Complications in Facial Plastic Surgery
86
of a septal hematoma, abscess, or subtotal perforation.
These disastrous complications may be prevented by
having a high index of suspicion for septal hematoma
and by careful reapproximation of the septal mucosal
fl aps intraoperatively. Any signs of a septal hematoma
or abscess should be emergently addressed. Patients
with infl ammatory disorders, such as Wegener’s granu-
lomatosis, may also be susceptible to a saddle nose de-
formity, and one should consider maintaining increased
septal support (or not disrupting the septum at all) in
aff ected patients.
Excessive narrowing of the middle vault is common
after rhinoplasty and often manifests postoperatively as
an inverted-V deformity.19,20 Over time, scar contracture
and negative pressure from airfl ow will tend to increase
inferomedial collapse of the upper lateral cartilages. In-
feromedial collapse of the caudal margin of the upper
lateral cartilage can result in a collapse of the middle
vault that compromises the nasal valve. This may occur
when the upper lateral cartilages are divided from the
nasal septum during hump removal. Loss of support of
the upper lateral cartilages may also occur whenever a
cephalic trim of the lateral crura is performed or with
lateral osteotomies and medialization of the upper lat-
eral cartilages. In most patients, these maneuvers will
not result in middle vault collapse; however, a combi-
nation of these maneuvers in a high-risk patient may
result in excessive narrowing of the middle vault, with
internal nasal valve collapse.4,5,21
Residual nasal deviation may be seen postoperatively.
This can be due to incomplete osteotomies, in which
case revision that completes the osteotomies is indi-
cated. However, in cases in which the surgeon is confi -
dent that the nose was fully mobile intraoperatively, a
residual, subtle nasal deviation may be corrected by the
use of nasal exercises.
Complications secondary to dorsal augmentation can
be seen postoperatively as well. These include graft vis-
ibility, misplacement, and migration. To reduce the risk
of dorsal graft visibility, the surgeon should carve the
graft into a canoe-like shape, with all edges beveled
(Fig. 10.14). For further camoufl age, the edges can be
covered with perichondrium. If the graft is noted to be
visible postoperatively, correction can be done in a simi-
lar fashion.
To reduce the risk of dorsal graft mobility, the sur-
geon should place the graft into a tight dorsal pocket.
Care should be taken not to make the pocket too large
or high, because this graft is usually used to set the
nasal starting point. Another error that may occur is
setting the nasal starting point in a rhinoplasty for an
Asian patient at the same location as for a Caucasian pa-
tient (at the level of the upper eyelid crease). For Asians
the nasal starting point is lower, at the level of the mid-
pupillary line.
Movement of the dorsal graft after placement can be
problematic. To try to prevent this complication, the
tibular skin).11,18 These grafts must be strong, so costal
cartilage is a good choice for grafting material. Compos-
ite auricular cartilage and skin grafts also may be placed
at the marginal incision to help correct both alar retrac-
tion and a defi ciency in the vestibular skin (which may
be seen with caudal repositioning of the ala).
Defi cient columellar show may be the result of hang-
ing alar lobules or columellar retraction. A retracted col-
umella may result from excessive resection of the caudal
septum. This may be corrected with either a caudal ex-
tension graft or an extended columellar strut graft.
Nasal Dorsum
One common complication arising from any rhinoplasty
that involves the dorsum is irregularity. This complication
may be created following osseous hump reduction and
osteotomies. Dorsal irregularities also may arise along
the cartilaginous dorsum due to asymmetric collapse or
migration of the upper lateral cartilages relative to the
septum. If adequate smoothing of the bony dorsum is not
performed, palpable or visible edges may result. Another
troublesome complication is the open roof deformity,
which follows bony hump removal with osteotomies that
do not adequately medialize the nasal bones. It is possible
to avoid these complications with close inspection and
palpation of the nasal dorsum intraoperatively. Any irreg-
ularities may require smoothing or camoufl aging while
stabilizing the dorsum and middle vault.
A more dramatic deformity results from the improper
positioning of the height of the upper or middle third of
the nasal dorsum. This complication may be seen in pa-
tients who have a low radix preoperatively. An inexperi-
enced surgeon who fails to recognize this preoperatively
may adjust the dorsal alignment by reducing a relative
convexity at the upper and middle vaults. This reduc-
tion may lead to a scooped appearance of the nasal dor-
sum. This problem can be prevented by augmenting the
radix to an appropriate level, with less removal of the
dorsal hump instead. Correction of this complication
may require dorsal or radix grafting.
An overly reduced nasal dorsum at the middle vault
may also lead to a saddle nose deformity. Collapse of the
mid-dorsum will create less shadowing on a frontal view
and an illusion of increased width. This undesirable re-
sult can be avoided by maintaining an ideal dorsal pro-
fi le with an adequately projected nasal tip. In patients
with a saddle nose deformity, the dorsal height may be
augmented with cartilaginous grafts. A graft from the
nasal septum or auricular concha can be used for dorsal
augmentation, although when signifi cant dorsal height
is needed, a costal cartilage graft may be required.
A saddle nose deformity can also result from a loss
of septal support. This may occur following removal of
septal cartilage if there is a failure to preserve an ad-
equate (at least 1.5 cm) L-shaped dorsal and caudal
strut. The deformity may also be seen as a consequence
10 Rhinoplasty Complications
87
sal valve collapse may be addressed by deprojecting an
overly projected nasal tip to increase the width of slit-
like nostrils, realigning cephalically positioned lateral
crura into a more caudal location, and placing structural
grafts (alar batten grafts and alar rim grafts) to provide
lateral wall and external valve support that will help
prevent collapse.
Nasal airway obstruction may also occur because of a
fi xed obstruction, such as a deviated septum. This may
be addressed with removal of the deviated septal carti-
lage, with preservation of a 1.5 cm L-shaped septal strut
to maintain adequate support and prevent saddling
of the dorsum. Any cartilaginous or bony septal spurs
present on the maxillary bone should be removed as
well. In cases of dorsal or caudal septal deviation, sub-
total septal reconstruction may be indicated to correct
the obstruction.
Infection
After rhinoplasty, infection in the patient can range from
a mild cellulitis to septicemia or cavernous sinus throm-
bosis. Despite the presence of potentially pathogenic
commensals within the nasal cavities, the reported rate
of perioperative infection has been low, usually less than
3.0 percent.24–26 A rarely reported serious complication
is toxic shock syndrome after rhinoplasty with the in-
sertion of nasal packing.27 Because it has a rapid onset,
patients should be counseled to return to the hospital or
the offi ce if they have any suggestive signs or symptoms,
such as high fever, weakness, and tachycardia.
The use of perioperative antibiotics in rhinoplasty has
been controversial. Recent studies have demonstrated
benefi t from the prophylactic use of antibiotics at the
time of surgery but no decreased infection rate with
postoperative antibiotic use.28,29 However, most would
dorsal graft should be fi xated by sutures in at least two
points (to the upper lateral cartilages). An additional fi x-
ation point is established by having a tight dorsal pocket
cephalically. If the graft appears to sit off of the midline
postoperatively, the surgeon can direct the patient to
perform specifi c nasal exercises to help reposition the
graft properly.
Persistent Nasal Airway Obstruction
A common complaint in patients undergoing rhinoplasty
is that of worsening or persistent nasal airway obstruc-
tion. This can be subdivided into either a dynamic ob-
struction (e.g., nasal valve collapse) or a fi xed one (e.g.,
deviated septum). Dynamic forms of nasal obstruction
are infl uenced by nasal airfl ow and are usually second-
ary to a defi ciency in structural support of the lateral na-
sal wall. This collapse of the nasal wall occurs because
negative airway pressure is generated during inspiration.
Examination of a patient who complains of nasal airway
obstruction should include examination of the internal
and external nasal valves, the nasal septum and turbi-
nates along the lateral nasal wall, and the nasal airway
during quiet nasal breathing. The technique used to cor-
rect the problem should be selected carefully, based on
the likely causes of the obstruction. If the cause of the ob-
struction is not identifi ed and addressed correctly, there
may be persistent airway obstruction postoperatively.
Nasal breathing can also be compromised by external
nasal valve collapse, with collapse of the nostril mar-
gin on moderate to deep inspiration through the nose
(Fig. 10.15).5,22 This is often seen in patients with nar-
row, slit-like nostrils, a projecting nasal tip, and thin alar
sidewalls.9,10,23 Cephalic positioning of the lateral crura,
which results in a lack of support of the alar lobule, may
predispose patients to this phenomenon. External na-
Fig. 10.14 Canoe-shaped costal cartilage dorsal graft. The
shape of the dorsal graft will create a natural appearing
dorsum.
Fig. 10.15 Patient with weakened lateral walls. (A) Narrowing
of nostrils. (B) External nasal valve collapse noted on moder-
ate inspiration through the nostrils
A
B
Complications in Facial Plastic Surgery
88
sa. If opposing tears in the septal mucosa are created,
they may be sutured, and crushed cartilage, costal car-
tilage perichondrium, or acellular dermis (Alloderm,
LifeCell Corp.) may be placed between the fl aps to fa-
cilitate mucosal coverage. Although most perforations
will heal spontaneously, persistent small defects may
be repaired through the use of grafts or local fl aps. Any
patient with a septal perforation should be instructed
to keep the nasal mucosa moist and free of crusts with
the use of aggressive saline irrigation, ointments, and
humidifi cation.
◆Conclusion
Many aesthetic and functional abnormalities seen af-
ter rhinoplasty can be avoided by identifying those
patients who are at risk of developing such complica-
tions. To prevent these secondary deformities, establish
a surgical plan based on the patient’s specifi c anatomy
and anticipated postoperative healing. Intraoperatively,
identify any maneuvers that may predispose to the de-
velopment of complications and undertake appropriate
measures to minimize the risk of a resulting deformity.
Finally, patients should be followed closely during the
postoperative period to identify any developing compli-
cations that may need to be addressed in the offi ce set-
ting or revision surgery.
recommend their use in the setting of active infection
or septal hematoma, or if nasal packing or alloplastic
implants are present. We continue to use perioperative
antibiotics on all rhinoplasty patients.
Hemorrhage
Postoperative bleeding is one of the more common
complications following nasal surgery. Multiple series
have reported a rate below 4 percent.26,30–32 Teichgrae-
ber et al. found that postoperative bleeding was more
frequent in patients who also underwent a septoplas-
ty or turbinectomy.32 Bleeding is most often seen af-
ter packing or splints have been removed. Persistent
bleeding can be common at osteotomy sites or along
the maxillary crest. If there is no success from con-
servative measures, such as topical vasoconstriction,
silver nitrate cautery, or anterior packing, a return
to the operating room may be warranted to localize
and control the site of bleeding. As discussed previ-
ously, the most eff ective way to manage postopera-
tive epistaxis is preoperative identifi cation of patients
who may be at higher risk of bleeding. A personal and
family history of bleeding should be elicited, and the
patient should be instructed to refrain from aspirin,
nonsteroidal anti-infl ammatory medications, vitamin
E, and herbal supplements for at least three weeks be-
fore and two to four weeks after surgery. A preopera-
tive laboratory workup should also be completed, with
a complete blood count and coagulation profi le.
Necrosis
Necrosis of various tissue components may occur after
rhinoplasty, and it can lead to septal perforation, sad-
dle-nose deformity, skin necrosis, and cartilage lysis.20
Skin necrosis may be seen following the insertion of
an alloplastic implant or after aggressive thinning and
electrocautery of the SSTE. Initially, the overlying skin
will become erythematous, with subsequent blanching
and necrosis. If this process is suspected, any underlying
inciting factors, such as an alloplastic implant, should be
removed immediately. Certain patients may be at great-
er risk for postoperative necrosis because of preexisting
medical conditions. Patients with diabetes, vascular dis-
orders, connective tissue diseases, or epithelial disor-
ders may have small vessel disease that can compromise
healing. These patients are often not good candidates for
rhinoplasty, but if surgery is performed, these patients
must be monitored closely for any signs or symptoms of
impending complication(s).
Septal Perforation
Septal perforation can occur from damage of the mu-
coperichondrial fl aps during septoplasty and also may
result from a compromised blood supply to the muco-
PEARLS OF WISDOM
Complications from rhinoplasty arise from errors in analysis,
technique, and surgical judgment.
Careful preoperative evaluation is essential to reduce the num-
ber of postoperative complications.
Computer imaging is a useful tool for communication between
the surgeon and patient and helps to ensure that they have
similar expectations and goals for any surgery.
In any revision rhinoplasty, the surgeon must carefully evalu-
ate the patient for any additional factors that may increase
the risk of complications. These include a damaged SSTE, the
presence of alloplastic implant(s), and a compromised nasal
vascular supply.
To reduce the number of postoperative problems, the surgeon
must be vigilant intraoperatively to maintain meticulous tech-
nique, to take the time to correct any potential errors, and to
camoufl age all potentially visible grafts intraoperatively.
Frequent and long-term examination of the postoperative
rhinoplasty patient will help the surgeon to identify complica-
tions in a timely manner.
Every complication in rhinoplasty should be seen as an oppor-
tunity for the surgeon to improve his or her preoperative as-
sessment, intraoperative techniques, and postoperative care.
10 Rhinoplasty Complications
89
17. Tardy ME Jr, Toriumi D. Alar retraction: composite graft cor-
rection. Facial Plast Surg 1989;6(2):101–107
18. Gunter JP, Friedman RM. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast Reconstr Surg
1997;99(4):943–952, discussion 953–955
19. Perkins SW, Tardy ME. External columellar incisional approach
to revision of the lower third of the nose. Facial Plast Surg Clin
North Am 1993;1:79–98
20. Holt GR, Garner ET, McLarey D. Postoperative sequelae and
complications of rhinoplasty. Otolaryngol Clin North Am
1987;20(4):853–876
21. Zijlker TD, Vuyk HD. Nasal valve surgery: spreader grafts. In:
Trenite GJN, ed. Rhinoplasty: A Practical Guide to Functional and
Aesthetic Surgery of the Nose. Amsterdam: Kugler; 1993:67–73
22. Constantian MB. The incompetent external nasal valve: patho-
physiology and treatment in primary and secondary rhino-
plasty. Plast Reconstr Surg 1994;93(5):919–931, discussion
932–933
23. Sheen JH. Spreader graft: a method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg 1984;73(2):230–239
24. Weimert TA, Yoder MG. Antibiotics and nasal surgery. Laryn-
goscope 1980;90(4):667–672
25. Lawson W, Kessler S, Biller HF. Unusual and fatal complications
of rhinoplasty. Arch Otolaryngol 1983;109(3):164–169
26. Foda HMT. External rhinoplasty: a critical analysis of 500 cas-
es. J Laryngol Otol 2003;117(6):473–477
27. Tobin G, Shaw RC, Goodpasture HC. Toxic shock syndrome
following breast and nasal surgery. Plast Reconstr Surg 1987;
80(1):111–114
28. Rajan GP, Fergie N, Fischer U, Romer M, Radivojevic V, Hee
GK. Antibiotic prophylaxis in septorhinoplasty? A prospec-
tive, randomized study. Plast Reconstr Surg 2005;116(7):
1995–1998
29. Andrews PJ, East CA, Jayaraj SM, Badia L, Panagamuwa C, Har-
ding L. Prophylactic vs postoperative antibiotic use in com-
plex septorhinoplasty surgery: a prospective, randomized,
single-blind trial comparing effi cacy. Arch Facial Plast Surg
2006;8(2):84–87
30. Goldwyn RM. Unexpected bleeding after elective nasal sur-
gery. Ann Plast Surg 1979;2(3):201–204
31. McKinney P, Cook JQ. A critical evaluation of 200 rhinoplasties.
Ann Plast Surg 1981;7(5):357–361
32. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery complica-
tions. Plast Reconstr Surg 1990;85(4):527–531
References
1. Sharp HR, Tingay RS, Coman S, Mills V, Roberts DN. Computer
imaging and patient satisfaction in rhinoplasty surgery. J Lar-
yngol Otol 2002;116(12):1009–1013
2. Kim DW, Toriumi DM. Nasal analysis for secondary rhinoplasty.
Facial Plast Surg Clin North Am 2003;11(3):399–419
3. Guyuron B, Zarandy S, Tirgan A. von Willebrand’s disease and
plastic surgery. Ann Plast Surg 1994;32(4):351–355
4. Toriumi DM, Johnson CM. Open structure rhinoplasty: fea-
tured technical points and long-term follow-up. Facial Plast
Surg Clin North Am 1993;1:1–22
5. Toriumi DM. Management of the middle nasal vault in rhino-
plasty. Op Tech Plast Reconstr Surg 1995;2:16–30
6. Anderson JR. Straightening the crooked nose. Trans Am Acad
Ophthalmol Otolaryngol 1972;76(4):938–945
7. Toriumi DM, Ries WR. Innovative surgical management of the
crooked nose. Facial Plast Surg Clin North Am 1993;1:63–78
8. Kim DW, Toriumi DM. Management of posttraumatic nasal
deformities: the crooked nose and the saddle nose. Facial Plast
Surg Clin North Am 2004;12(1):111–132
9. Tardy ME, Garner ET. Inspiratory nasal obstruction second-
ary to alar and nasal valve collapse: technique for repair using
autologous cartilage. Oper Tech Otolaryngol--Head Neck Surg
1990;1:215–218
10. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar
batten grafts for correction of nasal valve collapse. Arch Oto-
laryngol Head Neck Surg 1997;123(8):802–808
11. Toriumi DM. New concepts in nasal tip contouring. Arch Facial
Plast Surg 2006;8(3):156–185
12. Johnson CM, Toriumi DM. Open Structure Rhinoplasty. Phila-
delphia: WB Saunders; 1990
13. Toriumi DM. Structure concept in nasal tip surgery. Op Tech
Plast Reconstr Surg 2000;7:175–186
14. Tardy ME Jr, Kron TK, Younger R, Key M. The cartilaginous pol-
lybeak: etiology, prevention, and treatment. Facial Plast Surg
1989;6(2):113–120
15. Kridel RW, Yoon PJ, Koch RJ. Prevention and correction of na-
sal tip bossae in rhinoplasty. Arch Facial Plast Surg 2003;5(5):
416–422
16. Gillman GS, Simons RL, Lee DJ. Nasal tip bossae in rhinoplasty.
Etiology, predisposing factors, and management techniques.
Arch Facial Plast Surg 1999;1(2):83–89
90
Rejuvenation procedures of the aging face are increas-
ing in frequency. Numerous techniques have been de-
scribed since the fi rst facelift was performed by Lexer in
1906.1 In 1968 Skoog performed the facelift procedure
in a subfascial plane, improving the surgical results in
the lower face.2 This led to Mitz and Peyronie’s contribu-
tion in 1976, defi ning the superfi cial fascia enveloping
the face.3 They termed this fascia the superfi cial muscu-
loaponeurotic system (SMAS). Identifying and defi ning
the SMAS layer has led to a better understanding of fa-
cial anatomy and has spurred a variety of surgical face-
lift techniques.
The facelift procedure remains the gold standard for
surgical rejuvenation of the midface and lower face.
Although numerous technical variations of the facelift
have been described, the basic premise involves eleva-
tion of a facial skin fl ap with tightening of the under-
lying superfi cial fascia. After this is accomplished, the
overlying excess skin is trimmed and reapproximated.
When executed correctly, the rhytidectomy (facelift)
procedure provides signifi cant improvement in the ap-
pearance of the lower two-thirds of the face. This chap-
ter identifi es the common complications associated
with this procedure and describes ways to prevent and
treat these complications. The discussion covers preven-
tion and management of preoperative, intraoperative,
and postoperative problems.
◆Preoperative Considerations
To prevent complications such as bleeding and skin ne-
crosis, the surgeon must perform a careful preoperative
work-up. This includes obtaining a detailed medical his-
tory and performing a thorough physical examination.
The history should include the identifi cation of all med-
ical conditions that can cause poor wound healing, such
as tobacco use, hypertension, peripheral artery disease,
diabetes mellitus, and prior radiation therapy. The his-
tory should also identify any medications that can cause
perioperative bleeding or delayed wound healing.
Informed Consent
Informed consent must be obtained before any medi-
cal intervention or surgical procedure. The informed
choice process is even more important in elective
cosmetic surgery, such as rhytidectomy. This process
is defi ned as a two-way communication between the
practitioner and patient, during which the goals of
therapy are discussed, along with all therapeutic op-
tions, their associated risks, and potential complica-
tions. Informed consent involves full disclosure and
must be presented in a clear and understandable
manner.
Adequate informed consent in cosmetic surgery
requires both the patient and surgeon to have good
communication skills. The surgeon must thoroughly
explain the procedure, the attendant risks, the inci-
sions, preoperative and postoperative care, and ex-
pected healing times. The surgeon should assess
the patient’s ability to withstand the aesthetic sur-
gery, both physically and psychologically. The pa-
tient should be able to process this information, ask
questions, and avoid the temptation to have precon-
ceived ideas and expectations related to the surgical
procedures.
Informed consent fails when there is a lack of com-
munication. This occurs when the surgeon does not
take the time or have the skills to explain the proce-
dure adequately. Informed consent is also unsuccessful
when the patient has preconceived ideas about surgery
and unrealistic expectations relating to the cosmetic
outcome. Poor communication between practitioners
and patients is more likely if the patient has underlying
psychological issues, such as anxiety, depression, body
dysmorphic disorder (BDD), or signifi cant problems
with self-image.4 Inadequately performed informed
consent in cosmetic surgery is common. Poor commu-
nication can lead to anger, frustration, and litigation;
for these reasons, the number of malpractice suits fi led
against cosmetic surgeons is relatively high in relation
to other specialties.5
11
Facelift Complications
Jonathan M. Sykes, Ji-Eon Kim, and Ira D. Papel
11 Facelift Complications
91
of facelift fl aps, some medical conditions can predis-
pose patients to these complications. Diabetes mellitus
increases the risk of postoperative bruising, delayed
healing, and infection. Although perioperative control
of serum glucose should be obtained, patients with dia-
betes mellitus continue to have small-vessel peripheral
artery disease, which may compromise vascular supply
to the skin fl aps. Cigarette smoking also decreases vas-
cularity to skin fl aps and therefore increases the risk of
wound-healing issues and fl ap necrosis.7 For this reason,
many surgeons refuse to perform facelift surgery on ac-
tive smokers. Smokers should be encouraged to cease
cigarette use for four weeks before and at least two
weeks after the facelift procedure. If facelifts are per-
formed on active smokers or on patients with diabetes
mellitus, fl ap length should be decreased to minimize
the potential for fl ap compromise.
◆Hematoma
Subcutaneous hematoma is one of the most common
complications of facelift surgery. The incidence ranges
from 2 to 15% of cases, depending on the published re-
ports.7,8 The occurrence of a hematoma requires urgent
treatment, and even if the hematoma is successfully
evacuated, the sequelae may be long lasting.
The prevention of facelift hematoma should be the
surgeon’s highest priority. This demands that the sur-
geon take a careful preoperative history and as much
as possible eliminate or reduce known risk factors. For
example, all rhytidectomy patients should discontinue
medications containing aspirin for at least two weeks be-
fore surgery. Many patients are not aware that common
over-the-counter preparations contain aspirin. Patients
should be asked to read the labels of all medications in
the two weeks prior to surgery. If patients are on anti-
coagulants such as warfarin sodium, the surgeon should
consult with their primary physician to determine if it
is safe to discontinue anticoagulation for elective aes-
thetic surgery. Other risk factors include the chronic use
of nonsteroidal anti-infl ammatory medications, platelet
inhibitors, and high doses of vitamin E.
Tobacco smoking has been linked to an increased risk
of complications in facelift surgery, including hemato-
ma. All smokers must be required to stop smoking for at
least four weeks before surgery. Some patients will not
be fully truthful in reporting their progress in smoking
cessation, but the tobacco smell can be easily detected
in the preoperative area. The surgeon must be willing
to cancel surgery in this situation. Smokers also have a
much higher incidence of fl ap necrosis.
Hypertension is also a signifi cant risk factor. Labile
blood pressure in the postoperative period may predis-
pose a patient to bleeding and hematoma.9 Preoperative
screening should be performed to identify uncontrolled
hypertension. Patients should be encouraged to con-
Medical Conditions
Many systemic medicines, both prescribed and over-
the-counter, can increase the risk of intraoperative and
postoperative bleeding. The list includes well-known
anticoagulants such as oral warfarin, platelet function
inhibitors such as aspirin, and nonsteroidal anti-infl am-
matory medications. Other less commonly recognized
oral remedies that can increase the risk of perioperative
bleeding include vitamins such as vitamin E, herbal sup-
plements such as Gingko biloba, fi sh oil, and antioxidants
(Table 11.1).6 It is important to provide patients with a
thorough list of medicines and supplements to avoid.
A comprehensive medical history should be obtained
from the patient. This is often facilitated by providing
a detailed questionnaire before the initial consultation.
All preoperative medical conditions and prior surger-
ies should be known and discussed. In particular, any
conditions that may impact fl ap vascularity or postop-
erative healing should be identifi ed. Some medical con-
ditions, such as hypertension, may increase the risk of
postoperative bleeding. For this reason, medical condi-
tions should be evaluated and treated preoperatively to
minimize postoperative risks.
Certain medical conditions predispose the aesthetic
surgery patient to postoperative complications. These
include cardiac disease, peripheral vascular disease, and
associated hypertension. Pulmonary disease, such as
emphysema or chronic obstructive pulmonary disease,
can increase the incidence of diminished fl ap vascular-
ity and associated fl ap necrosis. In addition, patients
with pulmonary diseases have a greater chance of post-
operative coughing and straining, which can increase
the risk of postoperative hematoma.
Although it is very uncommon to experience impair-
ment in facelift fl ap vascularity or even frank necrosis
Table 11.1
Medicines to Avoid Prior to Rhytidectomy
(Not Comprehensive)
Aspirin/NSAID
products
Aleve, aspirin, BC powder, Buff erin,
Diclofenac, Excedrin, Florinal, Goody’s
headache powder, ibuprofen, ketolarac,
Midol, Motrin, Naprosyn, Norgesic, sali-
cylic acid, Soma, Toradol
Herbal/natural
products
Ginger, Gingko biloba, garlic, ginseng,
echinacea, fi sh oils (omega-3 fatty
acids), dong quai, feverfew, licorice
root, pine bark extract, St. John’s wort,
yohimbine
Vitamins
Vitamin E
Anticoagulants
Heparin, warfarin
Complications in Facial Plastic Surgery
92
Failure to recognize a hematoma may lead to sig-
nifi cant postoperative complications (Fig. 11.3). Skin
necrosis with soft tissue loss is the most signifi cant
complication, and this may take many weeks to heal.
