Cosmetic Facial Surgery

Chapter 9  •  Cervicofacial Rhytidectomy
333
A
B
FIGURE 9-163.  Patient before and after cervicofacial rhytidectomy with SMASectomy and platysmaplasty.
A
B
FIGURE 9-164.  Patient before and after cervicofacial rhytidectomy with SMASectomy, platysmaplasty, brow lift, four-quadrant
blepharoplasty, and cheek implants.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-165.  Patient before and after cervicofacial rhytid-
ectomy and platysmaplasty with SMASectomy, simultane-
ous CO2 laser resurfacing, and cheek implants.
A
B
FIGURE 9-166.  Patient before and after facelift with SMASectomy, brow lift, and upper blepharoplasty.
A
B
FIGURE 9-167.  Patient before and after facelift with SMASectomy.

Chapter 9  •  Cervicofacial Rhytidectomy
335
A
B
FIGURE 9-168.  Patient before and after facelift with SMASectomy.
A
B
FIGURE 9-169.  Patient before and after facelift with SMASectomy, upper and lower blepharoplasty, cheek implants, and full-face
CO2 laser resurfacing.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-171.  Patient before and after facelift with SMASectomy, chin implant, and full-face CO2 laser resurfacing.
A
B
FIGURE 9-170.  Patient before and after facelift with SMASectomy.

Chapter 9  •  Cervicofacial Rhytidectomy
337
A
B
FIGURE 9-172.  Patient before and after facelift with upper and lower blepharoplasty and full-face CO2 laser resurfacing.
A
B
FIGURE 9-173.  Patient before and after facelift with
SMA­Sectomy, upper and lower blepharoplasty, and
chin implant.
Revision Facelift Surgery
Although facelift surgery is a predictable long-lasting procedure,
it is not permanent. The patient continues to age the minute
they wake up from anesthesia. The longevity of a surgical
procedure is influenced by many variables, including the
surgical procedure and technique, patient genetics, skin quality,
aging, and how the result is maintained or protected after
surgery.
Revision procedures are performed not only as a result of
relapse but also to improve a suboptimal outcome from a
pre­vious lift. In some respects, revision facelifts are easier than
procedures on previously unoperated patients, because the
patient has been through the experience already and is familiar
with the operation and recovery. In my experience, patients who
had a good experience and outcome with facelift surgery 15 to
20 years earlier make very good patients and are pleased with
their revision procedure. On the other hand, a patient who had
a facelift recently and is displeased can be a challenging patient.
Some of this depends on the reason for the revision. If the
patient is unrealistic about minimal and insignificant sequelae,

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-174.  A, Patient with a previous facelift with unfavorable scars and earlobe position. B, After revision facelift surgery
with noticeable improvement.
FIGURE 9-175.  Patient has significant unfavorable scarring of the postau-
ricular scar that was successfully excised during revision facelift surgery.
they are likely to be displeased with the revision procedure as
well. In addition, the surgeon needs to understand that the
“sins” of a previous surgeon may become the property of the
next surgeon. An example of this would be a patient who under-
went previous facelift surgery with a poor outcome, including
improper incision placement, temporal balding, problematic
scarring, and overcorrection. When the second surgeon operates
on this patient, he or she may improve some of the aesthetics,
but many of the problems will remain uncorrected and now are
the property of the second surgeon. I have seen patients with
poor outcomes who had excellent revision, but the second
surgeon received negative marketing because he was credited
with the surgery.
As stated, some revision facelifts are simple repeats of a well-
done previous procedure. These patients present without scar,
incision, volume, or hairline problems, and their second surgery
is uneventful. For those patients presenting with temporal bald-
ness, pixie earlobes, improperly placed scars, or corrected fat
removal, careful planning is a requisite and should be reserved
for the experienced surgeon.
Revision Surgical Procedure
The incision planning for the second surgery is somewhat
dependent upon the original incision placement and healing.
For normal well-placed and healed scars, the original scar lines
can be followed. Exceptions would include poorly placed previ-
ous scars or lobe position. Figure 9-174 shows a patient on
whom I performed a revision facelift. The patient presented
with a poorly placed and obvious preauricular incision and pixie
earlobe resulting from a procedure done at another clinic. The
excess skin enabled me to utilize a posttragal incision to remove
the previous scar and improve the lobe position. This conversion
was easy because there was abundant excess skin available but
is not possible with patients who may have had more recent
unfavorable facelift surgery. If there is inadequate skin to allow
the removal of previous scars, the revision procedure may need
to be postponed to wait for some skin excess to develop. Figure
9-175 shows an unfavorable postauricular scar to be excised
during revision facelift surgery. Adequate excess skin makes this
possible.
In some cases, the relapse is isolated to certain areas of the
face. A patient who presents for revision surgery to correct

Chapter 9  •  Cervicofacial Rhytidectomy
339
A
B
FIGURE 9-176.  Patient experienced relapse only in the submental and neck
regions but not the jowls. Only a posterior auricular incision was required
to correct this problem.
FIGURE 9-177.  A patient with previous facelift, illustrating the abundance of
subcutaneous scar tissue and the paucity of adipose tissue.
FIGURE 9-178.  Patient who had a previous facelift with visible scar tissue
and the previous suspension sutures.
FIGURE 9-179.  Regardless of how tightly original sutures are placed, it is
not uncommon to find them loosened with revision surgery.
isolated cheek and jowl excess may only require a preauricular
incision. Similarly, a patient presenting with isolated neck and
submental skin may be corrected with only a posterior auricular
incision (Figure 9-176).
Previous subcutaneous scarring can also affect the revision
procedure. Most often the revision dissection is easier than a
virgin procedure, because there is a distinct plane of scar tissue
and less bleeding. Occasionally the scar tissue can impede the
reoperation, making flap development more challenging.
Besides scar tissue, there is usually a dearth of adipose tissue
(Figure 9-177). Because of heavy scarring and the thready
nature of the SMAS in the previously operated patient, open
SMAS procedures may not be possible and thus plication is
utilized. In some cases, the scar tissue is so plentiful that a skin-
only tightening procedure is all that can be predictable and
safely performed. It is not uncommon to encounter previous
sutures or devices such as facial implants (Figure 9-178). It is
also not uncommon to encounter previously placed lose sutures
(Figure 9-179). This is testament to the fact that no matter how

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-181.  Patient before and after revision facelift surgery with cheek implants and CO2 laser resurfacing. Note the temporary
hyperpigmentation from the facial laser.
A
B
FIGURE 9-180.  A, A patient with poor vector tension causing an upswept look as well as a pixie earlobe. B, The patient after
revision surgery to improve the vector pull and pixie lobe. Cheek implants also improved the result by restoring midface volume.
tightly sutures are placed, with time they will lose support, and
it is most likely the scar tissue that maintains the original
suspension.
Figure 9-180 shows a patient who had a poorly performed
facelift initially at another clinic. Figure 9-180, A shows incor-
rect skin-vector pull, causing an upswept look. In addition, she
exhibits a pixie ear deformity. Figure 9-180, B shows the patient
after revision facelift surgery was performed. Although it
improved the earlobe and general appearance, fully correcting
the previous skin pull vector was challenging.
Figure 9-181 shows a patient who had facelift surgery 20
years ago. She is shown after I performed a revision facelift with
SMASectomy, cheek implants, and full-face CO2 laser
resurfacing.

Chapter 9  •  Cervicofacial Rhytidectomy
341
Figure 9-182 shows a patient with two previous facelift sur-
geries. I treated her with an additional facelift, but because of
the scarred and fibrotic SMAS, a skin-only procedure was per-
formed, which suited the patient well.
Complications in Facelift Surgery
and Their Prevention
Of all cosmetic procedures, none are more life changing or
visibly exposed in everyday life than facelift surgery. A natural-
appearing facelift can change a patient’s life in innumerable
ways. It can not only make them look younger but also feel
younger, which can impact their entire affect. Contrarily, an
unnatural facelift or one with significant complications can
negatively impact the patient’s appearance and attitude. It can
also harm the doctor’s reputation and cause lawsuits. Although
no surgeon can guarantee a procedure without complications,
most facelift complications are predictable and frequently avoid-
able by obeying sound preoperative, intraoperative, and postop-
erative techniques. Even the best surgeon with the best patient
with the best anesthesiologist and surgical team can and will
experience complications associated with facelift surgery.
It is impossible to cover all facelift complications in this
chapter. Some were discussed as part of the description of pro-
cedures earlier in the chapter. The remainder of this chapter will
focus on some of the more common complications and discus-
sion of their prevention.
Preoperative Considerations
Intraoperative or postoperative death is of course the most tragic
complication and sometimes will happen as a consequence of
circumstances beyond the surgeon’s control. The best offense for
such a tragedy is a good defense. This begins with picking
appropriate patients for the given procedure. Facelift patients
are frequently elderly and may have multisystem disease and be
on multiple medications. Most patients do well with proper
medical, anesthetic, and surgical management, but some patients
are clearly unsuitable candidates. The surgeon’s enthusiasm to
operate should never supersede common sense. We must
remember that no one needs a facelift; it is an elective procedure
and not one worth dying for.
In my practice, all facelift patients receive a thorough preop-
erative history and physical exam by their primary care physi-
cian. This includes ECG, chest x-ray if indicated, and appropriate
blood and coagulation studies. In addition, the anesthesiologist
reviews the charts of any questionable patients a week before
the procedure. Although most patients totally understand the
necessity of a thorough workup, occasionally a patient will balk
at the hassle, and in this case I convince or dismiss them. The
liability outweighs the procedure.
Patients with controlled hypertension or diabetes are most
often cleared and fare well. Patients with cardiac or respiratory
problems present more of a risk. Cardiac patients (those with
previous angina or coronary artery disease) must receive signifi-
cant preop work by a cardiologist and will frequently undergo
cardiac CT, stress test, and similar evaluation. Important infor-
mation for the surgeon to acquire includes the following ques-
tions: What is the valve function? What is the ventricular
function? What is the status of the coronary artery system? Is
the patient arrhythmogenic? Always remember that a patient is
only as healthy as their coronary arteries.
Patients with emphysema must undergo pulmonary consul-
tation and tests related to pulmonary function. Ultimately,
every medically compromised patient is a calculated risk, and
A
B
FIGURE 9-182.  Patient underwent two previous facelifts and was treated by the author with a skin-only lift.

