Revision Facelift Surgery
Revision facelift is a broad term that includes numerous variables and common reasons are listed.
Improving a recent substandard surgical outcome from another surgeon
Any given surgeon who performs a lot of facelifts and has consistently natural and long-lasting results can develop a good reputation for the procedure. In this day and age of the Internet and social media, an excellent reputation can be local, national, and international. With this reputation brings numerous requests to improve a poor outcome from another surgeon. These requests may be shortly after the patient’s surgery or years later. Having the reputation and ability to improve a substandard result is an honor, however it can also have drawbacks. I have had numerous patients with really poor facelift results from elsewhere come to my office for consultation for improvement. These patients may present on a busy day with a full waiting room, and some other new facelift consultation patients have commented to my staff that: “They did not want to look unnatural, like the lady sitting in the reception room”. They thought these patients represented my work when in reality they were here for repair. This is something a surgeon and staff can keep in mind and discreetly handle. It is a great feeling for a surgeon and staff to take a poor result and convert it to a good one and make a happy patient. One problem is that many times, the patient may present with problems that although can be improved, will never look natural. In cases like this, that last surgeon to operate on such a patient (you or me) will now become “the doctor”. Although the patient was improved, the result will never be great and the last surgeon to touch the patient may get the bad rap. This can be more of a problem with local patients who mingle with other local patients. I once had a local patient who had a poor facelift from a local surgeon. The patient had severe temporal balding, severe pixie earlobes and residual neck skin and jowls. I retreated this patient and she and I were both extremely pleased with the improvement. Unfortunately, despite my efforts, the patient still had stigmata of poor facelift surgery. If someone sees her result, they may feel that I caused the hairline problems, even though I actually improved her. Surgeons who perform significant revision surgery need to find ways to explain this to future and current prospective patients.
Improving a recent substandard result from one’s own work.
Regardless of the skill of any surgeon, he or she will occasionally have to touch up their own work. Sometimes this is because the patient sees an insufficiency or sometimes the surgeon brings it up. No surgeon wants an unhappy patient so if a sincere patient with realistic expectations has something that can be improved, it must be addressed in the interest of patient relations and reputation. On the other hand, I have had patients happy with their result, but I personally saw something that could and should be improved. It is imperative that my patients walking around in my city have results commensurate with my ability, and for that reason I will bring it up with the patient that we need to revise something. It is most frequently some minor excess submental skin, minor jowl liposuction, or laser scar revision ( Figs. 9.1–9.6 ). I once had a visiting plastic surgeon who was observing in my office, comment that if a patient thinks their result is good, then why bring up a deficiency? This answer is simple, a great result is positive marketing and a result that does not meet my personal standards is bad marketing. If it can be better, then make it better. It will pay off many times in the long run. The other side of this coin is the patient that truly does have an acceptable result and is not happy. This multifactorial situation is addressed in previous chapters.
Despite accurate diagnosis, a small percentage of patients will heal with skin excess in the submental region ( Figs. 9.7–9.10 ). On some patients, it seems that regardless of the vectors of pull on the preauricular and postauricular flaps, a small area in the submental region is resistant to improvement. This can be a result of the shape of the mandible and simple physics of the flap vectors. As stated earlier, removing a small ellipse of skin with the submental incision may assist in addressing this area. When patients undergo a large facelift and still require skin excision, these small local procedures may be adequate for small excess. Some patients, however, may have enough neck and jowl skin excess to warrant reopening the incisions to pull and excise more skin. I have performed revision cases where the patient had isolated submental skin and only required opening the postauricular incisions to tighten the neck. I have also had patients with excess jowl skin and minor neck excess on whom I only opened the anterior incisions to remove excess skin. Finally, despite having a comprehensive and aggressive facelift, a very small number of patients have enough excess skin to require both the preauricular and postauricular incisions opened ( Fig. 9.11 ).
Revision surgery is most common in patients with increased skin elasticity or patients with abnormally excessive submental and jowl skin such as postbariatric surgery or massive weight loss patients ( Fig. 9.12 ). I tell these patients preoperatively that they may well need significant revision after 6 months to get the result they want. In rare cases, some patients simply need two facelifts. There is a limit to the amount of skin that can be safely and effectively removed at a single surgery. I always photograph the amount of skin excess intraoperatively to prove to the patient that as much skin excess was removed as safely possible ( Fig. 9.13 ).