There will usually be some permanent scars, but most
superfi cial necrosis heals in a surprisingly acceptable
manner. In many patients with even minor hematomas,
subcutaneous edema and irregularity may persist for
many months before subsiding. At times, this can lead to
permanent subcutaneous irregularities (Fig. 11.4).
tinue their antihypertensive medication throughout
the preoperative period. If hypertension is not well con-
trolled, patients should be referred to their primary care
physicians to adjust their antihypertensive medication.
Meticulous surgical technique with care to dissect in
proper tissue planes, combined with careful hemostasis,
is essential for successful rhytidectomy surgery.
The clinical presentation of a hematoma includes
pressure and pain beyond the postoperative discomfort
usually expected. Because bulky dressings may hide a
hematoma, the surgeon must be suspicious of a hema-
toma if the patient has unilateral or severe pain. If a he-
matoma is suspected, the dressings should be removed
for close inspection. Once a hematoma is diagnosed,
treatment should begin immediately to drain the collec-
tion and prevent further complications. Since the skin
fl aps receive blood supply from the subdermal plexus,
the pressure of a hematoma may reduce blood fl ow to
the skin fl ap and lead to later skin necrosis (Figs. 11.1,
11.2). Large collections of blood and serum usually re-
quire opening of the incisions, evacuation and irrigation
of the subcutaneous cavity, identifi cation of the site of
the bleeding, and reclosure of the incisions. This may re-
quire general anesthesia to ensure an adequate airway
and patient comfort. In most circumstances, however,
this procedure can be accomplished with local anesthe-
sia if the patient is cooperative.
Smaller collections may require only a rolling of the
fl aps using gauze, combined with removal of a few su-
tures, to evacuate the fl uid. Even small organized clots
can be extruded with this method. At times, aspira-
tion with a #16 or #18 gauge needle may be all that is
necessary, if the area is still liquid. Aspiration of small
amounts of serum is common on the day after surgery
and usually causes minimal discomfort for the patient.
Fig. 11.1 Postauricular skin fl ap necrosis.
Fig. 11.2 Posterolateral neck skin fl ap necrosis.
Fig. 11.3 Neck hematoma after facelift surgery.
11 Facelift Complications
93
Facial nerve injuries may recover spontaneously if
the nerve injury is not complete. Reinnervation may oc-
cur if multiple branches are present in one area. In the
temporal area, botulinum toxin can be used to paralyze
the normal (uninjured) side for a short period and simu-
late facial symmetry.13 Fortunately, a high percentage of
these nerve injuries usually recover.
◆Hairline Distortion
The surgeon can easily prevent alteration of the natural
hairline after rhytidectomy. The position and amount of
the temporal hair tuft should be maintained, and the nat-
ural line of the postauricular hair must also be preserved.
The primary vector of elevation of the skin-SMAS com-
plex in the midface is vertical. If the temporal skin in-
cision is made vertically (as a coronal extension of the
preauricular incision) and the skin is closed according to
the deep suspension sutures, the temporal hair tuft will
be unnaturally elevated (Fig. 11.6). There are two simple
methods to avoid temporal hairline elevation. The fi rst is
to make the temporal incision at the hairline (tricophyt-
ic). If the tricophytic incision is used, it is important to
bevel the incision (leaving follicles on the temporal fl ap),
to allow hair to grow through the eventual scar later. The
second method to avoid temporal tuft elevation is to ad-
vance the temporal hair fl ap inferiorly before closing the
incision. This will ensure that the fi rst closure suture (or
staple) recreates the original hairline position.
In the postauricular region, it is also important to avoid
changing the natural position of the hairline. The usual
vector of pull of the neck skin is directly posterior. If the
entire fl ap is moved in this direction (without attention
to the hairline), an unnatural step-off is produced in
the postauricular hairline. A postauricular step-off can
be avoided by aligning the hairline fi rst, before placing
any other closure sutures (staples). If the hairline align-
◆Motor Nerve Injuries
Facial nerve injuries in rhytidectomy are rare. The inci-
dence is thought to be in the area of 1 to 3%.10 The most
common facial nerve branches injured are the temporal
and marginal mandibular nerves. This type of injury is
very symptomatic for the patient and is best avoided by
careful surgical technique and thorough knowledge of
anatomy. Careful dissection in the subcutaneous plane
in the temporal region will avoid the facial nerve.11
Avoiding aggressive cautery in this thin tissue will also
help prevent inadvertent thermal injury to the nerve.
The facial nerve branches are deep to the facial mus-
cles in most of the face. In the temporal region, the motor
nerves run superfi cial over the zygomatic arch within
the temporoparietal fascia, where the temporal branch
is vulnerable to aggressive dissection. The cervical and
marginal branches are vulnerable as they course about
one centimeter anterior to the posterior border of the
platysma muscle (Fig. 11.5). If the posterior edge of the
platysma is elevated too far for suspension to the mas-
toid periosteum, the nerves may be damaged.12 Injuries
to the main trunk of the facial nerve should be very rare
in the usual rhytidectomy dissection area, because the
thickness of the parotid gland protects the nerve.
With the use of deep plane rhytidectomy techniques,
the buccal and zygomatic branches of the facial nerve
are more exposed than in subcutaneous short fl ap
techniques. Dissection below the platysma just above
the parotidomasseteric fascia exposes the nerves just
beneath the thin fascia. Careless use of cautery or scis-
sors in this area can harm the nerves and cause facial
asymmetry.
Fig. 11.4 Skin and soft-tissue irregularity after facelift surgery.
Fig. 11.5 Injury to the right marginal mandibular branch of
the facial nerve after facelift surgery.
Complications in Facial Plastic Surgery
94
curs in 1 to 7% of patients.14 The great auricular nerve
provides sensation to the lower half of the ear, the peri-
auricular skin, and the skin over the angle of the man-
dible. The nerve is located in the fascia overlying the
sternocleidomastoid (SCM) muscle at the anterior bor-
der of this muscle. The surgeon should take care to raise
the postauricular skin fl ap in a very superfi cial plane, as
the SCM muscle becomes very superfi cial in this area.
This will avoid injury to the great auricular nerve. If
the nerve is transected, reapproximation with #9–0 or
#10–0 nylon suture should be performed at the time
of injury. If a transected nerve is not repaired, a painful
neuroma may occur.
◆Alopecia
Hair loss after rhytidectomy causes emotional distress
to most patients. Hair loss occurs from injury to the hair
follicles, either from traction or from actual follicle tran-
section. The reported incidence of alopecia is approxi-
mately 2.8%.15
Transection of hair follicles is uncommon and can
be avoided by careful fl ap elevation and visualization
of the undersurface of the follicles.16 Injury to the hair
follicles from either traction or from electrocautery is
more common than actual follicle transection. Hair re-
growth usually occurs in 45 to 90 days. If suffi cient hair
regrowth does not occur, areas of alopecia may be treat-
ed with microfollicular hair grafts or with advancement
of temporal scalp fl aps.
◆Parotid Fistula
Parotid fi stula after rhytidectomy is a rare complication
and can be avoided by a careful knowledge of the applied
anatomy. The parotid fascia is typically a dense connec-
tive tissue that protects the parotid gland on its lateral
(superfi cial) surface. The SMAS layer is often fused with
the true parotid fascia immediately in front of the ear;
for this reason, elevation of a SMAS fl ap is usually not
initiated in the immediate preauricular region.
Careful subcutaneous elevation in the preauricu-
lar and infraauricular regions will avoid injury to the
parotid fascia and underlying parotid gland. This will
prevent the complication of parotid fi stula. If injury to
the gland does occur, intraoperative repair of the gland
and the overlying fascia can usually prevent postopera-
tive fi stula. If parotid fi stula occurs, botulinum toxin
may be used to minimize symptoms.
◆Infection
Perioperative infection following rhytidectomy is rare.
The incidence of infection is less than 1%, and this low
frequency is due to the very rich vascular supply of the
ment suture is accomplished fi rst, all other closure can
then be performed, with Burow’s triangles occurring to
match fl aps. Alternatively, the postauricular incision can
be made at the hairline so that it does not cause hairline
elevation or an unsightly step-off . However, a posterior
hairline incision can be noticeable, particularly if the pa-
tient wears short hair or if the hair color is dark.
◆Sensory Nerve Injury
Elevation of a cervicofacial skin fl ap always causes tran-
sient hypesthesia or anesthesia. This change in sensa-
tion is most noticeable in the periauricular region and
usually exists for three to six months. It is important for
the facial plastic surgeon to inform the patient preop-
eratively about the expected numbness and the variable
nature of the return of sensation. The patient should
understand that postoperative numbness is an expecta-
tion, not a complication.
The most commonly injured nerve in rhytidectomy
surgery is the great auricular nerve, which is a cervical
sensory branch from C2 and C3. Injury to this nerve oc-
Fig. 11.6 Unnaturally elevated temporal hair tuft after facelift
surgery. Used with permission from Clevens RA. “Avoiding
Patient Dissatisfaction and Complications in Facelift Surgery.”
Facial Plastic Surgery Clinics of North America. Nov 2009.
17(4). p. 519., Fig. 4.
11 Facelift Complications
95
promise to the distal edges of the fl ap increases. Similar-
ly, if too much skin is excised during fl ap advancement,
the risk of fl ap necrosis increases. In patients with an
increased preoperative risk of fl ap compromise (e.g.,
smokers, diabetics, patients with prior history of radia-
tion therapy), a shorter, thicker skin fl ap decreases the
risk of fl ap necrosis.
Postoperative causes of facelift skin fl ap compromise
include excessively tight dressings and lack of recogni-
tion of seromas, hematomas, or infection. Untreated
hematomas or seromas may compromise distal skin
vascularity, resulting in epidermolysis and full-thick-
ness skin loss. For this reason, early recognition and
treatment of hematomas and seromas are advised.
◆Hypertrophic Scarring
The preauricular scars created during rhytidectomy
usually heal in a relatively unnoticeable manner. How-
ever, in some instances scars may become hypertrophic,
or keloid scars may develop.
Unsightly scars are occasionally unpreventable. These
usually occur in thick-skinned, darkly pigmented indi-
viduals who may have a history of poor wound healing
of scars from prior surgeries. In most cases, however,
perioperative circumstances contribute to the poor scar
formation. Scars may thicken or widen as a side eff ect of
increased wound tension. If the deep-layer closure does
not adequately decrease tension on the skin closure, the
cutaneous scars may become hypertrophic and widen.
For this reason, it is important that the facelift surgeon
place an adequate amount of deep sutures to reduce
cutaneous wound tension suffi ciently. Additionally, the
surgeon should not resect skin too much, to help pre-
vent increased incisional tension during closure.
Other perioperative conditions can contribute to poor
wound healing and increased scarring. These include
bleeding, hematoma, infection, and poor vascularity to
the skin fl aps. Compromised vascularity to facelift skin
fl aps is more common in patients who smoke, have had
prior radiation therapy, or have a history of diabetes
mellitus. In cases in which fl ap vascularity is in ques-
tion, a thicker, shorter fl ap minimizes the chance of
facelift fl ap compromise.
Hypertrophic scars occur most frequently in the
postauricular region. Keloid scars are less common.
Treatment includes early recognition and the topical ap-
plication of steroid or silicone-impregnated tape. Intra-
lesional steroid injections (triamcinolone 10 to 40 mg/
ml) can be injected directly intradermally. These injec-
tions can be repeated (approximately every four weeks)
and help to soften and fl atten hypertrophic scars. In rare
instances, scar revision is necessary. Of course, the basic
principle of minimizing skin wound tension is crucial if
improvement is to be achieved with postauricular scar
revision. Again, repeated intralesional steroid injections
are to be expected after scar revision.
cervicofacial skin and soft tissues.17 Although postop-
erative facelift infection is uncommon, its risk increases
in diabetic patients, smokers, and patients who are im-
munocompromised. Unevacuated hematomas may also
predispose patients to infection.
The symptoms and signs associated with postopera-
tive facelift infection include pain, swelling, and ten-
derness greater than that typically encountered after
facelift. The wounds may be locally tender or erythem-
tous, and the patient will often develop a fever.
Infection is often prevented with the use of periopera-
tive prophylactic antibiotics. Antibiotics should be ad-
ministered between 30 minutes and 2 hours before the
initial skin incision and stopped within 48 hours after
surgery. If infection does occur, management includes
(1) local wound care, (2) aspiration or incision and
drainage if an abscess is suspected, (3) removal of in-
fected sutures, (4) culture and sensitivity of the wound,
and (5) initiation of appropriate systemic antibiotics.
Local wound care after facelift infection is essential.
Proper care increases the chances that the infection
will not spread. Local wound care includes the use of
one-half strength hydrogen peroxide topically, often
followed by a thin topical application of antibiotic oint-
ment. In cases of progressive infection, it is appropriate
to obtain an infectious disease consultation.
◆Skin Flap Necrosis
The viability of skin fl aps after a facelift is based on a
variety of factors related to the patient’s preoperative
condition and the surgeon’s intraoperative technique.
The vascular supply to the facial skin is typically very
rich. Conditions that aff ect the microcirculation to the
skin can increase the risk of the fl ap necrosis after a
facelift. These conditions include diabetes mellitus, ath-
erosclerosis, a prior history of radiation therapy, chronic
pulmonary disease (such as COPD or emphysema), and
smoking.
The eff ects of smoking on skin fl ap survival have
been well documented both clinically and experimen-
tally. Nicotine releases catecholamines, which impair
epithelialization and decrease infl ammation. Accord-
ing to Rees, 80% of patients with skin slough after face-
lift smoked more than one package of cigarettes per
day at the time of their surgery. He estimated the risk
of skin slough in active smokers to be 12 to 13 times
the risk of necrosis in the nonsmoking patient.18 For
this reason, it is advised that smokers cease smoking
for at least two weeks preoperatively and three weeks
postoperatively. Many surgeons refuse to operate on
active smokers.
Intraoperative causes of fl ap necrosis after facelift
are related to the length and thickness of the skin fl ap.
Other intraoperative causes of fl ap compromise include
increased tension on the skin wound (and fl ap edges).
When the skin fl ap is longer and thinner, the risk of com-
Complications in Facial Plastic Surgery
96
References
1.
Fomon S. The surgery of injury and plastic repair. Baltimore:
Williams and Wilkins; 1939:1344
2.
Skoog T. Plastic Surgery: New Methods and Refi nements.
Philadephia, PA: WB Sauders Co; 1974
3.
Mitz V, Peyronie M. The superfi cial musculo-aponeurotic sys-
tem (SMAS) in the parotid and cheek area. Plast Reconstr Surg
1976;58(1):80–88
4.
Shridharani SM, Magarakis M, Manson PN, Rodriguez ED. Psy-
chology of plastic and reconstructive surgery: a systematic clini-
cal review. Plast Reconstr Surg 2010;126(6):2243–2251
5. Kaplan JL, Hammert WC, Zin JE. Lawsuits against plastic sur-
geons: Does locale aff ect incidence of claims? Can J Plast Surg
2007;15(3):155–157
6. Destro MW, Speranzini MB, Cavalheiro Filho C, Destro T,
Destro C. Bilateral haematoma after rhytidoplasty and blepha-
roplasty following chronic use of Ginkgo biloba. Br J Plast Surg
2005;58(1):100–101
7. Grover R, Jones BM, Waterhouse N. The prevention of haema-
toma following rhytidectomy: a review of 1078 consecutive
facelifts. Br J Plast Surg 2001;54(6):481–486
8. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of he-
matoma requiring surgical evacuation following male rhyt-
idectomy: a 30-year review of 985 cases. Plast Reconstr Surg
2005;116(7):1973–1985, discussion 1986–1987
9. Berner RE, Morain WD, Noe JM. Postoperative hypertension
as an etiological factor in hematoma after rhytidectomy.
Prevention with chlorpromazine. Plast Reconstr Surg 1976;
57(3):314–319
10. Payne DL. Facial nerve defi cits following face lift surgery. Am J
Otol 1992;13(1):91–92
11. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidec-
tomy. Anatomical variations and pitfalls. Plast Reconstr Surg
1979;64(6):781–795
12. Daane SP, Owsley JQ. Incidence of cervical branch injury
with “marginal mandibular nerve pseudo-paralysis” in pa-
tients undergoing face lift. Plast Reconstr Surg 2003;111(7):
2414–2418
13. Clark RP, Berris CE. Botulinum toxin: a treatment for facial
asymmetry caused by facial nerve paralysis. Plast Reconstr
Surg 1989;84(2):353–355
14. McKinney P, Katrana DJ. Prevention of injury to the great
auricular nerve during rhytidectomy. Plast Reconstr Surg
1980;66(5):675–679
15. Webster RC, Davidson TM, White MF, Bush JE, Smith RC. Con-
servative face lift surgery. Arch Otolaryngol 1976;102(11):
657–662
16. Kridel RW, Liu ES. Techniques for creating inconspicuous face-
lift scars: avoiding visible incisions and loss of temporal hair.
Arch Facial Plast Surg 2003;5(4):325–333
17. LeRoy JL Jr, Rees TD, Nolan WB III. Infections requiring hos-
pital readmission following face lift surgery: incidence,
treatment, and sequelae. Plast Reconstr Surg 1994;93(3):
533–536
18. Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast
Surg 1978;5(1):109–119
◆Conclusion
The facelift procedure is the gold standard for reju-
venation of the midface and lower face. The surgeon
must consider several factors to minimize the risk of
complications associated with facelift surgery. Obtain-
ing proper informed consent prior to surgery requires
good communication between the surgeon and patient.
Medical conditions that may predispose the patient to
excessive bleeding or fl ap necrosis should be identifi ed,
and medications that predispose the patient to postop-
erative bleeding must be avoided if possible.
Subcutaneous hematomas are one of the most com-
mon complications after facelift surgery and can result
in serious adverse consequences. Injury to a branch
of the facial nerve can often be avoided by thorough
knowledge of the facial anatomy and careful dissection
technique. Hairline distortions of the temporal and post-
auricular area can occur because of the vector of lift, but
they can be avoided with careful planning. Less com-
mon complications of facelift surgery include alopecia,
parotid fi stula, and wound infection. Skin fl ap necrosis,
when large, can have devastating consequences. There-
fore, careful preoperative screening is recommended.
When skin fl ap necrosis is encountered after surgery,
early detection and management are essential. Hyper-
trophic scarring can often be minimized or managed by
taking care to avoid some of the previously mentioned
potential complications and by using intralesional ste-
roid injections. With careful attention to detail and
sound technique, the surgeon can minimize many of the
complications of facelift surgery.
PEARLS OF WISDOM
A detailed informed consent explaining the proposed proce-
dure, potential complications, risks, and possible limitations of
the surgery should be obtained.
It is important to select the patient carefully and to determine
if the patient has reasonable expectations.
A comprehensive medical history should be obtained. The
patient should be given a list of medicines to avoid periopera-
tively to minimize the chance of postoperative bleeding.
Existing medical conditions, such as hypertension, should be
well controlled prior to surgery.
A thorough knowledge of facial anatomy minimizes the risk of
sensory or motor nerve injury.
Meticulous postoperative care, including psychological sup-
port, is crucial to ensure optimal physical and mental healing
from surgery.
97
Contemporary care in facial plastic surgery mandates
familiarity and facility with facial implants. Over the
past few decades, trends have stressed the restoration of
facial volume and the importance of enhancing skeletal
facial proportions. One has only to look at the success
of facial fi llers to see this. Like injectable fi llers, facial
implantation has also become an increasingly popular
way to replenish lost volume and to correct contour ab-
normalities that result from developmental, traumatic
or age-related etiologies. When it is possible, most
surgeons prefer the implantation of autologous tissue;
however, the additional morbidity associated with the
harvest of donor tissue, the limitation of tissue avail-
ability, and the risk of graft distortion or resorption are
potential drawbacks. Alternatives to autologous tissue
include allografts, xenografts, and alloplastic materials.
The use of allograft tissue tends to have similar limita-
tions to the use of autologous tissue in terms of resorp-
tion and distortion (perhaps more so), in addition to the
remote possibility of disease transmission. Their more
predictable long-term outcomes and limitless avail-
ability make alloplastic implants particularly attractive;
however, the use of alloplastic implants is not without
its own set of risks (including elevated risk of infec-
tion), and the search for the optimal implant material
continues.1
◆The Ideal Facial Implant
Table 12.1 outlines the commonly used facial implant
materials and their characteristics.
Most alloplastic implants used today for facial en-
hancement are synthetic polymers. These are macro-
molecules of repeating monomeric units. They may be
solid polymers, such as polydimethylsiloxane or solid
silicone (Silastic, Dow Corning, Midland, MI) and poly-
methylmethacrylate; porous polymers, such as high
density porous polyethylene (MEDPOR, Porex Surgical,
Newman, GA) and fi brillated expanded polytetrafl uo-
roethylene (ePTFE) (Gore-Tex, WL Gore, Flagstaff , AZ);
or meshed polymers such as polyethylene terephthal-
ate (Mersilene, Ethicon, Somerville, NJ). In addition, cer-
tain metals such as gold (Au-79) and titanium (Ti-22)
are used as implants, primarily for reconstructive pur-
poses.2 Ceramics such as hydroxyapatite are also useful,
particularly in craniofacial reconstructive procedures.
The biocompatibility or interaction between implant
and host is infl uenced by many factors, including the
chemical composition of the implant material, host reac-
tion, and surgical technique. The ideal implant material
is nontoxic, nonantigenic, noncarcinogenic, acceptable
to the host, durable, and resistant to infection. It is cost-
eff ective, easy to sculpt or customize without compro-
mising its integrity, easy to insert, and able to withstand
mechanical strain without changing its shape. It has few
surface imperfections, is able to conform to irregular
surfaces, and is easily removable without causing sig-
nifi cant tissue injury.3 Although a multitude of implant
materials are available in the market, currently none
satisfy all these criteria. Each implant material has its
own risks and benefi ts, and there is presently no ideal
permanent implant.
◆Implant Complications
Understanding the complications associated with fa-
cial implantation from study of the literature has its
limitations. Some surgeons are reluctant to report com-
plications or poor results, and patients with adverse
outcomes often seek alternative opinions and are lost
to follow-up.4 In any event, complications from facial
implantation do occur and result from a combination of
factors related to the patient (host), the implant mate-
rial, and the surgeon’s technique. The following discus-
sion will treat each of these areas separately.
Patient-Related Complications
Patient-related complications are typically from mis-
managed expectations that lead the patient to be dis-
satisfi ed with the outcome. These complications are
largely preventable with open and frank communica-
tion between patient and surgeon. Prevention begins
with a comprehensive evaluation of the patient, includ-
12
Complications with Facial Implantation
Edwin F. Williams III and Srinivasan Krishna
Complications in Facial Plastic Surgery
98
Complications Related to Surgical Technique
Complications from surgical technique are somewhat
generic to any implantation procedure, but the risk var-
ies with specifi c sites and the implant material(s) used.
Most surgical complications are fortunately minor and
self limiting. Major complications must be dealt with
expeditiously to avoid long-term sequelae. A thorough
knowledge of the anatomy and meticulous attention to
surgical technique are critical to avoid adverse surgical
outcomes. The surgical complications commonly en-
countered with facial implants are discussed below.
Hematoma
Blood that accumulates in a tight pocket can lead to
pressure necrosis of the overlying skin and soft tissue,
resulting in implant exposure and extrusion. Hemato-
mata need to be drained and the bleeding controlled in
a timely fashion.6
ing careful analysis of standardized digital photographs.
Consistent photographic techniques with appropriate
views are essential for accurate preoperative and post-
operative comparisons. Inadequate preoperative analy-
sis can lead to selection of the improper implant and an
unhappy patient. Computerized morphing techniques
may be used to manage patient expectations and dem-
onstrate the need for appropriate additional interven-
tions to achieve the best possible aesthetic outcome.
One must be careful to emphasize that such morphing
is an approximation and by no means a guarantee of a
surgical result. Having the patient sign a waiver to this
eff ect is helpful from a legal standpoint.5
Although they are designed to be inert, specifi c im-
plant materials can cause hypersensitivity reactions in
some patients and therefore produce adverse outcomes.
Hypersensitivity tends to be more common with fi ller
materials such as bovine collagen, which has a 2–3% in-
cidence of an allergic or hypersensitivity reaction and
requires double skin testing prior to usage.
Table 12.1
Facial Implant Characteristics
Material
Polydimethyl-
siloxane
Expanded
polytetra-
fl uoroethylene
(ePTFE)
High density
polyethylene
Polyester fi ber
Polymethyl-
methacrylate
Hydroxyapatite/
carbonated
apatite cement
Trade name
Silastic (silicone
rubber)
Gore-Tex
MEDPOR
Marlex mesh
Mersilene/
Dacron
Cranioplast
Bone Source/
Norian CRS
Tissue interface
fi brous capsule
limited tissue
in-growth
fi brovascular
and osseous
in-growth
tissue in-
growth
tissue in-
growth
osseointegration
Advantages
easy to contour
and remove
comes in sheet
or tubular
forms, can be
layered, easily
removed
versatile, stable,
resists infection
easy to contour,
can be layered
can be molded
in situ
paste—can be
molded easily
Disadvantages
bone resorp-
tion, exposure
palpable,
expensive
diffi cult to
remove
diffi cult to
remove
exothermic
reaction, expo-
sure
exposure or
infection
Complications
malposition.
extrusion,
infection
malposition.
extrusion,
infection
malposition.
extrusion,
infection
infection, extru-
sion
malposition,
infection
exposure,
infection
Common sites
for use
chin, malar,
cranioplasty
chin, malar,
lips, nose,
nasolabial folds
malar, orbit,
chin, mandible
chin, malar,
nose
orbital, cranial,
malar recon-
struction
craniofacial
Adapted from Sykes JM, Tollefson TT, Frodel Jr, JL. In: Cummings CW, ed. Cummings Otolaryngology—Head & Neck Surgery. Philadelphia: Elsevier Mosby
Publishers; 2005:801–821.
Trade nam es include Silastic (Dow Corning, Midland, MI), Gore-Tex (WL Gore, Flagstaff , AZ), MEDPOR (Porex Surgical, Newnan, GA), Cranioplast (Ad-
vanced Biomaterial Systems, Passaic, NJ), Norian CRS (Synthes-Stratec, Paoli, PA), BoneSource (Stryker Leibinger, Flint, MI).
