The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

This patient is a good example of a staged procedure over the course of 15 years. At
age 36, she requested improvement of her jowls and submental regions. She was
pleased with the results she obtained from suction-assisted liposuction (SAL) of the
jowls and submental regions.
1722
Part VIII  Face Lift and Neck Lift

Six years later, the patient returned at age 42 and requested surgical correction of
her neck and cheeks. She is shown 2 years after undergoing a rhytidectomy. As can
be seen, the excess fat in her jowls and submental area were greatly improved with
lipocontouring alone. However, as she continued to age, the deeper tissues began to
descend, and the rhytidectomy allowed repositioning of the deeper structures and
better definition of the jawline.
A planned, staged procedure should also be anticipated in patients who are typically
difficult to achieve excellent results in one stage or in those with tissues that are prone
to early recurrence of laxity. These patients can be identified by the poor quality of
their skin and/or the heaviness of their tissues and should be counseled regarding the
expected staged procedure so that the results that both the surgeon and patient an-
ticipate can be achieved.
1723
Chapter 49  Reoperative Rhytidectomy

This 66-year-old woman had considerable loss of skin elasticity, with very loose tis-
sues in the neck and a rounded facial appearance. This type of patient is a likely can-
didate for an early secondary correction, even as early as 1 year after the primary
procedure, because of the probable recurrence of jowling and tissue laxity. Patients
must be informed of this in advance to avoid dissatisfaction and unrealistic expec-
tations. She is shown 4 months after undergoing an extended SMAS rhytidectomy.
1724
Part VIII  Face Lift and Neck Lift
The patient developed a postoperative neck he -
matoma. Although the hematoma was drained,
she developed a fibrous mass in the central aspect
of her neck that failed steroid injection therapy.
She subsequently underwent direct excision of the
mass 7 months after the initial procedure.

The patient returned 1 year after her primary rhytidectomy with persistent fullness
in the jowls and requested surgical correction. She underwent SAL of the jowls and
was pleased with the early results.
1725
Chapter 49  Reoperative Rhytidectomy
One year later, she began to develop early descent of the malar fat pad, prominent
nasolabial and labiomental folds, and early signs of neck laxity.

Six months after her secondary rhytidectomy, the patient was again pleased with the
results; the recurrent jowling and tissue laxity have been significantly improved.
1726
Part VIII  Face Lift and Neck Lift
4 months after
primary extended SMAS rhytidectomy
1 year later:
following SAL of jowls
18 months later:
6 months after secondary rhytidectomy

1727
Chapter 49  Reoperative Rhytidectomy
Dissatisfaction With Previous Results
Even if they have not had any surgical complications, some patients are still dissat-
isfied with the results from their previous rhytidectomy. It is very important for the
reoperative surgeon to spend adequate time with these patients to clearly understand
what their expectations are and to discuss with them in detail exactly what results
can realistically be achieved. These patients may or may not have discussed their
dissatisfaction with the results with their previous surgeon when they seek correc-
tion. It is important in this situation to obtain the patient record from their previ-
ous surgeon.
Early Complications
The face-lift operation, like any other aesthetic procedure, presents risk for early
complications, as shown in the box.
Hematoma after a face lift is a significant source of morbidity. Various authors re-
port the incidence among all patients at 1% to 12.9%. The risk factors for hematoma
include hypertension, especially when it is uncontrolled preoperatively; male sex;
bleeding disorders; and the use of various medications that interfere with coagula-
tion. Clearly, prevention is paramount in reducing the incidence of postoperative
hematoma. Blood pressure control pays the highest dividends in this effort. The in-
cidence of hematoma among patients undergoing facial rejuvenation with local anes-
thesia and sedation may be a bit lower than for those who are given a general anes-
thetic. However, with either group it is crucial that blood pressure be normalized
before the start of the procedure. If the patient’s blood pressure remains greater than
180 systolic or 90 diastolic after initial sedation, we do not proceed until the blood
pressure is diminished. Persistent elevation is an indication for referral and workup by
the patient’s primary physician. Clonidine has been recommended as a useful agent
for preoperative control of blood pressure at doses of 0.1 to 0.2 mg orally the morn-
ing of surgery.
Early Complications of Rhytidectomy
 Hematoma
 Infection
 Skin slough
 Nerve injury (sensory and motor)
 Dysphagia
 Emotional issues

Men have a higher incidence than women of bleeding during face-lift procedures and
more frequently develop postoperative hematomas (between 3.97% and 12.9% of
cases). This phenomenon is probably caused by the presence in men’s faces of more
sebaceous glands and hair follicles, each of which is surrounded by a more exten-
sive capillary network. As a result, the vascularity of male skin is increased, leading
to greater potential for blood vessel disruption. Because of this phenomenon, more-
limited undermining in men as well as a conservative closed approach to the neck
can decrease the surface area at risk for postoperative bleeding. The use of fibrin glue
has also shown some benefits for rhytidectomy.
We ask our anesthetists to avoid spikes in blood pressure as the patient emerges from
general anesthesia, because this is the time of great risk for the development of a
hematoma. Drains are useful as a monitoring mechanism for the amount of bleed-
ing, but it is well accepted that they do not prevent hematoma. Head elevation, cool
compresses, pain control, and continued sedation are all useful for maintaining blood
pressure at an acceptable level.
Management of Hematomas
Hematomas that develop after a face-lift procedure can fall into two categories: small
ones that can be drained at the bedside without returning the patient to the operat-
ing room, and large ones in which the cheek and/or neck must be reopened and ex-
plored to control the bleeding source.
Bedside Management of Hematomas
The key to successful management of a hematoma is early detection. When detected
early, it is more likely that the hematoma can be managed without a return to the
operating room. Bedside management is accomplished by removal of enough sutures
or staples to be able to remove clots and fresh blood. Preparation for this procedure
should include some oral pain medication or sedation if the patient is overly anx-
ious. Blood pressure must be under good control. Thorazine and nitropaste are use-
ful agents for decreasing blood pressure by vasodilation. Towels or “chucks” are
spread beneath the patient’s head, and the area is prepared with a solution such as
povidone-iodine (Betadine) solution. A Yankauer suction tip or red Robinson catheter
is helpful for evacuating all the clots; the surgeon can then assess ongoing bleeding.
The area is irrigated profusely with saline solution until the return is clear. Then a
solution of 20 to 30 ml of 0.25% lidocaine with 1:200,000 epinephrine is injected
under the flap. Compression is held for 5 to 10 minutes, and a supportive circum-
ferential dressing is applied.
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Part VIII  Face Lift and Neck Lift

1729
Chapter 49  Reoperative Rhytidectomy
Operative Treatment of Hematomas
If the hematoma is large and seems to involve both cheeks and the neck, a return to
the operating room is indicated. Other factors that should influence the surgeon to-
ward a return to the operating room are these:
 An uncooperative patient
 An overly anxious patient
 A large, delayed hematoma
 Labile blood pressure
 Bilateral hematomas
 A compromised airway
If the patient is having difficulty breathing, immediate removal of sutures and de-
compression are essential. Since intubation and airway control in the presence of a
large hematoma can be exceedingly difficult, we prefer to initially get control of the
situation with the patient under local anesthesia with a little sedation. Often very
little is needed, because the tissues are frequently still numb from the initial proce-
dure, and antianxiety and pain medications may already have been given. The sur-
geon must try to locate the primary source of fresh bleeding and pack that area while
evacuating the remainder. With large hematomas, we usually remove the majority
of the sutures to make absolutely certain that all sources of bleeding have been con-
trolled, because the worst scenario is to think one has control of the bleeding source,
only to find that the hematoma has recurred after the patient has left the operating
room. Profuse irrigation with saline solution and dilute hydrogen peroxide will usu-
ally reveal the bleeding source. Of course, the surgeon can feel most confident when
a single “pumper” is found. When multiple bleeding vessels are encountered, we pre-
fer to keep the patient in the operating room under observation a bit longer until we
are certain no further bleeding is going to occur. Drains should always be replaced
and their proper function confirmed.
Four hours after undergoing a face lift, an endo-
scopic brow lift, and an upper and lower blepha -
roplasty, this 59-year-old woman developed an ob-
vious hema toma involving both cheek pockets and
the neck. Exploration revealed two arterial bleed-
ing points in the neck that were controlled. All re-
gions were washed out and the skin was reclosed.