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Chapter 9  •  Cervicofacial Rhytidectomy
the more consultations performed preoperatively the better.
With medically compromised patients, aggressive or multiple
procedures may be best avoided in favor of more conservative
or singular procedures.
No matter how badly a surgeon wants to perform a proce-
dure, a bad decision can end tragically. Having said this, many
patients with multisystem disease routinely undergo procedures
such as total joint replacement and do well. Always remember,
however, that cosmetic surgery is elective surgery.
Smokers present well-known surgical and anesthetic risks.
Increased secretions, more reactive airways, decreased lung
capacity, and oxygenation problems affect anesthesia safety and
efficacy. Postoperatively, these patients may be at greater risk for
tissue necrosis and delayed healing. As stated earlier, I utilize a
specialized smoker’s consent form that details the various prob-
lems associated with smoking and surgery, and I also perform a
more conservative procedure. Whereas I may simultaneously
laser normal facelift patients, I may refrain from concomitant
laser resurfacing so as not to stress the lipocutaneous flap in
smokers. To reiterate, my experience has shown that complica-
tion rates for smokers are not alarmingly greater than for non-
smokers, and smoking is not an absolute contraindication to
rhytidectomy but warrants conservatism.
Deep vein thrombosis (DVT) (or resultant pulmonary
embolus) is a problem that may occur in longer surgeries such
as facelift. Combining facelift with other cosmetic facial proce-
dures can lead to 5- to 6-hour cases of immobilization during
anesthesia. Obese patients, medically compromised patients,
patients on birth control pills, and others can have an increased
incidence of DVT. I believe general anesthesia increases the
possibility of DVT due to the absolute extended immobility of
the patient. I prefer IV sedation because the anesthetic plane is
not as deep, and the patient can move their extremities. All my
facelift patients (or procedures that last longer than 2 hours)
wear compression hose during surgery. In higher-risk patients
or those undergoing general anesthesia, I use pneumatic com-
pression devices. In addition, my anesthetist and staff regularly
massage and mobilize the patient’s extremities to induce blood
flow and prevent pressure points.
There is no substitute for ardent preoperative evaluation,
testing, workup, and prevention. Something as simple as
aspirin or any medication that influences platelet function can
contribute to hematoma and begin a cascade of resultant
complications.
Although not a physical complication, physiologic issues can
complicate an otherwise normal procedure as well as make the
cosmetic experience unfavorable for the patient, surgeon, and
staff. Healing after multiple cosmetic facial procedures can be
an emotional roller coaster for the patient. Their image is dis-
torted, and their emotional and physical reserves can be pushed
to the limit. No matter how accurately the surgeon explains the
procedure and healing to the patient, the shock of looking in
the mirror or a left-handed comment from a caregiver can put
a patient into acute depression. I have seen very strong, well-
adjusted patients crash in the first week or two and become
emotional wrecks. On the other hand, I have had fragile patients
who were already on antidepressants slide through recovery
without any emotional issues. Preoperatively, I explain to the
patient that there are many emotional ups and downs in the
early recovery period, and they and their family must be pre-
pared. Our facial image is the very core of our well-being and
emotions, and when a patient looks in the mirror and sees a
swollen, distorted, and bruised face, it is scary. It is not abnor-
mal for them to have “buyer’s remorse” and feel they made a
tragic mistake having surgery. They may also feel they chose the
wrong surgeon, because they had a friend who had cosmetic
facial surgery and did not have these problems. In addition, pain
and sleep deprivation (which are both common) can wear down
even the strongest patients. It is important to prescribe adequate
medications to keep the patient comfortable, as well as sleep
medication if needed. An anxiolytic prescribed before bed or
throughout the day can work wonders. In addition, many
patients are placed on steroids, which can also cause emotional
issues.
The quality of the caregiver is also an important consider-
ation. I sometimes see a husband who for various reasons is
against his spouse having cosmetic surgery. There are no worse
words to a bruised, swollen, miserable patient than “I told you
not to do this.” It is a good idea to have the spouse or caregiver
present at the preoperative appointment for a “pep talk” address-
ing support issues.
Intraoperative Considerations
Problems that occur during the operation include surgical and
anesthetic complications. Airway is always the prime consider-
ation with any anesthetic. There are arguments for and against
an intubated airway, and this depends upon multiple factors
between the anesthesiologist and surgeon. As stated earlier, I
prefer IV conscious or deep sedation. We sometimes utilize
laryngeal mask airways (LMA), elongated nasal pharyngeal
airways (Rusch tubes), or simple nasal oxygen cannulas. The
patient’s anatomy, size, respiratory status, airway obstruction,
and length of surgery factor into the appropriate choice. When
a noninvasive airway is utilized, the ability to intubate must be
an ever-present consideration, and the appropriate medications
and equipment are at arm’s reach.
Hypertensive patients can be managed with 0.1 to 0.2 mg
of clonidine immediately preop to lower blood pressure. Blood
pressure control throughout the surgery is important, and small
doses of beta blockers such as labetalol may be given when
required. Narcotics are kept to a minimum to prevent extended
recovery and postoperative nausea and vomiting (PONV).
Patients who undergo procedures that last longer than 4 hours
may require catheterization.
Nerve pressure points in the extremities must also be con-
sidered because of long periods of immobilization. Adequate
padding on the operating table and periodic mobilizing of the
extremities by the anesthetist and staff are important. These are
just a few of the many considerations that require thought and
preparation during surgery.
Intraoperative Surgical Complications
Hemostasis is a prime consideration of facelift surgery, and
careful attention to bleeding must be paid throughout the entire
procedure. Nothing is more stressful than dealing with a post-
operative expanding hematoma in the middle of the night. This

Chapter 9  •  Cervicofacial Rhytidectomy
343
A
B
FIGURE 9-183.  Allowing the delicate lipocutaneous facelift flap to contact cauterized tissue prior to cooling can cause a full-
thickness burn.
is something that must be planned for in advance and antici-
pated for each case. Most novice surgeons have found them-
selves in the precarious position of having to take a patient back
to the office surgery center after hours and the stress of not being
to reach their staff, the surgical instruments are still dirty in the
sink, the anesthetic medications are locked up and you are alone
with an anxious patient and family. An ounce of prevention is
definitely worth many pounds of cure in this situation. The key
is to anticipate the complication. It involves having staff on call
to respond, having sterile instruments available, and having
access to anesthetic medications and personnel. Having a proac-
tive plan for dealing with hematoma or other emergent compli-
cations is a significant necessity.
Prevention of postoperative hemorrhage is critical. It is dif-
ficult to attempt to “catch up” with bleeding at the end of a
case, prior to wound closure. The astute surgeon will continually
control bleeding throughout each step of the facelift. I prefer
the 4.0-MHz radiowave system (Ellman International) to con-
ventional electrosurgery. This system provides simultaneous
incision with coagulation and produces less lateral thermal
damage than conventional electrosurgery. Using a combination
of bayonet bipolar forceps (large tip and fine tip), ball electrode,
and indirect forceps coagulation allow the surgeon a multitude
of means of addressing bleeding.
In the discussion of complications, a small but significant
point is to protect the delicate lipocutaneous flap from thermal
insult when using electrosurgery. Any electrosurgical coagula-
tion can produce heat, so cauterizing fat can create a heat sink
that can remain very hot for several seconds. It is important for
the assistant to prevent the skin flap from contacting the cauter-
ized area until it is cool; otherwise a full-thickness thermal burn
can occur (Figure 9-183).
Postoperative Surgical Complications
As noted earlier, postoperative expanding hematoma is a true
emergency in facelift surgery.29-31 An expanding hematoma puts
the delicate lipocutaneous flap under significant pressure and
can compromise the dermal plexus and other vascular nourish-
ment of the flap. This can result in minor or major loss of flap
viability, with resultant skin necrosis and full-thickness scarring.
The points of prevention were addressed previously, but when
an expanding hematoma does occur (statistics range from 2%
to 15% of cases), the surgeon must be able to rapidly diagnose
and treat the complication to avert tissue loss.29
Postoperative bleeding with hematoma can occur immedi-
ately at the end of the case and is noticed when washing the
hair or bandaging the patient. Every attempt should be made
at that time to evacuate and control the bleeding. Since the
surgeon is frequently out of the operating suite at this time, the
staff must be well trained in recognizing problematic bleeding.
Fortunately, this early “on-the-table” accumulation of blood will
frequently respond to evacuation with a small, blunt liposuction
cannula (or needle aspiration) and light compression (Figure
9-184). The blood is suctioned, and compression of the pre- and
postauricular flaps are performed with small stacks of 4 × 4
gauze. The area is checked again after 10 minutes for reaccumu-
lation. If there is a reaccumulation, the evacuation and pressure
can be repeated, but continued accumulation is grounds for
opening the incision and exploring and controlling the bleed-
ing, especially if the accumulation is bright red blood.
Postoperative hematomas can be categorized into minor and
major. A minor accumulation of blood can be evacuated the
following day or is oftentimes resorbed. A major hematoma that
is expanding in real time is emergent. Since these frequently
occur in the early postoperative period, it makes sense to recover

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Chapter 9  •  Cervicofacial Rhytidectomy
the patient in your facility for several hours. Having said this,
the next 24 hours still present a vulnerable period, and checking
on the patient throughout the evening is time well spent. Also,
educating the patient on the signs and symptoms of expanding
hematoma can increase the chances of early treatment. During
the past decade (and almost 700 facelifts) I have personally had
6 cases of major expanding hematomas that required emergent
treatment. Two of these, although significantly distorting the
patient’s face, were not recognized by the patient or family and
seen at the next morning’s postoperative visit. One of these was
unilateral, and the other was bilateral. It is possible to have a
unilateral bleeding source that dissects across the submental
midline and affects both sides. The other two patients called
within 8 hours of their facelift, reporting severe unilateral pain.
They were noticeably agitated and reported rapid-onset swelling
with bleeding from the incision sites. One of these patients also
reported difficulty closing her mouth. This resulted from dissec-
tion of blood into the buccal space, which expanded between
the upper and lower teeth. Figure 9-185, A shows two patients
presenting with unilateral major hematoma at the 24-hour
postop appointment. Figure 9-185, C and D show other views
of the hematoma, illustrating active bleeding from the anterior
and posterior flaps.
All these patients were treated in the same successful manner,
though none of them conveniently. Treatment of a major
expanding hematoma requires removing the sutures and opening
the flaps to explore for the bleeder(s). Generally these patients
are scared, agitated, and in pain, and treatment is difficult
without IV sedation. Once the flaps are opened, large “currant
jelly” clots are observed and débrided with gauze and a large-
bore liposuction cannula (Figure 9-186). If the hematoma is
early in formation or not tamponaded, bright red blood may be
present (Figure 9-187). Figure 9-188 shows a hematoma 24
hours later, illustrating the “currant jelly” clotted blood and the
same area after hemostasis.
The operative sites are then irrigated with saline to assist
identification of the source or sources of bleeding. I believe the
accumulation of a large clot acts as an irritant to the underlying
tissue and frequently causes multiple bleeding sites other than
the actual offending vessel. Generally these areas of irritation-
induced bleeding are easily controlled, but sometimes finding
the exact offending vessel can be difficult. In some cases, the
surgeon will find that the offending bleeder is a venous or arte-
rial vessel that was previously cauterized and has ruptured.
Other cases present a bleeder that was hidden under the flap or
simply overlooked. I have never seen a sub-SMAS bleeder that
caused a hematoma, and the offending vessel is usually identi-
fied. In resistant cases, it helps to pack the flaps with chilled
saline gauze and apply pressure for several minutes before reex-
ploring (Figure 9-189). In some cases, it can be a vessel on the
dermal side of the flap or a deeper large vessel such as the super-
ficial temporal vessels that are pierced with a suture needle later
in the case. Once the bleeding is controlled, the incisions are
resutured. The flap and incisions heal after being reopened and
manipulated. In the hematomas I have treated, the offending
side has always healed without complication.
Although the offending vessels are sometimes hard to visual-
ize, conscientious persistence must be utilized. It also helps to
have larger-bore suction tips available. The patient’s pain level
and blood pressure must also be monitored; hypertension can
obviously increase bleeding. Figure 9-190 shows two actual
intraoperative bleeders that I have personally isolated in major
hematoma treatment. The surgeon must continually be looking
for potential bleeding sites throughout the entire facelift proce-
dure. Figure 9-191 shows several potential sites.
In the case that all vessels are cauterized and the bleeding
persists, a possible bleeding diathesis must be considered and
appropriate stat labs drawn. Transfusion is a rare possibility.
After the bleeding is controlled, the wound is reclosed and
generally heals as well as the unaffected side (Figure 9-192).
Moderate icing and pressure are applied overnight with a com-
pressive dressing (Figure 9-193).
Minor Hematoma
Major expanding hematomas are an emergency, but minor
hematomas that represent nonexpanding collections of blood
are self-limiting and can be treated with simple aspiration
(Figure 9-194). If the area has clotted, it may require 4 to 5
repeated aspirations over the next week to 10 days to remove
the serum and degraded blood liquids.
Seromas are not true active bleeding or clotted blood but
rather serum from the healing process and blood breakdown
products. They are more amber colored and do not pose a threat
other than delayed healing. Simple aspiration with an 18-gauge
needle is effective and may need repeating several times if the
collection recurs (Figure 9-195). Uncommonly, seromas or even
hematomas can be delayed and present weeks later (Figure
9-196).
For the novice surgeon, the first hematoma (especially in the
middle of the night) can be very frightening. If a doctor has the
proficiency to perform a facelift, they have the same potential
proficiency to control bleeding. The surgeon needs to take a
deep breath, relax, and go to work, realizing that they will
succeed in hemostasis. As frightening as it may be for a novice
surgeon, it is always probably more frightening for the patient
and family, and they need reassurance that the outcome will be
FIGURE 9-184.  Small, early accumulations of blood in the immediate post-
operative period can frequently be evacuated and controlled with pressure
before bandaging. Continued accumulation warrants exploration and
control of the source.
Text continued on page 349.