12 Complications with Facial Implantation
99
positive and anaerobic coverage is indicated. Commonly
cultured organisms include staphylococcal and strep-
toccoccal species and anaerobes. Certain implants with
good vascular ingrowth may be salvageable (such as
Gore-Tex and MEDPOR) with antibacterial therapy, but
infection frequently requires removal of the implant.
Preventive measures to help reduce the incidence of
such complications include timely cessation of aspirin,
anticoagulants, nonsteroidal anti-infl ammatory medi-
cations (NSAIDs), vitamins (especially vitamin E), and
herbal medications. As long as it is cleared with the pa-
tient’s primary physician, patients should be off these
medications long enough to return the blood clotting
cascade or platelet function to normal. Most commonly,
two weeks before surgery is suffi cient. Steroids are com-
monly administered intraoperatively, and continued for
24 hours perioperatively to decrease postoperative ede-
ma. Similarly, an appropriate intravenous dose of a fi rst-
generation cephalosporin or clindamycin should be
administered (ideally 30 minutes before the initial in-
cision), and perioperative antibiotics (again, with good
gram-positive and anaerobic coverage) are prescribed
for fi ve days. A pressure dressing can be helpful for the
fi rst 24–48 hours after any implantation procedure to
decrease the risk of a hematoma and limit edema. Pa-
Nerve Injury
Depending on the site of implantation, nerve injury can
manifest as paresthesias or dysesthesias involving the
infraorbital or mental nerve. Occasionally, weakness
involving the frontotemporal or marginal mandibular
branches of the facial nerve (VII) can also occur. Nerve
injuries are commonly neurapraxias resulting from ag-
gressive retraction or transmitted thermal injury, and
they typically resolve in less than three weeks. Should
they persist beyond that time period, one must have a
low threshold for exploring the area and ruling out mal-
position of the implant and induced neurapraxia.7 Very
rarely, nerve injuries can be permanent.6
Prolonged Edema
Postoperative facial edema after implantation typically
resolves in three weeks or less. Occasionally edema can
last several months and can be caused by chronic infl am-
mation. Discrete areas may be treated with intralesional
triamcinolone.6 Patients commonly need reassurance.
Implant Migration and Extrusion
Displacement of the implant from its intended position
is a well-known complication of facial implant surgery.
Malposition itself is problematic (e.g., a chin implant
that lies obliquely to or off the midline), but it also can
cause problematic asymmetry when paired implants are
employed (e.g., malar implants may be diff erently posi-
tioned). Malposition can result from an improperly sized
pocket or inadequately secured implant3 (Fig. 12.1). Pock-
et inadequacy or an excessively sized implant may cause
pressure necrosis of the overlying skin/soft tissue enve-
lope, resulting in exposure and eventual extrusion. A dis-
placed implant needs to be repositioned expeditiously.
Extrusion can also occur from an infected implant. Extru-
sion warrants implant removal, with possible reinsertion
once the extrusion site is completely healed.6
Persistent Seromas
Persistent seromas tend to occur most often with Silastic
(silicone) implants and may need to be drained repeat-
edly.8 The exact pathophysiology of seroma formation
after silicone implantation is unclear.
Infection
Infection can occur with any implantation procedure but
may be more common with intraoral approaches. Some
studies suggest that soaking the implant in an antibiotic
solution (Bacitracin 50,000 units in 1 liter of normal sa-
line) and using perioperative antibiotics may decrease
the incidence of implant-related infections.3 Should an
infection occur, aggressive antibiotic therapy with gram-
★
Fig. 12.1 Coronal CT of the face revealing signifi cant displace-
ment of a 10-year-old Silastic malar implant. The patient was
experiencing right facial swelling, discomfort, and other symp-
toms consistent with unilateral maxillary sinusitis. Physical ex-
amination also revealed a 3 mm oroantral fi stula on the aff ected
side. In addition to the displaced implant, the CT also illustrates
soft tissue near the right maxillary ostium (star), which was con-
sistent with polypoid degeneration seen on nasal endoscopy.
The fi stula tract is also partially visualized on CT (arrow).
Complications in Facial Plastic Surgery
100
dislodged. It is also prone to extrude when the overly-
ing soft-tissue coverage is thin, as in nasal or auricular
applications.8
One of the most comprehensive reviews of implant
complications was published in 1997 by Rubin and
Yaremchuk.4 Based on a review of nearly 200 clinical
studies, they reported on complication rates related
to specifi c implant materials and sites. Their fi ndings,
along with additional data from more recent studies, are
summarized in Table 12.2.
◆Facial Enhancement with Implants
The study of facial anatomy has led to a greater under-
standing of the ideal facial proportions that contribute
to attractiveness. Certain convex facial features (e.g., the
malar eminence or the chin) can be either masculiniz-
ing or feminizing, depending on their size and contour,
independent of traditional facial proportions. Further-
more, the aging face characteristically changes in a
relatively consistent fashion according to skeletal and
soft-tissue alterations, and it can be rejuvenated with
implants that act to mitigate these changes. As a result,
procedures have evolved for certain anatomic areas that
are particularly amenable to augmentation in the hu-
man face, including the chin (menton), the malar emi-
nences, the lateral mandible, the nasolabial folds, the
lips, and the nose.
Chin and Mandibular Implants
The authors prefer ePTFE (Gore-Tex) for mentoplasty,
even though it is signifi cantly more expensive than al-
ternative materials. The main reason for this preference
tients are additionally instructed to elevate their heads
and to use cold compresses on the surgical site for the
fi rst 48 hours after surgery.
Implant-Related Complications
Implant-related complications tend to vary with the
implant material used and site of implantation. As pre-
viously indicated, implant and host factors are inter-
related. Common implant-related problems include
infl ammation, edema, displacement, infection, expo-
sure, extrusion and bone resorption. Rare complica-
tions include the potential risk of carcinogenicity, but
the level of this risk is ill-defi ned in the literature. Sili-
cone, in particular, has been implicated as an etiologic
factor in certain connective tissue diseases, yet several
large series show no increased risk in women following
silicone breast augmentation.4 A link to anaplastic large
cell lymphoma occurring in the fi brous capsule around
silicone breast implants, however, is presently under
FDA investigation.9 It is unknown if this would have any
implications for facial implantation.
Many of the implant materials used today have a long
track record of safety. For example, ePTFE (Gore-Tex) has
been used for more than 20 years, especially in vascular
surgery, with excellent biocompatibility and long-term
success. Gore-Tex and other porous polymers have a vari-
able degree of tissue in-growth, making them relatively
stable.3 The tubular form of ePTFE (Softform, Ultrasoft,
Advanta) has been used for subcutaneous augmentation
of nasolabial folds, the perioral area, facial scars, soft-
tissue defects, and lip augmentation. Over the long term,
Softform (Collagen Corporation, Palo Alto, CA) becomes
fi rmer, more palpable, and tends to shorten due to fi brous
in-growth into the interstices of the material. Ultrasoft
(Tissue Technologies Inc., San Francisco, CA), which has
thinner walls, was developed to circumvent some of these
problems and has been more acceptable.10 A dual poros-
ity ePTFE implant, Advanta (Atrium Medical Corpora-
tion, Hudson, NH) is softer, has better biointegration and
less risk of shrinkage and migration.11 Because the risk of
palpability and extrusion (Fig. 12.2) is higher when the
implant is placed closer to the surface, it is advisable to
be very conservative with the use of ePTFE for soft-tissue
augmentation. Additionally, there is a higher risk of infec-
tion, particularly with using ePTFE in the lips. The naso-
labial fold is one area where its use has been found to be
favorable. Currently, with the availability of semiperma-
nent soft-tissue injectable fi llers with excellent long-term
safety profi les, many practioners have essentially aban-
doned the use of ePTFE implants in the perioral area in fa-
vor of these injectable fi llers that can be used in the offi ce.
Solid silicone (Silastic) implants have also been in use
for many years. Silastic implants are enveloped by a thin
organized capsule with a mild chronic infl ammatory re-
action. There is, however, no bonding between the sili-
cone and the capsule, and hence it is more prone to be
Fig. 12.2 Extrusion of Gore-Tex implant, 2.5 months after
subcutaneous implantation for depressed acne scarring in
right temporal area.
12 Complications with Facial Implantation 101
is the ease of removability. Gore-Tex also lends itself to
easy sculpting and does not cause the signifi cant bone
erosion seen with other materials (Fig. 12.3). A popu-
lar technique uses a submental approach with place-
ment of the implant in subperiosteal pockets laterally,
while ensuring that the central portion of the implant,
at the symphysis, is placed superfi cial to the periosteum.
Mersilene mesh tends to have much more fi brovascular
in-growth, which makes removal quite challenging and
leads to signifi cant morbidity if removal ever becomes
necessary.3 The patient in Fig. 12.4 required removal
of her Mersilene chin implant seven months after her
initial procedure. This removal resulted in extensive
bruising and infl ammation in the perioral area. She sub-
sequently had a second procedure to insert a Gore-Tex
chin implant and had a satisfactory outcome.
Two surgical approaches are commonly used for men-
toplasty. In the authors’ experience, the submental ap-
proach is more favorable than the transoral approach.
In the transoral approach, the mentalis muscle is dis-
inserted from the mandibular symphysis, which can
result in problems with implant positioning, often lead-
ing to inferior displacement of the implant and altera-
tion in the location and appearance of the labiomental
sulcus. Downward displacement of the overlying soft
tissue and muscle can result in a “witch’s chin” defor-
mity.7 This observation has been supported by Zide et
al., who reviewed over 100 postoperative problems with
chin augmentation and reported a higher incidence of
complications with the transoral approach, specifi cally
pertaining to implant position.12
Table 12.2
Complication Rates with Various Implants and Sites
Implant Site
Chin
Nasal
Malar
Implant material
Silicone
Surgical
mesh
ePTFE
Silicone
Surgical
mesh
ePTFE
Silicone
Porous
polyethylene
Patients
1220
1245
324
229
266
484
404
9
Number of studies
6
5
1
4
3
6
7
1
Follow-up time
Up to 3 Y
Up to 2 Y
5M–10 Y
6 M–15 Y
11 M–5 Y
1–6 Y
1.5–4 Y
Up to 4 Y
Mean rate of
infection, %
0.7
1.6
0.6
<0.5
5.3
1.7
1.2
0
Mean rate of
displacement, %
<0.5
1.0
0
0.9
0
0.8
2
0
Adapted from Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a
comprehensive review of the literature. Plast Reconstr Surg 1997;100:1336–1353, and from Godin MD, Costa L, Romo T, et al. Gore-Tex chin implants, a
review of 324 cases. Arch Facial Plast Surg 2003;5:224–227.
Abbreviations: M: months; Y: years
Fig. 12.3 Lateral skull X-ray illustrating mandibular bone ero-
sion associated with a chin implant performed 20 years earlier.
Godin et al. published a retrospective review of 324
Gore-Tex chin implants performed by six diff erent sur-
geons.13 The submental approach was used in 95% of the
cases. Only two implants (0.6%) required removal for
Complications in Facial Plastic Surgery
102
can be prevented by placing the implant in a supraperi-
osteal plane.15,16
As with mentoplasty, complications of midlateral and
posterolateral mandibular augmentation also include
malposition, infection, extrusion and nerve damage.
These can be minimized by paying careful attention to
technique, specifi cally to subperiosteal elevation, stay-
ing away from the mental foramen, and double-layered
closure of the wound.7
Malar Implants
Several approaches to midfacial augmentation have been
described, including transoral, subciliary, rhytidectomy,
transconjunctival, transtemporal, and transcoronal. The
transoral approach is the most common. Avoidance of
complications in malar (and submalar) implantation is
largely technique dependent. Injury to the infraorbital
nerve is avoided by passing the retractor lateral and
parallel to the nerve. Care is taken to avoid transecting
the zygomaticus muscle to prevent permanent muscle
weakness that can aff ect lip elevation and change smile
confi guration. Patients are evaluated within 48–72
hours, with special attention to ensure symmetry. An
appropriate cavity and adequate fi xation are critical to
avoiding displacement of malar implants. Implant mal-
position can lead to revisional surgery. Fixation is easily
achieved using a transoral screw to the maxilla or a per-
cutaneous suture fi xation over a bolster.3,7
The authors prefer the transoral approach for malar
augmentation and use Gore-Tex implants secured with
a screw. In our experience, infections are uncommon,
but may lead to implant extrusion when they occur. The
patient in Figs. 12.5A,B underwent malar augmenta-
tion with Gore-Tex implants. She developed an infec-
tion about a month later (Fig. 12.5A) and was treated
aggressively with antibiotics. Her clinical response was
not satisfactory and implant removal was off ered. The
patient refused and wanted to continue with conserva-
tive measures. With time, she developed skin necrosis
and exposure of the implant (Fig. 12.5B), which was
eventually removed.
Metzinger et al. published a fi ve-year review of malar
augmentation with Silastic implants in 60 patients, the
majority of which were performed through a transoral
approach.16 Their average follow-up was 41 months.
They had no infections, hematomas, seromas, measur-
able bone resorption, extrusions, or facial nerve inju-
ries. They had four cases of superior displacement, one
misalignment, three transient trigeminal hypesthesias,
and one case of persistent edema. Although they had no
infections, their overall complication rate was 16.7%, but
only 3.4% required a revision procedure.
Binder et al. described the successful use of custom-
ized Silastic midfacial and submalar implants through
an intraoral approach in 22 patients who had facial
wasting syndrome associated with HIV.17 In their se-
persistent infection after multiple courses of antibiot-
ics were tried. Four patients (1.2%) requested implant
removal due to dissatisfaction with their appearance.
Soaking the implant preoperatively in antibiotic solu-
tion produced no signifi cant diff erence in infection
rates. It must be remembered that chin implants can get
infected up to 10 years later, which is typically second-
ary to seeding from a dental source.7 Ongoing research
in biofi lms may elucidate some of the mechanisms for
such infections and their best therapy.
Gross et al. published a review of their senior author’s 14
years of experience with Mersilene mesh augmentation
mentoplasty in 264 patients.14 The submental approach
was used more commonly, and all implants were placed
subperiosteally. Mean follow-up was fi ve years. The overall
complication rate was 2.3%, with an infection rate of 0.8%
and displacement rate of 1.5%. Temporary paresthesias
were noted in 5.3% of patients. There was no diff erence
in the complication rate based on the approach (transoral
versus submental). They concluded that Mersilene mesh
was a safe, inexpensive, and well-tolerated implant.
Bone resorption has been noted with mandibular aug-
mentation, particularly of the anterior mandible, more
so than with any other alloplastic implantation (Fig.
12.3). This tends to occur more often with some implant
materials such as Silastic, acrylic, and MEDPOR.14 It typi-
cally occurs with subperiosteal implant placement and
Fig. 12.4 Extensive bruising and infl ammation following
removal of a Mersilene chin implant.
12 Complications with Facial Implantation 103
implant removal, both of which were in the nasal area.
In both cases, Staphylococcus aureus was cultured and
treated successfully with antibiotics. The authors caution
against the use of Gore-Tex in cases of revision rhinoplas-
ty, where the soft-tissue envelope tends to be quite thin.19
ries, there were no serious complications. Two patients
required implant removal for an infection. In one case,
the implant was replaced successfully after antibiotic
therapy.
Nasal Implants
The thin skin/soft-tissue envelope of the nasal dorsum
puts dorsal nasal implants at high risk for extrusion. In
Ruben and Yaremchuk’s review,4 extrusion rates were
close to 23% for silicone, but were negligible with surgi-
cal mesh and ePTFE. However, infection rates were 5.3%
for mesh and 1.7% for ePTFE. Therefore, autologous tis-
sue is most advisable for nasal grafting. Of the alloplas-
tic implants, Gore-Tex is favored over other alternatives.
Infections are uncommon but may require implant re-
moval when they occur. The patient in Fig. 12.6 devel-
oped erythema and induration four months after dorsal
augmentation rhinoplasty with Gore-Tex. She did not
respond to aggressive antibiotic therapy with cepha-
lexin and ciprofl oxacin, resulting in implant removal a
month later. Cultures grew Staphylococcus aureus. She
was subsequently off ered a revision procedure with au-
tologous rib grafting but has been reluctant to undergo
further surgery.
Godin et al. published a retrospective review of 309 pa-
tients who underwent rhinoplasty with Gore-Tex implan-
tation. The average follow up was 40.4 months. The overall
infection rate requiring graft removal was 3.2%, with a sig-
nifi cant diff erence between primary (1.2%) and revision
rhinoplasties (5.4%). The average time period between
placement and removal of the implant was 16 months.
The only predisposing factor identifi ed in this study was
nasal septal perforation, which was present in 30% of the
patients requiring implant removal for infection.18
Schoenrock et al. reported on their series of 750 Gore-
Tex facial implants.19 They had two infections requiring
Fig. 12.5 (A) Infected malar
implant approximately one
month after transoral place-
ment. Notice thinning and
impending skin erosion. (B)
Skin ulceration and exposure
of infected malar implant.
Fig. 12.6 Oblique view of a patient with erythema and
induration after placement of Gore-Tex implant for nasal
dorsal augmentation. Antibiotic therapy failed and implant
was removed a month later. Culture grew coagulase-negative
Staphylococcus aureus and Streptococcus viridans.
A
B
Complications in Facial Plastic Surgery
104
uracil injections for problematic cicatricial nodularity
after fat transfer, although this latter option is not well elu-
cidated in the literature. If persistent nodularity remains
despite conservative measures or if the problem is simply
◆Autologous Fat
Transfer of autologous fat is rapidly gaining in popular-
ity, due in part to its ease of harvest, persistence, and
usefulness in nearly all anatomic areas commonly en-
hanced with volume. Thus any discussion of facial im-
plantation must include lipotransfer. Complications
from lipotransfer tend to be technique dependent but
not universally so. The commonly encountered compli-
cations include prolonged edema, induration, bruising,
and asymmetry. The lower eyelid and lateral canthal
area tend to be less forgiving, and contour irregularities
are more noticeable20 (Fig. 12.7). Occasionally, persis-
tent infl ammation can lead to granulomatous nodules
(Fig. 12.8) or hyperpigmentation (Fig. 12.9). Infections
are rare with strict aseptic technique.20
Although signifi cant complications with fat transfer
have been described, they are quite rare and can largely
be avoided by the use of appropriate techniques and
precautions.21–24
Specifi cally, fat embolism can be a devastating com-
plication of facial lipotransfer, and adherence to the con-
temporary tenets of injecting fat in minuscule amounts,
using multiple passes with a 0.9–1.2 mm blunt cannula,
for example, has reduced the incidence of complications
signifi cantly. Injections are performed as the cannula is
withdrawn and with minimal force.20 Granulomatous in-
fl ammation may be treated successfully with intralesional
triamcinolone, and there may also be a role for 5-fl uoro-
Fig. 12.7 Visible nodularity of the lateral canthal area and
malar crescent, 6 months after autologous lipotransfer.
Fig. 12.8 Granulomatous infl ammation in tear trough area
following autologous lipotransfer.
Fig. 12.9 Brownish hyperpigmentation in lower eyelid area
following autologous lipotransfer.
12 Complications with Facial Implantation 105
5. Buckingham ED, Lam SL, Williams EF III. In: Williams III EF,
Lam SM, eds. Comprehensive Facial Rejuvenation. Philadel-
phia: Lippincott Williams and Wilkins; 2004:28.
6. Roy DB, Mangat DS. Facial implants. Dermatol Clin 2005;
23(3):541–547, vii–viii
7. Terino EO. Complications of chin and malar augmentation. In:
Peck G, ed. Complications and Problems in Aesthetic Plastic
Surgery. New York: Gower Medical Publishers; 1991
8. Davis PKB, Jones SM. The complications of Silastic implants.
Experience with 137 consecutive cases. Br J Plast Surg 1971;
24(4):405–411
9. FDA Medical Device Safety Communication: Reports of Anaplas-
tic Large Cell Lymphoma (ALCL) in Women with Breast Implants.
The U.S. Food and Drug Administration. January 26, 2011.
10. Monhian N, Ahn MS, Maas CS. Injectable and Implantable Ma-
terials for Facial Wrinkles. In: Papel ID, ed. Facial Plastic and
Reconstructive Surgery. New York: Thieme Medical Publish-
ing; 2002:247–261
11. Truswell WH. Dual-porosity expanded polytetrafl uoro-
ethylene soft tissue implant: a new implant for facial soft
tissue augmentation. Arch Facial Plast Surg 2002;4(2):
92–97
12. Zide BM, Pfeifer TM, Longaker MT. Chin surgery: I. Aug-
mentation—the allures and the alerts. Plast Reconstr Surg
1999;104(6):1843–1853, discussion 1861–1862
13. Godin MD, Costa L, Romo T, Truswell W, Wang T, Williams
E. Gore-Tex chin implants: a review of 324 cases. Arch Facial
Plast Surg 2003;5(3):224–227
14. Gross EJ, Hamilton MM, Ackermann K, Perkins SW. Mersilene
mesh chin augmentation. A 14-year experience. Arch Facial
Plast Surg 1999;1(3):183–189, discussion 190
15. Li KK, Cheney ML. The use of sliding genioplasty for treat-
ment of failed chin implants. Laryngoscope 1996;106(3 Pt 1):
363–366
16. Metzinger SE, McCollough EG, Campbell JP, Rousso DE. Malar
augmentation: a 5-year retrospective review of the Silastic
midfacial malar implant. Arch Otolaryngol Head Neck Surg
1999;125(9):980–987
17. Binder WJ, Bloom DC. The use of custom-designed midfacial
and submalar implants in the treatment of facial wasting syn-
drome. Arch Facial Plast Surg 2004;6(6):394–397
18. Godin MS, Waldman SR, Johnson CM Jr. Nasal augmentation
using Gore-Tex. A 10-year experience. Arch Facial Plast Surg
1999;1(2):118–121, discussion 122
19. Schoenrock LD, Repucci AD. Correction of subcutaneous fa-
cial defects using Gore-Tex. Facial Plast Surg Clin North Am
1994;2:373–387
20. Krishna S, Williams EF III. Lipocontouring in conjunction with
the minimal incision brow and subperiosteal midface lift: the
next dimension in midface rejuvenation. Facial Plast Surg Clin
North Am 2006;14(3):221–228
21. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP,
Tschopp H. Middle cerebral artery occlusion and ocular fat
embolism after autologous fat injection in the face. J Neurol
1998;245(1):53–54
22. Ricaurte JC, Murali R, Mandell W. Uncomplicated postopera-
tive lipoid meningitis secondary to autologous fat graft necro-
sis. Clin Infect Dis 2000;30(3):613–615
23. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately
following autologous fat injection into the face. Neurology
2003;61(8):1151–1152
24. Miller JJ, Popp JC. Fat hypertrophy after autologous fat transfer.
Ophthal Plast Reconstr Surg 2002;18(3):228–231
one of too much injected fat, surgical excision probably
remains the best option. Hyperpigmentation typically re-
sponds to topical applications of hydroquinone.
◆Conclusion
Alloplastic implantation is a readily available and du-
rable option for aesthetic and functional facial enhance-
ment. As with all facial plastic surgery interventions,
careful patient selection and risk-benefi t assessment
are critical to a successful outcome. When the proce-
dure is performed correctly in appropriate individuals,
enhanced facial proportions and rejuvenation are safe
and achievable with facial implants. Such complications
as implant malposition, asymmetry, or infection are
ultimately treatable with implant removal and replace-
ment if necessary. Semipermanent implants, such as au-
tologous fat, are an excellent alternative to permanent
fi ller materials and are rapidly gaining in popularity.
PEARLS OF WISDOM
There is no ideal implant material, although autologous tissue
is often best.
Comprehensive preoperative evaluation, consistent photog-
raphy, and open communication to manage the expecta-
tions of the patient are essential for successful facial implant
outcomes.
Facial implants placed on bone or the periosteum are less likely
to extrude.
Ease of removal is an important consideration in the choice of
facial implant material.
Implant-associated infection typically requires implant re-
moval.
Autologous fat transfer is an excellent soft-tissue volume en-
hancement technique, with minimal morbidity and favorable
long-term results.
References
1. Quatela VC, Sabini P. Synthetic Implants. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. New York: Thieme Medi-
cal Publishing; 2002:61–72
2. Silver FH, Maas CS. Biology of synthetic facial implant materi-
als. Facial Plast Surg Clin North Am 1994;2:241–253
3. Binder WJ, Moelleken B, Tobias GW. Aesthetic Facial Implants.
In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. New
York: Thieme Medical Publishing; 2002:276–298
4. Rubin JP, Yaremchuk MJ. Complications and toxicities of im-
plantable biomaterials used in facial reconstructive and aes-
thetic surgery: a comprehensive review of the literature. Plast
Reconstr Surg 1997;100(5):1336–1353
106
Facial trauma patients suff er injuries to complex soft-tis-
sue structures as well as to components of the facial skel-
eton. Proper healing depends upon principles common
to the management of facial trauma—that is, strict at-
tention to soft-tissue closure techniques, patient health
factors, meticulous wound care, and adequate reduction
and fi xation of fractures. The individual anatomic and
functional features of each facial subsite, however, must
be appreciated more fully to understand the develop-
ment and management of complications. This chapter
will address each of the major regions of the craniofacial
skeleton separately—the mandible, orbit and zygoma,
maxilla, naso-orbital ethmoid complex, and frontal si-
nus—as well as important facial soft-tissue structures.
◆Mandibular Fractures
Infection is the most common adverse event following
the treatment of mandibular fractures, with reported
rates from 2.9% to 30% of cases.1–6 Reported rates of in-
fection must be interpreted within the context of trends
in treatment modalities. Rigid fi xation techniques have
assumed a primary role in fracture treatment in many
medical centers in the United States over the past 20
years.3,7 Improved bone stability and reliability of heal-
ing with correct application of the techniques have
resulted in signifi cant improvements in the clinical out-
comes in facial trauma. Thus, it is generally expected
that rates of infection in the era of rigid fi xation are less
compared with rates in years past. Infection rates in
clinical reports must also be judged based on the site of
the mandibular fracture, the length of any prophylactic
antibiotic course, patient compliance factors, and surgi-
cal technique.3,8,9
Infection may develop in instances of delayed treat-
ment, patient comorbidities that result in immuno-
compromise, technical errors resulting in improper
reduction or stabilization (or both), and bacterial seed-
ing of the fracture site, particularly in the presence of
preexisting caries or dental infection.1,2,9–11 Infection in
the fractured mandible often starts to develop when
there is excessive movement of the ends of the fracture.1
Successful bone healing occurs two diff erent ways, de-
pending upon the mobility and interval distance of the
fractured segments: healing and indirect bone healing.