The question always at hand is: “Who pays for revision surgery?” Many surgeons charge for all and any procedure regardless of “whose fault it was”. Although some patients may agree to pay for the same procedure twice, most will not be happy doing so. My preoperative facelift consent clearly states that there will be a charge for revision surgery, but I rarely charge what the revision is worth. Charging for revision surgery depends on why a revision is needed. The surgeon may have caused an untoward situation such as a pixie ear or hairline change and personally I feel it is unfair to charge the patient for this. In other cases, the problem can be purely out of the control of the surgeon. In cases like this I may charge a “materials fee” and anesthesia fee to offset my time but I rarely have significant charges for revision during the first year postoperative. I truly believe that although I may lose some production, the value will come back to me many times over. Word gets around about a surgeon’s reputation and backing up his or her work. Patients are, after all, consumers and although no surgeon can give a true “warranty”, I believe that free or very low-cost revision surgery is simply another form of marketing. If someone pays $20,000 for a facelift with multiple procedures, they expect a level of coverage if the result is compromised. Also as stated earlier, these patients will be walking around town and I want them to be proud of my work and brag about my office and not have their friends see shortcomings that would be attributed to my skill or lack thereof. Always remember, we market with every patient and it can be positive or negative.
Readdressing a good result that has changed over the years as a result of the natural aging process.
Of the types of revisions mentioned, redoing a lift on a happy patient who has had a decade of improvement is much less complicated. They are generally quite happy and probably had a good surgical experience the first time. They are educated on the procedure and recovery from the first surgery and understand that it is simply time for another lift. Although facelift surgery is a predictable long-lasting procedure, it is not permanent. The patient continues to age the minute they wake up from anesthesia. The longevity of a surgical procedure is influenced by many variables, including the patient’s age, surgical procedure and technique, patient genetics, skin quality, and how the result is maintained or protected after surgery. A well-done cervicofacial rhytidectomy with medial and lateral platysmaplasty and superficial musculoaponeurotic system (SMAS)-ectomy can last 10 to 12 years before many patients would seek revision ( Figs. 9.14 and 9.15 ). Most patients understand and prepare for this. This longevity is so variable and whereas one patient may get 15 years out of a facelift, another patient could experience postsurgical change several years after the procedure. Although the surgeon has some component of control over longevity, no one can control nature. All consultations, consents, and perioperative discussions should address the variability of facelift “shelf life”. I know one respected facial plastic surgeon who tells all of his patients that they may require revision as early as 2 years later.
As stated, some revision facelifts are simple repeats of a well-done previous procedure and are a repeat of the previous pleasant experience. Like colonoscopy, patients wish they did not have to repeat the procedure but accept that they do.
Revising a facelift is similar to the previous surgery but may be easier or harder in numerous ways. Re-incising previous incisions can produce tragal, hairline, and lobe changes and this should be discussed with patients. This does not mean that these areas will be changed, but multiple surgeries can induce changes to these areas. Secondary surgery can be easier or harder because of scar tissue from previous surgery ( Fig. 9.16A ). In some circumstances, the scar tissue forms a “glide plane” and the dissection is very simple with little tissue resistance. In other cases, the scar tissue can be extreme and make dissection complicated and offer significant resistance ( Fig. 9.16B ).
Patients with extreme scar tissue may not have “SMAS” tissue that can be mobilized and require a “skin only” procedure ( Fig. 9.18 ).
Complications in Facelift Surgery and Their Prevention
When reading this chapter, the reader will see some uncommon and severe complications. Not all of these are my cases but many of them are. You are asked to keep in mind that these represent well-documented cases from over 1200 facelifts and 34 years of practice. Looking at them all in a single chapter may question the competence of a surgeon in some minds. Many surgeons have similar and worse complications (including death) but do not document them; they forget about them or hide them and do not teach from them. I can assure the reader that my victories greatly outweigh my setbacks. I meticulously document all complications with pictures, videos and charting. What is important to me is to learn and teach from them.
Of all cosmetic procedures, none are more life changing or visibly exposed in everyday life than facelift surgery. A natural-appearing facelift can change a patient’s life in innumerable ways. It can not only make them look younger but also feel younger, which can impact their entire affect. Contrarily, an unnatural facelift or one with significant complications can negatively impact the patient’s appearance and attitude. It can also harm the doctor’s reputation and produce lawsuits. Although no surgeon can guarantee a procedure without complications, most facelift complications are predictable and frequently avoidable by obeying sound preoperative, intraoperative, and postoperative techniques. Even the best surgeon with the best patient and the best anesthesiologist and surgical team can and will experience complications associated with facelift surgery. The amount of complications that a surgeon experiences is also related to the volume of surgery they perform. A surgeon who does 10 facelifts per year will statistically see fewer complications or sequela than a surgeon who performs 100 facelifts a year. One of my attending surgeons used to say: “If you are busy enough and practice long enough, you will sooner or later see it all”. It is impossible to cover all facelift complications in this chapter, and many complications were discussed earlier when discussing incisions, etc. The remainder of this chapter will focus on some of the more common complications and discussion of their recognition and prevention.