The patient is seen 4 months postoperatively with near-complete resolution of the
sequelae of this complication.
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Part VIII  Face Lift and Neck Lift

The consequences can be devastating if a large hematoma goes untreated. This 48-
year-old woman was seen in consultation after having undergone a primary rhytidec-
tomy in another state. Postoperatively she developed bilateral hematomas that were
treated conservatively. She developed extensive preauricular and cheek scarring for
which she underwent a “pickle-fork” procedure 5 weeks later. The patient presented
to our practice 7 weeks after her primary rhytidectomy requesting correction of the
deformity. She was depressed and was unable to resume her normal activities. The
mainstay of treatment of any patient with significant deformity as a result of com-
plications is to not reoperate too soon. In this situation we attempted conservative
nonsurgical treatments, including ultrasound and endermologie, while waiting for
the tissues to soften. Of key importance is avoidance of additional traumatic injury
to the area by manipulation or injections. After 1 year we felt that the tissues and
the patient were ready to undergo definitive correction. The plan was to release the
scar tissue between the dermis and the SMAS and provide a pad of soft tissue be-
tween these layers. Because the patient also requested an abdominoplasty, we devel-
oped a plan to harvest dermal fat grafts from her pannus for use in the cheeks.
1731
Chapter 49  Reoperative Rhytidectomy

1732
Part VIII  Face Lift and Neck Lift
The dermal fat grafts were spread out and sutured under tension at the periphery of
the released pocket. In addition, autologous fat injection was performed in the bi-
lateral nasolabial folds. Very little facial skin was removed during this procedure,
which is common in secondary face-lifting.
The patient is seen 3 years after the revisionary facial procedure. Although the lat-
eral cheek rhytids have not been completely eliminated, they are greatly improved,
the patient’s depression has resolved, and she has resumed her normal activities.

Skin Slough
Skin sloughs usually occur as a result of closure under excessive tension. Blood un-
der the flap, tight dressings, flexed neck positioning, smoking, and diabetes are all
contributing factors. If impending tissue necrosis is diagnosed in the early postop-
erative period by flap cyanosis or lack of capillary refill, sutures should be imme -
diately removed and the skin allowed to retract. As in the case of a released nipple-
areola complex, the open wound can be covered with Xeroform and a light dressing
for 5 to 7 days, at which time one is often able to reclose the wound with salvage of
the skin flap. If hyperbaric oxygen therapy is available, treatments once or twice daily
for 5 days can be helpful in salvaging underperfused skin flaps.
If the skin is clearly demarcating, usually conservative treatment is indicated. The
surgeon should make certain that the patient is not continuing to smoke if he or she
is a smoker. These patients will require repeated reassurance, because this compli-
cation may seriously affect their ability to return to work or other social activities.
On the other hand, little wound care is necessary in the eschar phase. When spon-
taneous separation begins to occur, we debride any nonviable tissue and begin dress-
ing changes. Allowing the wound to contract and heal spontaneously usually gives
a result that is a better color and texture match than a skin graft would. Obviously,
if flap advancement and reclosure is a possibility, this is the best option. However,
usually there is too much tension to accomplish this.
Infection
Fortunately, infections following face lifts are rare, but they can have devastating con-
sequences. Prevention is the key. We have all our patients wash their faces themselves
at least three times with an antibacterial soap on the morning of surgery. It is diffi-
cult to maintain a strict sterile field with facial rejuvenation surgery because of the
presence of hair and the oral and nasal cavities within the field, as well as the endo-
tracheal tube or airways and oxygen. Nevertheless, every attempt must be made to
avoid contamination, especially when the procedure is prolonged. We have found
that soaking braided sutures in Betadine before use has decreased small suture in-
fections, especially in the region of the platysma plication. Also, before closure of the
cheek dissection, we meticulously irrigate all open areas with dilute Betadine to wash
out any debris, particularly loose fat globules.
1733
Chapter 49  Reoperative Rhytidectomy

Infections may arise in undrained hematomas or seromas; these are often seen as col-
lections in dependent portions of the undermined area. An overlying erythema is
usually the first sign, but there may be little or no associated pain or fever. Drainage
is of paramount importance, even more crucial than appropriate antibiotic selection;
however, cultures should be obtained to guide antibiotic selection. If the combina-
tion of drainage and antibiotic agents fails to rapidly resolve the problem, operative
exploration should be considered to rule out an infected foreign body. Cotton used to
plug the external auditory meatus has been known to drop into the wound and
should be accounted for in the sponge and needle counts. In severe infections of the
face, thorough irrigation, debridement of any nonviable tissue, and wide drainage
is generally effective, in addition to administration of an appropriate antibiotic. Hos-
pitalization and intravenous antibiotic therapy are rarely needed, but anything less
than rapid resolution of the infection should be treated in this manner.
Parotid Fistula
Parotid injury has become a more common event with face-lift techniques that in-
volve dissection in the sub-SMAS plane. Unfortunately, it is even more likely when
the SMAS has been previously elevated, as in some secondary face lifts. With any sec-
ondary facial procedure the parotid is at greater risk of injury because of altered
anatomy and scarring. The gland is at highest risk over its superficial lobe, just at
the mandibular angle. The superficial fascia can usually be separated from the parotid
fascia unless the plane has been previously obliterated surgically. Actually, raising
both the superficial fascia and the parotid fascia in continuity is sometimes advan-
tageous when the superficial fascia is thin, because this adds strength for the deep
tissue fixation. However, one is dissecting right on top of the glandular lobules of
the parotid, which can look very similar to the sub-SMAS fat and is therefore sus-
ceptible to injury. This is how most parotid injuries occur. The duct is rarely injured
but can be obstructed if the gland is torqued by suture fixation.
The key to management is to recognize the injury to the parotid at the moment it
occurs so that the plane of dissection is immediately corrected. The injured parotid is
simply coagulated with the electrocautery or rarely, oversewn with fine sutures if the
injury appears to enter the terminal ductules. The area is drained and compression
applied for 48 hours. If there is obvious saliva appearing in the drain, the drain should
remain in place until the output is minimal. Generally, these fistulas are self-limited
as long as the duct is not obstructed. Sialography or duct endoscopy had been re-
ported to be helpful in reopening an obstructed duct. Injuries late in the postopera-
tive period are diagnosed by a swelling and fluid collection over the parotid that on
aspiration yields a high amylase titer. Generally, the patient is afebrile. The swelling
often increases with eating. It is managed by inserting a closed suction drain, adding
a pressure dressing, and administering antibiotic agents. Atropine and glycopyrro-
late have been reported to be helpful for their antisialagogue effects.
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Part VIII  Face Lift and Neck Lift

1735
Chapter 49  Reoperative Rhytidectomy
Nerve Injury
Any branch of the facial nerve can be injured during a face lift. With the anatomy
altered from primary surgery, deeper dissections beneath the SMAS during second-
ary face lifts risk injury to the facial nerve. The frontal branch of the facial nerve is the
most commonly injured branch, followed by the marginal mandibular and the buc-
cal branches. Although severed branches do occur, the more typical injury results
from traction or thermal injury from the use of cautery in close proximity. The vast
majority of nerves which are still in continuity recover in time although this can take
up to a year or more. Most recover within 2 weeks to 3 months.
When frontal branch weakness is noted postoperatively and persists beyond 1 month,
we favor the use of botulinum toxin to weaken the normal side of the face if the pa-
tient will accept it while the injured side recovers. Often, as the botulinum toxin
wears off, the nerve has recovered on the injured side and symmetrical movement is
reestablished.
If the nerve has not recovered by 1 year after surgery, a more permanent solution is
to perform either a direct or an endoscopic brow lift on the affected side, as well as
on the normal side, if indicated. A similar strategy can be used for the marginal
mandibular branch with weakening of the depressor anguli oris on the normal side
with botulinum toxin. Resection of this muscle has been reported for perioral reju-
venation and could be considered if the smile remains asymmetrical beyond 1 year.
Injuries to the great auricular nerve are usually managed conservatively; often sen-
sation will return spontaneously.