Complete immobilization with exact approximation
of the fractured ends allows direct bone healing with
minimal development of an intervening callus.1,12 When
these conditions are not completely satisfi ed but the
fractured ends are not distracted, the bone edges will
experience some movement in the initial postinjury
phase.1,12 Indirect bone healing commences in this situ-
ation. This process involves a cascade of events marked
by the diff erentiation of hematoma to fi brocartilage
and ultimately to bone. The formation of a callus occurs
early in the process of indirect bone healing and serves
as an early stabilizer of the bone segments and also as
a foundation for the ingrowth of more specialized tis-
sues.1,7,12 If there is a wide gap between the fracture seg-
ments, interfragmentary motion may be excessive, so a
callus will not form.7,11 Excessive motion, which is often
seen in delayed patient presentations or with the use of
inappropriate stabilization techniques, promotes seed-
ing of bacteria into the fracture1 and the ingrowth of fi -
brous tissue instead of cartilaginous and bone precursor
cells.11,13
The initial choice of fracture treatment must be tai-
lored to the fracture. Once biomechanical forces act-
ing on the mandible were elucidated by pioneers such
as Champy, Michelet, Luhr, and Spiessl, techniques for
proper plate application followed.7,14 The ideal osteo-
synthesis line (Fig. 13.1) described by Champy is based
on an understanding of the three forces that act on the
mandible during function: tensional, compressive, and
torsional.7,14–16 When occlusal force is applied anteriorly,
tensional forces are generated at the alveolar ridge and
follow a line posteriorly along the oblique line. Tension
tends to distract a fracture. Generally, compression oc-
curs at the inferior border of the mandible during func-
tion, although forces applied in proximity to the fracture
will often tend to compress the alveolar border and dis-
tract the inferior border.15,16 The suprahyoid muscles
(digastric m., mylohyoid m., stylohyoid m., and geniohy-
oid m.) exert a torsional force on the anterior mandible
(symphysis and parasymphyseal region), which requires
13
Complications of Facial Trauma Repair
Sydney C. Butts and Robert M. Kellman
13 Complications of Facial Trauma Repair 107
be remembered that the infection is not likely to resolve
unless rigid fi xation is established and that bone healing
is jeopardized until stabilization is achieved.1,18 The use
of antibiotics and minimization of patient comorbidities
(e.g., malnutrition) certainly play adjunctive roles.
Incidence of posttraumatic osteomyelitis is related to
fracture infection. Whereas an infected fracture is con-
sidered a soft-tissue reaction to the stimulus of fracture
mobility, posttraumatic osteomyelitis (PTOM) is a true
bone infection. The clinical presentation includes se-
vere pain and commonly an orocutaneous fi stula with
purulent discharge.19 These two entities will be distin-
guished radiographically by nuclear scans showing both
an active infl ammatory process in the bone as well as
increased bone turnover.19 The treatment of PTOM has
evolved in response to the availability of improved rigid
fi xation systems. PTOM may be managed in single or
multiple stages. An open approach to the fracture al-
lows the wide exposure required. Any failed hardware
is removed. Wide bone debridement to healthy bleed-
ing bone is undertaken. Load-bearing osteosynthesis is
then applied in the form of a reconstruction plate. It is
essential that the screws be placed in healthy bone. A
suction drain is placed in the wound. If the amount of
debridement required has resulted in a segmental de-
fect, the decision must be made as to whether primary
cancellous bone grafting will be performed. Alternative-
ly, the patient may be placed on intravenous antibiotics
and brought back for the bone graft after the infection
has cleared. Kellman19 reported results of primary bone
grafting and rigid fi xation in 14 patients with PTOM. Ini-
tially, bone grafting was performed as a secondary pro-
cedure. Later in the clinical experience, primary plating
and bone grafting were instituted. All of the patients
went on to union with no further complications, con-
fi rming the safety of this approach.
One factor that diff erentiates bone from many other
tissues in the body is its ability to replace small gaps
in tissue with bone instead of scar. As described ear-
lier, bone ingrowth into the fracture site occurs by two
processes, depending on the degree of movement at the
fracture site. The growth factors and early cellular infi l-
trates that characterize a fracture hematoma are simi-
lar to those involved in soft-tissue wound healing. It is
not surprising, then, that if osteogenesis is hampered
in the early wound (increased fragmentary motion, in-
fection, necrosis), bone healing is delayed and fi brous
tissue ingrowth occurs by default. Certain conditions
at the fracture site promote fi brous ingrowth over os-
teogenesis.13 The duration until bony union under op-
timal repair conditions has been defi ned as four weeks
in children, six weeks in adults, and eight weeks in the
elderly.12,13 These time frames were more clinically rel-
evant when closed reduction was the primary modal-
ity for treating mandible fractures, because the time to
healing determined the length of treatment. However,
in the age of rigid fi xation, the concept of delayed union
that both the tension zone and the compression zone
along the inferior border of the mandible be stabilized.15
Although the ideal osteosynthesis line originally de-
scribed by Champy does not mandate the use of supe-
rior and inferior border plates for fi xation of the body
and angle, there is debate among surgeons regarding
the ideal arrangement of fi xation in these regions, given
higher rates of infection in these areas of the mandible
despite rigid fi xation.3,17
It is clear from historical outcomes that if the bio-
mechanical forces and principles of osteosynthesis
are respected, the application of rigid fi xation will be
successful most of the time. If, however, the hardware
fails to achieve its goals, it becomes a foreign body
and therefore an additional catalyst for infection. The
physical fi ndings in a patient with an infected mandi-
ble fracture include edema over the fracture site, pain,
mobility of the fracture segments on palpation, puru-
lent drainage, or hardware exposure.1 When we recall
that most infected mandible fractures arise in the set-
ting of fragmentary motion, it follows that treatment of
this complication requires proper fi xation of the mobile
segments.1,18 Treatment calls for incision and drainage
of abscess collections, removal of ineff ective hardware,
and the establishment of fracture immobility. Maxil-
lomandibular fi xation, stronger internal fi xation, or an
external fi xator are all ways this can be achieved. Teeth
in the fracture line are often extracted once an infection
or healing delay has developed.1 Any devitalized tissue
must also be debrided. Although it may seem counter-
intuitive to place hardware into an infected fi eld, it must
Fig. 13.1 The ideal mandibular osteosynthesis line. This line,
defi ned by Champy, marks the optimal location for the ap-
plication of rigid fi xation. Used with permission from Costan-
tino PD and Wolpe M. Facial Plating Systems. In Papel ID, ed.
Facial Plastic and Reconstructive Surgery. New York: Thieme;
2002:769–781.
Complications in Facial Plastic Surgery
108
that 73.5% of patients with greater than 5 mm of frag-
ment displacement had hypesthesia based on pretreat-
ment sensory testing, compared with 25.8% of patients
in which the fracture was not displaced. Over all, 58%
of their patients had hypesthesia immediately after the
mandibular injury, with 46.6% reported to have some
persistent sensory defi cit after one year. In most of these
cases, the residual defi cit was mild, and many patients
were subjectively unaware of signifi cant hypesthesia.
Patients who were edentulous had worse rates of recov-
ery. Marchena et al.28 also published long-term follow-
up data. The incidence of immediate postinjury sensory
disturbance was 56%. They also found that the degree of
fracture displacement was related to increased rates of
postinjury hypesthesia. Objective testing revealed that
only ⅓ of patients experienced full sensory recovery,
though just 55% had awareness of the defi cit.
Widening of the lower face has been described as a
complication after open reduction internal fi xation of
symphyseal fractures, particularly in the presence of
subcondylar fracture(s) due to a failure to close the lin-
gual cortical side of the fracture. This allows fl aring of
the mandibular angles, which results in the increased
width. To prevent distraction of the lingual cortex, the
plate should be slightly overbent at the line of the frac-
ture to ensure compression of the lingual side. In the
presence of bilateral subcondylar fractures, the angles
should be pushed together to minimize this risk.29
◆Condylar and Subcondylar Fractures
Fractures of the condylar process of the mandible de-
serve individual consideration, because treatment goals
for such injuries diff er from those of injuries to other
areas of the mandible. Successful outcome of treatment
is judged primarily by the presence of unimpaired func-
tion of the temporomandibular joint (TMJ), whether or
not reduction of the fracture is attained.1,30 With the
high performance of titanium fi xation plating systems
and safer methods of approaching the TMJ,31 stricter cri-
teria for successful treatment outcomes can be expected
in the future, including restoration of posterior facial
height and symmetric jaw movements, in addition to
the attainment of premorbid occlusion.32,33
Clinically, unilateral condylar fractures can present
with premature contact of the posterior dentition on
the side of the fracture due to shortened ramus height,
which generally occurs due to the overlap of the frac-
tured fragments.34 The patient will therefore have a
contralateral posterior open bite. The mandible deviates
toward the fractured side because of unopposed action
of the contralateral lateral pterygoid muscle (which is
pulling the contralateral condylar process toward the
midline).35 Bilateral condylar process fractures result in
an anterior open bite (premature contact of the poste-
rior dentition bilaterally), as well as retrognathia.30
takes more of a historical place. Delayed union results
from incomplete healing caused by motion. When max-
illary-mandibular fi xation (MMF) is applied, incomplete
healing due to motion can often be corrected by further
stabilization.13 However, in the presence of a rigid fi xa-
tion appliance, motion generally indicates failure of the
fi xation. Rather than MMF, correction generally requires
removal of loose hardware, usually with the application
of new, stronger fi xation.1,3,12,20
Nonunion, in which the bone edges are in proximity
but fi brous tissue has grown between the edges, can of-
ten be corrected by excising the intervening fi brous tis-
sue that has bridged the bone gap and inserting proper
rigid fi xation, using a load-bearing repair.12,13,21 As men-
tioned previously, bone grafting may be necessary to
bridge any gaps. Large volumes of cancellous bone can
be harvested from the iliac crest or tibia.1,15
Rates of bone healing disturbance described as non-
union have been reported in 1–3% of treated mandible
fractures.12,18 Most patients in a review by Haug and
Schwimmer18 had improper fracture stabilization, ei-
ther because of fl awed application of rigid fi xation or
loosening of closed fi xation devices. Over half of their
patient group developed infections. In Mathog’s series,
9 of 25 patients were identifi ed as having poor fracture
fi xation.12 In both studies, the body of the mandible had
the highest rate of nonunion or fi brous union, which
confi rms the role that weak stabilization plays, as this
region of the mandible is subject to strong forces from
the muscles of mastication.
Malunion results when the bone fragments heal in a
way that does not restore the premorbid occlusion. Al-
though fractures of the parasymphyseal region are read-
ily approached intraorally, the application of plates and
screws to fractures in the posterior body and angle can
be diffi cult transorally.15 If intraoral repair poses diffi cul-
ty for the surgeon, there should be no hesitation about
employing extraoral approaches to avoid compromising
treatment. The surgeon must be meticulous about at-
taining adequate occlusion and must use information
from the patient, past dental radiographs, dental mod-
els, photographs, and the patient’s wear facets to restore
premorbid occlusion. Seemingly minor bony discrepan-
cies can result in obvious changes in occlusion and thus
an unsatisfactory outcome. Minor malocclusions can
sometimes be treated with occlusal grinding,18 but more
signifi cant problems require orthodontic intervention22
and sometimes orthognathic surgery.23–25
The incidence and degree of sensory disturbance in
the distribution of the inferior alveolar nerve (V3) can
be related to the initial trauma or to subsequent surgi-
cal manipulation. The areas of the mandible through
which the inferior alveolar nerve runs are most vulner-
able and are the focus of most reports.26–28 Preopera-
tively, the degree of displacement of the fractured bone
ends has consistently been shown to be correlated with
rates of sensory defi cits. Iizuka and Lindqvist27 reported
13 Complications of Facial Trauma Repair 109
with MMF developed malocclusion, compared to 1 of 28
patients who had the joint opened. Ellis et al.36 found
that at one year follow-up, patients who had closed
treatment were consistently rated to have signifi cantly
higher percentages of poor occlusions compared to cas-
es treated with ORIF. Malocclusion may be the result of
poor reduction of the fracture segments with persistent
ipsilateral premature contact, or it may be the result of
growth interference in a pediatric fracture. The condy-
lar head can partially resorb over time as a response to
the initial injury or from the surgical manipulation re-
quired during treatment.37,41 The malocclusion in these
instances is caused by a shortened vertical ramus height
on the fractured side. For less severe malocclusions, or-
thodontics may be adequate treatment.34 Orthognathic
surgery can correct the malocclusion by using osteoto-
mies to reposition the proximal ramus and restore the
ramus height in more severe cases.24,41 This is a success-
ful approach for unilateral cases. A vertical ramus os-
teotomy allows the proximal segment to be positioned
superiorly to equalize the ramus heights. If anterior or
posterior repositioning is required, a sagittal split oste-
otomy is performed.41
When planning orthognathic surgery to correct trau-
matic dental-skeletal anomalies, the surgeon must use
an approach that not only corrects malocclusion but
also repositions the bone fragments in a stable manner
to avoid relapse. This may mean performing osteoto-
mies away from the site of the initial injury.42 Superior
movements and clockwise rotation of the mandibular
ramus are stable, while inferior positioning of the ra-
mus and counterclockwise rotation are unfavorable.43
Although one option to correct an anterior open bite
would involve bilateral mandibular ramus osteotomies,
the resulting counterclockwise rotation of the distal
segments required to restore occlusion is a situation
prone to relapse. Alternatively, the anterior open bite
may be corrected by a LeFort I osteotomy with posterior
impaction of the maxilla.23 This allows autorotation of
the mandible superiorly with closure of the open bite.
When condylar/subcondylar fracture patients are
treated with MMF, the premorbid condyle position is
not always achieved. Often the condylar process is dis-
placed in such a way that the fracture segments overlap,
or the condyle may not be positioned upright. Either of
these situations shortens the total height of the posteri-
or mandible and may result in decreased posterior facial
height and facial asymmetry.32,34 In a study of posterior
facial heights of patients undergoing closed or open
reduction, Ellis32 found a statistically signifi cant diff er-
ence between the fractured and nonfractured sides in
patients treated with closed reduction (mean of 5 mm
decreased posterior facial height at two years follow-
up). Most patients achieved functional occlusion; how-
ever, their facial appearance was not commented upon,
so it is not clear how directly the change in ramus height
translated to obvious facial asymmetry.
It is important to consider initial treatment options,
for certain types of therapy and aftercare may decrease
complication rates. First, it should be pointed out that
though many have advocated closed reduction using
MMF, it is in fact a misnomer, as MMF does not result
in reduction of the fracture, although it can restore the
occlusion. For many years, closed reduction of condylar
fractures was used almost exclusively. The main factors
guiding this preference were functional adaptation at
the joint, reasonably good occlusal outcomes, and the
high complication rates experienced with open reduc-
tion, particularly the unsavory complication of facial
nerve paralysis.18,30,34,36
Functional adaptation is the ability of the masticatory
muscles to continue to function despite imperfect reduc-
tion of the condylar process after fracture.37 Since this in
fact occurs, treatment of condylar fractures focuses on
occlusal guidance.30 Training elastics attached to arch
bars are applied so that the teeth are guided into occlu-
sion. In many centers the standard treatment of the ma-
jority of condylar fractures has been and continues to be
MMF for a short period (seven to fourteen days) followed
by elastic MMF for occlusal guidance until the patient
can attain a reproducible occlusion.18,34,36 The patient also
begins jaw physiotherapy exercises after rigid MMF is re-
leased. This includes jaw-opening exercises and lateral
excursive movements. Function, despite nonanatomical
reduction, is critical to muscle adaptation and the pre-
vention of TMJ ankylosis, trismus, and growth distur-
bances in pediatric patients.30,35,37,38 In our institutions,
we believe that a period of rigid MMF actually delays the
initiation of physiotherapy, so we prefer to progress im-
mediately to training elastics and physiotherapy.
Zide and Kent39 provided a classically accepted list
of absolute and relative indications for open reduction
of condylar fractures. The absolute indications include
fracture dislocation of the condyle into the middle crani-
al fossa, lateral extracapsular dislocation of the condyle,
an inability to restore occlusion with closed techniques,
a foreign body within the TMJ, an open or penetrating
injury to the TMJ, and a fracture that results in me-
chanical obstruction of TMJ. Open approaches to the
TMJ include the submandibular approach (Risdon), the
preauricular approach, the retromandibular approach,
and the intraoral approach, which may be performed
with endoscopic guidance.15,30,31,34 Stated advantages of
open reduction and fi xation include restoration of ra-
mus height, avoidance of facial asymmetry, the possibil-
ity of immediate function and superior occlusal results
found by some authors, even when absolute indications
are not present.31–34 Few surgeons open fractures of the
condylar head, though this may become more common
in the future as well.34
Several reports have evaluated the development of
malocclusion in groups of patients treated with MMF
versus open reduction and internal fi xation. Worssae
and Thorn40 found that 8 of 24 (30%) of patients treated
Complications in Facial Plastic Surgery
110
Many surgical approaches have been described. All of
the described protocols advocate safe but aggressive
removal of the bony or fi brous lesion. In a series of 14
patients (both pediatric and adult), Kaban et al.44 re-
ported retrospective data with a treatment protocol
that included resection of all abnormal bone, unilateral
or bilateral coronoidectomy to augment mobility, an au-
tologous costochondral graft to replace the condyle, and
lining of the glenoid fossa with a turned-down tempo-
ralis muscle fl ap. All patients were placed in MMF for a
brief time and then enrolled in jaw physiotherapy for
one year. Other surgical approaches call for lining the
TMJ with auricular cartilage or total joint replacement
with an allopastic joint.30,46,47
Growth disturbance of the condyle highlights the im-
portance of restoring normal joint function in the pedi-
atric population.35,47,48 It has been confi rmed by human
and animal studies that fractures heal more quickly in
younger patients.30 Although functional adaptation is
the rule in restoration of joint function in adults, young
children usually experience joint remodeling and reca-
pitulation of the premorbid condyle and fossa anatomy
after treatment.44 The development of scar tissue can
tether the downward growth of the condyle and ramus
if early treatment and therapy are not instituted. Fa-
cial stigma include a shortened ramus on the fractured
side, deviation of the chin toward the fractured side,
and fl attening of the face on the contralateral side.30,48
Dental compensations lead to a posterior crossbite on
the aff ected side. Condylar fractures can be diffi cult to
diagnose in children if the evaluating physician does not
have a high clinical suspicion. The examination may be
limited, especially if the child is anxious. The condylar
fracture may be diffi cult to detect by plain fi lms (man-
dible series), since there is a higher percentage of green-
stick fractures in children.30 It is recommended that a
condylar fracture be suspected in children with trauma
to the chin and conclusively ruled out.30 Distraction os-
teogenesis is being used successfully in the treatment of
the hypoplastic ramus in these patients.48
◆Orbit and Zygoma Fractures
Fractures of the facial bones around the eye can be as-
sociated with globe malpositions. Enophthalmos is
defi ned as posterior displacement of the globe, while
hypoglobus refers to inferior displacement of the
globe.49–51 Increased orbital volume caused by trauma
is the most frequent cause of enophthalmos and hy-
pophthalmos. Other factors contributing to the devel-
opment of enophthalmos include tethering of orbital
contents within an unrepaired fracture and fi brosis and
scar contracture of intraorbital contents.51–55 Atrophy of
intraorbital fat has been, for the most part, discounted
as a signifi cant factor, although actual loss of orbital fat
certainly can be.54
TMJ ankylosis occurs when the joint space is partially
or totally obliterated by fi brous or osseous tissue. Pa-
tients with unilateral ankylosis will have trismus and
deviation to the aff ected side. Reviews of TMJ ankylosis
implicate trauma as the cause in 30–98% of cases.44–46
Although the pathophysiology of ankylosis is not com-
pletely understood, several factors are known to play a
signifi cant role. Bone growth is enhanced in the presence
of hematomas and growth factors released by platelets
within clots. This is felt to be particularly important in
pediatric condylar fractures, because the condylar head
is highly vascular.30,37,47 In addition, damage to the me-
niscus and joint dislocation37 have been correlated with
increased rates of ankylosis. Prolonged joint immobili-
zation during extended courses of rigid MMF, combined
with inadequate adherence to a protocol of jaw motion
exercises, results in decreased TMJ function during con-
valescence. These factors predispose the patient to the
development of ankylosis, although ankylosis can still
develop despite mobilization. When a patient with trau-
matic TMJ ankylosis is encountered, evaluation requires
a maxillofacial CT scan to assess the full extent of the
lesion (Fig. 13.2). As pointed out by Raveh,47 the bony
overgrowth can extend beyond the glenoid fossa to the
adjacent middle cranial fossa and medially along the
skull base.
Surgery is indicated to improve the maximal interin-
cisal opening (MIO), restore joint function, and prevent
future growth disturbance in pediatric patients.44,45,47
Fig.13.2 Coronal CT scan of left temporomandibular joint
ankylosis.
13 Complications of Facial Trauma Repair 111
full restoration of the orbital volume present before
the injury.49,54,60,61 Three to twelve percent of repaired
zygomatico-maxillary complex (ZMC) fractures may be
complicated by enophthalmos.63–66 Hawes and Dortz-
bach found that while 7% of patients who had repair of
the orbital fracture within two months of the injury de-
veloped enophthalmos, 88% of patients presenting for
treatment two months after their injury had enophthal-
mos.59 Catone et al. presented their data on 20 patients
with unrepaired orbital blowout fractures, 15% of whom
developed enophthalmos.58
Malar Flattening and Increased Facial Width
The zygoma makes up the inferolateral orbit through
three of its fi ve projections67 (Fig. 13.4). Volume-en-
hancing vectors of movement include lateral displace-
ment of the zygoma and inferior distraction exacerbated
by the pull of the masseter muscle.56,63 The zygoma con-
tributes signifi cantly to facial form, and its posterior dis-
placement leads to a fl attened malar prominence and
increased facial width from outward bowing of the zy-
gomatic arch54,61 (Fig. 13.4).
Some important technical errors can lead to failures of
primary repair of orbitozygomatic fractures. Adequate
dissection into the posterior orbit is required to identify
the posterior ledge of the fracture, which may extend 40
mm posterior to the infraorbital rim.54,67 Exposure of the
medial orbital wall must be addressed when required,
and this wall is sometimes overlooked.54,56,68 The key
surgical principle in the treatment of zygomatico-max-
illary complex (ZMC) fractures is three-point reduction
of the zygoma and at least two-point fi xation.56,63,67 Two-
point reduction does not ensure that the zygoma is not
rotated at another articulation.56,63,67
Enophthalmos results from fractures of the orbital
walls behind the axis of the globe (Fig. 13.3), which in-
cludes all of the lateral wall, most of the medial wall,
and the posterior aspects of the inferior and superior
walls.54,56 Hypoglobus results from bone loss from the
fl oor at the globe axis.54,56 Bone loss anterior to the globe
axis does not generally aff ect globe position56 (Fig.
13.3). Facial trauma surgeons usually encounter enoph-
thalmos as a delayed complication of orbital blowout
and zygomatic fractures, since only rather severe frac-
tures will present with acute enophthalmos.49,52,57–59
Patients with unrepaired fractures and orbital volume
increases will typically develop enophthalmos weeks
after the injury, once edema has resolved.57,59,60 With
CT scan imaging now a routine part of the work-up in
patients with facial trauma, large-volume fractures
are detected immediately.57,58 The goal of early fracture
management is to predict, based on CT assessment of
the fractures, which patients are likely to develop en-
ophthalmos.57 Many surgeons advocate treating high-
risk fractures within one to two weeks of the injury, at a
point when edema has resolved but before fi brosis has
developed.57–59,61 There have been strong advocates for
a more expectant posture whose justifi cation relied on
a relatively low rate of postinjury enophathlmos and
successful camoufl age treatment when it did arise;62
however, this management philosophy is not commonly
accepted today. Currently, a large-volume fracture (50%
or more of the orbital wall involved) is a clear indication
for exploration and repair.57
Posttraumatic enophthalmos is due to orbital blow-
out fractures and displaced zygomatic fractures.54 Pa-
tients presenting with late enophthalmos generally fall
into two groups: those who were not treated primarily
and those who have had prior surgical repair without
Fig. 13.3 Globe axis. (A) Bone loss at
the axis can lead to changes in vertical
globe position while posterior globe dis-
placement occurs only with bone loss
of the posterior orbital fl oor. (B) Section
located at the axis of the orbit. Some of
the fl oor is anterior to this plane but all
of the lateral wall is posterior to it. Used
with permission from Pearl RM. Treat-
ment of Enophthalmos. Clinics in Plastic
Surgery 1992;19(1):99–111.
A
B
Complications in Facial Plastic Surgery
112
is harder to predict and depends on the degree of nerve
injury. Prolapse of orbital contents can result in both
enophthalmos (delayed) and diplopia and explain why
these symptoms often coexist.54,68 The goals of treat-
ment in this instance are volume restoration with globe
repositioning and improved extraocular muscle func-
tion after it is released from the constraint of the frac-
ture.54–56,60,68 The increased use of endoscopic approaches
to the repair of orbital blow-out fractures off ers several
advantages in terms of visualization and avoidance of
a lower lid incision. Application in the right cases and
recognition of the limitations of this approach are im-
portant factors in adequate repair with the endoscopic
technique. Endoscopy via the transantral route also has
a role as an adjunct to standard eyelid approaches to
Diplopia
Persistent diplopia may occur in patients after timely
primary fracture repairs. Diplopia in the acute setting
has several causes, which can be broadly categorized as
mechanical or neurogenic. Extraocular muscle entrap-
ment, edema, or hemorrhage (either in combination
or isolation) may contribute to mechanical restriction
of globe motion. Injury to the motor nerve of an extra-
ocular muscle represents a neurologic cause of diplopia
after orbitozygomatic trauma.58,68 As might be expected,
postoperative resolution of diplopia is variable, depend-
ing on its cause. Edema should resolve with a gradual
improvement of diplopia over one to two weeks.57 The
course of recovery of diplopia from a neurogenic cause
Fig. 13.4 Zygomatico-maxillary complex (ZMC) fractures occur
when the fi ve projections of the zygoma are disrupted. (A) Coronal
CT scan showing fractures at the zygomatico-frontal articulation,
the orbital fl oor and the zygomatico-maxillary articulation. (B)
shows disruption of the zygomaticosphenoid articulation and (C) is
an axial CT scan demonstrating the fractured zygomatic arch.