Chapter 9  •  Cervicofacial Rhytidectomy
345
A
B
C
D
FIGURE 9-185.  A, This patient was unaware of a problem and is shown at 24 hours postop. B–D, Another patient was in severe
pain and agitated the evening of surgery and was treated that night. C–D, A true major hematoma is usually very obvious, with
disfiguring swelling and active, bright red blood if the bleeding is still active.

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Chapter 9  •  Cervicofacial Rhytidectomy
FIGURE 9-186.  The typical “currant jelly” clot that is visualized after opening the surgical site where a major hematoma is present.
A
B
FIGURE 9-187.  A, Postoperative hematoma has not yet clotted and is in the active stage of expansion. B, The surgical field
after successful hemostasis.
A
B
FIGURE 9-188.  A, This “currant jelly” hematoma is 24 hours old. B, Same area evacuated, with hemostasis controlled.

Chapter 9  •  Cervicofacial Rhytidectomy
347
FIGURE 9-189.  If the offending vessel(s) cannot be located after the sutures are removed and the hematoma evacuated, gauze
soaked in chilled saline is packed in the wound for several minutes, and the surgical site is explored.
A
B
FIGURE 9-190.  A bleeder in the cheek (A) and a bleeder on the dermal side of the flap (B) were causative in this case.
A
B
FIGURE 9-191.  A, The superficial temporal vein or other deep, large vessels can be damaged during surgery and bleed. B, The
underside of the lipocutaneous flap can contain smaller vessels capable of causing an expanding hematoma and should not
be overlooked.

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-192.  A, Patient with hematoma (see also Figure 9-185, A). B, Patient 8 days after treatment of hematoma and resu-
turing surgical site.
A
B
FIGURE 9-193.  After the bleeding is controlled and the flaps resutured (A), a pressure dressing is placed overnight, and ice is
applied to the affected side (B).

Chapter 9  •  Cervicofacial Rhytidectomy
349
FIGURE 9-195.  A seroma that presented at 1 week being aspirated. The
fluid is not viscous, and the dark color is from blood degradation.
FIGURE 9-196.  The presence of hematoma or seroma can be delayed.
This patient presented at 18 days with a hematoma surrounded by an
area of bruising. This image shows aspiration of the collection.
A
B
FIGURE 9-194.  A, A minor hematoma 6 days postop. B, The hematoma being aspirated.
okay. If this remote possibility is discussed in the preoperative
consent process, it saves a lot of worry and apology if it occurs.
Postoperative Edema and Ecchymosis
Other postoperative facelift complications that are commonly
seen include edema and ecchymosis. Although all facelift
patients will experience some degree of postsurgical edema,
some patients will exhibit impressive swelling. Patients undergo-
ing multiple procedures including brow lift, midface implants,
lip implants, and simultaneous laser resurfacing can swell to
alarming proportions (Figure 9-197). Although this usually does
not present significant problems, it could cause excess tension
on the suture lines. The biggest problem is generally the fear of
the patient and family that something bad has happened. Treat-
ment with oral steroids will usually hasten the resolution of the
severe edema, but some patients take longer than others. A
tapering regimen of methylprednisolone is commonly used but
in my experience is much less effective than using a nontapering
dose of prednisone. The patient is given 15 (20 mg) tablets of
prednisone and takes 60 mg (3 tablets at the same time) once

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Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-197.  A, Patient before surgery; B, 24 hours postop; and C, 30 days after multiple facial procedures including rhyt-
idectomy, midface implants, lip implants, upper and lower eyelid surgery, and laser resurfacing. Multiple combined procedures
can cause extreme swelling in some patients.
A
B
FIGURE 9-198.  Two patients are shown 48 hours after the same facelift procedure, and the differences in individual propensity
for bruising are illustrated. It is very difficult to predict the amount of bruising any patient may have.
a day for 5 days. This therapy has proven much more dramatic
than common tapering packs in my practice. Patients undergo-
ing multiple procedures, as well as their families, must be made
aware of the possibility of severe edema at the consent process.
In addition, patients with the type of swelling shown in Figure
9-197 must be assessed for airway patency. The possibility of
allergic reaction must also be considered.
Ecchymosis is another aspect of the consent process that
should be discussed preoperatively. Most experienced surgeons
can explain procedures to patients with accuracy, but edema and
ecchymosis remain the most difficult to predict. I see patients
who tell me they will severely bruise, and they heal without any
ecchymosis, whereas some young and healthy patients with
totally normal coagulation studies sometimes bruise remarkably
(Figure 9-198). It is best to predict bruising, and if it doesn’t
occur, the surgeon is a hero.
I believe the standard of care is to obtain coagulation studies
on facelift patients, although there is rarely a correlation to

Chapter 9  •  Cervicofacial Rhytidectomy
351
A
B
C
FIGURE 9-199.  Patient with facial nerve paresis of the left-sided buccal and zygomatic facial nerve branches at 1 week (A),
2 months (B), and 3 months (C) after surgery. Her improvement at 90 days is consistent with this type of minor nerve
injuries.
ecchymosis. Avoiding all the common medications that may
affect platelet function is pretty basic and well known to all
surgeons. Herbs and homeopathic preparations such as ginkgo,
garlic, ginseng and St. John’s wort had been implicated in coagu-
lation abnormalities, but this has been refuted.30
In my experience, pretunneling the facelift flaps with a blunt
cannula prior to scissors dissection has seemed to reduce ecchy-
mosis. Some surgeons advocate pre and postoperative Arnica
montana for reduction of bruising.
Neurologic Complications
Motor Nerve Injury
Two of the most feared complications of facelift surgery are
motor and sensory nerve damage and flap necrosis.31-33 These,
unlike many of the complications discussed previously, can be
tragic for the patient and surgeon as well, leading to damage of
reputation and litigation.
Frontal, buccal, zygomatic, marginal mandibular, and cervi-
cal nerve injury can result from many different things, including
direct injury (clamps, needles, scalpels an scissors), neuropraxia
(stretching from over aggressive retraction), thermal injury from
cautery, or compression injury from sutures, edema, hematoma,
and other causes. This is very disconcerting for the patient and
surgeon in the early postoperative period, but most of these will
spontaneously resolve within weeks or months. The gradual
return of function to the affected area is seen and greeted with
relief by all involved. Patients should be reassured that the nerve
weakness is likely temporary but advised (hopefully preopera-
tively) that return of full function cannot be guaranteed. In the
hundreds of facelifts I have performed over the past 12 years, I
have experienced no permanent motor nerve injuries. Four or
five patients had unilateral paresis of the buccal, zygomatic, or
marginal mandibular branches, with altered animation that
returned within 90 to 120 days (Figures 9-199 and 9-200).
Motor nerve injuries that do not seem to improve or those that
are severe and include multiple nerve branches should be evalu-
ated by a surgeon experienced in microneurosurgery after 90
days. The buccal and zygomatic branches are very arborized and
intertwined. For this reason, a permanent injury is rare, but this
also makes it difficult to characterize the exact nerve injury.
Rami of the zygomatic branch of the facial nerve innervate
the lower portion of the orbicularis oculi and if injured can
affect lid closure. This is an unusual injury, and an affected
patient is shown in Figure 9-201.
The marginal mandibular branch is a commonly affected
motor nerve and can be damaged during cervicofacial rhytidec-
tomy, submental liposuction, and chin implant surgery. When
a patient with damage to this nerve smiles, the affected side does
not depress, owing to the loss of innervation of the depressor
anguli oris and/or the depressor labii. Sometimes this can also
be related to a cervical nerve injury in that the platysma also
depresses the lip or corner of the mouth in many patients. In
these patients, the motor function of the platysma would likely
be involved. Figure 9-202 shows a patient with a right-sided
marginal mandibular nerve injury. To temporarily minimize this
asymmetry, the normal side can be treated with a small amount
of neurotoxin to even out the asymmetry. Most patients are
content to wait for the nerve function to improve.
The frontal branch of the temporal nerve can be disrupted
during brow lift procedures or in the area of the zygomatic arch
during facelift procedures. In over 500 facelifts, I have never
personally experienced a frontal branch injury. If it does occur,
the unaffected side can be treated with neurotoxin to temporar-
ily control asymmetric movement.
Sensory Nerve Complications
Facelift patients must be educated in the fact that they will all
have some component of sensory deficit, especially in the pre-
and postauricular regions. Generally this will spontaneously
resolve over a 90-day period. They must be reassured when it
takes longer; reinnervation usually ensues with time. Regardless
of the amount of preoperative discussion about temporary par-
esthesia, extended numbness can cause patient anxiety in the
postoperative period. I tell all preoperative facelift patients that
the area in front of, below, and behind the ear are likely to be
numb for up to 90 days. Some patients experience very little
paresthesia or improve in the first several weeks, but most
patients will be numb for a while. This can work to positive
advantage because uncomplicated facelift surgery is generally
not extremely painful, in part due to the paresthesia.
The infraorbital and mental sensory nerves are at risk during
facial implant procedures, which are frequently performed with
facelift surgery.
Perhaps the most commonly affected sensory nerve is
the greater auricular nerve (GAN). This nerve crosses the

A
B
D
C
FIGURE 9-201.  Patient underwent facelift with cheek implants and developed a large hematoma of the left-sided implant. She
is shown 1 week after surgery (A), 1 month after surgery (the implant had been removed), (B) 2 months after surgery (C), and
with total resolution at 3 months after the procedure with full functional recovery (D).
A
B
C
D
FIGURE 9-200.  Patient experienced paresis of the zygomatic and/or buccal branch of the facial nerve. She is shown at 2 weeks
(A), 4 weeks (B), 8 weeks (C), and with final resolution by 16 weeks (D).

