Key points

Introduction

Rhytidectomy continues to be one of the most common aesthetic procedures performed by plastic surgeons, as reported in the annual statistics by the American Society for Aesthetic Plastic Surgery. It consistently ranks within the top 10 aesthetic surgical procedures performed in the United States each year, with more than 100,000 performed in 2010, an increase of 28.5% since 1997. Despite widespread public acceptance of aesthetic surgery, complications related to facelift surgery persist. This article reviews the common complications and proposes strategies to reduce or eliminate them wherever possible.

Complications related to facelift surgery can be divided into 3 main areas: preoperative assessment and surgical planning, intraoperative surgical maneuvers, and postoperative care. Although some complications are unavoidable and unforeseen with any surgical procedure, patients are less forgiving and tolerant of those associated with an aesthetic surgical procedure.

Some complications can be avoided during the preoperative evaluation. A thorough history and physical elicit evidence of prior complications associated with anesthesia and surgery. Easy bruising or postoperative bleeding should alert the surgeon that a coagulation work-up may be indicated. Patients are instructed to avoid the use of aspirin and nonsteroidal antiinflammatory drugs for at least 2 weeks before surgery. Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications, including arrhythmias ( Box 1 ). Chemotherapeutic agents and oral steroid usage can alter wound healing and must be discontinued several weeks before elective surgery. In addition, close communication and clearance with the patient’s primary care physician and specialist is needed to determine suitability for elective aesthetic surgery.

The initial consultation must include a thorough assessment of the patient’s signs of facial aging. This assessment includes an evaluation of skin tone and laxity, facial rhytids, dyschromia, previous facial scars, skin atrophy, telangiectasia (worsened with facial surgery), and presence or absence of facial fat. Facial fat is important in that care must be taken during flap elevation to avoid perforation of the superficial muscular aponeurotic system (SMAS) and facial nerve injury. Furthermore, aggressive liposuction in such patients may result in visible and/or palpable contour irregularities of the face and neck.

Facial nerve paresis or paralysis must be documented and demonstrated to the patient. Submalar hollowing, microgenia, and facial asymmetry need to be recognized and discussed with the patient. Submandibular gland ptosis, low-riding hyoid, and platysmal bands are also documented. Deep neck rhytids, perioral rhytids, and nasolabial folds are unaffected by rhytidectomy so alternative treatment plans can be discussed at the initial consultation. The hairline needs to be inspected carefully. The position of the frontal and temporal hairlines should be noted along with any alopecia.

Patient expectations and goals should be discussed. It may be possible to identify a particularly difficult or manipulative patient before the consultation based on the patient’s interactions with the office staff. The aesthetic deformities must be correctly identified during this consultation, and the surgeon needs to develop an appropriate surgical plan to manage each deformity. It is paramount that an open and honest dialogue occurs between surgeon and patient as to the deformities that will be improved at the time of rhytidectomy. Realistic goals need to be agreed on with the patient in advance because a thorough preoperative discussion and explanation of the limitations of rhytidectomy are interpreted by the patient as a sign of a meticulous and ethical plastic surgeon. If this discussion occurs only after surgery, it is viewed with suspicion by the patient and interpreted as making excuses for an outcome that the patient perceives as suboptimal.

An evaluation of the skin is critical in the aesthetic analysis of every patient. Extensive skin laxity may alert the surgeon that a minor touch-up or further skin excision may be needed several months after the initial rhytidectomy, especially in elderly patients and those with prior extensive sun exposure or steroid use. Facial dyschromia and telangiectasia can be exacerbated by rhytidectomy.

Facial asymmetry is common in patients who present for aesthetic surgery. This asymmetry may be the result of, among other things, prior facial surgery, trauma, facial nerve injury, soft tissue atrophy, skeletal abnormalities, brow ptosis, or alopecia. It is necessary to point out this asymmetry to the patient in a mirror and explain that it may persist after rhytidectomy. Submalar atrophy may respond to soft tissue augmentation performed at the same time as the rhytidectomy, especially in the case of fat transfer. Microgenia can be corrected concurrently and creates a more youthful jaw and neck contour.

Submandibular gland ptosis is not improved by most rhytidectomy techniques and may even be accentuated with aggressive liposuction in the submandibular area. This limitation needs to be discussed with the patient at the initial consultation. Techniques are available to remove the submandibular glands causing this ptosis but the author (an otolaryngologist and plastic surgeon) does not advocate such an approach. Such surgery can result in significant morbidity, including facial nerve, lingual nerve, and hypoglossal nerve injury and hemorrhage from the facial and lingual arteries, which might compromise the patient’s airway.

Platysmal laxity should be noted at the consultation and a surgical plan formulated to improve this deformity. In general, platysmal laxity can be improved with plication. However, overly aggressive surgery, including extensive subplatysmal lipectomy and digastric muscle resection, can produce an unnatural and overly operated-on appearance to the neck, including witch’s chin, cobra deformity, and a skeletonized and cadaveric neck, which does not look rejuvenated.

It is important to evaluate the patient’s hairline and look for evidence of alopecia. The present position of the temporal and mastoid hairlines needs to be respected in the design of any rhytidectomy incisions. The temporal hairline must not be elevated or narrowed as the result of a poorly designed incision. The upper end of the rhytidectomy incision should be placed along and parallel to the lower end of the temporal hairline and should not extend above the upper edge of the pinna. If it does, the temporal hairline is raised and narrowed, compromising the final aesthetic result and making reconstruction of this valuable landmark difficult. Hairline incisions in the mastoid and post auricular area should be avoided because they often result in hypopigmented and quite obvious scars that prevent the patient from wearing her hair up, which might expose them. If it is necessary to extend the incision behind the ear, then it is prudent to continue it into the hair-bearing scalp.