A
B
C
13 Complications of Facial Trauma Repair 113
Vision Loss
Severe vision loss has been reported in 0.8–1.6% of cases
in recent reports of facial fractures involving the orbit or
trauma to the periorbital structures.71–73 Incidences are
higher when direct trauma to the globe is considered.74
Visual loss may develop after the initial presentation
but before any planned surgical intervention.74 Because
many orbitozygomatic fractures can be managed elec-
tively, patients must receive adequate counseling so
they are familiar with the signs and symptoms of orbital
pathology that should cause them to seek medical at-
tention before the scheduled date for their operation.
Visual impairment is a rare complication of facial frac-
ture surgery that has been reported in 0.3% of ZMC frac-
ture repairs.72,74 Girotto et al. reported a 0.24% incidence
of blindness after repair of 1240 midfacial fractures
over a 10-year period.74 The most common reason for
blindness after surgery to repair facial fractures in the
orbital region is the development of a retrobulbar hem-
orrhage.72,75–77 Blindness that develops in the absence of
this fi nding is caused by traumatic optic neuropathy or
other perioperative conditions that decrease end-organ
perfusion.72,74,78,79
Retrobulbar Hemorrhage
Retrobulbar hemorrhage usually occurs secondary to an
arterial bleed in the orbit, either from the infraorbital,
anterior, or posterior ethmoid arteries.76,77,80 The ensuing
hematoma causes increased intraocular pressure, which
leads to compression of the arteries that supply the optic
nerve and results in ischemia.76–78,80 Irreversible loss of
ganglion cells in the optic nerve can occur within 90 min-
utes,81 so the development of this complication is a true
surgical emergency. The clinical fi ndings associated with
retrobulbar hemorrhage include proptosis, pain, subcon-
junctival hemorrhage, sluggish or absent aff erent pupil-
lary refl ex, Marcus Gunn pupil, and loss of vision.75–78,80 A
CT scan should not be pursued if there are clear physical
fi ndings, because the time needed to acquire it will delay
treatment and further threaten vision.77,80
Protocols for the management of retrobulbar hemor-
rhage have been outlined and are summarized in Table
13.1.76–78,80 An immediate decrease in the intraocular
pressure can be accomplished at the bedside by per-
forming a lateral canthotomy and inferior cantholysis
under local anesthesia. This allows the lower eyelid to
be distracted from the orbital rim and may allow partial
evacuation of the clot.77,78 Orbital incisions used to gain
access to the fracture may need to be opened (transcon-
junctival or subciliary) and the clot expressed through
them.77 Medical therapy can help reduce intraocular
pressure (mannitol, acetazolamide, or timolol eye drops)
and may be protective by decreasing the generation of
the by-products of ischemia, such as oxygen free radi-
cals (high doses of steroids); specifi c dosing regimens
confi rm complete reduction of the orbital contents and
proper placement of fl oor implants.69
Several aspects of the residual injury can be quanti-
fi ed. Zygomatic fractures may present with all of these
secondary fi ndings, while orbital blowout fractures are
less often associated with the facial deformities outlined
below. Posterior globe displacement is well visualized
from the worm’s eye or bird’s eye view. A Hertel exoph-
thalmometer quantifi es globe projection by measuring
the projection of the orbit relative to the lateral orbital
rim.49,54,60 Any diff erence greater than 3 mm between the
globes is abnormal,49,68 though diff erences of 1–2 mm
may be noticeable on some people. When the lateral or-
bital rim is displaced (as may be the case in a ZMC frac-
ture) a Naugle exophthalmometer is used—the reference
point is the forehead.54 From the worm’s eye view, the
distance between the brow and the upper lid may be re-
vealing as well. Vertical globe dystopia from hypoglobus
(hypophthalmos) can result in an inability to level the
planes of the retinas, with splitting of images even in the
primary gaze.68 Superior sulcus deformity and pseudo-
ptosis of the upper lid may also be seen (Fig. 13.5). The
lateral canthus can be inferiorly displaced if the fracture
of the lateral orbital wall is superior to Whitnall’s tu-
bercle (the attachment point of the lateral canthal ten-
don).49,51,52,54 As the zygoma is pulled inferiorly, so too is
the lateral attachment of the eyelids, giving a downward
slant to the palpebral fi ssure. Malar fl attening and in-
creased facial width are common hallmarks of displace-
ment of the zygoma.61,63 Ptosis of cheek soft tissues with
deepening of the nasolabial fold and an aged appearance
may accompany the initial injury or result from failure
to properly resuspend the soft tissues after surgery.54,70
Descent of the cheek soft tissue can contribute to lower
eyelid displacement.
Fig. 13.5 Right superior sulcus deformity and hypoglobus.
The patient had complex frontal sinus and orbital fractures.
Titanium mesh used to reconstruct the anterior table of the
frontal sinus became infected and was ultimately removed.
Complications in Facial Plastic Surgery
114
compression, removal of scarring, and excision of a neu-
roma if present, with neurorrhaphy and endoneurial or
perineurial repair depending on the degree of injury.
Specifi c indications for this procedure include worsen-
ing sensory defi cit and dysesthesia or paresthesia that is
intolerable to the patient.87 Some patients may develop
dysesthesia afterward, so careful patient selection and
preoperative counseling are advised.
Anisocoria
Posterior exploration of the orbit to identify the edge
of the orbital fl oor fracture may result in injury to the
ciliary ganglion where the parasympathetic nerve fi bers
synapse en route to the sphincter of the iris. The action
of the ciliary nerve results in pupillary constriction. An-
isocoria is unequal size of the right and left pupils. In
this case, mydriasis of the pupil of the operated eye is
the cause. The pupil is reactive, but in certain instances
a tonic pupil develops.88 This condition results from an
injury that directly involves the ciliary ganglion or the
postganglionic fi bers (short ciliary nerves) that inner-
vate the sphincter of the iris. Preganglionic fi bers run
in close proximity to the inferior oblique and inferior
rectus muscles. Elevation of these muscles out of the or-
bital fl oor fracture may traumatize these nerve fi bers.
Reported cases of postsurgical anisocoria show this con-
dition to be self-limited.88,89
◆ Late Considerations of
Orbitozygomatic Trauma
Implant-associated complications can be seen in the use
of autogenous or alloplastic materials. Generally, autoge-
nous materials are more resistant to infection and extru-
sion. Alloplastic implants diff er in terms of permanence
(resorbable vs. non-resorbable). However, alloplastic
implants have a lifetime risk of infection, migration, and
extrusion (Fig. 13.6). Porous implants allow some vas-
cular ingrowth, which potentially imparts resistance to
infection and improves fi xation to the wound bed.
Ophthalmologic examination is a prerequisite to any
corrective orbital surgery. CT scans in axial, coronal, and
sagittal planes are routinely obtained. 3-D reconstruc-
tions can be obtained to assess posttraumatic (residual)
deformities of the zygoma. CT-based navigation systems
are now being used at several centers to simulate the
osteotomies and movements required to restore the
premorbid zygomatic position.70,90,91 The fi nal position
of the bone is then registered, and markers are placed
on the bone intraoperatively to transmit the position
and movements in space until the predetermined posi-
tion is reached.70,90,91 Stereolithography is a more recent
adjunct used for model surgery and planning.70 Stereo-
lithographic models reproduce the craniofacial skeleton
have been outlined.76–78,80 Generally, medical therapy
is adjunctive and may allow the situation to be tempo-
rized until the patient can be brought to the operating
room for formal exploration or decompression. Certain
protocols suggest instituting medical therapy once the
diagnosis has been made and using the stability of vi-
sion to determine whether formal decompression is re-
quired.80 Orbital decompression may be accomplished
through a variety of approaches.77,78 It is essential to
recognize a retrobulbar hemorrhage in the postopera-
tive period to prevent signifi cant visual loss. A clearly
defi ned and strictly followed postoperative regimen of
visual checks is the best way to ensure close monitoring
of the patient’s vision.75 We use a regimen for monitor-
ing that has also been described in the literature75,80: vi-
sion checks are performed every 15 minutes for the fi rst
hour, every 30 minutes for the second hour, and hourly
until the next day.
Trigeminal Nerve Paresthesia
Alteration of sensation in the distribution of the infraor-
bital nerve branch of the fi fth cranial nerve (V2) is one
the most common complications of fracture treatment
in this region. At initial presentation, 80–94% of patients
with orbitozygomatic fractures have sensory distur-
bance of the V2.82,83 Reports of 40–50% of patients with
some persistent sensory disturbance, whether surgery
or observation was chosen, confi rm the high prevalence
of this complication.84–86 Rigid fi xation of ZMC fractures
has been shown to result in greater rates of sensory re-
covery compared with closed or open reduction with-
out fi xation.85,86 Some patients may suff er from chronic
pain in the V2 distribution, which is confi rmed by an in-
fraorbital nerve block.87 Decompression of the nerve as
it exits the infraorbital foramen at the time of fracture
repair has a positive eff ect on sensory recovery.87 Mi-
crosurgery of the infraorbital nerve has been discussed
in the literature recently. Procedures include nerve de-
Table 13.1
Management of Retrobulbar Hemorrhage
a. Perform immediate lateral canthotomy and inferior can-
tholysis at the bedside under local anesthesia with opening
of surgical incisions (transconjunctival or subciliary).
b. Contact an ophthalmologist for urgent consultation.
c. Initiate medical decompression of intraorbital pressure
(mannitol, acetazolamide, timolol eye drops).
d. Return the patient to the OR for surgical exploration, evacu-
ation of any hematoma, control of hemorrhage, and orbital
decompression.
13 Complications of Facial Trauma Repair 115
of the periobita53,60,68 has been advocated, but more re-
cent surgical descriptions support directed dissections
of the tethered areas.54,55 Dissection must allow ad-
vancement of the orbit to correct the enophthalmos. The
surgeon assesses the potential for orbital advancement
intraoperatively by performing the forced traction test.54
Techniques to correct enophthalmos after chronic
ZMC fractures use many of the techniques outlined
above with some important diff erences. Surgical goals
not only include correction of functional impairments
(diplopia and lower lid dysfunction) but also must ad-
dress malar and other periorbital deformities more
commonly associated with zygomatic fractures. Dis-
placement of the lateral wall is usually the main con-
tributor to increased orbital volume in a ZMC fracture,
with orbital fl oor disruption usually being a less signifi -
cant source.56 Both the volume enlargement and malar
hypoplasia can be corrected by onlay grafting alone,
as described by Freihofer.94 For more severe displace-
ment, the zygoma is osteotomized and repositioned.
It is then placed back to a more anatomical position,
restoring malar projection and decreasing intraorbital
volume.49,54–56 Despite this movement of the zygoma, the
orbit often must be explored to repair any concomitant
orbital fl oor fracture with an onlay graft.56 Often the
original fracture lines can be identifi ed and osteoto-
mized to free the bone. Intraorbital bone cuts begin at
the inferior orbital fi ssure63 and proceed anteromedially
toward the infraorbital rim and superolaterally through
the zygomatico-sphenoid suture to meet the osteotomy
through the zygomaticofrontal suture.55,56 An osteotomy
along the anterior face of the maxilla and then through
the zygomatico-maxillary suture is connected to the os-
teotomy along the temporal aspect of the zygoma. Final-
ly, the zygomatic arch is osteotomized63 (Fig. 13.7). Bone
grafting may be required once the zygoma is reduced to
span defi cits created by the bone movement. Variations
in surgical technique center on the type of exposure ob-
tained, the amount of intraorbital dissection performed,
and (more recently) the use of models and or CT navi-
gation systems. Mathog et al. reported the results of
surgical correction of enophthalmos, diplopia, or both
in a series of 38 patients.60 Only two of the thirty-eight
patients had persistent enophthalmos greater than two
millimeters postoperatively. Twenty patients suff ered
from diplopia, with 15 experiencing resolution and four
patients improvement.60 Surgical methods included
multiple approaches to the orbit, 270 degree periorbital
dissection, and directed placement of bone grafts at the
sites of defi cits. Other reports suggest less optimistic re-
sults when orbital blowout fractures are repaired after
signifi cant time delays.59 This fi nding suggests the need
for more aggressive orbital dissection to free scarred tis-
sues and advance the globe and also suggests that the
persistent posttraumatic diplopia seen in many patients
may not be correctable.
and can then be sectioned so the zygoma is reduced to
its premorbid position. This technology, while adding
additional expense, has the advantage of improving pre-
cision and possibly decreasing the time of the operation.
Several approaches allow access to the orbit and zygo-
ma, including the transconjunctival approach via a pre-
or postseptal route.14 The subciliary incision is perhaps
more direct but has a higher rate of ectropion, and most
surgeons have abandoned the direct infraorbital lower
lid incision because of poor exposure and signifi cant
problems with lower lid edema. Additional incisions
that can facilitate exposure of the orbit and malar com-
plex include the medial canthal (Lynch), coronal, lateral
brow, upper blepharoplasty, and the upper gingivobuc-
cal sulcus incisions. Descriptions of their execution are
detailed elsewhere.14,25,53,54,56,92–94
The benefi ts of late correction of orbitofacial deformi-
ty and diplopia must be explained to the patient in the
context of both the surgical risks and the realistic out-
comes of surgery. The risks include vision loss (includ-
ing blindness), worsening of diplopia, hypesthesia of the
maxillary nerve (V2), retrobulbar hemorrhage, implant
extrusion, and lower lid shortening.51,54,94,95 Although
these risks are similar to those encountered when pri-
mary surgery is performed, they are heightened in the
chronic orbit, where scarring has set in and anatomic
landmarks may be distorted. Chronic diplopia may not
completely resolve and occasionally worsens. The pa-
tient should also be informed that improvement may
require several stages.54,96–98 Patients with persistent
diplopia after secondary reconstructive attempts should
consider prisms or strabismus surgery, in consultation
with an ophthalmologist.52,99
The volume enlargement that results after orbital
blow-out fractures is corrected by onlay grafting.54,68,95
Grafts are placed at the globe axis to correct hypoglo-
bus and along the posterior orbital fl oor or medial or-
bital wall to address enophthalmos.51,56 Using the same
techniques that are employed in the acute setting, the
surgeon explores the orbit, and the orbital contents are
reduced. Traditionally a nearly circumferential elevation
Fig. 13.6 Extruding orbital implant with ectropion.
Complications in Facial Plastic Surgery
116
mal crest.102,103 NOE fractures result in lateral displace-
ment of the medial orbital wall and the tendon along
with it. The normal distance between the medial canthi
is 30 mm.104 Telecanthus is one of the central physical
fi ndings and should be quantifi ed. Epicanthal folds and
rounding and displacement of the medial commissure
inferiorly and anteriorly complete the medial orbital
deformity.53,103,105,106 The nasal bones and septum are of-
ten fractured as well, resulting in collapse of the nasal
dorsum and a saddle nose deformity.100,103,105 The nasal
length is shortened from the telescoping eff ect of the
nasal bone collapse.100,103,105 Loss of dorsal nasal height
often exaggerates the appearance of telecanthus and ex-
acerbates the development of epicanthal folds.
Complications of NOE fractures include their accom-
panying orbital and nasal deformity.105 Stabilization of
the medial canthal tendon aims to neutralize the forces
that tend to pull the canthus laterally. If the medial can-
thus is attached to a large, stable bone segment, it can be
osteotomized and reduced to correct the deformity.105
If a more severe disruption of the canthal attachment
is present, the tendon itself is wire-fi xated and medial-
ized by securing the wire transnasally to the contralat-
eral supra-orbital rim or medial orbit.101,103,105 The wire
is threaded through the remaining lacrimal bone pos-
terior to the lacrimal fossa. It is essential that the ten-
don be pulled in a superior-posterior direction.101,102,105
Saddle nose deformity is managed with autogenous or
alloplastic grafting materials. Cranial bone grafts and
Cheek soft tissues are suspended superolaterally to ei-
ther correct or prevent tissue ptosis. This complements
correction of lower lid distraction by decreasing the
downward pull of the cheek soft tissue on the lower lid.
Suspension with an appropriate vector, as executed in
rhytidectomy surgery, should be performed.54,61,95 Often
superior reduction of the zygoma will restore the posi-
tion of the lateral canthus.49,56 Otherwise, lateral cantho-
pexy is performed.54,56,61
◆Naso-orbital-ethmoid Fractures
The naso-orbital-ethmoid (NOE) region represents the
anatomic convergence of several subunits of the mid-
face. The importance of injury in this area is heightened
by its border with the frontal sinus and anterior skull
base.100 NOE fractures include disruption of the angular
process of the maxilla, the medial orbital wall, the medi-
al infraorbital rim, the pyriform aperture and the lateral
nasal wall.101 These fracture lines are the boundaries of
what is known as the central segment (Fig. 13.8). It con-
tains the medial canthal tendon, and its proper reduc-
tion is essential for restitution of the form and function
of the tendon. The medial canthal tendon attaches to
the lacrimal bone via three extensions of the orbicularis
oculi muscle. A horizontal limb attaches to the anterior
lacrimal crest, a vertical (superior) limb attaches to the
frontal process of the maxilla at its articulation with
the frontal bone, and the third (posterior) limb inserts
posteriorly to the lacrimal sac on the posterior lacri-
Fig. 13.7 Zygomatic osteotomies to mobilize the zygoma for
correction of malunion. These include the suture lines at the
zygomatic articulations and an osteotomy along the orbital
fl oor. Used with permission from Longaker MT and Kawamoto
HK. Evolving Thoughts on Correcting Posttraumatic Enoph-
thalmos. Plast Reconstr Surg 1998;101(4):899–906.
Fig. 13.8 Naso-orbital-ethmoid fracture. The boundaries
of the fracture segment that defi ne the central segment to
which the medial canthal tendon attaches are demonstrated
on the CT scan of this patient
13 Complications of Facial Trauma Repair 117
use of Adams suspension wires to prevent facial elon-
gation actually resulted in rotation and foreshorten-
ing.115 A simultaneous palatal fracture allows changes
in the transverse dimension and a resulting posterior
crossbite.114 Often a midfacial fracture is a component
of a panfacial fracture, and malunion of other areas of
the facial skeleton may be preventing proper reduction
of the midface. A thorough survey of these other areas
should be undertaken.
Late malocclusion that results after maxillary frac-
tures is approached in the same way as other dentofa-
cial abnormalities. The evaluation includes maxillofacial
CT scans with true coronal images, a lateral cephalo-
gram, and Panorex for assistance with presurgical plan-
ning.25,43,113 Dental models are also obtained and mounted
on an articulator to recreate the malocclusion.25,43,113
Model surgery is performed to simulate the osteotomies
that will be performed intraoperatively.43 The LeFort I
osteotomy is the mainstay of corrective surgery.23 Seg-
mentation of the maxilla may be used to correct trans-
verse defi ciency, and asymmetric impaction procedures
(posterior>anterior for an anterior open bite) are varia-
tions that can be employed to correct more complex
malocclusions.23
◆Frontal Sinus
Many classifi cation systems and treatment algorithms
exist to guide management of frontal sinus frac-
tures.116–122 Simply put, treatment seeks to reduce the
fracture and restore proper function. In certain injuries,
however, attempts at restoration of function potentially
lead to life-threatening complications.117,118,121,123,124 Of all
the regions of the facial skeleton discussed thus far, the
frontal sinus is the one area in which lack of function is
an outcome that the patient can tolerate.118,121,125,126
Over all, complication rates after frontal sinus trau-
ma range from 0 to 67%.116–119,122,124,126 Major complica-
tions listed in multiple case reviews are cerebrospinal
fl uid leak (2–10%116–118,121), mucocele or mucopyocele
(1–6%116,117,121), frontal sinusitis (1–19%116,118,119,121,124,126)
meningitis (1–4%116,117,121,123,124), and other intracranial
infections (2%124,126). Other complications often con-
sidered to be minor are forehead deformity, forehead
numbness, and chronic frontal headache in the absence
of drainage problems.118,121,126 The incidence of some
complications is diffi cult to defi ne, because of the de-
lays in presentation and lack of patient follow-up that
are sometimes characteristic of frontal sinus fractures.
When complications arise, several central questions
should be considered: (1) Has the forehead contour
been reestablished? (2) Can the sinus function reliably?
(3) Are the dura/intracranial contents separated from
the sinus? Most classifi cation schemes divide frontal
sinus fractures into three main groupings118–121,123: (a)
anterior table fractures with or without displacement
costochondral grafts are most frequently used.100,101,105
The use of alloplastic materials for dorsal augmentation
has shown success, but caution is advised.
Injury to the lacrimal system requiring a secondary
bypass procedure may occur in 17–24% of NOE frac-
tures.106–108 Soft-tissue injury to the medial lower eyelid
is another signifi cant cause of obstruction of the naso-
lacrimal system.109 Compression of the lacrimal sac or
bone fragments of the nasolacrimal duct during surgi-
cal manipulation to accomplish reduction can also pro-
duce obstruction.106 Nasolacrimal injuries will result in
epiphora and persistent stenosis that may lead to dac-
ryocystitis.51,106,110 In some instances, the obstruction is
temporary, and defi nitive management should be post-
poned because some patients will regain function three
to six months after the injury.107,110 In patients with
midfacial fractures, the distal portion of the nasolacri-
mal system is most often injured.107,108 It is important
to recognize more proximal injuries, particularly to the
inferior canaliculus, because primary repair over a stent
may prevent long-term sequelae.111 Prophylactic stent-
ing of the nasolacrimal duct is recommended in signifi -
cant injuries in the area of the lacrimal fossa or the bony
canal.112 Spinelli et al. placed lacrimal stents (Guibor
silicone tubes) in all patients with NOE fractures. Of 19
patients, only three developed epiphora, which spon-
taneously resolved in all.112 The duration of intubation
varied among the group of patients. The Jones I and II
tests are used to determine the site of obstruction.106,112
Dacryocystography is performed by cannulating the
lower canaliculus and injecting radiopaque dye, after
which an anterior-posterior skull X-ray is taken, which
should identify the site of the lesion.106 Initially, conser-
vative therapy is attempted, consisting of lower eyelid
massage and the application of steroid eye drops to the
medial fornix.106 If drainage problems persist, a dacryo-
cystorhinostomy (DCR) can bypass the obstruction by
diverting drainage from the lacrimal fossa into the nasal
cavity.106,107 More proximal injuries require additional
oculoplastic techniques to reestablish drainage.106
◆Midfacial Fractures
Malocclusion is one of the most signifi cant negative
functional sequelae of fractures of the maxilla.25,113 As
discussed in the section on mandible fractures, the
same principles of bone healing apply to the maxilla.
However, delayed union and nonunion are less frequent
complications, as the maxilla is subject to lower func-
tional loads.7 Facial height and width alteration are
commonly seen after malunion, in addition to an an-
terior open bite malocclusion secondary to posterior-
superior rotation of the maxilla.114 This results when
MMF is not established before placement of rigid fi xa-
tion, along with failure to disimpact an impacted max-
illa.114 It was also more common in the past, when the
Complications in Facial Plastic Surgery
118
bility of frontal sinus obliteration to every injured naso-
frontal duct.129–133
With these considerations in mind, several reasonable
management options may be chosen. First, repair of the
anterior table fracture alone is performed. The patient
must adhere to a close, regular follow-up with a sinus
CT scan, initially at six-month intervals. If a complication
develops, surgery is off ered to improve sinus drainage via
endoscopic techniques, or the sinus is obliterated.132–134
Reestablishment of nasofrontal duct function has the
potential to obviate the need for sinus obliteration, un-
less patency is not restored. The modifi ed Lothrop or Draf
III procedure allows widening of both nasofrontal ducts,
with removal of the intersinus septum and a portion of
the frontal sinus fl oor.129,130 Less extensive endoscopic
procedures include simply stenting the duct for several
months.118,119 Har-el and Kennedy support the use of endo-
scopic sinus surgery for the treatment of mucoceles.135,136
Mucoceles are mucous-fi lled cysts that emanate from
remnants of respiratory mucosa in the frontal sinus.137
Impaired sinus drainage allows them to expand into ad-
jacent structures, including the orbit, ethmoid sinus, and
brain.135–137 A mucopyocele is an infected mucocele. Tra-
ditionally, mucoceles are treated aggressively with wide
exposure and removal of the cyst.135,136 Cranialization may
be necessary if the mucocele has resulted in destruction of
the posterior table of the frontal sinus. The goal of endo-
scopic management is to marsupialize the mucocele and
improve sinus drainage by using the extended frontal si-
nusotomy procedures described above.135,136
Success with endoscopic frontal sinus surgery has
disproven the notion that frontal sinus function can-
not be reestablished by operating on the nasofrontal
duct.118,119,129,130,132,133 Now more than ever, management
of frontal sinus fractures includes endoscopic techniques
for both observation and treatment. If endoscopic meth-
ods are ineff ective, traditional frontal sinus obliteration
is available as a salvage operation. It should be under-
scored that complications after frontal sinus trauma can
present after a long delay, sometimes many years after
the initial injury.116,119,137 Long-term yearly follow-up of
patients is widely advocated to allow the detection of
functional sinus problems before a more serious com-
plication develops.127,137
◆Soft-Tissue Trauma
Scar contracture, webbing, notching, hypertrophic or
keloidal scars that violate subunits or relaxed skin ten-
sion lines, and soft-tissue depression are among the un-
desired outcomes after soft-tissue trauma healing.138–142
Associated functional defi cits can include ectropion,
entropion, epiphora, lagophthalmos, alar stenosis, lip
incompetence or oral commissure webbing with drool-
ing, and ear canal stenosis with conductive hearing loss.
Scar revision procedures, as well as techniques used in
or comminution, (b) bitabular fractures with signifi cant
disruption of the posterior table [these fractures usually
involve the frontal sinus outfl ow tract (the nasofrontal
duct) with exposure of dura or brain], and (c) fractures
of the frontal sinus outfl ow tract with an intact (or
minimally disrupted) posterior table. The latter fracture
pattern is usually seen when an anterior table fracture
extends onto the fl oor of the sinus or when a concomi-
tant NOE fracture is present.118,120,127
Complications arising from the fi rst group (group a)
include persistent forehead deformity or failure of allo-
plastic frontal cranioplasty.118,119,123 Correction involves
replacement of missing or displaced bone segments.