Intraoperative Surgical Complications
Hemostasis is a prime consideration of facelift surgery, and careful attention to bleeding must be observed throughout the entire procedure ( Fig. 9.19 ). Few cosmetic surgical experiences are more stressful than dealing with a postoperative expanding hematoma in the middle of the night. This is something that must be planned for in advance and anticipated for each case. Most novice surgeons have found themselves in the precarious position of having to take a patient back to the office surgery center after hours and the stress of not being able to reach their staff, the surgical instruments are still dirty in the sink, the anesthetic medications are locked up, and the surgeon is alone with an anxious patient and family. An ounce of prevention is definitely worth many pounds of cure in this situation. The key is to anticipate the complication. This involves having staff on call to respond, having sterile instruments available, and having access to anesthetic and medications and personnel. Having a proactive plan for dealing with hematoma or other emergent complications is a significant necessity.
Prevention of postoperative hemorrhage is critical. It is difficult to attempt to “catch up” with bleeding at the end of a case, before wound closure. The astute surgeon will continually control bleeding throughout each step of the facelift. Using a combination of bayonet bipolar forceps (large tip and fine tip), ball electrode, and indirect forceps coagulation allow the surgeon a multitude of means of addressing bleeding. I personally use 4.0 MHz radio wave surgery ( www.ellman.com ). In the discussion of complications, it is imperative to protect the delicate lipocutaneous flap from thermal insult when using electrosurgery. Any electrosurgical coagulation can produce heat, so cauterizing fat can create a heat sink that can remain very hot for several seconds. It is important for the assistant to prevent the skin flap from contacting the cauterized area until it is cool; otherwise a full-thickness thermal burn can occur ( Fig. 9.20 ).
Cauterization must also be used carefully around areas of motor or sensory nerves because lateral heat transmission can cause nerve damage.
Some anesthesia providers and or surgeons prefer hypotensive anesthesia to reduce bleeding. In these cases, the patient should be returned to a normotensive state before closure or bleeding points may be missed and contribute to postoperative hematoma.
Postoperative Surgical Complications
As noted earlier, postoperative expanding hematoma is a true emergency in facelift surgery and although rare, can result in fatal outcome from airway compromise. An expanding hematoma also puts the delicate lipocutaneous flap under significant pressure and can compromise the vascularity of the flap. This can result in minor or major loss of flap viability, with resultant skin necrosis and full-thickness scarring. The points of prevention were addressed previously, but when an expanding hematoma does occur (statistics range from 0%–15% of facelifts in the published literature), the surgeon must be able to rapidly diagnose and treat the complication. Postoperative bleeding with hematoma can occur during the case where the surgeon has sutured the incisions on one side of the facelift and while working on the contralateral side, a hematoma forms on the first side. Hematoma can also occur while still on the operating table at the end of the case and is noticed when washing the hair or bandaging the patient ( Fig. 9.21 ). A minor amount of blood may be evacuated from the region by expressing through the suture or staple line or aspirated with a small liposuction cannula. If a collection of blood is evacuated and close observation shows no rebleeding, the patient may be transferred to the postanesthesia suite. If it appears that the area has continual bleeding, then the sutures and staples must be removed and the source of bleeding identified.
Expanding hematoma can also occur immediately after surgery, and I have personally seen two cases that occurred in the postanesthesia suite in the first hour after surgery ( Fig. 9.22 ).
Postoperative hematomas can be categorized into minor and major. A minor accumulation of blood can be aspirated when noticed and is sometimes resorbed without treatment. A major hematoma that is expanding in real time is an emergency. Because these frequently occur in the early postoperative period, it makes sense to recover the patient in your facility for several hours, although the next 24 hours still present a vulnerable period. Checking on the patient throughout the evening is time well spent. Also educating the patient and caregivers on the signs and symptoms of expanding hematoma can increase the chances of early treatment. Although most hematomas are unilateral, it is possible to have a unilateral bleeding source that dissects across the submental midline and affects both sides. Out of over 1200 consecutive facelifts, I have personally had 12 to 15 cases of major expanding hematomas that required emergent treatment. Two of these, although significantly distorting the patient’s face, were not recognized by the patient or family and seen at the next morning’s postoperative visit. All other hematoma patients called within 8 hours of their facelift, reporting unilateral pain, facial distortion, and bleeding. They were noticeably agitated and reported rapid-onset swelling with bleeding from the incision sites ( Figs. 9.23 and 9.24 ). One of these patients also reported difficulty closing her mouth. This resulted from dissection of blood into the buccal space, which expanded between the upper and lower teeth. When the surgeon is called by the caregiver saying there is pain, swelling, and bleeding, a presumptive diagnosis of expanding should be considered. In the rare case the patient would be in airway distress (I have never seen this), then the emergency medical technician (EMT) system should be activated.