Dysphagia
Dysphagia is attributable to platysmal tightening, which is a dramatic change for pa-
tients who are accustomed to a loose neck. Diazepam is effective for symptomatic
treatment early on, and no surgical intervention is ever indicated, because the mus-
cle always relaxes with time.
Emotional Issues
Recovery from a face lift is an emotional rollercoaster for some patients. The effects
of anesthesia, steroids, and other medications as well as fear of their eventual ap-
pearance can take a serious toll on the emotional well-being of face-lift patients. Pre-
operative education can help prepare them for “the blues” that frequently accom-
pany the recovery process. Having a relationship with a clinical psychologist in your
community can pay great dividends if intervention seems to be necessary and you
need to refer the patient. For most individuals, reassurance is all that is necessary
until the swelling and associated distortion has resolved. A recent patient satisfac-
tion long-term follow-up study showed that the overwhelming majority described
their improvement in facial appearance as “very good” or “beyond expectations.”
Aesthetic Evaluation for Reoperative Rhytidectomy
With better understanding of the aging process, we now know that repeated pulling
of the skin, especially in a disadvantageous direction, will not restore a youthful ap-
pearance, but rather yield an appearance that belies repeated surgery and may be
exceedingly difficult to correct. The lateral sweep of the lifted lateral cheek and jowl
but uncorrected midface is a classic example of this. Therefore patient evaluation
must begin by careful analysis of which features are yielding an aged appearance.
Although the aesthetic evaluation for a secondary rhytidectomy is similar to that of
a primary rhytidectomy, there are certain physical examination characteristics that
may differ. There is on average 8 to 12 years between the time of the primary rhytidec-
tomy and the secondary rhytidectomy. During that time, the patient’s skin quality
and texture deteriorates from further actinic damage. In addition, some areas of the
face retain their tightened support, whereas other areas, such as the midface, con-
tinue to descend, creating an unnaturally aged appearance. Other unnatural ap-
pearances created by a previous rhytidectomy include distortion of the hairline and
sideburns, malposition of the earlobe, loss of tragal definition, facial asymmetries,
cross-cheek depressions, and visible scars. It is important to recognize these changes
so that an appropriate and accurate treatment plan can be formulated.
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Part VIII  Face Lift and Neck Lift

1737
Chapter 49  Reoperative Rhytidectomy
Factors to Be Considered in Secondary Facial Rejuvenation
 Quality and texture of skin
 Degree of skin relaxation
 Degree of fat atrophy with residual
hollowing
 Facial asymmetries
 Depth of nasolabial, labiomental, and
nasojugal creasing
 Ear and earlobe malposition, ptosis,
and deformities
 Tragal definition and position
 Hairline shifts or hair loss
 Visibility and quality of previous scars
 Perioral lines, lip thickness and length
 Platysmal banding and laxity
 Submandibular gland prominence
 Chin shape and ptosis
 Contour deformities of the neck result-
ing from excess fat in neck or jowls
 Malar flattening
 Digastric muscle prominence
 Dentition
It is a mistake to immediately conclude that what every patient must have is your
definitive face lift, as if whoever did it the first time might be lacking your skill. Many
patients may have come to you because they have heard that you are not a surgeon
who immediately wants to do another face lift on everyone. You now have multiple
approaches available, so the first rule is to listen to your patient! Then ask, “What
is it about your face that is beginning to bother you?” and “Were these features im-
proved after your first face lift?” Starting with questions like these will assist you to
tailor valuable consultation time toward the patient’s primary concerns rather than
discussing all sorts of items that the patient will simply not consider. Nevertheless,
the consultation is also an opportunity to help educate the patient about procedures
or treatments that will give lasting improvement versus treatment options that he or
she may have heard about but for which the patient is not a candidate. Botulinum
toxin and fillers are, quite obviously, not going to produce a face-lift–like result, but
some patients are confused about issues such as these.
In recent years, much more attention has been paid to the midface as well as to vol-
umetric shaping of the face. These are issues that might not have been addressed dur-
ing the patient’s initial face lift. Of course, if the patient returns to the surgeon who
performed the original procedure, access to the original records will be at hand. If
the original surgery was done by someone else, it may not be possible to determine
the exact technique and what was done the first time around. If the assessment re-
veals an aged midface appearance, this will need to be addressed during surgery.
Also, the addition of fillers, including autologous fat grafting for volumetric re-
placement, is more commonly done today. Therefore it is likely that the patient has
not benefitted from some of the newer technologic innovations that plastic surgeons
have available to them.

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Part VIII  Face Lift and Neck Lift
Often the quality of the skin has either further deteriorated or has never been treated
in a secondary patient. This may be the primary source of concern for the patient,
and improvement is more a matter of resurfacing, filling, or skin care.
Anatomic Differences in Reoperative Rhytidectomy
Skin and Scars
During the interval between the primary rhytidec-
tomy and the planned secondary rhytidectomy, the
patient’s skin continues to age and thin. There is on-
going loss of collagen in the dermal layer, which
causes increased skin laxity and a decreased ability
to maintain support with tension. As mentioned ear-
lier, the degree to which the tissues lose support de-
pends on the anatomic area. Although the preau-
ricular area maintains a high degree of support,
evidenced by the lack of excess skin in this area re-
moved in secondary rhytidectomy, the preauricular
scars can become noticeable with small amounts of
migration.
The postauricular scars are also vulnerable to this migration and visibility. The sur-
geon should make every effort in either a primary or a secondary rhytidectomy to
place the scars in areas that are least noticeable.
The patient’s scars from previous procedures are an important consideration when
planning reoperative surgery. The character of the scars should be noted. Although
rare, scars may have developed into hypertrophic or keloid scars. These scars may be
improved with a secondary procedure, but the patient must be aware that they may

recur or even worsen. The location of the scars limits the surgeon’s ability to place
the scars of a secondary procedure in an inconspicuous location. The surgeon should
try to place the final scar in an ideal location but should not commit to the final lo-
cation until after the skin flap has been elevated and the amount of excess skin de-
termined.
Hair Line
A previous temporal incision may have
decreased or completely eliminated the
patient’s sideburns. If the distance be-
tween the lateral canthus and anterior
portion of the patient’s sideburn is long,
an anterior hairline incision should be
considered to prevent the loss of the pa-
tient’s sideburn. The incision is usually
inconspicuous and is much more attrac-
tive than the loss of the sideburn. We try
to stay below the sideburn whenever
possible and extend the incision as re-
quired for adequate skin redraping in the
lateral temporal region.
Subcutaneous Tissue
1739
Chapter 49  Reoperative Rhytidectomy
In secondary rhytidectomy patients, the amount of subcutaneous tissue under the
previously undermined skin is atrophic. The previous elevation of the skin flap func-
tions as a “delayed flap,” which provides a better blood supply to the skin. It is less
likely to have skin blood supply issues unless the patient is a smoker. In such a case,
it is important for the patient to quit smoking for at least 4 weeks before surgery
and for 4 weeks after. Although the blood supply is of less concern in a secondary
rhytidectomy, the previous elevation causes scar tissue to form, and in combination

1740
Part VIII  Face Lift and Neck Lift
with atrophic subcutaneous tissue, there is an inability to dissect distinct layers, as
in this patient, who had undergone three previous rhytidectomy procedures. It is rec-
ommended to proceed with knife dissection until the planes are well established.
Previous SMAS Elevation
It is important to determine from the patient’s medical documentation whether the
SMAS was elevated in the previous rhytidectomy. If not, a secondary procedure pro-
vides a good opportunity to improve the midface with tension on the underlying
structures. If the SMAS has been elevated previously, the scar tissue between the
SMAS and the underlying parotid fascia is much more difficult to separate. The mo-
bility of the SMAS should be assessed to determine whether plication alone will ac-
complish the improvement desired.
Buccal fat pad
SMAS
Parotidomasseteric fascia
Mimetic muscle
SMAS
Mimetic muscle (platysma)
Subcutaneous layer
Skin
Subcutaneous layer
Parotidomasseteric fascia
Plane of facial nerve
This is a patient who had previously undergone a
primary rhytidectomy with an extended SMAS dis-
section. She had concerns for recurrent facial aging
in the lower third of her face and underwent a sec-
ondary rhytidectomy. During the procedure the
amount of correction needed to rejuvenate the lower
third of the face could be achieved with SMAS pli-
cation alone. The markings before the plication can
be seen.