Autogenous split calvarial bone grafts can be safely har-
vested and may be contoured to recreate the preinjury
forehead contour.128
The second group (group b) represents the most se-
vere injuries, for there may be a signifi cant brain injury
and concomitant fractures of the skull base. Neurosur-
gical consultation is usually mandated. Sinus function
may need to be sacrifi ced because of the high risk of
intracranial infection. In these instances, cranialization
removes the posterior table of the sinus and all sinus
mucosa lining the remaining anterior wall. The frontal
ducts must be obliterated to seal off and compartmen-
talize the nasal cavity below.125 Cranialization itself is
not without complications, which include mucocele or
mucopyocele, cerebrospinal fl uid leak, pneumocepha-
lus, meningitis, or other intracranial infections that can
result when a watertight and airtight seal does not ex-
ist between the sinus and brain.117,118 Exploration in the
setting of one of these complications must identify and
reseal the frontal ducts and ensure that the dural repair
is intact.119,125 Reinforcement of the anterior skull base
with a pericranial fl ap during the initial cranialization
may prevent communication between the sinus and in-
tracranial cavities.123,127
Nasofrontal duct injury (the third group, c) can result
in permanently impaired sinus drainage with the devel-
opment of frontal sinusitis, mucocele or mucopyocele,
or osteomyelitis of the frontal bone.124 In the setting of a
co-existing posterior table fracture that does not require
cranialization, these complications carry the more sig-
nifi cant potential consequence of intracranial extension.
Historically, high rates of these complications and the
inability to reestablish duct function bolstered recom-
mendations that sinus function be sacrifi ced in this set-
ting.124,126 To accomplish frontal sinus obliteration, the
surgeon removed mucosa from the frontal sinus cavity
and occluded the nasofrontal duct to prevent the growth
of respiratory mucosa from the middle meatus, creating
a safe sinus.122,127,129 Until recently, frontal sinus oblit-
eration using an osteoplastic fl ap to access the frontal
sinus was considered the gold standard treatment op-
tion.116,118,127,130 The success of endoscopic frontal sinus
procedures for the treatment of chronic sinus disease,
however, has prompted a reexamination of the applica-
13 Complications of Facial Trauma Repair 119
in its course along the masseter muscle.143,144,146–148 Proxi-
mal injuries or intraglandular injuries may not be ame-
nable to repair, and distal injuries (beyond the anterior
edge of the masseter) can be successfully managed by re-
implantation of the distal stump to reestablish intraoral
drainage.143,145,146,148 Microsurgical techniques are readily
adapted to use in the management of acute duct inju-
ries.145 A stent is placed in the duct for 7–21 days.143–146
The complications that accompany parotid duct inju-
ries include sialocele, salivary fi stula, and chronic par-
otitis.133,144,148 The rarity of parotid duct injuries does not
allow the benefi t of consulting results from large case
studies. One of the three patients reported by Landau
and Stewart who had primary duct repair developed a
fi stula.144 The three cases reported by Tachmes et al. had
no reported complications.143 Patients whose injuries
were initially unrecognized compose the majority of
cases that develop impaired duct function after trauma.
rhinoplasty, cheiloplasty, and oculoplastic surgery, are
all employed to improve secondary deformities and are
covered in depth in several excellent references.51,53,140–142
Lacerating injuries to the parotid gland and lateral
cheek warrant special consideration due to the tech-
niques that are required in their management. Tissue
that is not viable is debrided, and primary repair is per-
formed with attention to repairing the gland’s capsule.143
Vulnerable structures include Stensen’s duct and the fa-
cial nerve, and these must be explored carefully if injury
is suspected143–146 (Fig. 13.9). Trauma signifi cant enough
to lacerate the parotid duct has been reported to have a
40–55% association with injury of adjacent facial nerve
branches—most frequently the buccal branch.143,144 As-
sociated facial nerve injuries mandate immediate ex-
ploration of the nerve ends. Debate still exists about the
decision to undertake primary repair of parotid duct
transection. Primary repair of the duct is recommended
Fig. 13.9 Parotid and facial nerve injury. A 30-year-old patient sustained a penetrating trauma to the left cheek with a laceration of
the parotid duct and buccal branches of the facial nerve. (A) Preoperatvie photograph showing paralysis of upper lip elevators and
fl attening of the nasolabial fold. (B) Intraoperative photograph shows cannulation of the distal parotid duct via the intraoral opening
of Stensen’s duct. (C) Intraoperative photograph showing repair of Stensen’s duct inferiorly (over a polyethelene stent left in place for
10 days) and the two transected buccal branches. (D) One year postoperative photograph showing marked improvement in function
of lip elevators. Patient regained full resting symmetry as well. The patient initially had impaired salivary fl ow that was transient.
A
B
C
D
Complications in Facial Plastic Surgery
120
In a review of posttraumatic fi stulae and sialoceles, Lan-
dau and Stewart reported that 11 of the 14 patients with
penetrating trauma to the cheek did not have this injury
addressed within 24 hours of the initial trauma.144
A sialogram is perhaps the most sensitive method for
determining the site of leakage once a parotid duct com-
plication has developed; however, sialoendoscopy is a
newer method that allows direct visualization of Stensen’s
duct.144,146,147 Medical management of these complica-
tions includes needle aspiration of salivary collections,
pressure dressings, anticholinergic drugs, and the sub-
stitution of enteral feeding for oral intake until normal
salivary fl ow is reestablished.144–149 Parekh et al. outlined
their successful strategy for medical management.147 This
requires that the patient take nothing by mouth (enteral
feeds or total parental nutrition are given) until the fi s-
tula or sialocele has resolved. Adjunctive measures were
not considered necessary with this regimen.
Intraparotid botulinum toxin A injections are becom-
ing more commonplace after parotid duct injury be-
cause of their effi cacy and safety. Marchese-Ragona et al.
used EMG-guidance for precise injection into the gland
and for prevention of inadvertent masticator muscle or
facial muscle injection.150,151 Others use ultrasound guid-
ance, and in some reports simple percutaneous injec-
tion is performed.152,153 Most reports indicate a clinical
response within two weeks of the fi rst injection and an
eff ect that lasts at least three months.150–153 In several
cases, only one injection was required, with no recru-
descence after several months of follow-up.150–154
Patients with sialoceles or salivary fi stulae who do
not respond to any of these interventions may require
ligation of the duct or total parotidectomy.146,147 A safer
surgical alternative has been described,148 whereby the
deep surface of the sialocele or fi stula tract is marsupi-
alized into the oral cavity with blunt instruments. The
external communication is closed, and the intraoral
wound allowed to drain into the mouth.
◆Conclusion
The adherence to time-tested principles of fracture
healing is the foundation of proper management and
the key to avoiding complications after trauma to the
facial skeleton. This review has also highlighted evolv-
ing trends in management that can be applied to the
treatment of complications. Access to high-resolution
imaging capabilities and image guidance can improve
surgical outcomes and decrease the morbidity associat-
ed with revision surgery. The use of surgical planning on
models of the patient is being extended to areas of the
craniofacial skeleton beyond the mandible, where model
surgery is commonly performed. Finally, collaboration
with other specialists, including ophthalmologists, neu-
rosurgeons, neuroradiologists, and dental specialists, is
encouraged to manage these complex cases.
References
1. Alpert B. Management of the complications of mandibu-
lar fracture treatment. Oper Tech Plast Reconstr Surg 1998;
5(4):325–333
2. Berstein L, McClurg FL. Mandibular fractures: a review of 156
consecutive cases. Laryngoscope 1977;87(6):957–961
3. Fox AJ, Kellman RM. Mandibular angle fractures: two-
miniplate fi xation and complications. Arch Facial Plast Surg
2003;5(6):464–469
4. James RB, Fredrickson C, Kent JN. Prospective study of man-
dibular fractures. J Oral Surg 1981;39(4):275–281
5. Nakamura S, Takenoshita Y, Oka M. Complications of mini-
plate osteosynthesis for mandibular fractures. J Oral Maxil-
lofac Surg 1994;52(3):233–238, discussion 238–239
6. Terris DJ, Lalakea ML, Tuff o KM, Shinn JB. Mandible fracture
repair: specifi c indications for newer techniques. Otolaryngol
Head Neck Surg 1994;111(6):751–757
PEARLS OF WISDOM
Comminuted or atrophic mandible fractures should be
repaired with load-bearing reconstruction plates and bicorti-
cal screws to ensure bony union. Note that atrophic bone
does not bear load well, so in such cases load-bearing repair
becomes even more critical.
Jaw physiotherapy for treatment of condylar fractures that do
not require ORIF should be started early to restore occlu-
sion, especially in pediatric patients, who are at higher risk of
developing TMJ ankylosis with long periods of rigid maxillo-
mandibular fi xation, which, of course, should be discouraged
in both children and adults.
All facial trauma surgeons must be prepared to perform a
lateral canthotomy and cantholysis when they suspect the
development of a retrobulbar hematoma clinically. Patients
can present with a hematoma as a result of the orbital trauma
itself or from the repair of an orbital fracture. Given the short
time window before irreversible vision loss can develop,
clinicians must be able to diagnose this complication quickly,
based on history and physical examination. Imaging can result
in the loss of valuable time before intervention.
It is important to inform patients with naso-orbital-ethmoid
fractures of the possibility of the development of nasolacrimal
dysfunction as result of the bony injuries, even after adequate
repair. It is reasonable to discuss the appropriateness of
prophylactic nasolacrimal intubation with the ophthalmology
team and add this to the procedure in the appropriate patient.
In the pediatric population, conservative (nonoperative)
therapy of fractures has a more signifi cant role in treatment
algorithms than in adults. Especially in the mandible, overly
aggressive procedures with extensive periosteal stripping can
result in growth disturbances. Bony healing is faster in children,
with a narrower therapeutic window for reduction procedures.
In pediatric patients (up to about ages 14–15 years), many
surgeons remove fi xation implants once bony union has been
achieved, for fear of growth disturbance and potential implant
migration.
13 Complications of Facial Trauma Repair 121
27. Iizuka T, Lindqvist C. Sensory disturbances associated with
rigid internal fi xation of mandibular fractures. J Oral Maxil-
lofac Surg 1991;49(12):1264–1268
28. Marchena JM, Padwa BL, Kaban LB. Sensory abnormalities
associated with mandibular fractures: incidence and natural
history. J Oral Maxillofac Surg 1998;56(7):822–825, discus-
sion 825–826
29. Ellis E III, Tharanon W. Facial width problems associated with
rigid fi xation of mandibular fractures: case reports. J Oral
Maxillofac Surg 1992;50(1):87–94
30. Kademani D, Rombach DM, Quinn PD. Trauma to the tem-
poromandibular joint region. In: Fonseca RJ, Walker RV, Betts
NJ, Barber HD, Powers MP, eds. Oral and Maxillofacial Trauma.
St. Louis: Elsevier; 2005:522–568
31. Kellman RM. Endoscopically assisted repair of subcondylar
fractures of the mandible: an evolving technique. Arch Facial
Plast Surg 2003;5(3):244–250
32. Ellis E III, Throckmorton G. Facial symmetry after closed and
open treatment of fractures of the mandibular condylar pro-
cess. J Oral Maxillofac Surg 2000;58(7):719–728, discussion
729–730
33. Ellis E III, Simon P, Throckmorton GS. Occlusal results after open
or closed treatment of fractures of the mandibular condylar
process. J Oral Maxillofac Surg 2000;58(3):260–268
34. Schön R, Fakler O, Gellrich NC, Schmelzeisen R. Five-year
experience with the transoral endoscopically assisted treat-
ment of displaced condylar mandible fractures. Plast Recon-
str Surg 2005;116(1):44–50
35. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: II.
Management of traumatic injury or fracture. Plast Reconstr
Surg 2005;116(2):28e–41e
36. Ellis E III, McFadden D, Simon P, Throckmorton G. Surgical com-
plications with open treatment of mandibular condylar process
fractures. J Oral Maxillofac Surg 2000;58(9):950–958
37. Raveh J, Vuillemin T, Lädrach K. Open reduction of the dislo-
cated, fractured condylar process: indications and surgical pro-
cedures. J Oral Maxillofac Surg 1989;47(2):120–127
38. Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA.
Management of mandible fractures. Plast Reconstr Surg
2006;117(3):48e–60e
39. Zide MF, Kent JN. Indications for open reduction of man-
dibular condyle fractures. J Oral Maxillofac Surg 1983;41(2):
89–98
40. Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment
of unilateral dislocated low subcondylar fractures: a clinical
study of 52 cases. J Oral Maxillofac Surg 1994;52(4):353–360,
discussion 360–361
41. Rubens BC, Stoelinga PJ, Weaver TJ, Blijdorp PA. Management
of malunited mandibular condylar fractures. Int J Oral Maxil-
lofac Surg 1990;19(1):22–25
42. Becking AG, Zijderveld SA, Tuinzing DB. Management of post-
traumatic malocclusion caused by condylar process fractures.
J Oral Maxillofac Surg 1998;56(12):1370–1374, discussion
1374–1375
43. Proffi t WR, Sarver DM. Treatment Planning: Optimizing Ben-
efi t to the Patient. In: Proffi t WR, White RP, Sarver DM, eds.
Contemporary Treatment of Dentofacial Deformity. St. Louis:
Mosby; 2003
44. Kaban LB, Perrott DH, Fisher K. A protocol for management
of temporomandibular joint ankylosis. J Oral Maxillofac Surg
1990;48(11):1145–1151, discussion 1152
7. Kellman RM. Clinical applications of bone plating systems to
facial fractures. In: Papel ID, ed. Facial Plastic and Reconstruc-
tive Surgery. New York: Thieme; 2002:720–737
8. Ellis E III, Walker L. Treatment of mandibular angle fractures
using two noncompression miniplates. J Oral Maxillofac Surg
1994;52(10):1032–1036, discussion 1036–1037
9. Furr AM, Schweinfurth JM, May WL. Factors associated with
long-term complications after repair of mandibular fractures.
Laryngoscope 2006;116(3):427–430
10. Haug RH, Schwimmer A. Fibrous union of the mandible:
a review of 27 patients. J Oral Maxillofac Surg 1994;52(8):
832–839
11. Mathog RH, Toma V, Clayman L, Wolf S. Nonunion of the man-
dible: an analysis of contributing factors. J Oral Maxillofac
Surg 2000;58(7):746–752, discussion 752–753
12. Prein J, Rahn BA. Scientifi c and Technical Background. In:
Prein J, ed. Manual of Internal Fixation in the Cranio-Facial
Skeleton. Berlin: Springer; 1998:1–49
13. Mathog RH. Nonunion of the mandible. Otolaryngol Clin
North Am 1983;16(3):533–547
14. Costantino PD, Wolpe M. Facial Plating Systems. In: Papel
ID, ed. Facial Plastic and Reconstructive Surgery. New York:
Thieme; 2002:769–781
15. Kellman RM, Marentette LJ. Atlas of Craniomaxillofacial Fixa-
tion. New York: Raven; 1995
16. Rudderman RH, Mullen RL. Biomechanics of the facial skel-
eton. Clin Plast Surg 1992;19(1):11–29
17. Levy FE, Smith RW, Odland RM, Marentette LJ. Monocortical
miniplate fi xation of mandibular angle fractures. Arch Otolar-
yngol Head Neck Surg 1991;117(2):149–154
18. Schilli W. Mandibular Fractures. In: Prein J, ed. Manual of In-
ternal Fixation in the Cranio-Facial Skeleton. Berlin: Springer;
1998:57–93
19. Kellman RM, Wright DT. Management of posttraumatic os-
teomyelitis of the mandible. In: Greenberg AM, Prein J, eds.
Craniomaxillofacial Reconstructive and Corrective Bone Sur-
gery: Principles of Internal Fixation Using the AO/ASIF Tech-
nique. New York: Springer; 2002:433–438
20. Chaushu G, Manor Y, Shoshani Y, Taicher S. Risk factors contrib-
uting to symptomatic plate removal in maxillofacial trauma
patients. Plast Reconstr Surg 2000;105(2):521–525
21. Barber HD, Bahram R, Woodbury SC, Silverstein KE, Fonseca
RJ. Mandibular Fractures. In: Fonseca RJ, Walker RV, Betts NJ,
Barber HD, Powers MP, eds. Oral and Maxillofacial Trauma. St.
Louis: Elsevier; 2005:479–522
22. Proffi t WR, White RP. Combining Surgery and Orthodontics:
Who Does What, When? In: Proffi t WR, White RP, Sarver DM,
eds. Contemporary Treatment of Dentofacial Deformity. St.
Louis: Mosby; 2003:245–267
23. Turvey TA, White RP. Maxillary Surgery. In: Proffi t WR, White
RP, Sarver DM, eds. Contemporary Treatment of Dentofacial
Deformity. St. Louis: Mosby; 2003:288–311
24. Blakey GH, White RP. Mandibular Surgery. In: Proffi t WR,
White RP, Sarver DM, eds. Contemporary Treatment of Den-
tofacial Deformity. St. Louis: Mosby; 2003
25. Tatum SA. Correction of post-traumatic maxillofacial defor-
mities involving occlusion. Facial Plast Surg Clin North Am
1998;6(4):535–556
26. Nagase DY, Courtemanche DJ, Peters DA. Plate removal in
traumatic facial fractures: 13-year practice review. Ann Plast
Surg 2005;55(6):608–611
Complications in Facial Plastic Surgery
122
ing a period of 20 years. J Craniomaxillofac Surg 1989;17(2):
64–68
66. Zingg M, Chowdhury K, Lädrach K, Vuillemin T, Sutter F,
Raveh J. Treatment of 813 zygoma-lateral orbital complex
fractures. New aspects. Arch Otolaryngol Head Neck Surg
1991;117(6):611–620, discussion 621–622
67. Markowitz BL, Manson PN. Zygomatic complex fractures. In:
Manual of Internal Fixation in the Cranio-Facial Skeleton. Ber-
lin: Springer; 1998:133–147
68. Mathog RH, Archer KF, Nesi FA. Posttraumatic enophthal-
mos and diplopia. Otolaryngol Head Neck Surg 1986;94(1):
69–77
69. Farwell DG, Sires BS, Kriet JD, Stanley RB Jr. Endoscopic re-
pair of orbital blowout fractures: use or misuse of a new ap-
proach? Arch Facial Plast Surg 2007;9(6):427–433
70. Klug C, Schicho K, Ploder O, et al. Point-to-point computer-
assisted navigation for precise transfer of planned zygoma
osteotomies from the stereolithographic model into reality. J
Oral Maxillofac Surg 2006;64(3):550–559
71. Ansari MH. Blindness after facial fractures: a 19-year retrospec-
tive study. J Oral Maxillofac Surg 2005;63(2):229–237
72. Li KK, Meara JG, Joseph MP. Reversal of blindness after facial
fracture repair by prompt optic nerve decompression. J Oral
Maxillofac Surg 1997;55(6):648–650
73. MacKinnon CA, David DJ, Cooter RD. Blindness and severe vi-
sual impairment in facial fractures: an 11 year review. Br J
Plast Surg 2002;55(1):1–7
74. Girotto JA, Gamble WB, Robertson B, et al. Blindness after re-
duction of facial fractures. Plast Reconstr Surg 1998;102(6):
1821–1834
75. Bater MC, Ramchandani PL, Brennan PA. Post-traumatic
eye observations. Br J Oral Maxillofac Surg 2005;43(5):
410–416
76. Popat H, Doyle PT, Davies SJ. Blindness following retrobulbar
haemorrhage—it can be prevented. Br J Oral Maxillofac Surg
2007;45(2):163–164
77. Rosdeutscher JD, Stadelmann WK. Diagnosis and treatment
of retrobulbar hematoma resulting from blunt periorbital
trauma. Ann Plast Surg 1998;41(6):618–622
78. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of
retrobulbar hemorrhage. J Oral Maxillofac Surg 1993;51(7):
780–782
79. Chang EL, Bernardino CR. Update on orbital trauma. Curr
Opin Ophthalmol 2004;15(5):411–415
80. Winterton JV, Patel K, Mizen KD. Review of management op-
tions for a retrobulbar hemorrhage. J Oral Maxillofac Surg
2007;65(2):296–299
81. Hayreh SS, Kolder HE, Weingeist TA. Central retinal ar-
tery occlusion and retinal tolerance time. Ophthalmology
1980;87(1):75–78
82. Levin LA, Beck RW, Joseph MP, Seiff S, Kraker R, The Interna-
tional Optic Nerve Study Group. The treatment of traumatic
optic neuropathy: the International Optic Nerve Trauma
Study. Ophthalmology 1999;106(7):1268–1277
83. Steinsapir KD. Treatment of traumatic optic neuropathy with
high-dose corticosteroid. J Neuroophthalmol 2006;26(1):
65–67
84. Jungell P, Lindqvist C. Paraesthesia of the infraorbital nerve
following fracture of the zygomatic complex. Int J Oral Maxil-
lofac Surg 1987;16(3):363–367
45. Posnick JC, Goldstein JA. Surgical management of temporo-
mandibular joint ankylosis in the pediatric population. Plast
Reconstr Surg 1993;91(5):791–798
46. Kaban LB, Perrott DH, Fisher K. A protocol for management of
temporomandibular joint ankylosis. (discussion) J Oral Max-
illofac Surg 1990;48:1152
47. Lei Z. Auricular cartilage graft interposition after temporo-
mandibular joint ankylosis surgery in children. J Oral Maxil-
lofac Surg 2002;60(9):985–987
48. Dean A, Alamillos F. Mandibular distraction in temporoman-
dibular joint ankylosis. Plast Reconstr Surg 1999;104(7):
2021–2031
49. Byrd HS, Hobar PC. Optimizing the management of second-
ary zygomatic fracture deformities. Aesthetic and functional
considerations. Clin Plast Surg 1992;19(1):259–273
50. Thaller SR, Zarem HA, Kawamoto HK. Surgical correc-
tion of late sequelae from facial bone fractures. Am J Surg
1987;154(1):149–153
51. Wolfe SA. Treatment of post-traumatic orbital deformities.
Clin Plast Surg 1988;15(2):225–238
52. Dufresne CR, Manson PN, Iliff NT. Early and late complications of
orbital fractures. Clin Plast Surg 1988;15(2):239–253
53. Hardesty RA, Coff ey JA Jr. Secondary craniomaxillofacial de-
formities. Current principles of management. Clin Plast Surg
1992;19(1):275–300
54. Kellman RM, Bersani T. Delayed and secondary repair of post-
traumatic enophthalmos and orbital deformities. Facial Plast
Surg Clin North Am 2002;10(3):311–323
55. Longaker MT, Kawamoto HK Jr. Evolving thoughts on cor-
recting posttraumatic enophthalmos. Plast Reconstr Surg
1998;101(4):899–906
56. Pearl RM. Treatment of enophthalmos. Clin Plast Surg 1992;
19(1):99–111
57. Burnstine MA. Clinical recommendations for repair of isolat-
ed orbital fl oor fractures: an evidence-based analysis. Oph-
thalmology 2002;109(7):1207–1210, discussion 1210–1211,
quiz 1212–1213
58. Catone GA, Morrissette MP, Carlson ER. A retrospective study
of untreated orbital blow-out fractures. J Oral Maxillofac Surg
1988;46(12):1033–1038
59. Hawes MJ, Dortzbach RK. Surgery on orbital fl oor fractures.
Infl uence of time of repair and fracture size. Ophthalmology
1983;90(9):1066–1070
60. Mathog RH, Hillstrom RP, Nesi FA. Surgical correction of en-
ophthalmos and diplopia. A report of 38 cases. Arch Otolaryn-
gol Head Neck Surg 1989;115(2):169–178
61. Yaremchuk MJ. Changing concepts in the management of
secondary orbital deformities. Clin Plast Surg 1992;19(1):
113–124
62. Putterman AM, Stevens T, Urist MJ. Nonsurgical management
of blow-out fractures of the orbital fl oor. Am J Ophthalmol
1974;77(2):232–239
63. Ellis E. Fractures of the Zygomatic Complex and Arch. In: Fon-
seca RJ, Walker RV, Betts NJ, Barber HD, Powers MP, eds. Oral
and Maxillofacial Trauma. St. Louis: Elsevier; 2005:569–642
64. Folkestad L, Westin T. Long-term sequelae after surgery for
orbital fl oor fractures. Otolaryngol Head Neck Surg 1999;
120(6):914–921
65. Souyris F, Klersy F, Jammet P, Payrot C. Malar bone fractures
and their sequelae. A statistical study of 1.393 cases cover-
13 Complications of Facial Trauma Repair 123
104. Holt GR, Holt JE. Nasoethmoid complex injuries. Otolaryngol
Clin North Am 1985;18(1):87–98
105. Yaremchuck MJ. Evaluation and Management of Chronic
Naso-orbito-ethmoid Fractures. In: Holck DEE, Ng JD, eds.
Evaluation and Treatment of Orbital Fractures: A Multidisci-
plinary Approach. Philadelphia: Elsevier; 2006:183–192
106. Osguthorpe JD, Hoang G. Nasolacrimal injuries. Evaluation
and management. Otolaryngol Clin North Am 1991;24(1):
59–78
107. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and in-
cidence of nasolacrimal injury in naso-orbital-ethmoid
fractures: the role of delayed assessment and dacryocystorhi-
nostomy. Br J Plast Surg 1985;38(1):116–121
108. Stranc MF. The pattern of lacrimal injuries in naso-ethmoid
fractures. Br J Plast Surg 1970;23(4):339–346
109. Lindsey JT. Lacrimal duct injuries revisited: a retrospec-
tive review of six patients. Ann Plast Surg 2000;44(2):
167–172
110. Becelli R, Renzi G, Mannino G, Cerulli G, Iannetti G. Post-
traumatic obstruction of lacrimal pathways: a retrospective
analysis of 58 consecutive naso-orbito-ethmoid fractures. J
Craniofac Surg 2004;15(1):29–33
111. Harris GJ, Fuerste FH. Lacrimal intubation in the primary
repair of midfacial fractures. Ophthalmology 1987;94(3):
242–247
112. Spinelli HM, Shapiro MD, Wei LL, Elahi E, Hirmand H. The
role of lacrimal intubation in the management of facial trau-
ma and tumor resection. Plast Reconstr Surg 2005;115(7):
1871–1876
113. Staff enberg DA, Kawamoto HK. Revisional surgery for midface
fractures:maloclussion and malposition. Oper Tech Plast Re-
constr Surg 1998;5(4):302–311
114. Forrest CR, Phillips JH, Prein J. Craniofacial Fractures. In: Prein
J, ed. Manual of Internal Fixation in the Cranio-Facial Skel-
eton. Berlin: Springer; 1998:108–126
115. Ellis E. Advances in Maxillofacial Trauma Surgery. In: Fon-
seca RJ, Walker RV, Betts NJ, Barber HD, Powers MP, eds.