This is an extremely stressful experience for patient, caregiver, and family. When the patient arrives at the office, they, and their caregivers or family must be reassured that as bad as this situation appears clinically, it will be rapidly treated, and the patient will do fine.
Although I have never encountered this, a patient with pending or acute respiratory distress should immediately have all sutures and staples removed to decompress the face.
I have experienced expanding hematoma in two patients who went unrecognized by the patient and caregiver and was not diagnosed until the next morning at 24-hour follow-up ( Fig. 9.25 ). This is unusual because the average patient and or caregiver would recognize such changes as they present.
As stated earlier in this chapter, expanding hematoma can occur from any event that increases blood pressure or produces a Valsalva situation. It is imperative that this is discussed in detail with patients and caregivers. The key to treating hematomas is not having them!
Treatment of a major expanding hematoma requires removing the sutures and opening the flaps to explore and control bleeder(s). In general, these patients are scared, agitated, and in pain, and treatment is difficult without intravenous sedation because further manipulation and discomfort worsens the experience and increases blood pressure. Although any bleeding vessel or tissue can lead to a hematoma, I have never encountered an isolated bleeder in the neck. Almost always, the surgeon will find several major bleeding points and scores of minor bleeding points when the flaps are opened and inspected. One caveat is if the surgeon feels that the bleeder is only isolated to one flap, he or she should open both flaps on the affected side because no one wants to return to the office twice in one night for a missed bleeding point that could have been identified the first time. Once the patient is made comfortable, the sutures and staples are removed and large “currant jelly” clots are observed ( Fig. 9.26 ).
As the clots are removed, the surgeon is usually confronted with multiple bleeding points. Confined bleeding as seen in expanding hematoma is an “irritant” to the underlying tissue and encourages global bleeding and oozing of the entire raw surfaces. In some cases, the surgeon may see bleeding in an area that bled during the initial surgery and was aggressively treated and has reoccurred. More often, the bleeding occurs at sites that did not present any significant hemorrhage during the initial procedure. When the flaps are opened, the clots removed, and the tissues inspected, the common surgeon’s response is “everything is bleeding”, and it usually is ( Fig. 9.27 ).
Critical blood loss is usually not a problem with postfacelift hematoma but could be a possibility and must be monitored. The treatment to this point can be very intimidating if not frightening to the novice surgeon facing his or her first hematoma. Initially, it may seem that the bleeding will never stop, and the surgeon can feel doomed. This is when the “inner surgeon” must kick in and manage the situation in a controlled manner with a cool head; the staff should be manage similarly. The first step after opening the incision and clearing the clots is to pack the surgical field with chilled saline gauze for 5 to 10 minutes ( Fig. 9.28 ).
Having bags of chilled saline requires forethought and should be part of the presurgical planning. The chilled saline gauze will generally slow bleeding significantly and allow the surgeon to begin exploring the surgical sites (neck and periauricular flaps) for active bleeding. I prefer to wear loupes for this process because many times bleeding occurs from small vessels or areas. If necessary, the chilled saline gauze packing is repeated. Selective cauterization with bipolar cautery is continued and most frequently a single offending vessel is located that produced the bleeding ( Fig. 9.29 ). This can be an arterial “pumper” or venous oozing. Once this vessel is controlled, the accessory bleeding points are addressed until hemostasis is achieved.
The introduction of kaolin treated hemostatic “combat” gauze used by the military for field wound management ( www.quickclot.com ) is useful in cosmetic facial surgery. After opening the wound and packing with iced saline, my protocol is to next pack the wound with hemostatic gauze for 5 to 10 minutes ( Fig. 9.30 ). Although this product assists in encouraging hemostasis, it will not suffice for cauterization or ligature of larger vessels. Once the iced saline, followed by the hemostatic gauze packing is completed, the gross bleeding is generally controlled and the offending “serious” vessels or bleeding points are easily identified.
The patient should be returned to a normotensive state before reclosing the incisions to confirm absolute hemostasis ( Fig. 9.31 ). One of the most disheartening points for the surgeon is that a lot of care and skill went into the initial trimming of the flaps and closing the incisions, and now the entire site has been disrupted. It continues to amaze me how well the flaps “reclose” and how well they heal after surgery, like nothing ever happened ( Fig. 9.32 and 9.33 ). Out of 12 to 15 hematomas I have experienced over a 20-year period that were returned to the operating room, I have never had one that was uncontrollable.
Topical thrombin is also used by some surgeons to control bleeding. If the aforementioned steps do not produce hemostasis, then the surgeon must consider external factors such as a bleeding diathesis. Appropriate laboratory tests should be drawn, and the patient transferred to a facility suitable for the diagnosis of bleeding disorders and the administration of blood factors, etc. In my experience, this is exceedingly rare because significant hemorrhage would have occurred at the initial procedure. This entire scenario enforces the point that no surgeon should undertake surgical procedures when he or she cannot manage the complications.