Introduction

Rhytidectomy continues to be one of the most common aesthetic procedures performed by plastic surgeons, as reported in the annual statistics by the American Society for Aesthetic Plastic Surgery. It consistently ranks within the top 10 aesthetic surgical procedures performed in the United States each year, with more than 100,000 performed in 2010, an increase of 28.5% since 1997. Despite widespread public acceptance of aesthetic surgery, complications related to facelift surgery persist. This article reviews the common complications and proposes strategies to reduce or eliminate them wherever possible.

Complications related to facelift surgery can be divided into 3 main areas: preoperative assessment and surgical planning, intraoperative surgical maneuvers, and postoperative care. Although some complications are unavoidable and unforeseen with any surgical procedure, patients are less forgiving and tolerant of those associated with an aesthetic surgical procedure.

Some complications can be avoided during the preoperative evaluation. A thorough history and physical elicit evidence of prior complications associated with anesthesia and surgery. Easy bruising or postoperative bleeding should alert the surgeon that a coagulation work-up may be indicated. Patients are instructed to avoid the use of aspirin and nonsteroidal antiinflammatory drugs for at least 2 weeks before surgery. Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications, including arrhythmias ( Box 1 ). Chemotherapeutic agents and oral steroid usage can alter wound healing and must be discontinued several weeks before elective surgery. In addition, close communication and clearance with the patient’s primary care physician and specialist is needed to determine suitability for elective aesthetic surgery.

The initial consultation must include a thorough assessment of the patient’s signs of facial aging. This assessment includes an evaluation of skin tone and laxity, facial rhytids, dyschromia, previous facial scars, skin atrophy, telangiectasia (worsened with facial surgery), and presence or absence of facial fat. Facial fat is important in that care must be taken during flap elevation to avoid perforation of the superficial muscular aponeurotic system (SMAS) and facial nerve injury. Furthermore, aggressive liposuction in such patients may result in visible and/or palpable contour irregularities of the face and neck.

Facial nerve paresis or paralysis must be documented and demonstrated to the patient. Submalar hollowing, microgenia, and facial asymmetry need to be recognized and discussed with the patient. Submandibular gland ptosis, low-riding hyoid, and platysmal bands are also documented. Deep neck rhytids, perioral rhytids, and nasolabial folds are unaffected by rhytidectomy so alternative treatment plans can be discussed at the initial consultation. The hairline needs to be inspected carefully. The position of the frontal and temporal hairlines should be noted along with any alopecia.

Patient expectations and goals should be discussed. It may be possible to identify a particularly difficult or manipulative patient before the consultation based on the patient’s interactions with the office staff. The aesthetic deformities must be correctly identified during this consultation, and the surgeon needs to develop an appropriate surgical plan to manage each deformity. It is paramount that an open and honest dialogue occurs between surgeon and patient as to the deformities that will be improved at the time of rhytidectomy. Realistic goals need to be agreed on with the patient in advance because a thorough preoperative discussion and explanation of the limitations of rhytidectomy are interpreted by the patient as a sign of a meticulous and ethical plastic surgeon. If this discussion occurs only after surgery, it is viewed with suspicion by the patient and interpreted as making excuses for an outcome that the patient perceives as suboptimal.

An evaluation of the skin is critical in the aesthetic analysis of every patient. Extensive skin laxity may alert the surgeon that a minor touch-up or further skin excision may be needed several months after the initial rhytidectomy, especially in elderly patients and those with prior extensive sun exposure or steroid use. Facial dyschromia and telangiectasia can be exacerbated by rhytidectomy.

Facial asymmetry is common in patients who present for aesthetic surgery. This asymmetry may be the result of, among other things, prior facial surgery, trauma, facial nerve injury, soft tissue atrophy, skeletal abnormalities, brow ptosis, or alopecia. It is necessary to point out this asymmetry to the patient in a mirror and explain that it may persist after rhytidectomy. Submalar atrophy may respond to soft tissue augmentation performed at the same time as the rhytidectomy, especially in the case of fat transfer. Microgenia can be corrected concurrently and creates a more youthful jaw and neck contour.

Submandibular gland ptosis is not improved by most rhytidectomy techniques and may even be accentuated with aggressive liposuction in the submandibular area. This limitation needs to be discussed with the patient at the initial consultation. Techniques are available to remove the submandibular glands causing this ptosis but the author (an otolaryngologist and plastic surgeon) does not advocate such an approach. Such surgery can result in significant morbidity, including facial nerve, lingual nerve, and hypoglossal nerve injury and hemorrhage from the facial and lingual arteries, which might compromise the patient’s airway.

Platysmal laxity should be noted at the consultation and a surgical plan formulated to improve this deformity. In general, platysmal laxity can be improved with plication. However, overly aggressive surgery, including extensive subplatysmal lipectomy and digastric muscle resection, can produce an unnatural and overly operated-on appearance to the neck, including witch’s chin, cobra deformity, and a skeletonized and cadaveric neck, which does not look rejuvenated.

It is important to evaluate the patient’s hairline and look for evidence of alopecia. The present position of the temporal and mastoid hairlines needs to be respected in the design of any rhytidectomy incisions. The temporal hairline must not be elevated or narrowed as the result of a poorly designed incision. The upper end of the rhytidectomy incision should be placed along and parallel to the lower end of the temporal hairline and should not extend above the upper edge of the pinna. If it does, the temporal hairline is raised and narrowed, compromising the final aesthetic result and making reconstruction of this valuable landmark difficult. Hairline incisions in the mastoid and post auricular area should be avoided because they often result in hypopigmented and quite obvious scars that prevent the patient from wearing her hair up, which might expose them. If it is necessary to extend the incision behind the ear, then it is prudent to continue it into the hair-bearing scalp.