Chapter 9  •  Cervicofacial Rhytidectomy
353
A
B
FIGURE 9-202.  Patient shortly after a facelift, with a right-sided marginal mandibular nerve injury. A, Her lip depressors are
affected; when she smiles, the affected side does not depress. B, Patient has normal function 11 weeks postoperatively.
FIGURE 9-203.  The greater auricular nerve is shown where it crosses the
belly of the sternocleidomastoid muscle.
sternocleidomastoid (SCM) muscle approximately 6.5 cm
below the external auditory canal (see Figure 9-7). As men-
tioned numerous times in the previous sections of this chapter,
there is very little subcutaneous tissue in the mastoid region and
the upper regions of the SCM muscle. In this region, the dermis
is virtually intimate to the fascia of the SCM, and it is not
uncommon to expose muscle fibers when performing flap dis-
section in this area. It is also possible to damage the GAN as it
superficially crosses the SCM (Figure 9-203). Figures 9-7, 9-9,
and 9-59 show these relationships. This nerve often has branches,
and I have inadvertently, although never intentionally, severed
these, resulting in no permanent sensory deficit. Figure 9-204,
A shows a transected GAN. If the nerve is transected, it should
be anastomosed with 7-0 Prolene suture (see Figure 9-204, B).
If for any reason it cannot be repaired, the stumps should be
tagged with a permanent suture for later identification if
necessary.
A damaged or repaired GAN can also develop a neuroma,
which manifests as an induration palpable through the skin over
the area of the nerve. A GAN neuroma can be painful and when
pressed by the examiner can radiate pain into the nerve
distribution.
The transverse cervical nerve horizontally crosses the SCM
inferior to the greater auricular nerve and provides sensory
innervation to the skin over the anterior triangle of the neck.
This nerve can be damaged in a low inferior cervical dissection.
Although a very rare injury, injury to the spinal accessory
nerve (cranial nerve XI, motor nerve) has occurred in facelift
surgery. This nerve exits on the posterior of the SCM (Erb’s
point). Since this nerve is posterior and deep, it remains out of
the field of dissection of most facelift flaps, but the surgeon must
keep its presence in mind because the physical problems of
shoulder droop are very problematic. Figure 9-205 shows the
relation of vulnerable nerves during cervical dissection.
External Jugular Vein
A surgeon can perform many facelifts and never visualize the
external jugular vein (EJV), but surgeons who have performed
hundreds of facelifts have more than likely encountered this
structure. Generally the EJV crosses the SCM at a similar level
as the GAN and then runs parallel to the GAN (see Figures
9-9 and 9-205). The EJV can be damaged by inadvertent deep
dissection; the vein is more superficial in some patients. The
vessel can be damaged with blunt liposuction cannulas or
punctured or transected with scissors or sharp instruments.
Figure 9-206 shows the close relationship of the EVJ and the
GAN to the SCM muscle. Although the EJV is usually not
encountered, all facelift surgeons must be cognizant of its posi-
tion and be on guard when dissecting in this area. As men-
tioned several times previously, pretunneling the flaps can assist
the surgeon in development of the lipocutaneous flap and
provide a more precise dissection plane to protect deeper sig-
nificant structures. The EJV (and the GAN) are also at risk for
being injured when placing deep sutures, and if the surgeon
sees brisk bleeding over the SCM after suturing, the stitch
should be removed and the area inspected for possible EJV
perforation. In the case of significant puncture or transsection,

354
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-204.  A, An inadvertent transsection of the greater auricular nerve while dissecting the posterior auricular flap cervically.
B, A nerve reanastomosis with suture.
FIGURE 9-205.  A rendition of the nerves at risk in cervical dissection during
facelift surgery. The greater auricular nerve is shown in white, the trans-
verse cervical nerve is shown in red, the spinal accessory nerve is shown
in yellow, and the external jugular vein is shown in blue.
brisk bleeding can occur from the EJV. As seen in Figure
9-206, the EJV can be as big as an index finger and obviously
present a problem with hemostasis. If significant damage is
done to the vein, a high-volume suction (tonsil suction) is used
to clear the area while the assistant exerts pressure on the neck
above and below the damaged area. The damaged vein must
be significantly ligated with permanent suture, and the surgeon
must be sure that the bleeding is controlled before wound
closure. This is another situation that can be very dramatic for
the beginning facelift surgeon, but if the surgeon keeps calm
and collected and has access to adequate suction, the bleeding
is easily controlled by ligation sutures. If the vein cannot be
significantly accessed through the flap, an incision through the
neck flap would be in order, but this would be an uncommon
situation. Figure 9-207 shows a transected EJV and ligation of
the offending vessel. Figure 9-208 shows a ligated EJV and its
close relationship to the GAN.
Complications Affecting Flap Viability
Necrosis of the lipocutaneous flap can lead to permanent scars,
extended recovery, stress for the surgeon and patient, and litiga-
tion. Causes vary from hematoma, flap sutures under tension,
bandage compression, patient sleeping position, inherent
healing problems, or from no discernable cause. Although it is
more common in smokers or patients with compromised health,
it can happen in the best of circumstances. Fortunately the
posterior auricular region is the area most prone to flap break-
down and is generally out of sight of the patient and can be
covered by hairstyle. Although these areas of nonviable tissue
appear extremely angry and inflamed in the initial phases, they
generally heal with minor scarring (Figure 9-209). Although
uncommon, the posterior ear surface can also be devitalized.
Figure 9-210 shows a patient who experienced wound break-
down behind the ear from pressure exerted by her reading
glasses.
All areas of all flaps are vulnerable to tissue breakdown and
subject to some of the factors previously described. Figure 9-211
shows wound breakdown at the temporal tuft incision.
Tissue death on the preauricular or visible anterior facial skin
can be much more problematic and severe, leaving permanent
scars that may require skin grafts. Small areas (the size of a
quarter) will generally scab over and regranulate from the base.
Some practitioners recommend topical application of nitroglyc-
erin paste in the early stages to encourage local vasodilatation.
Interim treatment with antibiotics and wound care is standard.
Hydrogen peroxide soaks and continual application of Biafine
topical emulsion (OrthoNeutrogena, Los Angeles, CA) have
been effective in my experience. I also prefer to not overly
débride the wound and leave the eschar in place. This treatment
will usually produce an acceptable scar that may need no further
treatment. Residual scars can be improved with CO2 laser resur-
facing. For large areas of flap necrosis, emergent efforts such as
hyperbaric oxygen therapy may be necessary as well as consulta-
tion with a wound care specialist. In severe cases, skin graft or
rotational flaps may be necessary. In hundreds of facelifts, I have
experienced five or six cases of preauricular wound necroses
which all healed by secondary intention. Figure 9-212 shows a

Chapter 9  •  Cervicofacial Rhytidectomy
355
A
B
FIGURE 9-206.  A, The astute surgeon will notice external jugular vein (EJV) prominence in the patient preoperatively. B, The
EJV and the greater auricular nerve are intimate when they cross the sternocleidomastoid border, and both structures can be
damaged during cervical dissection.
A
B
FIGURE 9-207.  A, A transected external jugular vein. B, With the vessel ends ligated.
A
B
EJV
GAN
Perf
FIGURE 9-208.  A, The relationship of the greater auricular nerve (GAN) and external jugular vein (EJV) in the neck. B, Close-up
of the repair and structures. The EJV is shown with a perforation (perf).

356
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-209.  Postauricular wound breakdown, although looking very serious in the initial phases, will generally heal with
acceptable results with simple wound care. The patient is shown at 10 days (A) and 5 months (B) after facelift surgery, with
posterior auricular wound breakdown. The patient was a smoker and was aware of this possible complication preoperatively.
A
B
FIGURE 9-210.  A, Patient was a voracious reader and wore her reading glasses immediately after surgery, which contributed
to wound breakdown with exposed cartilage. B, The area healed without incident and is shown 4 months after surgery.

Chapter 9  •  Cervicofacial Rhytidectomy
357
A
B
C
FIGURE 9-211.  Patient experienced necrosis at the temporal tuft incision and is shown at 2 weeks (A), 8 weeks (B), and 12
weeks (C) after surgery.
A
B
C
D
E
F
G
H
I
FIGURE 9-212.  Patient 1 day (A), 5 days (B), and 8 days (C) after surgery. The dusky appearance progressing to tissue slough
and eschar is evident. Two weeks (D), 3 weeks (E), and 4 weeks postop (F). The contracting eschar with a healthy granulating
base is shown. Seven weeks (G), 10 weeks (H), and 16 weeks postop (I). As the wound contracts, the new skin is relatively
consistent, and at 4 months, a linear hypertrophic scar remains. The scar was injected with triamcinolone, and CO2 laser
resurfacing is planned.

358
Chapter 9  •  Cervicofacial Rhytidectomy
preauricular flap devitalization complication. This patient was a
healthy nonsmoker who presented for cervicofacial rhytidec-
tomy with SMASectomy and full-face CO2 laser resurfacing. I
have lasered over hundreds of facelift patients without any sig-
nificant wound necrosis and do not attribute this case to the
simultaneous laser. This patient had a pigmented skin lesion
under her earlobe, and I excised it during the facelift. This
produced a horizontal incision anterior to the left earlobe, and
I believe this contributed to the devitalization. Fortunately this
was a very understanding patient, and she patiently performed
meticulous wound care. Generally, a flap in jeopardy of devital-
ization will become mottled and dusky in the early postopera-
tive period. In my experience, this ecchymotic appearance is
seen in the first 72 hours. Blistering is also an ominous sign that
can accompany bluish skin. The ecchymotic appearance will
soon become necrotic and slough. This then transitions to an
eschar with a soft and sometimes purulent base.
As stated earlier, no area of the lipocutaneous flap is immune
to breakdown. The tragus is vulnerable although rarely involved
(Figure 9-213). Many surgeons ask a lot of the tragus. Some
surgeons defat the tragus during tragal reconstruction, and some
surgeons use electrosurgery to destroy beard follicles in males.
No matter what else is done, the tragus represents a small, iso-
lated island of tissue and can sometimes be compromised
without any insult. Novice surgeons should tread lightly when
considering treating the dermal hair follicles of the tragus with
electrosurgery. With modern hair-removal lasers, bearded skin
on the tragus is much less of a concern. This region should
always be handled with care. In the case of tragal necrosis, the
area heals well by secondary intention but will remain erythema-
tous for an extended time. In addition, the wound contraction
of healing can distort the tragus, causing blunting or retraction.
Generous tissue should be left when the final tragal recontour-
ing and suturing is performed. Normal wound contraction can
impair tissue viability, especially if tension or excess sutures are
placed.
Any area of natural fold or crease is also at risk for vascular
compromise. The cervicomental angle (junction of neck and
submental region) or the region under the posterior mandibular
border, which are natural skin crease areas, can be affected.
Compression from overly tight bandages or even the patient’s
head position following surgery can limit flap vascularity. If
patients sleep with their chin flexed, this can compress the flap
and add to the compression from bandages, compromising
blood flow. The patient in Figure 9-214 experienced necrosis in
the cervicomental region after falling asleep upright in a recliner.
This coupled with the postop bandage probably constricted the
blood flow to the area.
Head position in the early postoperative period should be
neutral. I feel that the best scenario is for the patient to sleep
elevated on a recliner with a pillow that is firm enough to not
engulf their head and cause lateral pressure on the flaps. Some
surgeons recommend the horseshoe-type airline pillow for the
first week or two after facelift surgery, but I have personally seen
these abrade lasered skin on the neck, delaying healing and
causing transient pigmentation problems.
FIGURE 9-213.  Tissue necrosis of the tragal skin can be caused from surgi-
cal insults or sometimes occurs spontaneously.
A
B
C
FIGURE 9-214.  Patient experienced skin devitalization in the submentocervical area and is shown at 1 week (A), 6 weeks (B),
and 1 year after surgery (C). The region repigmented with minimal scarring.

