
3.
Changes in the patient’s physiology
Patient selection - physical factors:
1.
2.
3.
4.
5.
short, thick neck
low position of the hyoid bone in relation to the mandible
excessive body weight
badly sun-damaged skin
unaesthetic angles and contours of the facial bones
Improper surgical technique:
1. too much undermining
2. too little undermining
3. improper rotation of the flaps
13
4. uneven tensions causing facial imbalance and distortion or a quick
postoperative relaxation
Physiological changes:
any changes in the patient’s general health that would promote premature degeneration
of the skin may accelerate postoperative relaxation
1. weight fluctuations
2. hormonal imbalance
3. severe emotional upset
4. excess alcohol intake
5. systemic diseases (eg Ehlers-Danlos)
Secondary rhytidectomy
It is difficult to predict when a secondary rhytidectomy procedure will be required,
however it is important to inform patients that the result is not permanent because the
ageing process marches on. In general, younger patients have a more favourable and
durable result than older patients (60s and70s) with degenerative skin changes. The first
indicators of relaxation usually manifest at the cervicomental angle and along the jawline. Repeated face-lift operations at too frequent intervals result in loss of the natural
elastic properties of the skin and a “mask-like” appearance.
14
References
McCarthy
The Art of Aesthetic Plastic Surgery; ed JR Lewis
Aesthetic Surgery - Trouble. How to avoid it and how to treat it; ed EH Courtiss