After the bleeding is controlled, the wound is closed in the same manner it was originally. A light compression dressing is placed on the patient and they are discharged and seen the following day. A vacuum drain would be valuable as well because posthematoma patients often develop seromas from the breakdown of the clotting blood. Even if the vast majority of clots were removed during the hematoma treatment, residual clots will always remain. Although major expanding hematomas require emergent treatment, minor, nonexpanding hematomas represent small collections of blood and can be simply aspirated with an 18-gauge needle. Although most critical hematomas occur early in the postoperative experience, in rare instances they can spontaneously occur at a later date. I have seen several patients with normal postfacelift healing develop spontaneous minor hematoma several weeks after surgery ( Figs. 9.34 and 9.35 ). Possible causes include over excretion, a cauterized vessel that becomes disrupted, or a suture that erodes into a vessel.
It is not uncommon for major hematoma patients to develop postoperative seromas as the residual clotted blood is metabolized. Seroma formation is not limited to posthematoma cases and can be common with routine facelift surgery. The incidence is higher with more aggressive lifts and less common with smaller lifts. As stated earlier, my seroma rate fell almost to zero when I began using catheter vents or vacuum drains. Early identification and treatment of seromas is critical. Fluid collections must be aspirated so they don’t delay healing or produce inflammatory changes which can delay healing ( Fig. 9.36 ). Some seromas only require a single aspiration whereas others require multiple evacuations. In rare cases, aspiration is required over several weeks.
Seromas are not true active bleeding or clotted blood but rather serum from the healing process and blood breakdown products. They are initially dark, then change to a serosanguinous color and finally to amore amber colored ( Fig. 9.37B ) and do not pose a threat other than delayed healing.
Postoperative Edema and Ecchymosis
Other postoperative facelift complications that are commonly seen include edema and ecchymosis. Although all facelift patients will experience some degree of postsurgical edema, some patients will exhibit impressive swelling. Patients undergoing multiple procedures including browlift, midface implants, cheek implants, and especially simultaneous laser resurfacing can exhibit significant edema ( Fig. 9.37 ). Although this usually does not present significant problems, it could cause excess tension on the suture lines. The biggest problem is generally the fear of the patient and family that something bad has happened. Treatment with oral steroids will usually hasten the resolution of the severe edema, but some patients take longer than others. A tapering regimen of methylprednisolone is commonly used but in my experience, is much less effective than using a nontapering dose of prednisone. The patient is given 15 (20 mg) tablets of prednisone and takes 60 mg (three tablets at the same time) once a day for 5 days. This therapy has proven much more dramatic than common tapering packs in my practice. Patients undergoing multiple procedures, as well as their families, must be made aware of the possibility of severe edema at the consent process. The possibility of allergic reaction must also be considered. In addition, I keep pictures such as Fig. 9.37 to show a patient and or caregiver who is concerned with their current situation.
One of the best investments I have made is a $2500 ultrasound machine. We use this frequently on many types of swelling or inflammation. Many facial surgery patients will experience normal swelling but an abnormal psychological response to it. They can become very impatient and even more impatient if they feel that nothing is being done to improve their condition. In rare cases, a lack of action may prompt patients to seek a second opinion. Any patient that has swelling, whether usual or not, will benefit from in-office ultrasound treatments. Ultrasound treatment generates deep heat, is totally noninvasive, can be performed by staff, feels good, and can reduce edema. Whether the patient actually gets significant improvement from the treatment is secondary. What is most important is that the patient feels that something is being done to improve their situation. Sometimes it is the ultrasound that reduces the swelling and sometimes it is the psychologic or placebo effect that makes them feel better. In any event this device and treatment can go a long way in settling an overly concerned patient. The worst thing that any surgeon can do with an anxious patient is take no action. Patients expect a doctor to do something and, on that note, the ultrasound device has been very useful. We do not charge for these treatments and they only take about 10 minutes. We especially use this treatment for postfacelift patients who are 2 to 4 weeks out of their procedure but still manifest isolated submental or neck swelling.
Ecchymosis is another aspect of the consent process that should be discussed preoperatively. Most experienced surgeons can explain procedures to patients with accuracy, but edema and ecchymosis remain the most difficult to predict. I see patients who tell me they will severely bruise, and they heal without any ecchymosis, whereas some young and healthy patients with totally normal coagulation studies sometimes bruise remarkably ( Fig. 9.38 ).
A recent personal informal survey of 15 respected multispecialty facelift surgeons confirmed that none of them perform routine preoperative coagulation studies (prothrombin time/partial thromboplastin time) but all of them have their patients refrain from aspirin, Vitamin E, and fish oil.
