The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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VIII Surgical Rejuvenation of the Face and Neck
and sideburn distortions, and scar visibility. One should recognize
these changes so that an appropriate and eff ective treatment plan
can be formulated.
Factors to Consider in Secondary Facial
Rejuvenation
• Skin: quality, texture, rhytids, and relaxation
• Soft tissues: fat atrophy and descent; depth of nasolabial,
labiomental, and nasojugal creasing; jowling
• Skeleton and dentition: loss of supportive framework and
volume
• Facial aesthetic subunits:
̑ Periorbital region: brow ptosis, eyelid laxity, dermatocha-
lasis, and fat herniation
̑ Midface: malar fl attening
̑ Perioral region: buccal fat pad pseudoherniation, increased
upper lip length, decreased lip volume, downturning oral
commissures
̑ Jawline: loss of mandibular volume, chin atrophy and ptosis
̑ Earlobe: ptosis and defl ation
• Neck structures:
̑ Skin laxity
̑ Supraplatysmal and/or subplatysmal fat hypertrophy
̑ Platysmal banding and laxity
̑ Digastric muscle prominence and/or divergence
̑ SMG hypertrophy and ptosis
• Stigmata of previous rhytidectomy: facial asymmetry, visi-
bility and quality of scars, hairline shifts or alopecia, earlobe
malposition or deformities, poor tragal defi nition, lateral
sweep or poor direction of rhytids
54.4.1 3erWinenW AnDWRmiF 'i̵ erenFeV in
Reoperative Rhytidectomy
Skin and Scars
During the interval between primary and secondary rhytid-
ectomies, the patient’s skin continues to age and thin. There is
ongoing loss of dermal collagen, which causes increased skin
laxity and decreased ability to maintain support with tension.
The degree to which tissues lose support depends on anatomic
area. The preauricular area maintains a high degree of support,
evidenced by the lack of excess skin in this area removed in sec-
ondary rhytidectomy. Preauricular scars, however, can become
more noticeable with a small degree of migration.
The previously elevated skin fl ap functions as a ´delayed fl ap,µ
which provides better blood supply to the skin. It is less likely to
have cutaneous perfusion issues unless the patient is a smoker. In
such cases, it is important for patients to quit smoking for at least
4 weeks before surgery and for 4 weeks postoperatively. Although
skin perfusion is of less concern in a secondary rhytidectomy,
the previous elevation causes scar tissue to form. As a result, it
has lost some of its elasticity, so care must be taken not to place
too much tension on the skin closure. Importantly, one must be
cautious to ensure adequate perfusion to the area of skin between
the previous scar and the new.
Patients’ scars from previous procedures are important con-
siderations when planning reoperative surgery, including the
character of the scars. :hile unusual, scars may have developed
into hypertrophic or keloid scars. Scar malposition is much more
common. Postauricular scars often migrate away from the sulcus
and may have been placed too low and in visible locations during
the initial surgery. Scars may be improved with a secondary
procedure, but the patients must be made aware that they may
recur or even worsen. The locations of the scars may limit the
surgeon’s ability to place the secondary procedure scars within
inconspicuous locations. Sometimes there simply is not enough
skin to move the scars into a more hidden position. One must not
make the error of initially incising into the most favorable scar
location only to fi nd later when redraping the skin that one does
not have enough skin to cover the gap (Fig. 54.8).
Hairline
A prior temporal incision may have diminished or eliminated a
patient’s sideburns. If the distance between the lateral canthus
and the anterior portion of the patient’s sideburn is long, an ante-
rior hairline incision should be considered to prevent loss of the
patient’s sideburn. This incision is usually inconspicuous and much
less unattractive than sideburn loss. Our practice is to stay below
the sideburn whenever possible and to extend the incision as
necessary for adequate skin redraping in the lateral temporal area.
This approach is almost always required in secondary facelifting.
Subcutaneous Tissue
In secondary rhytidectomy patients, the subcutaneous tissue
under the previously undermined skin is atrophic. Additionally,
one must exercise extreme caution in secondary rhytidectomy,
as scars can obliterate tissue planes (Fig. 54.9). :e recommend
that dissection proceed with the scalpel under direct vision until
tissue planes are suffi ciently re-established.