Chapter 9  •  Cervicofacial Rhytidectomy
359
A
C
D
A
B
FIGURE 9-215.  A, Patient developed an unsightly adhesion in a naturally deep skin fold. The depressed adhesion was subcised
transcutaneously with a tissue dissector (B) until the depression was freed (C). A skin hook was used to elevate the tissue
from its base prior to applying the final dressing (D).
Related to this problem, but without flap compromise, are
contour irregularities that can result from similar phenomena.
The patient shown in Figure 9-215, A had extremely leathery
sun-damaged skin and slept on her right side with her neck
flexed and rotated towards her shoulder. She developed an
adhesion of this deeply creased area, which healed with the
dermis adherent to the deeper tissues, thus producing an
unsightly cosmetic appearance (see Figure 9-215, A). The area
was treated with wound subcision by undermining the adherent
area and controlling compression with a contoured pad that
allowed pressure to dissipate over the entire area (see Figure
9-215, B–D). She also modified her sleeping position and
healed uneventfully.
Sometimes patients are bothered by very small irregularities
and can focus on them despite a very favorable lift. Two of these
areas are contour irregularities at the suture lines of the earlobe
and the posterior auricular region (Figure 9-216). This can
occur from inattention to wound closure or taking big suture
“bites” when closing. In addition, the posterior auricular region
lies over the mastoid area, which does not have abundant sub-
dermal tissue, and wound contraction can occur. By using a
running intracuticular suture as previously described, a much
more aesthetic closure can be obtained without the irregularities
produced by running or interrupted skin sutures (Figure 9-217).
Another means of treating irregularities or webbing is Z-plasty
excision (Figure 9-218).
Redundant tissue can also be problematic in the submental
region. In patients with excessive neck and submental skin, even
with aggressive flap dissection, it is sometimes impossible to
gain sufficient skin tightening in the submental region. In addi-
tion, this is a frequent area for seroma formation, which can
also result in skin pouches in this region. If severe, a revision
procedure may be necessary to dissect and redrape the skin.
Minor skin excess can be treated with nonablative or ablative
skin tightening (Figure 9-219).
Parotid fistula is an uncommon but significant problem in
facelift surgery. This can occur from violating the parotid paren-
chyma or from deeply placed sutures. The flowing saliva can
accumulate and devitalize the flap in a similar manner as hema-
toma. Generally a parotid fistula is a self-limiting situation and
can resolve spontaneously. Needle aspiration of saliva collections
and placement of a transcutaneous scopolamine patch can assist
in “drying” the fistula. Botulinum toxin A can also be injected
into the gland or suspected offending region to decrease saliva-
tion via acetylcholine inhibition. In severe cases, surgical inter-
vention may be necessary to drain the fistula and remove
offending sutures. In minor cases, the fistula will only be appar-
ent at mealtime from increased salivation and will wane after
eating (Figure 9-220).
Suture reactions or infections can also occur with facelift
surgery. In my early career, I experienced multiple infected and
extruded sutures when I was using silk suture material (Figure

360
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
C
FIGURE 9-216.  A, Irregularities that can form in the posterior auricular region. B, The irregularities being leveled with a radiowave
surgical electrode. C, The immediate postablation result.
A
B
FIGURE 9-217.  Postauricular skin closure employing a running
subcuticular suture (A) produces a very aesthetic scar (B).
9-221). These infections or inflammatory reactions with extru-
sion can occur many months after the procedure. I never expe-
rienced this situation after switching to braided nylon suture for
the last several hundred facelifts.
As stated often throughout this chapter, the hair follicles
must be managed with care so as not to damage them. Hair loss
can occur from poor incision design or direct follicular damage.
Damage to the follicle can occur from too-superficial flap dis-
section or from thermal damage to the follicles from electrosur-
gical instrumentation. Finally, the administration of general
anesthesia has been implicated in transient hair loss. “Hair
shock” is a condition in which transient hair loss occurs from
follicular embarrassment (Figure 9-222). Generally this condi-
tion is transient and will improve over several months, although
it could be permanent depending on the extent of follicular
damage.
For cases of permanent hair loss from follicular damage
or hairline transposition from poor incision design, follicular
grafts may be necessary. Postfacelift hair transplantation is a
common procedure for surgeons who perform frequent hair
transplantation.
Serious infection in head and neck cosmetic facial surgery
is very rare, owing in part to the generous vascularity of
this region. In hundreds of facelift surgeries, I have never

A
B
C
FIGURE 9-218.  A, Wound contraction can sometimes produce webbing of concave areas such as the posterior auricular region.
B-C, This case was treated with geometric excision of the webbed areas.
A
B
FIGURE 9-219.  Patient has a residual skin pouch in the submental (A), which flattened nicely with ablative CO2 laser resurfacing (B).
A
B
FIGURE 9-220.  A, Postoperative patient. B, A saliva collection (outlined) when the patient sucks on a lemon candy.

362
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-221.  A, Infected silk suture that spontaneously eroded through the cheek skin. B, A sore, swollen lump on the cheek
that was incised and explored. An infected silk suture was the source.
A
C
B
D
FIGURE 9-222.  A–B, Patient with significant hair loss in the early postsurgery period. C–D, Same patient with hair regrowth 4
months after surgery.

Chapter 9  •  Cervicofacial Rhytidectomy
363
A
B
FIGURE 9-223.  A, Pseudomonas is a common inhabitant of the external ear and can infect the region. B, Although not an
infection, an allergic reaction from triple antibiotic ointment on the wound could be mistaken for infection.
FIGURE 9-224.  Wound dehiscence is shown in the temporal region with
minor devitalization of the tragal skin.
experienced a fulminant abscess requiring drainage. Minor
infections are generally self-limiting or respond well to antibiot-
ics (Figure 9-223).
Wound dehiscence can occur at any incision site. Small areas
of wound dehiscence are treated with wound care and allowed
to heal by secondary intention (Figure 9-224). Larger areas of
suture-line breakdown can be cleansed and reclosed in the early
postoperative period. Problems with detachment of the earlobe
are a more common postoperative problem. The earlobe can
separate from the cheek from dehiscence, infection, or trauma
(Figure 9-225). Traumatic dislocation is the most common
reason for the detached lobe. This can occur from sleeping on
the side, rolling over on the pillow, or from catching the healing
lobe with pullover clothing, hairbrushes, and the like. Patients
should be instructed to sleep on the back in the early postopera-
tive period and wear button-up shirts and blouses rather than
pullover clothing. If the detachment occurs in the first several
days, and the wound is clean, it can be prepped and reclosed.
For granulating inflamed detachments, the area is treated with
wound care, allowed to heal, and repaired at a later date.
Means by which to injure healing facelift tissue are countless.
Thermal injury can occur from hair dryers, curling irons, and
heating pads (Figure 9-226). Since most patients are insensate
in the early recovery period, a serious burn can occur from an
otherwise innocuous heat source. Patients must be cautioned
both verbally and in print against aggressive and injudicious use
of these items. Hair dryers should be used on low or cool set-
tings, and heating pads should be tested on normal skin and
not worn excessively.
With all the natural surgical complications that can occur,
factitious injury (that induced by the patient) is also seen. Post-
surgical patients can exhibit activities that are induced by stress
and anxiety and affect their healing. The patient shown in Figure
9-227 felt the suture knots under her cheek skin and was sure
they were foreign bodies she must scratch out. The patient in
Figure 9-228 continually picked at her earlobe and cheeks for
“a reason she could not control.” This behavior must be identi-
fied and documented. Sometimes these patients may require
antianxiety medications to control such behavior.
Postsurgical Revision
The best intentions of the surgeon are sometimes not met for
numerous reasons and can leave the patient and surgeon with
a suboptimal result. Sometimes, due to patient variability or

364
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-225.  A, An early traumatic earlobe detachment from pullover clothing. B, A late detachment with infection.
A
B
C
FIGURE 9-226.  Patient fell asleep with a heating pad on her left face and is shown with the burn 5 days after surgery (A), 2
weeks after the burn (B), and 3 months after surgery (C).
FIGURE 9-227.  Patient scratched at her left cheek because she felt the
palpable suture now was a foreign body she needed to dig out.
extreme skin excess and ptosis, the result is as good as it reason-
ably can be. Educating the patient on such matters at the
consent process can head off ill feelings. An example is a patient
with a short, thick neck and a low and anterior-sitting hyoid
bone. These patients have extremely oblique cervicomental
angles and in the best of circumstances (even with aggressive
submentoplasty) will never have a “90-degree neck.” Significant
preoperative examination and discussion, making no promises
that can’t be kept, can mitigate some of these postoperative
points of contention.
Other postoperative situations exist in which the patient was
simply undertreated (or overtreated) and requires revision. I
generally perform reasonable revisions free of charge in the first
year following facelift surgery, especially if problems were of my
doing. If they represent situations not necessarily reflective of
my work, then I may charge a reasonable materials or anesthesia
fee. A cosmetic surgeon’s results and reputation are everything.

Chapter 9  •  Cervicofacial Rhytidectomy
365
A
B
FIGURE 9-228.  Patient picked and scratched at her earlobes and cheeks for several months after the surgery for reasons she
could not explain. These lesions remained for months before she desisted.
A
B
FIGURE 9-229.  Hypertrophic scars are injected with steroid on a monthly basis and will generally improve. A, A common thick-
ened band behind the ear. B, A steroid injection to the scar.
All contingencies must be discussed and documented in writing
at the preoperative consent appointment. Some patients may
present with problems blamed on the surgeon but unrelated. I
have had several patients who experienced significant weight
gain in the first postoperative year, which obviously produced
facial changes. Patients must realize that this is not a fault of the
surgeon’s work. Some surgeons weigh patients at each appoint-
ment to document such a process. Patients may also have unrea-
sonable revision requests. There are certainly times when a given
result is the best result possible for that patient. A smoker, for
example, requires more conservative surgery and must compre-
hend the tradeoff in results.
Many odds and ends present after facelift surgery: unfavor-
able scars, excess tissue, earlobe asymmetries, residual fat pockets,
and so forth. Astute surgeons will include treating these rem-
nants as part of the global care. Unfavorable scars can be
injected, lasered, or revised. Early hypertrophic or keloid scars
should be injected with triamcinolone (40 mg/mL) as soon as
they present, then on a monthly basis (Figure 9-229). The
steroid is injected in small aliquots (0.1 mL) intralesionally
along the entire scar. Some scars will improve with time,
although I believe early intervention is a good option, depend-
ing how badly the scar bothers the patient. I will commonly
perform CO2 laser skin resurfacing on facelift scars to blend in
raised or depressed areas to better blend them (Figures 9-230 to
9-232).
In certain conditions such as wound breakdown, facelift scars
can become hypopigmented. Light laser resurfacing may be