Motor Nerve Injury
The most feared complications of facelift surgery are motor and sensory nerve damage and flap necrosis. These, unlike many of the complications discussed previously, can be tragic for the patient and surgeon as well, leading to damage of reputation and litigation.
Frontal, buccal, zygomatic, marginal mandibular, and cervical nerve injury can result from many different things, including direct injury (clamps, needles, scalpels, and scissors), neuropraxia (stretching from over aggressive retraction), thermal injury from cautery, or compression injury from sutures, edema, hematoma, and other causes. This is very disconcerting for the patient and surgeon in the early postoperative period, but most of these will spontaneously resolve within weeks or months. The gradual return of function to the affected area is seen and greeted with relief by all involved. Patients should be reassured that the nerve weakness is likely temporary but advised (hopefully preoperatively) that return of full function cannot be guaranteed. In the 1200 facelifts I have performed over the past 20 years, I have experienced no permanent motor nerve injuries. Between 8 and 10 patients had unilateral paresis of the buccal, zygomatic, or marginal mandibular branches, with altered animation that returned within 90 to 120 days ( Figs. 9.39–9.42 ). Motor nerve injuries that do not seem to improve or those that are severe and include multiple nerve branches should be evaluated after 90 days by a surgeon experienced in microneurosurgery. The buccal and zygomatic branches have numerous anastomoses. For this reason, a permanent injury from a distal injury is rare, but this also makes it difficult to characterize the exact nerve injury. Rami of the zygomatic branch of the facial nerve innervate the lower portion of the orbicularis oculi and, if injured, can affect lid closure. This is an unusual injury, and an affected patient is shown in Fig. 9.39 .
The marginal mandibular branch is a commonly affected motor nerve in facelift surgery and can be damaged during dissection, submental liposuction, and chin implant surgery. When a patient with damage to this nerve smiles or rolls their lower lip down, the affected side does not depress, owing to the loss of innervation of the depressor anguli oris and/or the depressor labii (see Figs. 9.40 and 9.41 ). Sometimes this can also be related to a cervical nerve injury in that the platysma also depresses the lip or corner of the mouth in many patients. In these patients, the motor function of the platysma would likely be involved. When the lip is affected from a marginal mandibular nerve injury, the normal side can be treated with a small amount of neurotoxin to even out the asymmetry (see Fig. 9.41 ).
Most patients are content to wait for the nerve function to improve. Showing them progress pictures over several months can confirm their improvement and relax nervous patients. Also showing them pictures of other patients with similar injury and resolution reinforces their patience to “wait it out”. Anecdotally, this would appear to be one of the most common nerve injuries because I frequently receive calls for advice from novice surgeons who have experienced marginal mandibular paresis and the vast majority have happy endings.
Total main facial nerve trunk injury is rare in facelift surgery because it is protected by the parotid gland but has been documented in rare cases. Injury to the frontal branch is rarer, and I have not experienced this in over 1200 facelifts.
The facial nerve branches are rarely in jeopardy until exiting the parotid gland and crossing the masseter. Novice surgeons should stay over the gland in the safe zone ( Fig. 9.43 ).
An even rarer motor nerve injury that has been documented with facelift surgery is damage to the cranial nerve 11, the spinal accessory nerve. This nerve innervates the sternocleidomastoid (SCM) and trapezius muscles, which assist in turning the head and shrugging the shoulders. The spinal accessory nerve exits on the posterior border of the SCM muscle at Erb’s point (the same level of the greater auricular nerve [GAN]) and enters the posterior triangle ( Fig. 9.44 ).
Technically, Erb’s point was classically described as a point where the cervical plexus exits from behind the posterior border of the SCM muscle. The four cutaneous nerves of the cervical plexus are the lesser occipital nerve, great auricular nerve, transverse cervical nerve, and supraclavicular nerve. The scientific literature has many different descriptions of “Erb’s point” and many articles describe the spinal accessory and GAN emerging from Erb’s point. This description will be used in this text.
At this point the platysma ends; the nerve is only protected by skin and variable amounts of subcutaneous fat and fascia and is vulnerable. Although injury is rare, all surgeons should keep in mind that an errant liposuction cannula, aggressive retraction, or lateral thermal damage from cauterization could injure this nerve ( Figs. 9.45–9.47 ).
Figs. 9.45 and 9.46 shows a patient with a spinal accessory nerve injury. The patient healed uneventfully from her facelift, and at her 3-month visit she complained of shoulder pain. Examination showed decreased range of motion and inability to abduct the affected side and confirmed by electromyography. Although the deficit and pain were slowly improving, a microneurosurgeon advised exploration and repair. Although waiting for increased function was an option, postponing the surgery could have closed the window of time for optimal treatment and nerve recovery; therefore the decision was made to explore and repair. Exploration showed a neuroma which was removed, primary nerve repair performed, and the patient regained normal function (see Fig. 9.45 ). Fig. 9.47 shows an outline of the incision used to treat the neuroma at the level of the injury. This location should be committed to memory because this is in approximation where the nerve is in jeopardy.