Facial Nerve Risk With Reelevation of SMAS
When the SMAS has been elevated previously, the facial nerve is at a greater risk dur-
ing dissection. In this situation, it is usually safer and easier to plicate the SMAS in the
areas that produce the effect that is desired.
1741
Chapter 49  Reoperative Rhytidectomy
This patient developed a marginal mandibular neuropraxia after a primary rhytidec-
tomy with SMAS elevation. Three years later, she returned with concerns for early
recurrent neck laxity and prominent labiomental folds. Because of her prior nerve
injury with SMAS elevation, we elected to use SMAS and platysmal plications for
correction.
Surgical Options for Reoperative Rhytidectomy
Determining which procedure is best for a patient depends on many variables. A
good understanding of what the patient’s goals are will help to narrow the options.
Once this is understood, determining what techniques were used in the previous sur-
gery will help to establish the surgeon’s risks and limitations.

Preventing and Correcting the “Overoperated” Look
Know When to Say When
1742
Part VIII  Face Lift and Neck Lift
Secondary Face Lift Options
 Isolated neck lift
 Threads/suspension suture technique
 “Tuck-up” procedure/mini–face lift
 SMAS procedures (complete, extended, or plication)
 Endoscopic approach to the midface
 Facial shaping and volume restoration with autologous fat injection
 Facial lipocontouring with liposuction
The overoperated look can occur from a single poorly performed procedure or from
multiple procedures performed on the same person. If a surgeon has performed mul-
tiple facial aesthetic procedures on a patient, yet he or she is requesting improve-
ments that will inevitably produce an unnatural overoperated look, the surgeon must
use better judgment and decline to proceed. It is important to thoroughly explain
why further surgical intervention could cause an unnatural and uncorrectable ap-
pearance, so the patient does not seek surgical correction elsewhere. Such a pursuit
would inevitably lead to further patient dissatisfaction and could also damage the
reputation of the surgeon and the practice.

The Lateral Sweep
1743
Chapter 49  Reoperative Rhytidectomy
In this patient with sun-damaged skin and facial wrinkling, the wrinkles run in a
cephalad direction as the result of a previous face lift. This problem usually becomes
more evident with animation and when the patient flexes the neck.
The term lateral sweep is given to the unnatural appearance of the cheeks after fa-
cial rejuvenation surgery when there is a distinct curve of the lower facial skin from
the jawline toward the superior portion of the ear. The curved rhytids present an ob-
vious overoperated look.
The lateral sweep is created because of skin tension differences between the pulling
vectors of the lifted tissues. The greatest tension on the skin is superolateral toward the
superior aspect of the ear, where the skin is anchored. The central portion of the
face, the midface, is farthest from the skin anchoring and therefore has the least skin
tension.
As the face ages, skin tension lessens and begins to descend. In an unoperated face,
the tissues descend at equal rates, creating the normal stigmata of facial aging: an
obvious lid-cheek junction, prominent nasolabial folds, marionette lines, downturned
oral commissures, jowling, loss of an obvious jawline, and cervical laxity with the
development of an obtuse cervicomental angle. However, in a patient who has un-
dergone facial rejuvenation surgery, the tissues descend at differing rates, because af-
ter the surgery, the skin and deeper tissues are under different tensions. As mentioned
earlier, the tissue of the midface is the farthest from the point of fixation after a
rhytidectomy and therefore has the least amount of tension. As the operated face
ages, the areas of least tension, the midface, begin to descend earlier. As the midface
descends and the inferior and lateral tissues retain their tension longer, the lateral
sweep is created.

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Part VIII  Face Lift and Neck Lift
Deeper tissue manipulation using the SMAS is used to try to minimize this occur-
rence by resuspending and tightening the tension on the midface tissue. However,
the point of fixation for this tissue is not as durable as it is for the skin and there-
fore still ages earlier. The composite rhytidectomy described by Hamra involves repo-
sitioning of the orbicularis oculi muscle in an attempt to strengthen the support of
the midface and to minimize the bunching that can occur in the periorbital area.
Tragal Distortion
Tragal distortion is a telltale sign of the overoperated face. It is caused by excessive
skin tension at the tragus when the incision is brought behind the tragus to disguise
the scar. This can be prevented by placing key sutures that will hold the majority of
the skin tension at the superior extent of the incision near the anterior and posterior
aspects of the ear. After these sutures have been placed, the excess skin can be judi-
ciously excised near the tragus to prevent any skin tension at this point. In addition,
we also remove some of the excess fascial tissue directly anterior to the tragus to cre-
ate the natural depression that should be present and use a deep dermal suture (5-0
PDS) to hold this depression in place.
If a previous surgery has created anterior displacement of the tragus as a result of
excessive skin tension, there are techniques to recreate the natural appearance. The
base of the tragus can be incised and released using a No. 15 blade scalpel, and a 5-0
nylon suture can be placed between the concha and the tragus to hold it in position.
This suture is removed in the clinic 3 weeks later.

Hairline Distortion
1745
Chapter 49  Reoperative Rhytidectomy
Secondary rhytidectomy procedures can cause hairline distortion, especially at the
level of the sideburn. If the previous rhytidectomy incision extended into the tem-
poral hair, then chances are the length of the patient’s sideburn has been shortened.
Although less skin is removed during a secondary rhytidectomy compared with a
primary rhytidectomy, any additional loss of sideburn hair will look overoperated
and unnatural. In this case, it is best to extend the incision just below and then cepha-
lad anterior to the sideburn. This incision should be beveled at an angle of 30 to 45
degrees to the external skin surface to permit hair growth through and anterior to
the scar. The resulting scar can be inconspicuous and does not risk causing hairline
distortion. The area of skin between the previous scar and the new incision should
have an adequate blood supply.
Pixie Ear and Earlobe Scar Migration
A pixie ear forms when there is too much skin tension at the base of the earlobe in-
set. This causes an elongation of the earlobe at the site of the inset that is unnatural
and is an obvious overoperated look.

This can be prevented by redistributing the skin tension to the appropriate place with
key sutures of 3-0 nylon at the superior extent of the anterior and posterior ear. Once
these key sutures have been placed and the tension removed from the base of the ear,
judicious skin excision can be performed. To further reduce the potential of devel-
oping a pixie ear, an area of excess skin at the base of the ear can be deepithelial-
ized and sutured to the base of the concha. This is especially helpful during a short-
scar face lift, where the postauricular incision stops at the base of the earlobe. In this
case, there is no posterior-superior key suture to redistribute the skin tension. This
suture will act to minimize the skin tension at the base of the earlobe inset.
1746
Part VIII  Face Lift and Neck Lift
Earlobe scar migration can also be a problem after primary rhytidectomy. Although
most scars can be hidden by the patient’s hair or make-up, this scar can be very up-
setting to the patient. After the scar has had time to mature, this abnormality can
easily be treated in the office under local anesthesia. The scar tissue can be deep-
ithelialized and sutured to the caudal portion of the conchal cartilage to provide
added support. The skin should be rotated posteriorly, as in this patient, to recreate
the natural aesthetic of the earlobe-cheek junction.

Obvious Scars
1747
Chapter 49  Reoperative Rhytidectomy
Visible scars are an obvious sign of an operated look. Most patients would prefer to
have the scars hidden from view. This can be accomplished with placing the anterior
incisions in or near the hairline and within the natural facial creases adjacent to the
anterior portion of the helix and earlobe and at the tragal margin. As the incision
continues around the posterior aspect of the ear, the incision should continue in the
posterior auricular crease. The incision should continue high before extending hor-
izontally into the posterior hairline. With this incision, the well-healed scars will be
very difficult to visualize. If the posterior horizontal incision is placed low, the scar
is quite obvious and hinders the patient’s ability to hide the scar when the hair is cut
short or pulled back.
It may be possible to reposition these scars higher if the incisions were initially placed
low or if tissue laxity has recurred and moved the incision lower. One should not
commit to the final location of this scar until the entire skin flap has been reelevated
and the excess amount of posterior skin is known.