366
Chapter 9  •  Cervicofacial Rhytidectomy
A
B
FIGURE 9-230.  A, Submental scar was treated with a single pass of the CO2 laser. B, Six weeks after laser treatment.
A
B
FIGURE 9-231.  A, Irregular scar is shown at 8 weeks. B, 4 weeks after three passes of CO2 laser.
employed in an attempt to blend the scar with the surrounding
skin. A skilled tattoo or permanent makeup artist can repigment
the area to blend with the normal skin (Figure 9-233).
The Informed Consent Process
Paramount to everything discussed in this chapter is adequate
preoperative informed consent and education for patients.
Although our offices perform these procedures weekly, we must
keep in mind that it is very foreign for our patients, and they
frequently have a “television mentality” that surgery and healing
occur very rapidly and without incident. A patient cannot be
overeducated about a procedure. Some patients don’t under-
stand as well as others, so preoperative teaching is always time
well spent. Patients must understand what is normal and what
is not, what is a sequela and what is a complication. They must
understand the entire process of what happens when there is a
problem, who will fix it, who will bear the cost, and other facts.
They must understand that their role in pre- and postoperative
care can have a dramatic impact upon the final result, and that
responsibility for surgical outcome is not the surgeon’s alone.
Supplementary consents can stress points that may require
additional emphasis. As mentioned, I use a “smoker’s consent”
to underline the problematic nature of facelift surgery in that
patient group. I also have a consent form titled “What Your
Facelift Won’t Do” that details facts such as “a facelift is not an
operation for wrinkles,” “a facelift won’t improve your eyes or
brow,” “a facelift will not make your nasolabial folds disappear,”
“you may need a touch up of your facelift,” and other details

Chapter 9  •  Cervicofacial Rhytidectomy
367
A
B
C
D
FIGURE 9-232.  A and C show unfavorable incision scars in the temple and posterior auricular region outlined for a “W Plasty”
revision. B and D show the areas after scar excision prior to undermining and closure.
A
B
FIGURE 9-233.  A hypopigmented facelift scar is shown in A. Tattoo apparatus and flesh-colored pigment is shown in B.

368
Chapter 9  •  Cervicofacial Rhytidectomy
FIGURE 9-234.  A mandatory and prominent timeout process is standard of
care and can be lifesaving and lawsuit saving.
patients may misunderstand about the procedure, recovery, and
result.
Although astute surgeons have always performed presurgical
“timeouts,” this step is now an accreditation standard.
Forgetting to perform a procedure on a patient is an inconve-
nience and embarrassment; performing the wrong procedure on
a patient can be a lawsuit. In addition, paying attention to
medical conditions, allergies, anesthetic problems, and the like
can be lifesaving. I use a widescreen TV monitor in my in-office
surgery center to list the relevant timeout data for each case
(Figure 9-234).
It has been stated many times that no surgeon should
perform a procedure unless able to manage the common com-
plications, and this is a good tenet to live by, especially for the
novice facelift surgeon.
References
  1. Lexer E: Zur gesichtsplastik. Arch Klin Chir 92:74, 1910.
  2. Joseph J: Plastic operation on protruding cheek. Stsch Med Wochenshr
47:287, 1921.
  3. Joseph J: Nasenplastikand sonstige gesichtsplastik negsteinen anhang tiber
mammaplastic. Leipaig Curt Kabitzach 525–527, 1928.
  4. Joseph J: Verbesserung meiner hangemangenplastic (melomioplastic). Dtxh
Med Wochenschr 54:567, 1928.
  5. Passot R: La cheirurgie esthetique des rides du visage. Press Med 27:258,
1919.
  6. Passot R: La xhirurgie esthetique pure (technique et resultants). Paris
Gaston Doin Cie 176–180, 1931.
  7. Morestin H: La reduction graduelle des deformities tegumentaries. Bull
Mem Soc Chir Paris 41:1233, 1915.
  8. Brouguet J: La xhirurgie esthetique de la face. Concours Med 1657–1670,
1921.
  9. Lagarde M: Nouvelles techniques pour le traitement des rides de la face et
de cou. Arch Franco-Belg Chir 31:1954, 1928.
10. Noel A: La Chirurgie Estique Son Role Social, Paris, 1926, Mason Cie, pp
62–66.
11. Noel A: La Chirurgie Esthetique, Clearmont (Oise), 1928, Thiron et Cie.
12. Skoog T: Plastic Surgery: New Methods and Refinements, Philadelphia,
1975, WB Saunders.
13. Mitz V, Peyronie M: The superficial musculoaponeurotic system (SMAS)
in the parotid and cheek area. Plast Reconstr Surg 58:80–88, 1976.
14. Adamson JC, Horton CE, Crawford HH: The surgical correction of the
“turkey gobbler” deformity. Plast Reconstr Surg 34:598, 1964.
15. Rees TD, Aston S: Clinical evaluation of submusculoaponeurotic dissection
and fixation in facelift surgery. Plast Reconstr Surg 60:881–889, 1977.
16. Webster RC, Smith RC, Papsidero MJ, Karolow WW, Smith KF: Com-
parison of SMAS plication with SMAS imbrication in face lifting. Laryn-
goscope 92(8 Pt 1):901–912, 1982 Aug.
17. Connell B: Cervical lift: surgical correction of fat contour problems com-
bined with full width platysmal muscle flap. Aesthetic Plast Surg 1:355–
365, 1978.
18. Connell BF: Contouring the neck in rhytidectomy by lipectomy and a
muscle sling. Plast Reconstr Surg 61:376–383, 1978.
19. Baker DC: Minimal Incision Rhytidectomy (Short Scar Facelift) with
Lateral SMASectomy: Evolution and Application. Aesthet Surg J 14–26,
2001 Jan/Feb.
20. Hamara ST: Composite Rhytidectomy, St. Louis, 1993, Quality
Publishing.
21. Tessier P: Subperiosteal facelift [in French]. Ann Chir Plast Esthet 34:193–
197, 1989.
22. Baker SR: Triplane rhytidectomy. Combining the best of all worlds. Arch
Otolaryngol Head Neck Surg 123(11):1167–1172, 1997 Nov.
23. Ramirez OM, Pozner JN: Subperiosteal minimally invasive laser endo-
scopic rhytidectomy. St. Louis: the SMILE facelift. Aesthetic Plast Surg
20:463–470, 1996.
24. Jost G, Levet Y: Parotid fascia and face lifting: a critical evaluation of the
SMAS concept. Plast Reconstr Surg 74(1):42–51, 1984 Jul.
25. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza-Katzer H, Fritsch H:
Does a superficial musculoaponeurotic system exist in the face and neck?
An anatomical study by the tissue plastination technique. Plast Reconstr
Surg 111(2):664–672, 2003 Feb; discussion 673–675.
26. Grey’s Anatomy, 20th edition, 1918. (accessed
12-10-09).
27. Baker DC: Lateral SMASectomy. Plast Reconstr Surg 100(2):509–513,
1997 Aug.
28. Baker D: Rhytidectomy with lateral SMASectomy. Facial Plast Surg
16(3):209–213, 2000.
29. Niamtu J: Expanding hematoma in face-lift surgery: literature review, case
presentations, and caveats. Dermatol Surg 31:1134–1144, 2005.
30. Beckert BW, Concannon MJ, Henry SL, Smith DS, Puckett CL: The effect
of herbal medicines on platelet function: an in vivo experiment and review
of the literature. Plast Reconstr Surg 120(7):2044–2050, 2007 Dec.
Review.
31. Baker DC: Complications of cervicofacial rhytidectomy. Clin Plast Surg
10(3):543–562, 1983 Jul.
32. Rees TD, Aston SJ: Complications of rhytidectomy. Clin Plast Surg
5(1):109–119, 1978 Jan.
33. Baker DC, Conley J: Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg 64(6):781–795,
1979 Dec.

369
10 
Facial Implants
T
he aging face has been discussed in a previous chapter.
Senescent changes associated with aging produce mid-
facial and lower facial ptosis that can begin in the late
third decade. Many novice and some accomplished surgeons do
not appreciate the subtleties of volume loss, and patients are
frequently made to look tighter but not younger. Appreciating
the pathophysiologic changes associated with aging allows the
cosmetic surgeon to diagnose and treat a variety of aging changes
in the middle and lower face.
Treatment options for midfacial rejuvenation include lifting
procedures,1-7 injectable synthetic fillers,8-12 autologous fat13-16
and facial implants.17-21 Each treatment option carries advan-
tages and disadvantages, but in this author’s opinion, midface
implants are an optimum choice in the average patient for
multiple reasons. Facial implants are a unique solution to aug-
menting the aging face and enhancing the youthful face.
Although many types of lifting and filling procedures exist,
facial implants offer a permanent but reversible solution. This
sounds like an oxymoron, but the fact is that when placed in
the subperiosteal plane and anchored with screw fixation, there
is nowhere for them go. They will not descend or displace with
the rest of the soft tissues of the aging face; hence they are
permanent. Silicone implants can easily be removed, because
they become surrounded with a well-defined tissue capsule, and
removal generally only takes minutes. Lifting procedures will
relapse, temporary fillers will be resorbed, injected fat can
atrophy, and permanent fillers can become ptotic with the sur-
rounding soft tissues, so the advantages of permanent augmen-
tation are obvious.
Facial implants come in a vast array of shapes, sizes, and
materials that make them suitable for almost every patient. They
can also be fabricated with computer-assisted design/computer-
assisted manufacturing (CAD-CAM) technology for custom
applications. Facial implants provide three-dimensional aug-
mentation and are also serviceable in that they can be easily
switched out for smaller or larger sizes.
Numerous materials exist for U.S. Food and Drug Admin-
istration (FDA) approved implants: silicone rubber, expanded
polytetrafluoroethylene (ePTFE; Gore-Tex), and porous poly-
ethylene. All these implants are biocompatible, and although
any implant can be successful when properly integrated, each
material has advantages and disadvantages. At the time of this
publication, no major U.S. company sells solid ePTFE facial
implants. Many surgeons utilize porous polyethylene implants,
but these can have significant drawbacks. Being rigid, they do
not conform to underlying bony anatomy, as do flexible
implants, and are more difficult to trim or adjust. When placing
flexible implants, smaller incisions can be utilized, and the
implants can be twisted and bent to facilitate insertion. If a
hard, solid implant sits off the bone, its ridge can be very sharp
and palpable, whereas a soft, flexible implant will be much less
noticeable. Most of these drawbacks are noncritical, but the
biggest drawback to porous polyethylene implants is their dif-
ficulty of removal. The porous nature of the material makes
tissue integration significant. This can be a positive influence in
terms of stabilizing the implant but also present extreme diffi-
culties when attempting removal. As have other surgeons, I have
spent many difficult hours removing porous polyethylene
implants. Since there is no distinct fibrous encapsulation and
distinct tissue ingrowth, the removal can be very traumatic. It
is not uncommon to disrupt muscle and other soft tissue that
become attached to the implant surface (Figure 10-1). This can
also damage surrounding nerves that become entrapped in the
tissue mass. These implants can become so adherent that they
fragment upon removal, leaving remnant tiny pieces that are
difficult to completely débride or remove.
My goal is not to discredit any specific implant or material.
I have successfully placed porous polyethylene implants, but as
my implant practice grew and patients across the country sought
my services, I removed numerous types of facial implants, and
repeated experience with the porous polyethylene has not been
positive. Implant removal can be so destructive that increased
swelling and trauma make simultaneous implant replacement
difficult and unpredictable, as well as cause soft-tissue defects
sometimes visible through the skin. For this reason, I am very
hesitant to remove porous polyethylene implants that were not
placed by me. Having said all this, I have also removed many
implants that were silicone rubber and ePTFE (including my
FIGURE 10-1.  This porous polyethylene implant was extremely difficult to
remove. Adherent masseter muscle was disrupted during removal and the
implant fragmented.