Sensory Nerve Complications
All facelift patients will experience some component of sensory deficit, especially in the preauricular, postauricular, and submental regions. This occurs from separating fine cutaneous nerve branches during flap dissection. Sensation will improve over a 90-day period and most patients will return to a normal state. Even though it is well covered in the preoperative discussion and consent, anxious patients require extra reassurance that sensation will improve.
Besides cutaneous paresthesia, the supraorbital and supratrochlear nerves can be affected from browlift procedures and the infraorbital and mental nerves can be involved during facial implant procedures, both of which are frequently performed with facelift surgery. If patients realize preoperatively that they will experience numbness and over time it will improve, the average person perseveres. Patients who are unreasonable or blaming, must be shown the informed consent they signed detailing that paresthesia can be extended and in rare cases permanent.
The most commonly affected sensory nerve is the GAN. This nerve crosses the SCM muscle approximately 6.5 cm below the external auditory canal ( Fig. 9.48 ). As mentioned numerous times in the previous sections of this chapter, there is very little subcutaneous tissue in the mastoid region and the upper regions of the SCM muscle. In this region, the dermis is virtually intimate to the fascia of the SCM, and it is not uncommon to expose muscle fibers when performing flap dissection in this area.
It is also possible to damage the GAN as it superficially crosses the SCM ( Fig. 9.49 ). At this point, the GAN is also in close approximation to the external jugular vein (EJV) and this region obviously must be shown great care with dissection and manipulation ( Fig. 9.50 ).
If the nerve is transected, it should be anastomosed with 7-0 Prolene suture and if for any reason it cannot be repaired, the stumps should be tagged with a permanent suture for later identification for secondary repairs ( Fig. 9.51 ). The GAN has an anterior and posterior branch. Damage to this nerve can produce paresthesia or anesthesia in dermatome ( Fig. 9.52 ).
A damaged or repaired GAN can also develop a neuroma, which manifests as an induration palpable through the skin over the area of the nerve. A GAN neuroma can be painful and when compressed by the examiner, can radiate pain into the associated dermatome. Magnetic resonance imaging scans and nerve conduction studies are useful for diagnosis.
The transverse cervical nerve horizontally crosses the SCM inferior to the GAN and provides sensory innervation to the skin over the anterior triangle of the neck. This nerve can be damaged in a low inferior cervical dissection (green color in Fig. 9.44 ).
External Jugular Vein
Although the EJV is present on both sides of every facelift, it is only occasionally encountered during dissection. Some patients have large, distended, and superficial EJVs, which can be encountered in normal dissection or from novice surgeons entering too deep of a plane. In general, the EJV crosses the SCM at a similar level as the GAN and then runs parallel to the GAN ( Fig. 9.53 ).
The vessel can be damaged with blunt liposuction cannulas or punctured or transected with scissors, sharp instruments, or suture needles. When suturing the posterior platysma border to the mastoid fascia (cable sutures), the surgeon should be vigilant to avoid puncturing the EJV. The suture needle must be placed either medial or lateral to the vessel. In the case of bleeding while suturing in or around this area, the stitch should be removed and the area inspected for possible EJV perforation. In the case of nick, puncture, or transection, brisk bleeding can occur from the EJV. A high-volume suction (tonsil suction) is used to clear the area while the assistant exerts pressure on the neck skin to compress the bleeding vessel. Confirmed bleeding necessitates EJV ligation with permanent suture, and the surgeon must be sure that the bleeding is controlled before wound closure. This is another situation that can be very traumatic for the beginning facelift surgeon, but if the surgeon keeps calm and collected and has access to adequate suction, the bleeding is easily controlled by ligation sutures. If the vein cannot be significantly accessed through the flap, an incision through the neck flap would be in order, but this would be an uncommon situation. This is another example of the fact that no surgeon should undertake an operation where he or she cannot manage the common complications.
Flap Viability Complications
Necrosis of the lipocutaneous flap can lead to permanent scars, extended recovery, stress for the surgeon and patient, and litigation. Loss of flap viability can occur from hematoma, flap sutures under tension, bandage compression, application of excessive heat or cold, patient sleeping position, inherent healing problems and infection, or from no apparent discernable causative factor. Although it is more common in smokers or patients with compromised health, it can occur in the best of circumstances.