Another rare complication of rhytidectomy is hypertrophic or keloid scar formation.
This patient underwent primary rhytidectomy and revision of an anterior vertical
midline chest keloid scar. She had other scars that had not developed keloid forma-
tion. She was counseled on the risks of obvious scar formation with her known his-
tory, but she elected to proceed with the operation. Postoperatively, we treated her
with Kenalog-40 injections diluted with 1% lidocaine, with slight improvement.
Recognizing Body Dysmorphic Disorder
When discussing any reoperative aesthetic surgery, it is important to recognize pa-
tients with body dysmorphic disorder (BDD). There are three diagnostic criteria listed
for the diagnosis:
1. A preoccupation with an imagined or slight defect in appearance
2. Marked distress or impairment in social, occupational, or other areas of func-
tioning resulting from the appearance preoccupation
3. The preoccupation is not attributable to the presence of another psychiatric
disorder
Patients with BDD may visit the plastic surgeon for correction of their presumed de-
formity. It is imperative that the surgeon know the signs of this disorder and refer
these patients to the appropriate mental health specialists. It has been reported that
patients with this disorder who have undergone corrective surgery have a high rate
of dissatisfaction with the results and have even become physically violent. (See Chap-
ters 1 and 8 for more detailed discussion of this disorder.)
1748
Part VIII  Face Lift and Neck Lift

How to Maintain Your Results
“How Long Will My Face Lift Last, Doctor?”
As mentioned earlier, most patients want to know the answer to this question in
their initial consultation. Patients who have already undergone a primary rhytidec-
tomy have a better understanding of what to expect. Although it is impossible to ac-
curately predict the longevity of this procedure for any given patient because indi-
vidual differences in current age, skin laxity, actinic damage, genetics, previous
procedures, and many other factors, studies show that 10 years is a good estimate.
Over the years, we have learned that the final result and longevity are influenced by
the types of procedures performed. Facial rejuvenation has evolved from simply a
skin-excision procedure to skin excision with manipulation of deep structures to skin
excision with manipulation of deep structures and the inclusion of adjuvant proce-
dures, such as chemical peels, laser resurfacing, dermabrasion, muscle modulation
with neurotoxin, and volume restoration with soft tissue fillers, implant augmenta-
tion, and/or autologous fat injections. With these various combinations, the proce-
dures can be tailored to the individual’s desires and goals to obtain the best results
and to improve longevity.
Lipofilling/Lipocontouring
Even with the evolution of rhytidectomy from skin-only resection to skin resection
combined with repositioning of deep tissue support, patients and their plastic sur-
geons longed for improvement in certain areas that were poorly corrected by rhytidec-
tomy. The areas of most concern are in the supraorbital hollow, tear trough defor-
mity, prominent nasolabial and labiomental folds, and the jowls. These areas are
either not improved after rhytidectomy, or they develop early recurrence of the de-
formities.
As the face ages, facial fat begins to descend (creating prominent nasolabial folds,
labiomental folds, and the lid-cheek junction), atrophy (creating the supraorbital
hollow, temporal hollow, tear trough deformity, prominent zygomatic arches, and
cheek depressions), and accumulate (creating the jowl). The results of these facial
changes create shadows at these anatomic transitions like that created in a valley be-
tween two mountains. To minimize this shadowing, one would either need to fill the
valley, decrease the size of the mountains, or a combination of both. As facial reju-
venation has evolved, we have learned that the face should be analyzed and treated
as a three-dimensional structure and that we must correct not only the skin and deep
tissue laxity but also the volumetric changes seen with aging.
1749
Chapter 49  Reoperative Rhytidectomy

With the improvements in technology, such as ultrasound-assisted liposuction (UAL),
and techniques of autologous fat injection, we can now improve these facial areas
that have been resistant to long-lasting facial rejuvenation. Liposuction (either SAL
or UAL) can remove the fat in areas of excess (analogous to decreasing the size of
the mountain); fat injection can add the fat needed in areas of deficiency (analogous
to filling the valley). Despite the lack of quantitative evidence of fat survivability,
clinical experience demonstrates its benefits. The combination of facial rejuvenation
lifting techniques with autologous facial fat injection and facial liposuction has sig-
nificantly advanced the field of facial rejuvenation by facilitating correction of the
volumetric changes seen with aging.
We prefer the use of UAL to slowly and precisely remove jowl fat in patients with
lipodystrophy in this area. After repositioning of the malar fat pad and SMAS in a
rhytidectomy, we carefully harvest fat for lipofilling of the areas of facial fat atrophy.
The donor site chosen depends on the patient’s preference and on adequate adipose
stores. We most commonly use the lower abdomen. This combination of reposition-
ing the malar fat pad with deep tissue support and replacing lost fat and/or removal
of excess fat has significantly improved the lasting results of facial rejuvenation. These
techniques can be used in a secondary rhytidectomy to help improve contour irreg-
ularities caused by previous facial procedures.
Soft Tissue Fillers
Soft tissue fillers can also be employed as a nonsurgical temporary treatment of fa-
cial aging. Many products have been used for soft tissue filling, but hyaluronic acid
products have some of the most widespread use. They differ based on the amount of
cross-linking present and their particle size. In general, the larger the particle size
and the more cross-linking present, the longer the results tend to last. The soft tis-
sue fillers differ in the material that is injected and their longevity. They can be used
for facial sculpting and are most frequently used for temporary improvement of
prominent nasolabial and labiomental folds, lip augmentation, and tear trough de-
formities. (See Chapter 12 for a more detailed description of these products.)
Dermabrasion
With the use of a small hand-held electrically powered instrument and an abrasive
substance, such as a wire brush or diamond fraise, the epidermis and a portion of
the superficial dermis is removed. The dermal appendages allow reepithelialization
to occur in approximately 7 days, thus improving the surface texture of the skin. This
technique can be used to improve acne scars and deep, coarse rhytids in the peri oral
area. The pilosebaceous glands of the face should be present in the skin for reepi -
thelialization to occur. This technique should not be used an areas with a paucity of
pilosebaceous glands due to the risk of abnormal scar formation. (See Chapter 14
for a detailed description of this technique.)
1750
Part VIII  Face Lift and Neck Lift

Laser Resurfacing
Laser skin resurfacing can be performed at the same time as a rhytidectomy. How-
ever, deep tissue penetration should not be used over the undermined skin unless the
fractional technique is used. We do not resurface the lateral cheeks, since this is the
area most at risk for healing problems because of the decreased blood supply in this
area of the skin flap. Deep perioral resurfacing will improve the vertical rhytids
around the lips that are not corrected with a rhytidectomy. Deep periorbital resur-
facing can be used to tighten loose skin around the eyes in patients who have previ-
ously undergone a blepharoplasty or in those with minimal excess skin. A micro–
laser peel can be performed on the central portion of the face in conjunction with a
rhytidectomy to remove up to 30 microns of epidermis; this will improve the patient’s
complexion and remove superficial pigmentation changes. The ProFractional laser
technology improves skin tone through collagen remodeling. With this technique,
microholes are made in the skin using the laser set at varying depths. As the skin re-
models, collagen is laid down and tightens the skin.
Chemical Peels
A chemical peel can help to improve the actinic changes of the skin. However, this
procedure should be performed after the patient has healed from the surgical pro-
cedure. The epidermis and varying degrees of dermis are removed through a chem-
ically induced injury. A neocollagen-rich layer replaces the dermis and reepithelial-
ization occurs. Different peels are available, including phenol peels, trichloroacetic
acid (TCA) peels, and glycolic acid peels. The depth of the peel is determined by the
type and concentration of the chemicals used. (See Chapter 15 for a more detailed
description of the available chemical peels used.)
Neurotoxin
Botulinum toxin is produced by the bacterium Clostridium botulinum and causes
muscle paralysis. The neurotoxin inhibits the release of acetylcholine at the presyn -
aptic cholinergic neuromuscular end plates. It was originally used to treat strabismus
in the 1970s but is currently used most frequently for improvement of dynamic fa-
cial rhytids.
Neurotoxin injections can be used to treat glabellar furrows (formed by the con-
traction of the corrugators supercilii and procerus muscles); horizontal forehead
rhytids (formed by the contraction of the frontalis muscles); periocular crow’s-feet
rhytids (formed by the contraction of the orbicularis oculi muscles); marionette lines
(accentuated by the contraction of the depressor anguli oris muscles); and vertical
lip rhytids (created by the orbicularis oris muscles). In addition, with appropriate
placement of the neurotoxin, the shape and position of the eyebrows can be changed
to improve eyebrow aesthetics.
1751
Chapter 49  Reoperative Rhytidectomy

1752
Part VIII  Face Lift and Neck Lift
Skin Care
Maintaining good skin health will help to improve the appearance and longevity of
the surgical results. There are many skin care products on the market today, but the
first step in good skin care is to avoid sun exposure. The genetic factors that con-
tribute to the aging of skin cannot be altered through behavioral changes, but the
effects of sun exposure can. We recommend that all of our patients be consistent in
their use of sunscreen products and sun exposure protection.
Patient Examples
This 60-year-old woman had undergone a primary rhytidectomy 4 years earlier and
was concerned about recurrent neck laxity and skin excess. She is seen 2 years after
an isolated neck lift.