370
Chapter 10  •  Facial Implants
author has refined choices to three broad categories that are
effective for almost all cosmetic (or reconstructive) patients.
The basis of implant selection lies in the recognition of where
the aging changes have occurred in the face and if they are single
or multiple in nature. As most patients age, they lose volume in
the submalar region. The submalar area includes the hollow area
of the infraorbital, anterolateral maxillary, and canine fossa
regions. If the surgeon pays close attention, they will notice that
loss of facial volume represents early aging change (late third,
early fourth decade) that is apparent in virtually all patients
regardless of gender.
Many aesthetic practitioners and most patients are unaware
of this phenomenon unless it is pointed out to them. If the
surgeon hands the patient a mirror and asks them to smile, the
lip elevators lift the ptotic malar fat and produce a more youth-
ful look. This simulation will cause many patients to comment,
“This is how I looked when I was younger.” If you hold the
elevated tissues in place with your thumb and index finger and
ask the patient to relax their smile, the midface volume quickly
drops to its aged position lower in the face when the fingers are
relaxed. In essence, the youthful cheek fat later becomes the
jowls. Having the patient recline in the exam chair will also
“reposition” the ptotic cheeks to a more youthful position and
can be used to illustrate aging and predictive correction. Close
observation will show that many of these patients have a hollow
submalar region but adequate and well-defined zygomatic and
malar aesthetics. That is to say that despite having lost submalar
fat, they have adequately projected cheekbones. This type of
patient is best treated with only submalar fill, since their problem
(and solution) is not malar deficiency but rather the loss of
submalar volume.
An example of submalar deficiency is illustrated in Figure
10-2, A. Figure 10-3, A shows the approximate positioning
of the submalar implant. The submalar implant (ImplanTech
Inc., Ventura, CA) is used in approximately 95% of my midface
own) but with much less trauma. Solid ePTFE implants can
sometimes be difficult to remove but not to the point of the
porous implants. Silicone rubber implants remain the easiest
implants to remove because of their well-developed fibrous cap-
sules. Any surgeon who places any type of facial implants must
anticipate the positive and negative qualities and inform the
patient of potential problems.
Cheek implants have existed for decades and have fallen in
and out of favor for various reasons. One of the biggest prob-
lems with early implants was the lack of anatomic form. The
early implants and the advocated positioning of them produced
“blocky” and unnatural results that were very apparent. They
were also usually placed high in the zygomaticomalar complex,
giving patients an exaggerated and unnatural appearance.
The last decade has brought a refinement of both implant
form and placement. Contemporary midface implants are avail-
able in many sizes and shapes and have different indications
dependent upon the aesthetic need. These anatomic implants
have also given way to more conservative surgical approaches
that, again, are designed to provide targeted, precise, and natu-
ral-appearing augmentation specific to various regions of the
midface. I recently reviewed my midface implant placement in
facelift patients and found that about 27% of my facelift patients
had concomitant cheek implants. I would say that 80% could
have used them but did not opt for the option. Obviously this
underlines the importance of volume replacement as part of my
comprehensive rejuvenation.
Midface Implants
Implant Selection
The greatest pitfall for the novice implant surgeon is under-
standing what implant is appropriate for a given aging indica-
tion. What implants to use and where to put them can be
confusing. Although this is related to personal preference, this
A
B
C
FIGURE 10-2.  A, Patient in need of submalar augmentation. B, Patient with adequate submalar fill but in need of zygomatic and
malar augmentation. C, Patient in need of zygomatic, malar, and submalar augmentation.

Chapter 10  •  Facial Implants
371
assume a normalized position and give the surgeon and patient
an idea of the surgical result (Figure 10-5).
Drawing the approximate implant position on the cheeks or
outlining a sample implant will provide guidance for the surgeon
when the implant is placed. Care is given to making sure that
both implant outlines are symmetric and in the region of desired
augmentation (Figure 10-6).
It is important to note, discuss, and document existing asym-
metries with the patient before surgery. It is common for
patients to have one side of the cheeks or midface bigger than
the other. In extreme cases, a medium implant may be placed
on one side and a large implant on the other. Most frequently,
the degree of asymmetry is such that it does not alter the final
result when using the same implant on both sides. To illustrate
the difference in symmetry, I keep a picture of me in each
consult room that shows my normal portrait and a mirrored
image of the right and left halves of my face (Figure 10-7). The
difference is remarkable, and I explain to the patient that the
average person has similar asymmetry. Numerous times over
the years, I have had to construct a similar image of a patient
to point this out to them.
Implants can also be placed on the patient’s face just before
placement; indexing marks are made to verify symmetric posi-
tioning (Figure 10-8). Noting where the medial edge of the
implant lies can serve as a guide for comparison when the
implants are placed intraorally. In other words, if the medial
edge of the implant lies in line with the pupil or limbus, this
can serve as an indexing guide when the implant is in place.
During preoperative evaluation, it is also important to evalu-
ate the patient’s oral health. Placing implants in the presence of
dental or periodontal disease can severely compromise the case
and result in infection (Figure 10-9). Patients with oral disease
must be treated to achieve a normal state of oral health prior to
implant placement.
The preoperative consent process should discuss the common
sequelae and complications experienced with midface implants.
implant patients and is thus by far my most common
implant.
The second type of common facial aesthetic deficiency is
apparent in patients who have adequate submalar and anterior
maxillary fill but have deficient “cheekbones” (see Figure 10-2,
B). This is the patient who has hypoplasia of the zygomatico-
malar regions or simply desires a more defined or “chiseled”
appearance, or in layman’s terms, “higher cheekbones.” I treat
these patients with the malar shell implant (ImplanTech Inc.)
(see Figure 10-3, B), which I use in approximately 1% to 2%
of patients.
The third type of common midfacial aging change is seen in
the patient with submalar deficiency and a need for zygomatico-
malar augmentation. These patients benefit from both anterior
maxillary (submalar) fill and malar (“high cheekbone”) augmen-
tation (see Figure 10-2, C). These can be patients who have lost
volume as a result of aging in both areas, or those patients who
have underdeveloped skeletal anatomy. Such patients are well
suited for treatment with the combined submalar shell implant
(ImplanTech Inc.) (see Figure 10-3, C). This implant is designed
to augment the submalar region as well as zygomatic and malar
regions; it constitutes 4% to 5% of my implant cases.
Figure 10-4 shows approximate skeletal positioning of the
described implants. As stated earlier, these three implant con-
figurations are used for the described aging changes and satisfy
all of the author’s aesthetic midfacial enhancement indications.
Preoperative Planning
Prior to surgical placement, the practitioner and the patient
must decide upon the area(s) to be enhanced and the size and
configuration of the implant. This can be difficult for the novice
surgeon, and beginning with easier and more straightforward
cases can assist the surgeon with the learning curve. Younger
patients with basic submalar implants are a good starting point.
As with other facial procedures, laying the patient back in
the chair and negating gravity will allow the ptotic tissues to
A
B
C
FIGURE 10-3.  Approximate positioning of the submalar implant (A), the malar shell implant (B), and the combined submalar
shell implant (C).

372
Chapter 10  •  Facial Implants
The midface is a vascular region, and significant swelling can
occur and take up to several weeks to resolve. In some cases, the
swelling can last longer, and the patient must understand that
it may take 6 weeks to begin to see the true level of augmenta-
tion. Almost all patients will experience temporary paresthesia,
but permanent numbness is rare. Oral animation will be tem-
porarily affected owing to the disruption of lip elevators and
orbicularis oris muscles. Patients must be made aware that
smiling and puckering and possibly speech may be temporarily
affected. This dysanimation usually resolves in the first 2 weeks.
Infection is rare and in my experience is more common in
smokers, who are not optimum candidates for midface implant
placement. The possibility of overcorrection, undercorrection,
and asymmetry must also be discussed. Fortunately, it is very
easy to remove midface implants, and that is a comforting point
for prospective patients. It also helps patients to realize that
cheek implants are serviceable, and larger or smaller implants
can be placed in lieu of their current implants. Replacement is
easier and less traumatic than primary placement, because the
pocket is already dissected from the previous surgery.
Surgical Placement
The surgical armamentarium is relatively simple for midface
implant placement and does not require highly specialized
A
B
C
FIGURE 10-4.  The submalar (A), malar shell (B), and combined submalar shell (C) are shown in their approximate position on
a dried specimen.
FIGURE 10-5.  Laying the patient back in the chair will allow the ptotic facial
tissues to normalize, which can give the surgeon and patient an idea of
the surgical result.

Chapter 10  •  Facial Implants
373
sub­periosteal plane. Midface implants can be placed with local
anesthesia, although IV sedation is frequently utilized. The
implants can be placed as a solitary cosmetic procedure or
concomitantly with other aesthetic procedures.
The procedure is begun by injecting about 5 mL of 2%
lidocaine, 1 : 100,000 epinephrine transcutaneously in the
subperiosteal plane along the region to be dissected. Since
many surgeons outline the implant on the cheek, the marked
area serves as a template for local injection, and the local is
taken 1 cm past all margins. This usually includes the anterior
maxilla, malar region, and anterior zygomatic arch region.
instruments (Figure 10-10). A number 9 periosteal elevator, a
long thin-tipped tonsil hemostat, an Aufricht nasal retractor,
and a Minnesota cheek retractor are useful instruments.
The placement of midfacial implants is a simple and straight-
forward surgical procedure for those surgeons with maxillofacial
experience and easily learned by others. With experience, actual
placement can be performed in less than 10 minutes. The
implants are always placed in the subperiosteal plane, and this
must remain an axiom of insertion. With the exception of
the infraorbital neurovascular bundle, there is little vulnerable
anatomy in the midface region when dissecting in the
A
B
FIGURE 10-6.  Tracing a sample implant in the desired position preoperatively will assist the surgeon in correct positioning. In
this patient, the hypoplastic region is outlined by tracing a large submalar implant on the patient’s cheek. When she smiles and
elevates the ptotic tissues, the implant outline lies in a favorable position.
A
B
C
FIGURE 10-7.  The author in a normal portrait (B). Both right halves mirrored (A), and both left halves mirrored (C). This type of
asymmetry exists in most patients to some degree.

374
Chapter 10  •  Facial Implants
FIGURE 10-8.  Placing the actual implants on the patient’s face just prior to
placement and making index marks can also guide the surgeon in sym-
metric implant placement.
A
B
FIGURE 10-9.  Patients with active dental or periodontal disease are not
candidates for transoral implant placement.
FIGURE 10-10.  This basic instrument tray is used by the author to place facial implants.