Oral and Maxillofacial Trauma. St. Louis: Elsevier; 2005:
329–375
116. Chen KT, Chen CT, Mardini S, Tsay PK, Chen YR. Frontal si-
nus fractures: a treatment algorithm and assessment of
outcomes based on 78 clinical cases. Plast Reconstr Surg
2006;118(2):457–468
117. Duvall AJ III, Porto DP, Lyons D, Boies LR Jr. Frontal sinus frac-
tures. Analysis of treatment results. Arch Otolaryngol Head
Neck Surg 1987;113(9):933–935
118. Gossman DG, Archer SM, Arosarena O. Management of
frontal sinus fractures: a review of 96 cases. Laryngoscope
2006;116(8):1357–1362
119. Ioannides C, Freihofer HP. Fractures of the frontal sinus: clas-
sifi cation and its implications for surgical treatment. Am J
Otolaryngol 1999;20(5):273–280
120. Stanley RB Jr, Becker TS. Injuries of the nasofrontal ori-
fi ces in frontal sinus fractures. Laryngoscope 1987;97(6):
728–731
121. Wallis A, Donald PJ. Frontal sinus fractures: a review of 72
cases. Laryngoscope 1988;98(6 Pt 1):593–598
122. Wolfe SA, Johnson P. Frontal sinus injuries: primary care
and management of late complications. Plast Reconstr Surg
1988;82(5):781–791
85. Taicher S, Ardekian L, Samet N, Shoshani Y, Kaff e I. Recovery
of the infraorbital nerve after zygomatic complex fractures: a
preliminary study of diff erent treatment methods. Int J Oral
Maxillofac Surg 1993;22(6):339–341
86. Vriens JPM, Moos KF. Morbidity of the infraorbital nerve fol-
lowing orbitozygomatic complex fractures. J Craniomaxillo-
fac Surg 1995;23(6):363–368
87. Ziccardi VB, Zuniga JR. Traumatic injuries of the trigeminal
nerve. In: Fonseca RJ, Walker RV, Betts NJ, Barber HD, Pow-
ers MP, eds. Oral and Maxillofacial Trauma. St. Louis: Elsevier;
2005:877–914
88. Bodker FS, Cytryn AS, Putterman AM, Marschall MA. Postop-
erative mydriasis after repair of orbital fl oor fracture. Am J
Ophthalmol 1993;115(3):372–375
89. Stromberg BV, Knibbe M. Anisocoria following reduction of
bilateral orbital fl oor fractures. Ann Plast Surg 1988;21(5):
486–488
90. Marmulla R, Niederdellmann H. Surgical planning of com-
puter-assisted repositioning osteotomies. Plast Reconstr Surg
1999;104(4):938–944
91. Westermark A, Zachow S, Eppley BL. Three-dimensional oste-
otomy planning in maxillofacial surgery including soft tissue
prediction. J Craniofac Surg 2005;16(1):100–104
92. Baumann A, Ewers R. Transcaruncular approach for recon-
struction of medial orbital wall fracture. Int J Oral Maxillofac
Surg 2000;29(4):264–267
93. Frodel JL, Marentette LJ. The coronal approach. Anatomic and
technical considerations and morbidity. Arch Otolaryngol
Head Neck Surg 1993;119(2):201–207, discussion 140
94. Freihofer PM, Borstlap WA. Reconstruction of the zygomatic
area. A comparison between osteotomy and onlay techniques.
J Craniomaxillofac Surg 1989;17(6):243–248
95. Hammer B, Prein J. Correction of post-traumatic orbital de-
formities: operative techniques and review of 26 patients. J
Craniomaxillofac Surg 1995;23(2):81–90
96. Costantino PD, Hiltzki DH, Fried CD, et al. Alloplastic Plating
Techniques in Orbital Fracture Repair. In: Holck DE, Ng JD, eds.
Evaluation and Treatment of Orbital Fractures: A Multidisci-
plinary Approach. Philadelphia: Elsevier; 2006:261–288
97. Baumann A, Burggasser G, Gauss N, Ewers R. Orbital fl oor re-
construction with an alloplastic resorbable polydioxanone
sheet. Int J Oral Maxillofac Surg 2002;31(4):367–373
98. Freihofer HPM. Eff ectiveness of secondary post-traumatic
periorbital reconstruction. J Craniomaxillofac Surg 1995;
23(3):143–150
99. Kushner BJ. Management of diplopia limited to down gaze.
Arch Ophthalmol 1995;113(11):1426–1430
100. Gruss JS. Naso-ethmoid-orbital fractures: classifi cation and
role of primary bone grafting. Plast Reconstr Surg 1985;
75(3):303–317
101. Markowitz BL, Manson PN, Sargent L, et al. Management of
the medial canthal tendon in nasoethmoid orbital fractures:
the importance of the central fragment in classifi cation and
treatment. Plast Reconstr Surg 1991;87(5):843–853
102. Ducic Y. Medial canthal ligament reattachment in skull
base surgery and trauma. Laryngoscope 2001;111(4 Pt 1):
734–737
103. Sargent LA, Rogers GF. Nasoethmoid orbital fractures: diag-
nosis and management. J Craniomaxillofac Trauma 1999;
5(1):19–27
Complications in Facial Plastic Surgery
124
139. Weber R, Draf W, Keerl R, et al. Magnetic resonance imaging
following fat obliteration of the frontal sinus. Neuroradiology
2002;44(1):52–58
140. Powers MP, Beck BW, Holton JB. Management of Soft Tissue
Injuries. In: Fonseca RJ, Walker RV, Betts NJ, Barber HD, Pow-
ers MP, eds. Oral and Maxillofacial Trauma. St. Louis: Elsevier;
2005:751–819
141. Thomas JR, Frost TW. Scar Revision and Camoufl age. In: Baker
SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St.
Louis:Mosby; 1995:587–595
142. Tatum SA. Concepts in midface reconstruction. Otolaryngol
Clin North Am 1997;30(4):563–592
143. Tachmes L, Woloszyn T, Marini C, et al. Parotid gland and
facial nerve trauma: a retrospective review. J Trauma 1990;
30(11):1395–1398
144. Landau R, Stewart M. Conservative management of post-trau-
matic parotid fi stulae and sialoceles: a prospective study. Br J
Surg 1985;72(1):42–44
145. Lewkowicz AA, Hasson O, Nahlieli O. Traumatic inju-
ries to the parotid gland and duct. J Oral Maxillofac Surg
2002;60(6):676–680
146. Steinberg MJ, Herréra AF. Management of parotid duct in-
juries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;99(2):136–141
147. Parekh D, Glezerson G, Stewart M, Esser J, Lawson HH. Post-
traumatic parotid fi stulae and sialoceles. A prospective
study of conservative management in 51 cases. Ann Surg
1989;209(1):105–111
148. Van Sickels JE. Parotid duct injuries. Oral Surg Oral Med Oral
Pathol 1981;52(4):364–367
149. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate sur-
gical repair necessary? Injury 1991;22(5):407–409
150. Marchese-Ragona R, Blotta P, Pastore A, Tugnoli V, Eleopra R,
De Grandis D. Management of parotid sialocele with botuli-
num toxin. Laryngoscope 1999;109(8):1344–1346
151. Marchese-Ragona R, De Filippis C, Staffi eri A, Restivo DA,
Restino DA. Parotid gland fi stula: treatment with botulinum
toxin. Plast Reconstr Surg 2001;107(3):886–887
152. Ellies M, Gottstein U, Rohrbach-Volland S, Arglebe C, Laskawi
R. Reduction of salivary fl ow with botulinum toxin: extended
report on 33 patients with drooling, salivary fi stulas, and si-
aladenitis. Laryngoscope 2004;114(10):1856–1860
153. von Lindern JJ, Niederhagen B, Appel T, Bergé S, Reich RH.
New prospects in the treatment of traumatic and postopera-
tive parotid fi stulas with type A botulinum toxin. Plast Recon-
str Surg 2002;109(7):2443–2445
154. May M. Nerve Repair. In: May M, Schaitkin BM, eds. The Facial
Nerve. New York: Thieme; 2000:571–611
123. Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 fron-
tal sinus fractures: current surgical management and complica-
tions. J Craniomaxillofac Surg 2000;28(3):133–139
124. Larrabee WF Jr, Travis LW, Tabb HG. Frontal sinus fractures—
their suppurative complications and surgical management.
Laryngoscope 1980;90(11 Pt 1):1810–1813
125. Donald PJ. Frontal sinus ablation by cranialization. Report of
21 cases. Arch Otolaryngol 1982;108(3):142–146
126. Wilson BC, Davidson B, Corey JP, Haydon RC III. Comparison
of complications following frontal sinus fractures managed
with exploration with or without obliteration over 10 years.
Laryngoscope 1988;98(5):516–520
127. Swinson BD, Jerjes W, Thompson G. Current practice in
the management of frontal sinus fractures. J Laryngol Otol
2004;118(12):927–932
128. Kellman RM. Safe and dependable harvesting of large outer-
table calvarial bone grafts. Arch Otolaryngol Head Neck Surg
1994;120(8):856–860
129. Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD.
Modern concepts of frontal sinus surgery. Laryngoscope
2001;111(1):137–146
130. Sillers MJ. Frontal sinus obliteration: an operation for the ar-
chives or modern armamentarium. Arch Otolaryngol Head
Neck Surg 2005;131(6):529–531
131. Mathur KK, Tatum SA, Kellman RM. Carbonated apatite and
hydroxyapatite in craniofacial reconstruction. Arch Facial
Plast Surg 2003;5(5):379–383
132. Davis WE. Growing obsolescence of the frontal sinus oblit-
eration procedure. Arch Otolaryngol Head Neck Surg
2005;131(6):532–533
133. Lanza DC. Frontal sinus obliteration is rarely indicated. Arch
Otolaryngol Head Neck Surg 2005;131(6):531–532
134. Smith TL, Han JK, Loehrl TA, Rhee JS. Endoscopic management
of the frontal recess in frontal sinus fractures: a shift in the
paradigm? Laryngoscope 2002;112(5):784–790
135. Koudstaal MJ, van der Wal KGH, Bijvoet HWC, Vincent AJPE,
Poublon RMI. Post-trauma mucocele formation in the fron-
tal sinus; a rationale of follow-up. Int J Oral Maxillofac Surg
2004;33(8):751–754
136. Har-El G. Endoscopic management of 108 sinus mucoceles.
Laryngoscope 2001;111(12):2131–2134
137. Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith
MM. Endoscopic sinus surgery for mucoceles: a viable alter-
native. Laryngoscope 1989;99(9):885–895
138. Loevner LA, Yousem DM, Lanza DC, Kennedy DW, Goldberg
AN. MR evaluation of frontal sinus osteoplastic fl aps with
autogenous fat grafts. AJNR Am J Neuroradiol 1995;16(8):
1721–1726
Successful management of facial paralysis requires an
experienced understanding of its cause, duration, and
the prognosis for facial paralysis recovery. Skills in both
reconstructive and aesthetic surgery are required to use
contemporary techniques to rehabilitate fully the pa-
tient with facial paralysis (Fig. 14.1). It is helpful dur-
ing the consultation process for the surgeon to divide
the face into upper, middle, and lower thirds. In each
facial region, reinnervation procedures as well as static
resuspension procedures are available for the patient.
Procedures to be considered fi rst assist with periorbital
rehabilitation—procedures that improve eyelid closure,
eye protection, and brow position. Such periorbital pro-
cedures include techniques to load the upper eyelid,
reposition the denervated lower eyelid, and reposition
the brow. Midfacial procedures are then considered to
correct nasal obstruction, provide support for the re-
tracted lower eyelid, reduce oral incompetence, and
improve facial symmetry. These goals are accomplished
with procedures such as midface lifts, static slings, free
muscle transfer, local muscle transfer, and nerve trans-
fers. Lower facial procedures address oral incompetence,
speech diffi culties, facial asymmetry, and the inability
to smile, and they include procedures such as facelift,
necklift, and oral commissuroplasty. This chapter will
address the prevention and management of complica-
tions in facial paralysis rehabilitiation by region. The
most common complication is failure to achieve the de-
sired improvement. Other complications, such as hema-
tomas, failure of wound healing, and infection may also
occur. The diversity of patient presentations and treat-
ment options makes this topic quite complex. Therefore,
each surgeon must understand the advantages and dis-
advantages of the procedures and balance those with
their comfort level and the procedures’ application to
their individual patients.
◆Preoperative Prevention Strategies
General Points
Avoidance of complications with facial reanimation be-
gins with the most fundamental aspects of patient care:
careful diagnosis and selection of appropriate treat-
ment. It is crucial to engage in thoughtful planning be-
fore entering the operating room and beginning a path
of treatment that could be inappropriate.
Understanding the causes of facial paralysis and its
pathophysiology will guide the surgeon’s assessment.
Although the diff erential diagnosis of facial palsy is very
extensive, usually a small number of causes account for
most cases that present to the surgeon’s offi ce. Trauma,
acoustic neuroma surgery, parotid neoplasms, and Bell’s
palsy with incomplete return of function compose the
bulk of encountered etiologies.
Treatment planning requires taking an extensive his-
tory, performing a physical examination, and possible
testing to determine what procedures may be benefi cial
to the patient. Initial consultations are often detailed,
because subsequent decisions are complex. The surgeon
should consider several questions to help guide the de-
cision-making process (Table 14.1).
125
14
Complications of Facial Reanimation
Patrick J. Byrne and Christopher R. Cote
Fig. 14.1 Contemporary management of facial paralysis. This
patient was initially treated with gold weight placement, and
subsequently underwent endoscopic browlift, lateral canthal
suspension with midface lif t, and temporalis tendon transfer.
(Chan JY, Byrne PJ. Management of facial paralysis in the 21st
century. Facial Plast Surg Aug 2011;27(4):346–357.)
Complications in Facial Plastic Surgery
126
untoward outcomes. The patient needs to be educated
about multiple issues and must be able to make an in-
formed decision regarding his or her treatment options.
A frank acknowledgment of the realistic potential for
improvement must be made early. If there has been a
complete facial nerve transection, then the chance for
a normal outcome does not exist with the current state
of medical knowledge. The patient and family need to
be made aware of this. The patient and family also need
to be engaged in the decision-making process as they
consider their options for reanimation.
The Eye
The fi rst priority for facial paralysis management is eye
protection. Visual fi eld preservation and correction of eye
or brow asymmetry are important but secondary. Proce-
dures to consider include browlifting (direct, coronal, or
endoscopic), upper lid loading (gold or platinum weight),
and lower lid tightening or elevation (tarsal strip cantho-
plasty, transorbital canthopexy, spacer grafts, midface
lifts). There are several things to look out for to prevent
complications. First, perform a careful physical examina-
tion. Attention is directed toward the patient’s current
ability to protect the eye and also to be aware of chronic
exposure. A useful mnemonic to help identify patients
who are especially at risk for exposure keratitis is BAD:
Look for the presence or absence of a Bell phenomenon
(B); if it is absent, that represents a risk factor for expo-
sure keratitis due to diminished ability to protect the
cornea. An absence of corneal refl ex (A for anesthesia)
indicates that the patient is also at increased risk for ex-
posure keratitis due to a diminished ability to sense the
irritation that would normally accompany an exposed
cornea. A patient with preexisting dry eye (D) has poor
tear production and is a higher-risk patient. The risk
for corneal exposure complications in patients with dry
eyes, absent Bell phenomenon, and diminished corneal
sensation is very real. The mental status and compliance
of the patient are also important. Appropriate eye pro-
tection and lubrication requires placement of lubricating
ointment, use of artifi cial tears, moisture chambers, and
eyelid taping. The physician must realistically assess the
patient’s ability to follow a course of treatment and if it is
compromised, a more aggressive treatment, such as tar-
sorrhaphy, may be appropriate in select cases.
A careful preoperative evaluation of the upper eyelid
will reduce the chance of ptosis caused by loading tech-
niques. The patient is observed and questioned while
trying on several sizes of gold weights. This can be facili-
tated by securing the weight to the lid with double-sided
tape. The goal is to maximize closure while minimizing
induced ptosis. Some iatrogenic ptosis is acceptable, but
only what remains asymptomatic to the patient.
Likewise, the lower eyelid must be carefully examined.
Laxity of a paralyzed eyelid may demonstrate ectropion,
lid retraction, lacrimal dysfunction, and insuffi cient
The answers to these and many other questions will
direct the thoughtful surgeon’s choices for the timing
of any intervention, medical versus surgical manage-
ment of the eye, static versus dynamic facial suspen-
sion, reanimation versus observation for recovery, free
tissue transfer versus local muscle transfer versus nerve
crossovers, reversible or nonreversible measures, or
concomitant contralateral procedures performed to im-
prove symmetry. This analysis can be extensive, and it is
required before operating on the patient. More detailed
discussion of these considerations is beyond the scope
of this text. Nonetheless, this list highlights the impor-
tance of the preoperative consultation.
Diagnostic facial nerve testing may be considered be-
fore undertaking a surgical procedure. A thorough eval-
uation and work-up may require imaging studies (CT or
MRI) and electrodiagnostic testing. Well-known tests for
prognosis include the maximum stimulation test, the
nerve excitability test, electromyography (EMG), and
electroneuronography (ENOG). Although most cases do
not require such testing, it is appropriate in others. This
is a topic beyond the scope of this chapter.1
Nonsurgical options may be chosen for management
of the patient’s facial paralysis, depending on the indi-
vidual’s circumstances. A compliant patient, for exam-
ple, may do well with aggressive medical eye protection.
Facial retraining has a role in many cases, and this form
of physical therapy may result in improved outcomes,
particularly if it is instituted early.
We suggest allotting an appropriate amount of time
in the clinic for such a complex discussion with any new
facial paralysis patient. We typically allocate more time
for this consultation than any other new facial plastic
surgery patient visit. Spending one hour on the initial
visit is typical. This is the fi rst step toward prevention of
Table 14.1
Questions to Aid with Facial Paralysis Surgical Planning
What is the etiology and duration of the paralysis?
What is the prognosis for recovery?
What is the patient’s age?
Is the paralysis complete or incomplete?
Are there areas of hyperfunction in addition to areas of paresis?
What troubles the patient most?
How much tissue laxity is present?
How compliant is the patient?
What are the patient’s expectations with regard to outcome,
recovery period, and the time necessary to assess the success
of an intervention?
14 Complications of Facial Reanimation 127
Patients who have undergone radiation treatments
are more likely to require revisions to static facial slings
from descent of the initially suspended soft tissues.
Implants may be more likely to extrude after radiation
therapy (Fig. 14.3). These patients also are at greater
risk of wound-healing complications in general. Caution
is advised in such patients, and they deserve to be ap-
propriately counseled about such risks.
◆ Identifi cation and Management of
Intraoperative Complications
Browlifting
Browlift incisions are placed in or along the hairline
with careful avoidance of follicle injury to prevent hair
loss. This can be done by making incisions parallel to
follicles and avoiding electrocautery injury to or suture
strangulation of follicles.
The rich vasculature of the brow region makes it es-
pecially at risk for the formation of a hematoma after
a subcutaneous browlift (direct or indirect browlift) is
performed. Particular attention to hemostasis is impor-
tant. It is so common to see this that we routinely hold
compression manually after we perform such a proce-
dure as the patient is emerging from anesthesia and
being transported to the recovery room. An immediate
postoperative pressure dressing, ice, and elevation may
mitigate this complication.
globe coverage. Lower eyelid elevation may be accom-
plished by a variety of methods. The tarsal strip cantho-
pexy is quite commonly performed. However, certain
anatomic fi ndings can aff ect the outcome. For example,
patients with maxillary hypoplasia and the so-called
negative vector, with relative proptosis, may be done a
disservice if canthopexy is performed (Fig. 14.2). Such
lower lid tightening may cause the eyelid margin to be
pulled under the convexity of the globe, thus worsening
lid position and eye protection. Alternative techniques
to elevate the lid, such as space grafting and midface lift-
ing, are preferable in such patients.
Midface and Lower Face
The procedures used here include facial nerve grafts,
cross face grafts, hypoglossal facial nerve transfers, free
muscle transfer, dynamic regional muscle transfer, and
static facial slings. Several preoperative considerations
are important when the surgeon evaluates a patient
for facial reanimation. First, the surgeon must choose
a treatment option with a reasonable likelihood of suc-
cess. Reinnervation techniques of native facial muscu-
lature (cross face grafts, hypoglossal nerve (XII)–facial
nerve (VII) anastomoses) are unlikely to be successful if
they are performed after a prolonged period of denerva-
tion. This duration is in most cases approximately one
year. Cases of spontaneous reinnervation, as well as suc-
cessful surgical reanimation, have certainly occurred
after delays longer than one year in particular patients;
however, this is the exception. The older the patient, the
less likely it is that either spontaneous recovery will oc-
cur or that reinnervation techniques will be successful.
Fig. 14.2 The negative vector. This refers to an anatomi-
cal observation (A) when the cheek tissue at the level of the
orbital rim (OR) is posterior to a vertical line drawn from the
lower lid margin (LL). A lid tightening procedure (B) could
have the undesired result of retraction of the lower lid due to
a “sliding” down the globe. (Illustration by Robert Brown.)
Fig. 14.3 This is an example of upper eyelid gold weight ex-
trusion. Proper placement of the weight deep to the orbicular-
is oculi muscle and on the tarsus can minimize this problem.
A
B
Complications in Facial Plastic Surgery
128
Lower Face
Technical points need to be considered when perform-
ing any static sling or dynamic muscle transfer. We rec-
ommend that when performing a sling, the surgeon
choose native material, such as fascia lata, or donor
grafts of human acellular dermis and engineered por-
cine dermis, both which have competing resorption and
rates of strength.2,3 Expanded polytetrafl uoroethylene
(ePTFE) should be avoided, because extrusion has been
found with these implants.4,5 Reports have been variable
regarding long-term success. The sling or muscle must
be aggressively secured. Over-correction is recommend-
ed. We use a combination of nonresorbable polypropyl-
ene sutures and resorbable polyglactin secured to the
deep tissues and redundantly to the suspension sling or
muscle.
Nerve repair includes many possible outcomes, de-
pending on the methods used. Primary repair is pre-
ferred over interposition grafting and crossover grafts
when possible. Nerve grafts need to be carefully placed
to optimize fascicular size match rather than external
diameter match. Magnifi cation is essential for this. A
tension-free closure is always important.
◆ Diagnosis and Management of
Perioperative and Postoperative
Complications
Brow
Hematoma formation can be seen in the early postop-
erative period and even up to ten days afterward. Early
recognition is crucial to avoid infection and tissue inju-
ry. When hematoma formation is encountered, immedi-
ate evacuation is warranted. On the other hand, serous
accumulation may be seen, and observation may be ap-
propriate for it. An immediate postoperative pressure
dressing, ice, and elevation may mitigate this complica-
tion. The need for additional intervention will depend
on the amount of fl uid accumulation; small fl uid collec-
tions may be observed, larger ones aspirated via a nee-
dle (followed by a compression dressing), and the largest
ones openly drained. A similar hematoma management
strategy may be considered in other areas of the face
and neck, though a retrobulbar hematoma needs the
most acute attention.
Alopecia at incisions may be observed and can often be
temporary. Observation for at least three to six months
is prudent in case there may be some recovery of hair
growth at that time. Patients may be candidates for mi-
crofollicular hair transplants should alopecia persist.
Inadequate or asymmetric elevation of the brow is not
uncommon. Secure over-fi xation intraoperatively is im-
perative, because descent due to gravity is signifi cant as
a result of lack of muscle tone. It is crucial that the meth-
Inadequate or asymmetric brow elevation may occur.
The reasons depend upon the technique selected. With
direct brow lifts, inadequate elevation is primarily the
result of suboptimal fi xation of the soft tissue to the
periosteum. A skin-only closure will certainly descend
with time. We recommend a permanent or long-lasting
resorbable suture (such as PDS) to fi xate the brow el-
evation. Place a minimum of three such sutures in each
case. Ensure that the suture needle grabs not only the
orbicularis muscle near the superior orbital rim but
also some deep dermis to obtain a reliable result. Too
much dermis will cause long-term dimpling and is best
avoided. The endoscopic browlift for facial paralysis re-
quires the same degree of complete bilateral release of
the frontal and frontal bar periosteum that a cosmetic
endoscopic browlift does. Keep in mind that if an en-
doscopic approach is preferred, one must perform a
bilateral browlift. Attempts to perform a unilateral en-
doscopic browlift to address paralytic brow ptosis will
prove disappointing. Fixation may be performed by any
one of a variety of methods.
Upper Lid Loading
Gold or platinum weights can cause ptosis. This is best
minimized by a careful preoperative evaluation that in-
cludes determining the appropriate size of the weight
by taping it to the outer lid prior to surgery with the
patient awake. Some manufacturers can provide a sizing
kit to make this easier. Intraoperative disruption of the
levator mechanism can also cause a signifi cant ptosis
once the lid is loaded. To avoid this, make sure that the
dissection is in the immediate suborbicular plane. At the
same time, extrusion can also occur. This is more likely
if the weight is placed too superfi cially in the immediate
subcutaneous plane where the wound may dehisce or
skin will thin. Migration, extrusion, and ulceration have
been shown to be prevented by suture fi xation of the
implant securely to the tarsus.
Lower Lid Elevation
Complications will obviously depend on the technique
chosen to address the issues of a paralytic lower eye-
lid. These techniques may include medial or lateral
canthoplasty, lateral tarsal strip, wedge excision, and
midface lifting. Common considerations include avoid-
ing ectropion and entropion. Trichiasis, which is related
to entropion and an inward turning of the eyelashes, is
prevented by very careful approximation of the lid and
lashes. Many of these procedures involve displacement
of the tarsus. Meticulous hemostasis is performed with
bipolar electrocautery to minimize the chance of hema-
toma formation. Over-tightening of the lower lid is best
avoided, as this may produce the unintended eff ect of
lowering the lid margin position, especially in the nega-
tive vector patient.
14 Complications of Facial Reanimation 129
medially or laterally. This will direct the surgeon as to
how to address the problem surgically. Later options
may include revision canthopexy, anterior or posterior
spacer grafting, and midface lifting.
Conversely, the patient may present postoperatively
with trichiasis and entropion caused by posterior la-
mellar scarring from transconjunctival approaches or
lid malposition during canthopexy. Focal areas may be
addressed with removal of hair follicles. Temporary epi-
lation is not likely to work long term, and some alterna-
tive methods may include permanent hair removal or
wedge excision. Nonetheless, these approaches are not
anatomic, and addressing the underlying cause may be a
better option. Posterior lamellar lid spacer grafts can be
used to address cicatrix, while revision of canthopexy
can also be considered.