This 47-year-old woman complained of continued facial aging and prominent scars
following an initial face lift at age 36 and a mini–face lift at age 41. The presideburn
scars were visible, as was descent of the malar fat pad and minor jowling. We per-
formed a tertiary face lift that included an extended SMAS technique to anchor the
malar fat pad to the malar periosteum. Her results are seen at 1 year.
1753
Chapter 49  Reoperative Rhytidectomy

{INSERT FIG 49-26 A-F HERE}
This 60-year-old woman had undergone an endoscopic brow lift, mini–face lift, and
lower lid blepharoplasty 4 years earlier. She was displeased with the appearance of
her eyebrows and felt she had a continually surprised look. She requested correction
of the eyebrow position. We performed a “reverse brow lift,” with mobilization of
the forehead in the subcutaneous plane and release of the periorbital ligaments
through an endoscopic approach and suture fixation of the medial brow through an
upper lid blepharoplasty incision. The patient was very pleased with the improve-
ment of the eyebrow shape; the medial portion of the brow had been moved more
caudally, correcting her constant surprised appearance.
1754
Part VIII  Face Lift and Neck Lift

This patient had undergone a primary face lift 10 years earlier. She now expressed
concern about her continued facial aging and obvious scars. The secondary proce-
dure was designed to elevate the postauricular scars up higher behind the ear and
restore the gap in the hairline, elevate the midface, and tighten the neck; an endo-
scopic brow lift was also performed. She is seen 4 years postoperatively.
1755
Chapter 49  Reoperative Rhytidectomy

1756
Part VIII  Face Lift and Neck Lift
Concluding Thoughts
Facial reoperative conditions vary, depending on the patient’s altered anatomy and
concerns. This may include the need to correct complications such as hematoma and
nerve injury. Adjunctive procedures are becoming more numerous and are being used
to a much greater extent today. Staged procedures in which the patient may need
early intervention can be anticipated or can be used to delay more definitive face-
lifting procedures. Improving the results of dissatisfied primary facial rejuvenation
patients can represent some of the more challenging cases; it can be difficult to achieve
results that both the surgeon and patient will accept. The most common reason for
reoperation is for the continued stigmata of aging.
It is important to make an accurate preoperative diagnosis and then design the re-
operative plan. The surgeon can retain patients in the practice by advising them re-
garding ways to maintain their results, such as skin care, neurotoxin therapy, dermal
fillers, laser skin resurfacing, and ultimately, additional surgical procedures.
Clinical Caveats
 The surgeon must educate the patient about the fact that a face lift does not last
forever.
 It is a mistake to conclude that every patient must have your definitive procedure,
as if the surgeon who performed the primary procedure lacked your skill.
 Attend to what bothers the patient about his or her face: listen to the patient!
 In a secondary procedure, there may be asymmetries resulting from the primary
procedure, and anatomic differences: the facial nerve may be in a different place.
 It is very important to determine exactly what was performed in the previous pro-
cedure, and in what plane.
 Because there has been increasing emphasis on the midface and volumetric shap-
ing in recent years, these issues might not have been addressed in the patient’s ini-
tial face lift.
 Patients with poor-quality skin and/or heavy tissues should be counseled that a
staged procedure may be necessary to achieve optimal results.
 Men have a higher incidence of hematoma after surgery, probably because of the
increased vascularity of male facial skin.

Annotated Bibliography
Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Re-
constr Surg 115:2119-2122; discussion 2123, 2005.
The authors describe their technique for management of hematomas following face-lift
surgery using an emergency “hematoma kit” at the bedside with monitoring while the pa-
tient is under sedation with analgesia. Contraindications are also discussed, such as de-
layed diagnosis, bilateral hematoma, and airway compromise. With close perioperative
monitoring and early diagnosis and treatment, costly returns to the operating room can
be minimized.
Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical
evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr
Surg 116:1973-1985; discussion 1986-1987, 2005.
This is an excellent, well-written, well-organized, comprehensive retrospective study on
the incidence of hematoma in male rhytidectomy patients. The authors have provided
an in-depth analysis of the causative factors and recommended therapeutic and pre-
ventive measures for management of this most common adverse event, including a very
practical table of commonly used medication in the perioperative period.
Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg 114:797-800, 2004.
Sequelae such as malposition of the sideburn, earlobe deformity, hypertrophic scars,
loss of tragal definition, uncorrected marionette lines, and neck contour irregularities
are often associated with secondary rhytidectomy. The author discusses some of his
methods for the prevention and correction of these problems and guidelines for laser
skin resurfacing combined with rhytidectomy.
Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year
quest. Reviewing 910 patients. Plast Reconstr Surg 113:381-387; discussion 388-390,
2004.
The authors examined the effects of various parameters (dressings, drains, fibrin glue,
and tumescent infiltration, with and without epinephrine) on the rate of hematoma in
this large consecutive retrospective study. Only the omission of epinephrine significantly
decreased the hematoma rate. An incisive critical analysis of their results by the discus-
sant suggests the restoration of normal blood pressure and other factors may be more
instrumental in achieving a low complication rate.
Matarasso A, Elkwood A, Rankin M. National plastic surgery survey: face lift techniques
and complications. Plast Reconstr Surg 106:1185-1195; discussion 1196, 2000.
Trends in the techniques used in rhytidectomy and complication rates and management
of complications among American plastic surgeons were surveyed. The conclusions
drawn were somewhat challenged by a 15% response rate, which was nonetheless statis-
tically significant. The discussant added conventional wisdom to this ambitious project.
1757
Chapter 49  Reoperative Rhytidectomy

Suggested Readings
Akers JO, Mascaro JR, Baker SM. Mycobacterium abscessus infection after facelift surgery:
a case report. J Oral Maxillofac Surg 58:572-574; discussion 574-575, 2000.
Baker JL Jr. Dermabrasion. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Tech-
niques, vol I. St Louis: Quality Medical Publishing, 2005.
Barron R, Margulis A, Icekson M. Iatrogenic parotid sialocele following rhytidectomy: di-
agnosis and treatment. Plast Reconstr Surg 108:1782-1784; discussion 1785-1786, 2001.
Broughton G II, Crosby MA, Coleman J, Rohrich RJ. Use of herbal supplements and vita-
mins in plastic surgery: a practical review. Plast Reconstr Surg 119:48e-66e, 2007.
Christian MM, Behroozan DS, Moy RL. Delayed infections following full-face CO2 laser
resurfacing and occlusive dressing use. Dermatol Surg 26:32-36, 2000.
Coleman SR. Structural fat grafting. In Nahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques, vol I. St Louis: Quality Medical Publishing, 2005.
Connell B, Semlacher R. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg
100:1513-1523, 1997.
Crerand CE, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr
Surg 118:167e-180e, 2006.
Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve
pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 111:2414-2418,
2003.
De Cordier BC, de la Torre JI, Al-Hakeem MS. Rejuvenation of the midface by elevating the
malar fat pad: review of technique, cases, and complications. Plast Reconstr Surg
110:1526-1536; discussion 1537-1540, 2002.
de la Cruz L, Berenguer B, de la Plaza R. Thromboembolism after face lift because of muta-
tion of the prothrombin gene. Plast Reconstr Surg 116:682-683, 2005.
Diagnostic and Statistical Manual of Mental Disorders, 4th ed (revised) (DSM IV-R). Wash-
ington, DC: American Psychiatric Association, 2000.
Feingold RS. Parotid salivary gland fistula following rhytidectomy. Plast Reconstr Surg
101:245, 1998.
Friel MT, Shaw RE, Trovato MJ, Owsley JQ. The measure of facelift patient satisfaction: the
Owsley facelift satisfaction survey with a long term follow-up study. Plast Reconstr Surg
March 2010 [Epub ahead of print].
Grover R, Jones BM, Waterhouse N. The prevention of hematoma following rhytidectomy: a
review of 1078 consecutive facelifts. Br J Plast Surg 54:481-486, 2001.
Guyuron B, Bokhari F, Thomas T. Secondary rhytidectomy. Plast Reconstr Surg 100:1281-
1284, 1997.
Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast
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Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin Plast Surg
28:621-638, 2001.
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Part VIII  Face Lift and Neck Lift

Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair.
Plast Reconstr Surg 102:1658-1666, 1998.
Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Re-
constr Surg 125:699-708, 2010.
Jallali N, Lamberty BG. A rare and nearly fatal complication of rhytidectomy. Plast Recon-
str Surg 114:279-280, 2004.
Kamer FM, Nguyen DB. Experience with fibrin glue in rhytidectomy. Plast Reconstr Surg
120:1045-1051; discussion 1052, 2007.
Kamer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast
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Kaufman MR, Miller TA. Autologous fat transfer for facial recontouring: is there science be-
hind the art? Plast Reconstr Surg 119:2287-2296, 2007.
Knize DM. Periauricular face lift incisions and the auricular anchor. Plast Reconstr Surg
104:1508-1520; discussion 1521-1523, 1999.
Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the develop-
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Little JW. Applications of the classic dermal fat graft in primary and secondary facial reju-
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104:259-272; discussion 273-276, 1999.
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Chapter 49  Reoperative Rhytidectomy

Rohrich RJ, Rios JL. Neck rejuvenation revisited. Plast Reconstr Surg 118:1251-1263, 2006.
Struck SK. Establishing the safety and efficacy of simultaneous facelift combined with in-
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Stuzin J, Baker TJ, Baker, TM. Discussion of Trepsat F. Volumetric face lifting. Plast Recon-
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Part VIII  Face Lift and Neck Lift

Avoiding Complications
in Facial Aesthetic Surgery

FOAD NAHAI
CHAPTER 50

1762
Part VIII  Face Lift and Neck Lift
T
he only surgeons who have no complications are those who do not operate, or
those who deny having complications. The rest of us take measures and make
every effort to minimize our complications. The overall complication rate for facial aes-
thetic surgery is reported to range from 1% to 10%; this rate is a little higher in men.
Data from the American Association for Accreditation of Ambulatory Surgery Fa-
cilities (AAAASF) reported by Keyes et al in 2008 included four deaths from face
lifts and related procedures. These deaths were caused by venous thromboembolism
(VTE) or oversedation and were associated with face lifts in combination with other
procedures. Our Paces Plastic Surgery 4-year review of 468 face lifts showed a com-
plication rate of 3.6% in patients who underwent face lifts and blepharoplasties.
However, when an additional procedure was performed, this incidence almost dou-
bled to 6.2%, and if two or more procedures were added to the face lift, the inci-
dence more than quadrupled to 14.9%.
The list of potential complications includes the following:
 Hematoma
 Hair problems
 Skin necrosis
 Scars
 Contour irregularities
 Ear deformities
 Nerve injury
 Seroma
 Infection
 Parotid fistula
 Venous thromboembolism
 Death
Hematoma is by far the most common complication, accounting for almost 70% of all
face-lift complications. Some complications are rare, some are devastating, and still oth-
ers are not true complications but rather quality or craftsmanship (“finesse”) issues.
Common complications include hematoma and temporary nerve paralysis. Devas-
tating complications include unrecognized or untreated hematomas, skin slough, per-
manent nerve injury, and VTE. Although an expanding hematoma is not uncommon,
an unrecognized or untreated hematoma is a real disaster that can lead to significant
skin necrosis or even airway compromise. Finesse issues include unfavorable results, un-

sightly scars, ear distortions, hairline distortions and hair loss, and contour irregu-
larities. Unusual complications include seroma, parotid fistula, and infection.
In terms of litigation, face lift ranks number five among aesthetic procedures, repre-
senting 9% of the total number of lawsuits filed, according to data from The Doc-
tor’s Company (Napa, CA) for 1997 to 2002.
Avoiding Hematoma
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
The incidence of hematomas with face lifts ranges from 1% to as high as 10%. Ac-
cording to data from the AAAASF, hematoma after a face lift and related procedures
managed on an outpatient basis ranked only second to hematoma after breast aug-
mentation and revision and second to abdominoplasty for hematomas managed on
an inpatient basis. The incidence in men and in patients with a history of hyperten-
sion is significantly higher.
Steps to minimize the risk of hematoma are taken before, during, and immediately
after the operation. Preoperative measures include a workup and control of blood
pressure and instructing the patient to avoid medications, dietary supplements, and
herbal remedies that may affect bleeding. There have been recent reports that some an-
tidepressants may play a role in the development of hematomas after face lifts. We
encourage our patients to take supplements of vitamin C to minimize bleeding prob-
lems. All men are questioned about prostatic symptoms, and it is essential that such
symptoms be controlled before a face-lift operation.

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Part VIII  Face Lift and Neck Lift
MEDICATIONS TO AVOID BEFORE SURGERY
Do not take vitamin E, garlic tablets, weight-loss products, aspirin, or aspirin products for
1 month before surgery, because these may promote bleeding.
If you are taking warfarin (Coumadin): Please notify us immediately; you must also contact your
physician who prescribed this drug. He or she will need to make the decision as to whether you can
be taken off this drug for surgery and will need to provide a written medical clearance.
ASPIRIN products include:
Alka-Seltzer
Anacin
Ascriptin
Bayer
BC Tablets
Bufferin
Cheracol
Cope
Coricidin
Darvon Compound
Dristan
Ecotrin
Empirin
Excedrin
Fiorinal
Midol
Percodan
Sine-Aid
Sine-Off
Soma Compound
Stendin
Triaminicin
Vanquish
IBUPROFEN medications include:
Advil
Alleve
Medipren
Motrin
Nuprin
Rufen
ANTIARTHRITIC medications include:
Anaprox
Ansaid
Butazolidin
Clinoril
Daypro
Dolobid
Feldene
Indocin
Naprosyn
Orudis
Relafen
Tolectin
Voltarin
DIETARY SUPPLEMENTS include:
Echinacea
Ephedra
Garlic tablets
Ginko biloba
Ginseng
Kava
St. John’s wort
Valerian
Vitamin E
Please take only acetaminophen (Tylenol) for pain before your surgery.
We encourage you to take 2000 to 3000 mg of vitamin C every day before your surgery and during the
recovery to alleviate bruising and swelling resulting from the surgery.

Intraoperative measures include close cooperation between the anesthesiologist and
the surgeon. When these two work as a team, the incidence of hematoma can be sig-
nificantly reduced. Rigorous control of blood pressure during the procedure is im-
portant. The actual blood pressure, whether high or normal, is not as important as
avoiding fluctuations in blood pressure. A report by Jones and colleagues suggested
that postoperative hematoma might be related to the rebound effect through the use
of vasoconstrictors; they recommended that vasoconstrictors be avoided. However,
I still inject vasoconstrictors and rely on meticulous hemostasis. Appropriate fluid
management during the procedure is also important. We routinely place a Foley
catheter for procedures taking 4 hours or longer so that the patient will not have a full
bladder in the recovery room.
The routine use of clonidine (a long-acting alpha-2-adrenergic blocker with central
and peripheral effects) has been advocated perioperatively to control the systolic
blood pressure. Most if not all of my patients undergo face lifts under general anes-
thesia, and I do not initiate clonidine therapy before the operation. All male patients
are routinely treated with oral clonidine in the recovery room, and if need be, with
parenteral antihypotensive agents until the clonidine becomes effective. Women are
given clonidine on an individual basis.
I think the immediate postoperative period is the most critical for avoiding hematoma.
In my experience most hematomas occur in the recovery room or within the first
12 to 18 hours postoperatively. Although delayed (up to 3 weeks) hematomas have
been reported, these are most likely caused by bleeding from the superficial tempo-
ral or other relatively large vessels. Close monitoring and observation in the recov-
ery room and during the first 12 hours postoperatively is the key to minimizing
hematoma.
Patients are monitored for pain, anxiety and agitation, blood pressure elevation, rest-
lessness, nausea and vomiting, and a full bladder. Aggressive control and treatment
of each of these will significantly reduce the incidence of hematoma. Therefore, in
all our male patients, in addition to clonidine, we administer postoperative sedation
and antianxiety medication. Selectively in female patients, we do the same. I have
found that by working with the same anesthesia team, the same operating room
team, and the same recovery room team, the incidence of hematoma in my personal
practice has been significantly reduced. When I was in practice at a university med-
ical center, I did not always work with the same team in the operating room, nor did
the same team always take care of my patients in the recovery room. During that
time, the incidence of hematoma in my patients was 6%; over the past years that
I have been in private practice, always working with the same team, the incidence has
been lowered to 1% to 2%. This parallels the experience reported by Baker et al in
private practice, after they instituted the guidelines that we have since adopted.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery

Sequential or repeated hematomas may indicate an underlying deficiency in the blood-
clotting system. Even a bilateral hematoma may point to blood-clotting problems.
We routinely review the patient’s platelet count and solicit a history of bleeding ten-
dencies, hematoma, or prolonged bleeding associated with previous dental or surgi-
cal procedures. In patients with unusual bleeding during the procedure or those with
sequential or bilateral hematoma, administration of desmopressin acetate (DDAVP)
has proved effective. The recommended dose is 0.3 g/kg given intravenously over a
10-minute period.
Management of Hematoma
Expeditious and appropriate management of hematoma will minimize its conse-
quences. Immediate decompression of an expanding hematoma in the recovery room
or at the bedside can often defuse the situation. Patients with expanding hematomas
are agitated, apprehensive, fearful, and in pain. Cutting the sutures and inserting a
gloved finger or sterile instrument will deliver the clots, relieving some of the ten-
sion, pain, and anxiety. Baker and colleagues advocate not only drainage but also
complete management of face-lift hematomas at the bedside. I prefer to take the pa-
tient back to the operating room for exploration and control of the hematoma rather
than trying to deal with it in the recovery room or at the bedside. Once the hematoma
has been decompressed, there is time to call a team if needed and prepare an oper-
ating room. In the operating room, with the patient under general anesthesia (if ap-
propriate), or otherwise under sedation and local anesthesia with full monitoring,
enough sutures are removed to allow access. If need be, all of the sutures are removed.
I resist the temptation to trivialize the hematoma and to minimize my treatment of
it. Once the wound has been adequately opened, all of the clots are evacuated. A di-
1766
Part VIII  Face Lift and Neck Lift
BP ELEVATION
NAUSEA
ANXIETY
PAIN
FREE OF HEMATOMA!
Free of . . .
Free of . . .
Free of . . .
Free of . . .

lute 10% solution of hydrogen peroxide is useful in breaking up the clots. The wound
is thoroughly explored, and sometimes no actual source of bleeding is identified. If
a source of bleeding is identified, it is suture-ligated or cauterized as needed. The
open wound is then observed for any further evidence of bleeding and then closed
over a suction drain.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
This patient, whose primary face lift was performed elsewhere, developed a small
localized hematoma in her right cheek. This was initially observed and was aspirated
at a later date. It has left her with a contour irregularity.
I have emphasized that an undrained, expanding hematoma can lead to disastrous
skin slough or even airway compromise. Even a small undrained hematoma will lead
to problems such as contour irregularities, prolonged ecchymosis, prolonged swelling,
seroma, and scarring. I prefer to open and drain all postoperative hematomas, re-
gardless of size, to minimize these sequelae.
In the final analysis, it is unlikely that hematomas can be totally eliminated. How-
ever, experienced surgeons, anesthesiologists, and operating room and recovery room
nurses can reduce the incidence of hematoma to 1% by focusing on details.
Management of Hematoma
 Remove sutures
 Evacuate all clots
 Irrigate with dilute peroxide to break up clots
 Close over drains

Avoiding Skin Slough
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Part VIII  Face Lift and Neck Lift
Skin slough most commonly results from tension on the skin rather than direct vas-
cular compromise. The two most common causes of tension are tight closures and
expanding hematomas. Factors leading to underlying circulatory problems that can
increase the risk of hematoma include smoking, acne scarring, and diabetes. Unusual
and devastating infections may also lead to skin necrosis.
Skin sloughs are minimized through measures taken before, during, and after the op-
eration. High-risk patients, including smokers and those with acne scars, are iden-
tified preoperatively. Smokers are advised to stop smoking 3 or 4 weeks before and af-
ter surgery. However, it is impossible without a urine test to establish that patients
have followed directions, because they all claim to have done so; I do not routinely ask
for a urine test to confirm that the patient has ceased smoking. These high-risk pa-
tients are also started on systemic and local antioxidants, such as oral and topical
vitamin C. The surgical approach to these patients is modified. Skin incisions, planes
of dissection, and the extent of skin undermining are significantly altered in high-
risk patients. Whenever possible, skin incisions are minimized and modified to avoid
long retroauricular flaps. Skin undermining is limited and deeper planes of dissec-
tion, such as subperiosteal, subgaleal, and sub-SMAS, are preferred. I have found the
short-scar face lift, which limits retroauricular incisions or undermining, is a good
option in smokers. In some smokers I recommend a two-stage procedure to achieve
an excellent result. I explain to all of them that given the restraints on the degree or
extent of undermining, they should not expect an outstanding result. Concomitant
skin resurfacing is restricted to the areas that have not been undermined or is post-
poned for a later time. Heavy or tight dressings are avoided, and the tissues are kept
moist through the judicious use of petrolatum-based ointments. Postoperatively, a
strict no-smoking policy is strongly emphasized.

Treatment of Skin Slough
The early treatment of skin ischemia or a pending slough is reduction of tension by
removing the sutures. If necessary, Nitrol nitroglycerin cream is applied to the com-
promised flap. In the rare patient in whom infection is the cause of sloughing, the
infection is aggressively treated. Hyperbaric oxygen has been advocated for the treat-
ment of face-lift flap compromise and necrosis. This may well be an option, espe-
cially in a patient who smokes. Long-term treatment of skin slough requires patience
from the surgeon and the patient. The surgeon must show a great deal of under-
standing and must frequently reassure the patient that eventually all of the wounds
will heal. It is best to allow open wounds to heal secondarily and to deal with the
consequences once the wound is healed. Late treatment of skin slough includes com-
pression, topical agents, steroid injection, and eventually scar revision or even sec-
ondary procedures.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
This patient had a full-thickness skin loss after a staphylococcal infection. She was
treated conservatively, and the area was kept moist. It had almost completely closed
through contraction and spontaneous reepithelialization by 6 weeks. The resultant
scar matured sufficiently so that no scar revision was necessary.
Nerve Injuries
Motor branches of the facial nerve and sensory nerves, mostly branches of the trigem-
inal nerve, are at risk during face lifts. Rare and unusual injuries to the accessory
nerve have been reported.

1770
Part VIII  Face Lift and Neck Lift
Zygomaticofacial nerve
Zygomaticotemporal nerve
Mental nerve
Supraorbital nerve
Supratrochlear nerve
Infraorbital nerve
Auriculotemporal nerve
Infratrochlear nerve
Sensory nerve injuries in facial aesthetic surgery are uncommon and are rarely of se-
rious consequence. The great auricular nerve is at risk during standard face-lift pro-
cedures; the supraorbital, supratrochlear, and zygomaticotemporal nerves are at risk
during brow lifts; the infraorbital nerve is at risk during subperiosteal midface lifts
and during the placement of cheek implants; the zygomaticofacial nerve is at risk
during subperiosteal midface procedures; and the mental nerve is at risk during chin
augmentation.
The great auricular nerve is most at risk during face and neck lifts. It emerges around
the posterior border of the sternocleidomastoid muscle at McKinney’s point, 6.5 cm
below the external auditory meatus, and courses almost directly upward to the ear-
Great auricular nerve
McKinney’s point
Spinal
accessory
nerve
6.5 cm
External
jugular vein
Sensory Nerves
Great auricular nerve
McKinney’s point
Spinal
accessory
nerve
External
jugular vein