Previous SMAS Elevation
It is important to determine from the patient’s records whether
the SMAS was elevated in the previous rhytidectomy. If not, a
secondary procedure provides a good opportunity to improve
the midface with tension on underlying structures. If the SMAS
has been previously elevated, the scar tissue between the SMAS
and underlying parotid fascia is much more diffi cult to separate.
Often, there is signifi cant variability in SMAS quality in secondary
cases. Our general approach for treating the SMAS secondarily is
to preserve as much of the tissue as possible through plication
maneuvers rather than re-elevation or resection. However, one
should assess the SMAS’s mobility to determine whether plica-
tion alone will accomplish the desired improvement.
Facial Nerve Risk with Re-elevation of SMAS
:hen the SMAS has been elevated previously, the facial nerve
is at a greater risk during dissection. In this scenario, it may be
safer and easier to plicate the SMAS in the areas that produce the
desired eff ect.
The patient in Fig. 54.10, for example, developed a marginal
mandibular neuropraxia following primary rhytidectomy with

54 Reoperative Rhytidectomy
825
Fig. 54.7 (a,b,c) This 66-year-old woman had considerable loss of skin elasticity, with very loose cervical tissues and a rounded face. This type of
patient is a candidate for 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 probability in advance to avoid dissatisfaction and unrealistic expectations. She fi rst
underwent an extended superfi cial musculoaponeurotic system rhytidectomy. The patient developed a postoperative neck hematoma. Although
the hematoma was drained, she developed a fi brous mass in the central aspect of her neck that failed steroid injection therapy. (d) She subsequently
underwent direct mass excision 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 liposuction of the jowls and was pleased with the early results. However, she
subsequently began to develop early descent of the malar fat pad, prominent nasolabial and labiomental folds, and early signs of neck laxity. (e,f)
Six months after her secondary rhytidectomy (18 months after the primary procedure), the patient was again pleased with the results; the recurrent
jowling and tissue laxity had been improved signifi cantly. Critical appraisal of our traditional method of treating the heavy neck here demonstrates
a near “cobra-shaped” deformity due to persistent divergent digastric muscles and without treatment of prominent ptotic submandibular glands
(SMGs). (g,h) Our approach to patients with heavy necks has since evolved. (i,j) One-year results obtained in the patient shown in g and h. (k) We
routinely assess contribution of deep neck structures to the heavy neck, including supra- and subplatysmal fat hypertrophy, divergence with or
without prominence of anterior bellies of digastric muscles, and enlargement and ptosis of SMGs. Deep cervicoplasty with treatment of each of
the aforementioned contributing structures is undertaken. (l) A hemostatic net is then utilized to redistribute the skin in desired vector, close all
potential deadspaces, and prevent hematoma formation.
i
j

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VIII Surgical Rejuvenation of the Face and Neck
SMAS elevation. Once recovered 3 years later, she returned to
address early recurrent neck laxity and prominent facial folds. Due
to her prior nerve injury, we preferred to stay away from where
the marginal mandibular and cervical branches of the facial nerve
were most prone to injury. Therefore, a plication of the lateral
border of the platysma was preferred over deep neck dissection.
Use of Primary Facelift Suture Material
One recently described, novel technique for secondary facelift-
ing incorporates previously placed permanent suture from a
patient’s primary facelift. It was found in a series of secondary
facelifts that an anchoring suture to Lore’s fascia had descended
since these patients’ primary facelifts were performed, account-
ing for recurrent neck skin laxity. Re-elevation of the suture
successfully restored facial rejuvenation without resorting to a
more aggressive submental dissection.
54.4.2 Persistent Buccal Fat
Pseudoherniation
Following elevation of midface tissues with SMAS flap, plication,
or resection in a primary facelift procedure, buccal fat pads
may become visible and prominent, whereas before, they were
masked and seemingly continuous with descended superficial
cheek fat compartments. Clinically, the patient may present
with a marble-sized mass in the cheek, lateral to the nasolabial
folds, that is adipose in consistency. A distinguishing feature is
that with upward pressure, the fat pad can be reduced into the
buccal space, with slow recurrence as digital pressure is removed.