Chapter 10  •  Facial Implants
375
to accommodate them. The combined submalar and shell
implants also require more dissection over the malar and zygo-
matic regions. It is important to not overdissect the implant
pocket; a large pocket can contribute to implant mobility. The
dissected pocket should be just slightly larger than the actual
implant (Figure 10-13).
When beginning the dissection, it is unnecessary to dissect
medially to the pyriform (also spelled piriform) aperture (nasal
region), because no part of the implant lies in this region. The
subperiosteal dissection is begun in the anterior maxillary
region, and the initial dissection vector is superior, so it is
important to protect the infraorbital neurovascular bundle
(Figure 10-14, A). The implants rarely impinge on the infraor-
bital nerve, and therefore aggressive infraorbital dissection is
Additionally, approximately 3 mL of the same anesthetic are
infiltrated in the soft-tissue planes in the mouth above the
canine tooth, primarily to reduce incisional bleeding. A 1-cm
incision is made approximately 10 to 15 mm above the canine
tooth (Figure 10-11). Using a radiowave microneedle to incise
the mucosa and soft tissues is hemostatic, and the incision is
carried to the periosteal level of the canine fossa region. The
oral mucosa is very pliable, and even with a small incision,
the surgical site can be well visualized when retracted (Figure
10-12). The extent of the dissection is dictated by the
shape and size of the intended implant. Small or medium
submalar implants require smaller dissection than combined
submalar or malar shell implants. The larger or more supero-
laterally placed implants require a larger dissection pocket
FIGURE 10-11.  The initial incision is made 10 to 15 mm above the canine
tooth in the unattached gingival mucosa.
A
B
FIGURE 10-12.  There is no need to make a large incision; the oral mucosa stretches considerably. Excessive incision can lessen
the implant stabilization and disrupt surrounding anatomy, which can lengthen recovery.
FIGURE 10-13.  Making the dissection pocket just slightly larger than the
anticipated implant will assist in stabilizing the implant and lessen recovery.
Too large a pocket encourages implant movement with oral function and
facilitates hematoma formation.

376
Chapter 10  •  Facial Implants
dissection is carried out over the malar region and extends over
the medial portion of the zygomatic arch. For small or medium
submalar implants, minor zygomatic dissection is required, but
for combined submalar and malar shell implants, more aggres-
sive malar and zygomatic dissection is necessary. These larger
implants also require more aggressive inferolateral dissection. It
is not uncommon to encounter the origin of the masseteric
tendon (or muscle) while dissecting in the area (Figure 10-17).
There is no need to violate or dissect this tendon or muscle,
because the silicone implant can safely lie over these soft-tissue
structures without a problem and frequently do with the larger-
style implants.
If the submalar implant is used, not much dissection is neces-
sary over the zygomatic region, only enough to accommodate
the tail. For larger implants such as the malar shell and com-
bined submalar shell, more dissection may be required to
accommodate the implant. By performing a sweeping maneuver
in the lateral pocket, the pocket is expanded (Figure 10-18).
This is especially useful over the masseteric tendon area. For very
large implants, extended dissection over the malar and zygo-
matic arch may be necessary (Figure 10-19).
After the implant pocket is dissected, the area is checked for
hemostasis, which is imperative to prevent hematoma forma-
tion. The pocket is then irrigated with antibiotic solution and
the implant placed. A long, thin tonsil clamp facilitates place-
ment in the narrow pocket (Figure 10-20). An Aufricht nasal
retractor or a Minnesota retractor is also convenient to assist
visualization and placement in the pocket. The implant is
grasped so that the tail is stabilized and placed into the pocket.
If the pocket is correct for the implant, the prosthesis will lie
passively and self-seat (Figure 10-21).
When inserting the implant, caution is exercised to prevent
the thin implant tail from folding over on itself (Figure 10-22).
Implants can be easily trimmed with scissors to further control
position and augmentation.
unnecessary. An exception is placing cheek implants in edentu-
lous patients. These patients have less maxillary bone and ride
higher, which can impinge on the nerve. A relief notch can be
made to accommodate the nerve when necessary (Figure 10-15).
When performing the initial subperiosteal dissection on the
anterior maxilla, a smaller neurovascular bundle may be encoun-
tered and mistaken for the infraorbital nerve (Figure 10-16, A).
The surgeon should keep in mind that the actual infraorbital
nerve is 5 to 8 mm inferior to the orbital rim and not confuse
it with this smaller vessel which can be sacrificed. Figure 10-16,
B shows the actual infraorbital nerve exiting the foramen.
After the anterior maxilla is dissected, the periosteal elevator
is angled, and the remainder of the dissection is primarily in an
oblique vector (see Figure 10-14, B). This oblique vector of
A
B
FIGURE 10-14.  The initial subperiosteal dissection vector is superior (A), then the dissection is directed in a superolateral direc-
tion heading over the malar and zygomatic regions (B). The orbit is protected with the finger of the operating hand.
FIGURE 10-15.  In certain cases, the implant can impinge on the infraorbital
neurovascular bundle. Notching the implant for relief is mandatory, or nerve
damage and pain can occur.

Chapter 10  •  Facial Implants
377
A
B
FIGURE 10-16.  A smaller neurovascular bundle is sometimes encountered on the anterior maxilla (A) and should not be mistaken
for the actual infraorbital nerve (B).
A
B
FIGURE 10-17.  A, The area of the masseteric tendon and the zygoma (circle). B, Same area in a live patient. (A Courtesy Primal
Pictures Ltd., London, )

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Chapter 10  •  Facial Implants
FIGURE 10-18.  A sweeping maneuver is made by using the periosteal
elevator at the lateral implant pocket, which assists in expansion of the
dissection pocket.
FIGURE 10-19.  Larger implant styles may require more aggressive dissec-
tion at the malar and zygomatic regions.
FIGURE 10-20.  A long, thin tonsil hemostat is useful to place the pliable
implant into a small cavity.
A
B
C
FIGURE 10-21.  The implant is placed into the pocket (A–B), and if the
pocket is correctly dissected, the implant should seat in a relatively stable
position. Implants are anatomically constructed to adapt to average
midface hard-tissue anatomy (C).

Chapter 10  •  Facial Implants
379
a 4-0 Vicryl suture from the anterior medial portion of the
implant to the deep tissues in that area, but this is a mobile fixa-
tion and not as stable as a screw. Many facial plastic surgeons
advocate the use of transcutaneous bolster sutures. I have never
used these and don’t feel they are necessary. In addition, this is
an unpleasant experience for the patient—no one appreciates
stitches protruding through their cheek.
The final step is to confirm that both implants are placed in
the correct position and symmetrically. This can be estimated
by observing the position of the implant relative to the teeth or
predrawn index marks on the face (see Figure 10-24, E).
The incision is closed with interrupted 4-0 gut suture (see
Figure 10-24, F). At the end of the procedure, several layers of
4 × 4 gauze are placed on the external cheeks and palmed with
the hand for 5 minutes to compress the surgical pocket (see
Figure 10-24, G).
Postoperative Care
No dressings are required, although some surgeons use compres-
sive garments. Postoperative care includes analgesics, antibiotics,
and tapering steroids if desired. The patient is instructed to
refrain from significant talking and animation for the first 48
hours and is asked to follow a liquid or soft diet for the same
time period. Ice packs are used for the first several days. The
amount of swelling can be quite variable. Whereas some patients
look great at 3 days, others may have significant swelling for 3
weeks. No immediate follow-up care is required, since the
sutures are resorbable. Postoperative appointments are generally
scheduled for 2 weeks, 1 month, and 3 months.
Sequelae and Complications
Although numerous complications have been described,22-28
they have been rare in the author’s experience.
Significant edema can occur in the early postoperative
period, especially if large implants are used or when implants
are placed concomitantly with other cosmetic facial procedures
After the implant is inserted into the dissection pocket, it is
again irrigated with antibiotic solution (Figure 10-23, A). The
surgeon then pushes on the external cheeks and manipulates
the upper lip (see Figure 10-23, B). If these maneuvers displace
the implant from the pocket or cause it to protrude out of the
incision, the pocket is enlarged or the implant trimmed (see
Figure 10-23, C). Trimming implants to customize them for
specific anatomy is common, and there is no harm in doing this.
If an implant does not fit, the surgeon can expand the pocket,
trim the implant, or use a smaller configuration.
When the implant is successfully placed, a decision is made
in reference to fixation. A well-conforming implant in a tight
pocket can be placed without fixation, and experience has
shown the implants to remain stable; some surgeons forego fixa-
tion. If the pocket is considerably larger than the implant, if the
implant does not stay in the desired position, or if there is
increased mobility of the implant, a single fixation screw can be
placed. I have placed well over 100 cheek implants without
screw fixation, but experience has shown that the procedure is
more predictable when using a single fixation screw. I have since
utilized rigid fixation screws on an additional several hundred
cheek implants, and it is now my standard of care. I have never
experienced a single case of implant shifting since switching to
screw fixation and hence, recommend it. The easiest means of
using screw fixation is to use 1.5- or 2-mm diameter self-drilling
screws (Figure 10-24, A). This allows easy seating of the screw
without the need for a drill. I generally place the screw through
the implant towards its periphery (as opposed to the thick center
of the implant) so a shorter screw can be used. It is important
not to overtighten the screw, or it can sink into the soft implant
and not hold. Additionally, the self-drilling screws are usually
not available in lengths longer than 8 mm. It is important not
to place the fixation in the thin bone of the anterior sinus wall;
it is vulnerable to perforation or loss of fixation. The fixation
screw is best placed in the thicker bone of the buttress area (see
Figure 10-24, B to D). An alternate means of fixation is to place
A
B
FIGURE 10-22.  Since some implant configurations have thin leading tails, care must be exercised to not fold the tail under the
implant during placement; otherwise a palpable and visible prominence will result.

380
Chapter 10  •  Facial Implants
A
C
B
E
D
FIGURE 10-23.  A, The surgical site is irrigated with antibiotic solution. B, The lips are stretched and (C) pressure is placed on
the cheeks. D, If the implant is displaced or extruded, then the pocket is enlarged or (E) the implant is trimmed.

Chapter 10  •  Facial Implants
381
A
C
D
B
FIGURE 10-24.  A, A typical 2-mm self-drilling screw fixation set as shown with the microscrews shown in the insert on a screw-
driver blade. B, The self-drilling screw is placed through the implant into the thickest bone available. Care is used to not push
the small screw through the thin anterior sinus wall. C–D, Both implants have been stabilized with self-drilling rigid fixation
screws.
(Figure 10-25). Cold packs and tapering steroids are routinely
used. Severe swelling may indicate hematoma formation, and if
the surgeon feels there is a significant hematoma, it must be
drained (Figure 10-26). This can usually be done by opening
the incision and suctioning the blood or clot from under or
around the implant, without compromising the result (Figure
10-27). An extremely large hematoma or a continued bleeding
source will require implant removal and replacement. Minor
hematomas or seromas will usually heal uneventfully without
treatment but in rare instances are aspirated.
Occasionally subconjunctival or periorbital ecchymosis is
seen but remains an uncommon finding (Figure 10-28).
Infection has been an uncommon experience. It usually
manifests in the first week or two and appears to be more
common in smokers. Infection is generally manifested by one
side failing to heal, with complaints of pain, increased swelling,
periorbital edema, and purulent drainage with a bad taste.
(Figures 10-29 and 10-30). The incision site will frequently be
very inflamed and sometimes open. It is possible to salvage a
minor infection with open incision and drainage, irrigation, and
systemic antibiotics. If an implant becomes infected and is
secured with screw fixation, I will attempt salvage with incision
and drainage, antibiotic rinses, and systemic antibiotics. The
lack of mobility assists in healing. In my experience, attempting
to salvage a mobile implant is futile and should not be attempted.
Resistant infections warrant implant removal, and the implant
can be replaced after healing. Because the explanted site will
have scar tissue and remnant implant capsule, the result is often
Continued