Decrease in flap perfusion can sometimes be seen with 24 hours of surgery or may not manifest until 10 to 12 days postoperative. Although dusky flap skin color can be an ominous sign portending necrosis, sometimes the dusky color is only a result of bruising ( Figs. 9.54 and 9.55 ). In the early days after facelift surgery, areas of the flap duskiness can be treated with topical nitroglycerin paste every 8 hours to encourage vasodilation with increased blood flow to the flap. Hyperbaric oxygen treatment (HBO) is an appropriate therapy if the surgeon is highly suspicious of significant impending flap necrosis. This can be a scary proposition for the patient who, at the point of the conversation, does not realize how much damage can ensue from major flap loss. The patient can be scared, confused, and worried about the cost and necessity of the suggested HBO treatment. In over 1000 facelifts, I have only ever referred a single patient for HBO therapy for flap necrosis. The patient decided not to have the treatment because they would have to quit smoking. Not all instances of assumed duskiness will portend absolute of necrosis. I have seen several patients where minor hypoperfusion only resulted in some skin peeling and other cases where I assumed the blood supply to the flap was compromised, only turned out to be bruising and the patient healed normally ( Fig. 9.56 ).
Fortunately, the posterior auricular region (the area most prone to flap breakdown) is generally out of sight of the patient and can be covered by hairstyle in females. Although these areas of nonviable tissue can appear extremely necrotic in the initial phases, they generally heal with acceptable scarring ( Figs. 9.57 and 9.58 ). Because of the ominous appearance of necrotic tissue that can truly scare patients, it is helpful to show the patient pictures of cases where necrotic areas healed with acceptable results. This allays their fears and provides confidence in the surgeon managing this complication.
Tissue death on the preauricular or visible anterior facial skin can be much more problematic and severe, leaving permanent scars that in rare instances may require skin grafts. Small areas (the size of a quarter) will generally scab over and regranulate from the base and do not require intensive wound care. Larger areas of skin slough and necrosis require treatment with antibiotics and more intensive wound care. Hydrogen peroxide soaks and continual application of Biafine topical emulsion (OrthoNeutrogena, Los Angeles, CA) have been effective in my experience ( Fig. 9.59 ). Any other burn or wound preparation that is suitable for raw skin is also appropriate and many different brands exist and are surgeon preference. I have only treated flap breakdown with open techniques and do not use dressings, unless it is necessary to keep the cream in place or protect the wound. Another means of wound care for necrotic wounds is a collagenase preparation such as Santyl ( www.santyl.com ) which aids in the removal of nonvital tissue. The manufacturer recommends covering the Santyl treated wound with some bandage barrier. I have used Mepilex form dressing ( www.molnlycke.com ) to cover the wound and the Santyl cream.
If patients have a competent caregiver who can manage the granulating wound, then home treatment is an option with regular office visits. If the patient does not have competent support, then the patient should return to the surgeon’s office for daily wound care. As the wound matures, the eschar shrinks and the scab edges evert. As this occurs, I trim the edges but do not disrupt the main eschar (see Fig. 9.58 and Fig. 9.60 ). It is important to understand that this eschar, albeit unsightly, is “nature’s Band-Aid” and the wound will heal best with this “scab” intact. This is especially important for patients who pick at their wounds. Each week, the eschar will curl up on the skin edges and this lifted portion of dead tissue can be trimmed away. This exposes peripheral areas of granulation that epithelialize and the eschar again everts at it edge. This continual process of dressing, debriding and trimming is repeated over several weeks until the wound heals. The patient is kept on antibiotics for the first several weeks but not continued for extended time. The wound can also be irrigated with antibiotic solution. If the wound becomes malodorous or exudate increases, cultures should be taken and antibiotics appropriately prescribed. Maturation and healing of a larger area of necrosis may take weeks to months to granulate and reepithelialize. This treatment will usually produce an acceptable scar that may need no further treatment. Residual scars can be improved with CO 2 laser resurfacing. It is important to remember that the wounds heal from the base up and in my opinion, leaving the eschar intact is preferable to removing it.
In severe cases, skin graft or rotational flaps may be necessary. In over 1200 facelifts I have performed, I have experienced 4 to 5 cases of preauricular wound necrosis and 10 to 12 cases of posterior auricular breakdown which all healed by secondary intention with acceptable aesthetic results. HBO therapy can make a significant difference in the healing time and result, and I have used it on two occasions ( Figs. 9.61–9.66 ). The accelerative effects of HBO can be phenomenal and in theory, it could be used for any healing wound. Insurance coverage is generally required and with elective cosmetic surgery, a diagnosis of “failed flap” has been adequate for patients to secure coverage. The patient shown in Fig. 9.61 made incredible strides in healing as shown in “day 19 to day 22”. Unbeknownst to my office, this patient has many other previous postsurgical healing problems with total joint surgery, abdominoplasty, and other procedures. Knowing this, in retrospect, would have changed my treatment plan. Sometimes a surgeon can cause a complication, sometimes a patient can cause a complication, and sometimes problems simply randomly occur without the fault of anyone.