Lid retraction is manifested as increased scleral show
and may be accompanied by ectropion or entropion.
Treatment is similar to the options listed above.
Finally, hematoma formation may occur due to inad-
equate hemostasis. Careful attention to this in the early
postoperative period may prevent a rare but devastat-
ing complication—blindness. More commonly, a pre-
septal hematoma would be encountered since most
procedures involve the anterior lamella. Management of
this would include a thorough ocular exam and wound
evacuation. When signifi cant orbital work has been per-
formed, there is an increased concern for this risk, and
we recommend overnight observation with visual fi eld
checks. Bleeding within the orbit may be manifested as
severe eye pain, loss of visual acuity, proptosis, aff erent
papillary defect, ophthalmoplegia, and increased intra-
ocular pressure. Immediate consultation with an oph-
thalmologist is strongly encouraged if a hematoma is
suspected. Computerized tomography can confi rm a di-
agnosis, though only if it is necessary, since any delay of
treatment can be catastrophic. Intervention with lateral
canthotomy and cantholysis should result in improve-
ment in pain, vision, and intraocular pressure.11
Corneal exposure keratitis is a complication that de-
serves special emphasis, because this is a potentially
catastrophic complication related to facial paralysis
and inadequate eye protection. The immediate postop-
erative period should include all medical measures for
protection of the eye while the patient is healing and
being followed for the outcome of the eyelid procedures.
These measures include frequent lubrication of the eye
using artifi cial tears, use of nighttime moisture cham-
bers, or more aggressive temporary measures, such as
tarsorrhaphy and lid suspensions. Taping or eye patches
are not advisable. Consider cooperation with an oph-
thalmologist who can perform corneal exams if there is
any question of compromised protection. Patient com-
pliance can be an important factor during this decision-
making process. If the patient fails to achieve the desired
protection, modifi cation of the medical regimen or more
aggressive procedures should be considered.
od of fi xation include anchoring to periostium or bone.
Some fi xation methods may better facilitate a revision.
For example, the Endotine device (MicroAire, Charlot-
tesville, VA) allows some revision in the early postopera-
tive period in the clinic setting.
Eyelids
Upper Eyelid Procedures
Certain problems related to improper weight position
and size may be observed. Inadequate lid descent occurs
when there was improper or no preoperative assess-
ment of the weight size. Ptosis may be the result of too
heavy an eyelid weight or injury to the levator mecha-
nism of the upper eyelid. If weight placement is too high
on the lid (not just above the lashes), the patient may
even experience lagophthalmos when lying supine.6
When load-bearing procedures are used, upper lid
weight migration can be related to surgical technique.
We recommend a horizontal incision at the supratarsal
crease or immediately above the lash line rather than
a smaller incision for creating a tight pocket. This will
allow careful supratarsal placement with at least three
anchoring sutures of 6–0 polyprolylene and positioning
deep to the orbicularis muscle. Wound dehiscense and
upper lid weight extrusion can occur when the incision
is placed at the level of the weight position instead of
above or below the weight. When these complications
occur, the weight will need to be removed and the
wound treated for infection if necessary. The patient can
be reassessed for any continued need for the weight. If
eye closure is adequate without it, you may choose not
to replace the weight. If the patient still needs and wants
a weight, then it may be wrapped in temporalis fascia or
even processed human pericardium and secured to the
tarsus in a suborbicular plane—points emphasized by
many experienced surgeons in the literature.6–10
Lower Eyelid Procedures
In the paralyzed face, lower eyelid procedures are usu-
ally selected to address the paralytic ectropion or lid
retraction. Elderly patients with involutional ectropion
may be at higher risk. Such dysfunction may aff ect eye
cosmesis, eye protection, and the lacrimal drainage
system. Postoperative follow-up should include careful
attention to the position of the eyelid, so that early in-
tervention can begin.
Postoperative ectropion may be temporary from
swelling, but it also could be due to an early cicatricial
ectropion. Choices for early intervention may include
eyelid taping suspension, a suspension Frost suture,
and tarsorrhaphy. Additional intermediate intervention
could include a steroid injection to soften scar forma-
tion. Careful attention during an examination should
note whether ectropion involves the entire lid or occurs
Complications in Facial Plastic Surgery
130
preexisting contralateral 12th nerve injury, because such
a patient may become an oral cripple if the opposite side
is transected. We have found that performing 12-7 cross-
overs with only a partial transection of the hypoglossal
nerve is safe and eff ective. The use of partial transection
and a jump graft is an attempt to reduce morbidity. With
this, the hypoglossal nerve is only partially transected
and a cable graft is interposed to the distal facial nerve.
Similar complications can occur, but less commonly.
Some authors report no incidence of this in small series.
Recurrent asymmetry is expected in the paralyzed
face. The denervated side of the face ages more rapid-
ly than the normal side. This is secondary to advanced
muscle atrophy, volume loss, and continued eff ects of
gravity. Proper counseling preoperatively is important,
and patients may benefi t from multiple procedures over
their lifetimes.
Oral commissure incompetence can be exacerbated
by static suspension procedures of the midface by cre-
ating an oral gap from elevation of the upper lip. Loss
of tone in the lower lip also contributes to problems
with drooling, air leakage, and discoordination when
chewing. These problems may be alleviated by several
dynamic procedures, including the mobilization of the
anterior belly of the digastric or simple lip wedge ex-
cision with commissuroplasty (Fig. 14.4). When per-
Midface and Lower Face
Hematoma formation after a standard facelift has been
reported in the range of 1 to 10%, so patients undergo-
ing more complex elevations will fall into that risk cate-
gory as well. Recognition of postoperative asymmetrical
swelling, bruising, and pain will prompt early evacuation.
Inattention to this can contribute to skin necrosis and
sloughing. In those cases, the patient may need wound
debridement and revision of scarring as indicated.
Salivary leaks or sialoceles can occur when there is an
injury to the parotid gland and its associated structures.
For instance, facial suspension may be performed in the
setting of parotidectomy, and a sialocele can be an early
or subacute complication that may require needle aspi-
ration and pressure dressing. The patient can be followed
on a regular basis, with needle aspirations repeated as
needed. This may be done multiple times and may take
weeks for resolution. For recalcitrant cases, open drain-
age or even parotidectomy may be considered. In ad-
dition, parotid duct injury should be anticipated when
dissection occurs in the deep planes of the face, such as
during a temporalis tendon transfer. Immediate repair
or diversion at a later point can be considered.
Sling or muscle transfer dehiscence with descent of oral
commissure may be an early or late result. This may be
a result of inadequate anchoring of the suture or exces-
sive tension, resorption of the sling from infl ammation,
infection, or foreign body rejection. See our comments
above on how to avoid this intraoperatively. When this
is encountered in the postoperative period, revision sus-
pension is often recommended. Be sure that the patient is
counseled on this possibility. Postoperative radiation af-
ter a sling increases the risk for dehiscense, and for these
patients in particular it can be more diffi cult to achieve
the desired results when their slings are revised.
Lack of cross face graft reinnervation is a possibility in
all cases, and the patient and surgeon must be prepared
to wait for successful results. Age, radiation history, and
reoperation can all aff ect the outcome, and the patient
must be counseled on the need to wait for a reasonable
outcome. End-to-end anastomosis confers the best facial
function, followed by cable nerve graft interposition and
then classic facial-hypoglossal transposition. Some re-
ports have observed a delay of up to two years before even
partial function is observed. Success in this area is usually
determined by a House-Brackmann score of III or IV and
is never better than this. This can be achieved in approxi-
mately 61–85% of cases for primary closure, 56% for cable
graft interposition, and 25–79% for crossover grafts.12–15
Donor site morbidity is a consideration when crossover
grafts are used. For example, the classic VII-XII crossover
procedure involves a complete transection of the hypo-
glossal nerve. Transection of the 12th cranial nerve can
cause speech and swallowing dysfunction in the tongue,
although this is the exception rather than the rule. Such
problems have been reported in up to 45% of patients.16,17
Full transection should not be done in a patient with a
Fig. 14.4 Commissuroplasty. One option for addressing lower
lip laxity is to incise along the vermilion border of the oral
commissure (A), separate the vermilion mucosa (B), and then
reapproximate skin and muscle (C), eff ectively narrowing the
oral aperture. (Illustration by Robert Brown.)
A
B
C
14 Complications of Facial Reanimation 131
References
1. Crumley RL, Armstrong WB, Byrne PJ. Rehabilitation of Facial
Paralysis, Chapter 35 of Cummings Otolaryngology: Head &
Neck Surgery, 4th ed. Philadelphia: Mosby; 2005
2. Rose EH. Autogenous fascia lata grafts: clinical applications in
reanimation of the totally or partially paralyzed face. Plast Re-
constr Surg 2005;116(1):20–32, discussion 33–35
3. Vural E, McLaughlin N, Hogue WR, Suva LJ. Comparison of
biomechanical properties of alloderm and enduragen as
static facial sling biomaterials. Laryngoscope 2006;116(3):
394–396
4. Constantinides M, Galli SK, Miller PJ. Complications of static
facial suspensions with expanded polytetrafl uoroethylene
(ePTFE). Laryngoscope 2001;111(12):2114–2121
5. Yousif NJ, Matloub M D And H, Summers AN. The midface sling:
a new technique to rejuvenate the midface. Plast Reconstr Surg
2002;110(6):1541–1553, discussion 1554–1557
6. Baylis HI, Goldberg RA, Wilson MC. Complications of Surgery
of the Upper Eyelid. In: Putterman AM, ed. Cosmetic Oculo-
plastic Surgery: Eyelid, Forehead, and Facial Techniques, 3rd
ed. Philadelphia: WB Saunders Co; 1998
7. Harrisberg BP, Singh RP, Croxson GR, Taylor RF, McCluskey PJ.
Long-term outcome of gold eyelid weights in patients with fa-
cial nerve palsy. Otol Neurotol 2001;22(3):397–400
8. Misra A, Grover R, Withey S, Grobbelaar AO, Harrison DH.
Reducing postoperative morbidity after the insertion of gold
weights to treat lagophthalmos. Ann Plast Surg 2000;45(6):
623–628
9. Thomas DA, Khalifa YM. Temporalis fascia in the management
of gold eyelid weight extrusion. Ophthal Plast Reconstr Surg
2005;21(2):153–155
10. Foster JA, Perry JD, Cahill KV, Holck DE, Kugler L. Processed hu-
man pericardium barrier for gold weight implantation. Oph-
thal Plast Reconstr Surg 2004;20(2):107–109
11. Baylis HI, Goldberg RA, Groth MJ. Complications of Surgery of
the Lower Eyelid. In: Putterman AM, ed. Cosmetic Oculoplastic
Surgery: Eyelid, Forehead, and Facial Techniques, 3rd ed. Phila-
delphia: WB Saunders Co; 1998
12. Malik TH, Kelly G, Ahmed A, Saeed SR, Ramsden RT. A com-
parison of surgical techniques used in dynamic reanimation of
the paralyzed face. Otol Neurotol 2005;26(2):284–291
13. Saeed SR, Ramsden RT. Rehabilitation of the paralysed face:
results of facial nerve surgery. J Laryngol Otol 1996;110(10):
922–925
14. Samii M, Matthies C. Management of 1000 vestibular
schwannomas (acoustic neuromas): the facial nerve—preser-
vation and restitution of function. Neurosurgery 1997;40(4):
684–694, discussion 694–695
15. Ryzenman JM, Pensak ML, Tew JM Jr. Facial paralysis and sur-
gical rehabilitation: a quality of life analysis in a cohort of
1,595 patients after acoustic neuroma surgery. Otol Neurotol
2005;26(3):516–521, discussion 521
16. May M, Sobol SM, Mester SJ. Hypoglossal-facial nerve in-
terpositional-jump graft for facial reanimation without
tongue atrophy. Otolaryngol Head Neck Surg 1991;104(6):
818–825
17. Hammerschlag PE. Facial reanimation with jump interposi-
tional graft hypoglossal facial anastomosis and hypoglossal fa-
cial anastomosis: evolution in management of facial paralysis.
Laryngoscope 1999;109(2 Pt 2, Suppl 90):1–23
forming a wedge excision of the lower lip, the surgeon
should remove a full-thickness v-shaped wedge on the
paralyzed side with meticulous three-layer closure of
mucosa, orbicularis muscle and skin, with careful atten-
tion to the vermillion border.
◆Conclusion
The overarching goal in the treatment of patients with
facial paralysis is a safe restoration of form and func-
tion. Complications seen in facial paralysis surgery are
as myriad as the treatments off ered and can range from
a lack of achieving the desired outcome (e.g., no im-
provement) to an aggravation or even worsening of the
patient’s condition (e.g., worsened corneal exposure or
increased asymmetry). Improper selection of treatment
can be the fi rst step to failure. Undoubtedly, all surgeons
will have their individual comfort levels with the vari-
ous treatment options, and the success of any given pro-
cedure may vary in each surgeon’s hands, but with early
identifi cation and aggressive management of complica-
tions, the surgical results will be optimized. A thorough
understanding of facial nerve pathophysiology, a de-
tailed assessment of the patient’s condition, meticulous
surgical technique, and experience with both good and
bad outcomes are all vital to treat the sequelae of facial
paralysis successfully.
PEARLS OF WISDOM
Spend a generous amount of time with the patient in the
preoperative period for surgical planning and counseling so as
to select the most appropriate treatment.
Remember B.A.D. to identify patients at risk for exposure
keratitis: absence of Bell’s phenomenon, absence of corneal
refl ex, and dry eyes.
Beware of negative vector lower eyelids.
Master your lid loading technique. Complications should be
minimal.
Regarding nerve repairs and grafts, prepare the patient for a
long wait and realization that normal function return will not
occur.
Classic XII-VII crossover grafts have better alternatives, such as
the XII-VII interposition jump graft. Hemiglossal dysfunction
can be problematic.
Careful follow-up, education and re-education of the patient
will maximize their satisfaction.
132
Surgical correction of anomalies associated with congeni-
tal malformation is both rewarding and challenging. Few
areas in facial plastic surgery display such myriad pre-
sentations that require careful analysis and exact surgical
planning. Many of the procedures are complex and danger-
ous, requiring highly specialized training and experience,
so it is not surprising that surgery for congenital anomalies
is associated with complications. This chapter discusses
many of these complications and their management. As
with all untoward results, prevention is the best practice,
and attention to detail and early acknowledgment of com-
plications are paramount to their management.
◆ Complications of the Surgical
Treatment of Craniosynostosis
Congenital craniofacial surgery refers to the correction
of congenital or developmental defects, such as those
resulting from premature fusion of cranial sutures or
branchial arch abnormalities. The surgical treatment
of craniosynostosis began in the latter half of the nine-
teenth century. Many of the techniques developed then
are still used today in modifi ed form. As might be imag-
ined, any surgery involving the cutting and moving of
craniofacial bones has signifi cant risks. These include
death, eye or brain damage, hemorrhage, infection, an-
esthesia problems, need for revision surgery, and others.
Mitigating factors include patient age and size, severity
of the deformity and the subsequent complexity of sur-
gery, and comorbidities.
Reported mortality rates range from zero to 3%, and
morbidity rates range from 1 to 40%, with the lowest rates
associated with the simplest surgeries (strip craniectomy
or synostectomy) on the least signifi cant deformities.1–4
The incidence of neurologic defi cits after strip craniecto-
mies was less than 1%. In the Shillito and Matson series,
the frequency of reoperation secondary to resynostosis
was 13.3% after correction of single sutures and 38% after
repair of multiple sutures.1 Complication rates increase
with the complexity of the surgical procedure. As more
bone is exposed, there is an increased occurrence of
blood loss, infection rate, risk of subgaleal collections, air
embolism, dural tears associated with cerebrospinal fl uid
(CSF) leak, and direct injury to the brain or eye.
Preventing Airway Complications
The prevalence of obstructive sleep apnea syndrome
in children with syndromic craniofacial synostosis has
been reported to be as high as 40%.5,6 Airway manage-
ment remains a constant and signifi cant problem in
craniofacial dysostosis. Children with craniofacial dys-
ostoses often have airway problems related to distortion
of the oropharynx by the cranial base. Midface retrusion
and acute skull base angles bring the soft palate against
the posterior pharyngeal wall, leading to breathing
problems and sleep apnea. Small nasal airways con-
tribute to the problem as well. In addition, laryngotra-
cheal anomalies may be associated with craniofacial
problems. Signs associated with increased respiratory
diffi culties include swallowing or gagging problems, in-
creased refl exes and spasticity, and sleep apnea (often
described by the parent as a worsening in the child’s
snoring). Preoperative endoscopic evaluation is essen-
tial. In some cases, a tracheostomy must be established
before surgery. Of children with syndromes involving
bony deformities of the face and skull, 20% unambigu-
ously required tracheostomy in a study of 251 patients
by Sculerati et al.7 Tracheostomy also reduces the risk
of postoperative problems, such as airway edema, aspi-
ration pneumonia, or pneumocephalus after monobloc
advancement. In some cases, Chiari malformations must
be decompressed to reduce brainstem dysfunction.
Complications Related to Timing of Surgery
The main issues regarding timing of surgery are skull
thickness and malleability, patient size and blood vol-
ume, brain growth potential, and intracranial con-
15
Surgical Correction of Congenital
Anomalies and Associated Complications
Sherard Austin Tatum III and Sven-Olrik Streubel
15 Surgical Correction of Congenital Anomalies and Associated Complications 133
tion to control hemorrhage can result in serious neuro-
logic injury or death if it is done posterior to the anterior
one-third of the sinus. Most deaths and serious neuro-
logic sequelae associated with craniosynostosis surgery
refl ect an inability to maintain adequate blood volume
perioperatively. Hypovolemia also increases the risk of
air embolism. Blood should be available from the be-
ginning of the procedure, and the patient’s hematocrit
should be monitored routinely throughout the proce-
dure. To reduce blood loss, some centers maintain sys-
temic hypotension (a mean blood pressure of 50 mm
Hg) during the operation. Epinephrine is injected into
the skin before the incision is made. Hemostasis at the
incision site is achieved with Raney clips or with cauter-
izing instruments, such as the Shaw scalpel or the Colo-
rado needle. Topical agents like thrombin and collagen
reduce blood loss as well. Systemic aminocaproic acid
also reduces blood loss in select cases. Many centers
now routinely arrange for donation of pedigree blood
from the family before surgery.
Pneumocephalus is expected after such dissections,
but tension pneumocephalus is a life-threatening emer-
gency and must be managed with decompression.
Subdural and epidural fl uid collections are likewise ex-
pected, but hematomas exerting a mass eff ect should
also be decompressed. Brain contusion or hemorrhage
may occur as a result of excessive retraction, and it will
be visible on postoperative computed tomography (CT)
imaging. The contusions and hemorrhage generally are
self-limiting and resolve, but neurologic sequelae may
result. The best way to manage complications is to avoid
them with gentle retraction on the dura. The tempo-
straint. In the fi rst year of life, the human brain grows
from roughly 335 g to 925 g, almost tripling in mass.
Fused sutures may restrict the skull growth required to
accommodate this brain growth. Before 1965, surgical
correction was undertaken later rather than earlier (i.e.,
after an age of 1 year) because of anesthesia and blood
volume issues. During the 1970s and into the 1980s,
arguments were advanced for surgery from one to six
months of age to leverage the growth potential and re-
duce elevated ICP. Scheduling surgery at four to nine
months of age allows for relative safety due to patient
size, takes advantage of rapid brain growth to support
and enhance the correction, and provides for malleable
skull bone that is thick enough to hold fi xation materials
without being too thick and stiff to allow easy remodel-
ing. The osteogenic dural stimulus in the infant (age less
than 12 months) allows for fi lling in of bony gaps after
repositioning, so bony defects are rare at this age. If ICP
is elevated, then an early operation is necessary to pre-
vent brain damage.
Blood Loss, Air Embolism, and Pneumocephalus
Excessive blood loss is still the most worrisome compli-
cation.8 This problem results from constant slow ooze
throughout cases requiring ten hours or more as well
as from acute bleeding from vascular injury. Dissection
over dural sinuses, particularly more posteriorly, risks
massive hemorrhage from dural sinus injury, especially
in the region of the torcular herophili (Fig. 15.1A,B).
Knowledge of the locations of these vessels relative to
the skull surface anatomy is critical. Sagittal sinus liga-
Fig. 15.1 Overlay of skull surface anatomy with dural and brain anato-
my: (A) vertex view, (B) lateral view. (Illustration by Robert Brown.)
A
B
Complications in Facial Plastic Surgery
134
closures can be as high as 95%. Many patients present
with surgical emergencies because of increased ICP.11
The decision of when to place a ventriculoperitoneal
(VP) shunt for cerebrospinal fl uid (CSF) diversion can be
complex. If the child has symptoms and signs of elevated
ICP caused by hydrocephalus, then a VP shunt is placed
fi rst. If the child is asymptomatic, it is best to wait until
after the craniofacial reconstruction to reduce the risk of
infection from a VP shunt in the fi eld of surgery. Elevat-
ed ICP often causes severe erosion of the skull bone (Fig.
15.3). These erosions are seen as scalloping of the inner
table of the calvarium on plain fi lms or full-thickness
defects on CT scanning (Fig. 15.4). The dura can erode
through the bone, making it technically diffi cult to el-
evate the pericranium from the dura.
Complications Due to Altered Anatomy
Children with craniofacial dysostoses have skull base
anomalies, the most common of which is the Chiari
malformation, and associated distortions of the fora-
men magnum.12 Consequently, a thorough preoperative
evaluation with magnetic resonance imaging (MRI) or
CT is essential to evaluate the brain stem and cervico-
medullary junction. Appropriate preoperative evalua-
tion prevents postoperative quadriplegia from spinal
cord or brain stem compression caused by inappropriate
surgical positioning during craniofacial reconstruction
(i.e., cervical hyperextension). Children with metopic
synostosis commonly have a maldeveloped, foreshort-
ened anterior fossa. A frontal lobe pseudoherniation
often occurs, moving the lobes downward to a position
between the orbits. In coronal synostosis, the tempo-
ral lobe tends to be located very anterior in the lateral
orbital wall. These abnormalities increase the risk of
dura and brain injury requiring careful brain retraction
ral branch of the facial nerve can be damaged sharply
during scalp elevation or injured by cautery or traction.
Again, avoidance is the best management. Widening of
the scalp scar (Fig. 15.2A,B) can result from excessive
tension on the closure or damage to the adjacent hair
follicles. Careful tissue handling and wound closure gen-
erally avoid these problems. In particularly long cases,
strangulating scalp clips or sutures should be used with
caution.
Hydrocephalus and Intracranial Pressure
Hydrocephalus and increased intracranial pressure, al-
though not synonymous, are closely related. They may
exist together or separately. Findings include neurologic
dysfunction, irritability, and visual disturbance. Com-
plete neurologic, ophthalmologic, and CT radiographic
examinations are necessary if these conditions are sus-
pected. Hydrocephalus is uncommon in children with
isolated single-suture synostosis but becomes more fre-
quent in multisuture synostosis and in cases involving
the skull base (i.e., craniofacial dysostosis such as Crou-
zon and Apert syndromes). Various series have reported
hydrocephalus in less than 50% of cases.1,9,10 Renier et al.
performed intraoperative ICP monitoring on an exten-
sive series of patients and found that the risk of increased
ICP in children with Kleeblattschädel or multiple suture
Fig. 15.2 Widened scalp scar: (A) top view, (B) lateral view.
Fig. 15.3 Intraoperative view showing inner table calvarial
scalloping.
A
B
15 Surgical Correction of Congenital Anomalies and Associated Complications 135
risk of infection, with shorter operations (e.g., strip cra-
niectomies) carrying a 3% risk of infection. Longer op-
erations may lead to increases in rates of infection of up
to 8%. A key factor in infection is the age of the child and
the developmental status of the sinuses. If the frontal
sinus communicates with the epidural space, the rate
of infection increases greatly, especially when advance-
ment procedures leave a dead space. In most cases, such
operations are performed before pneumatization of the
sinuses occurs at 3 years of age. Monobloc procedures
have the highest risk, because they cause connection
between the nasal and cranial cavities. Pericranial fl aps
and tissue sealants are used to reduce the risks. Osseo-
distraction rather than acute advancement is also as-
sociated with lower risks. Surgical prophylaxis should
target the typical off enders, mainly Streptococcus and
Staphylococcus. Copious irrigation to remove bone de-
bris and blood aids in the prevention of infections. In-
fection poses the risk of losing the osteotomized bone.
Cerebrospinal Fluid Leak
Dural tears with subsequent cerebrospinal fl uid (CSF)
leak occur most commonly at the bony sutures where
the dura is tightly attached in children under the age
of one year. Also, the skull erosion associated with el-
evated ICP leads to direct pericranium to dura contact
that increases the risk of tears. These tears increase the
incidence of postoperative CSF leakage and the risk of
meningitis. Therefore, meticulous attention must be
paid to closing such tears when leaks are present. If the
dura is torn, a watertight repair must be performed. At
the completion of the operation, it is advisable to check
with a Valsalva maneuver for persistent CSF leakage. Af-
ter surgery, large subgaleal collections can occasionally
result from CSF pooling. Such collections rarely require
treatment, because they usually resolve spontaneously.
If a leak persists, a lumbar spinal drain can be placed
for fi ve to seven days; the pressure reduction of CSF is
usually eff ective in correcting a CSF leak. Thereafter, the
surgical site must be reexplored and the CSF leak site
repaired.
Problems with Foreign Materials
In the past, metallic wires and miniplates have led to
extrusion through the skin or worse, migration into
the brain. Most craniofacial surgeons now use resorb-
able miniplates or suture material (Fig. 15.6). Various
commercial products are currently in use, primarily
composed of polyglycolic acid (PGA), poly-L-lactic acid
(PLLA), and PGA-PLLA copolymers. Miniplates pro-
vide additional structural support, particularly when
advancement and transposition techniques are per-
formed. The reported complications of resorbable plat-
ing systems include pronounced fi brous encapsulation
and visibility,15 palpability,16,17 sterile sinus formation,18
(Fig. 15.5). Preoperative computed tomography (CT) or
magnetic resonance imaging (MRI) helps to discover
such problems, allowing modifi cation of the surgical
approach as necessary to avoid these injuries.
Infection
Most operative series for craniosynostosis have been as-
sociated with an infection rate of 3 to 5%.13,14 The dura-
tion of the operation is directly related to the relative
Fig. 15.4 3D CT showing calvarial defects.
Fig. 15.5 Brain protection during bandeau osteotomies.
(Illustration by Robert Brown.)