Pseudoherniation of the buccal fat pad is due to the weakening of
the overlying fascia. Buccal lipoplasty can be performed in isola-
tion or in conjunction with secondary facelift by conservatively
removing the buccal tail with or without the main body to achieve
midface contouring. Care is taken to be mindful of the anatomy of
the buccal fat pad and the traversing parotid duct and facial nerve
and vein. The buccal fat pad can be approached intraorally (Fig.
54.11) or from the facelift through an anterior SMAS incision.
54.4.3 Inadequate Correction
of Hypertrophic or
Ptotic Deep Neck Structures
A common complaint following primary rhytidectomy, with
or without a neck lift, is residual fullness in the submental
and suprahyoid neck region. The neck volume is in a large part
accounted for by structures deep to the platysma, including the
subplatysmal fat and the SMGs, which respectively contribute,
on average, 30.7 and 24.5 to the neck ´fatµ volume (Fig. 54.7k).
As such, while some contouring of the neck can be achieved with
supraplatysmal fat removal (directly or through liposuction),
platysmaplasty, and neck skin redraping, neck fullness can still
persist due to hypertrophic deep neck structures (Fig. 54.12).
Large pockets of subplatysmal fat can present and herniate cen-
trally through the decussation between separated anterior bellies
of the digastric muscles. :hile closed methods of liposuction of
subplatysmal fat have been safely and successfully described, we
prefer direct fat excision through a submental incision, which
allows for adequate visualization of the excess fat below the pla-
tysma and an opportunity to address additional concerns.
:ith age, the SMGs can also undergo hypertrophy and/or
ptosis, resulting in blunting of the mandibular angle laterally and
loss of superior definition of the sternocleidomastoid muscles. In
patients with significant supra- or subplatysmal adipose excess,
this fullness can be masked, whereas in thinner patients, enlarged
and hanging SMGs can be distinctly visualized through the skin.
:hile some surgeons propose correction of ptotic glands with a
hammock-like suspension, we feel that relying on weakened and
lax connective tissues for repositioning alone is insufficient and
cause for revisional surgery. Partial resection of SMG is advocated
in cases where the gland lies beyond the mandibular border,
typically inferolaterally. The SMG can be approached safely from
medially through a submental incision or alternatively from
laterally through the rhytidectomy incision. An intracapsular
dissection and excision will minimize risk of injury to the facial
vessels and marginal mandibular nerve, which lie posterolateral
to the gland in the extracapsular space. Adequate cauterization
Fig. 54.8 The surgeon should try to place the final scar in an ideal
location; however, the surgeon should also not commit to the final
location until after the skin flap has been re-elevated and the amount
of excess skin determined. In many cases, there may be much less skin
to excise.
Fig. 54.9 The surgeon can be faced with an inability to dissect distinct
layers, combined with atrophic subcutaneous tissue, as in this patient,
who had undergone three previous rhytidectomy procedures.

54 Reoperative Rhytidectomy
827
of the raw gland surface and capsular closure minimizes any
postoperative hematoma and/or sialoma collection. Prophylactic
use of intraglandular botulinum toxin injection intraoperatively
may be considered but is not typical in our practice.
54.4.4 Failure of Skin Redistribution
and Contouring
In the event of hematoma or fluid collection, loss of skin contact
to underlying tissues and induration can compromise rhytid-
ectomy results. Even in the absence of such complications the
desired facial and neck contour can often be achieved intraoper-
atively, but the results may seem semipermanent and be lost as
the patient progresses through the stages of edema and healing.
A relatively novel concept, introduced by Andrp Auersvald as
the “hemostatic net,” is the use of transcutaneous temporary
sutures in all areas of skin undermining in the face and neck
following facelift and/or necklift. The sutures traverse from the
skin to the underlying SMAS and/or platysma, minimizing dead
space and eliminating any potential space for fluid or hematoma
to collect. More important, the net helps redistribute skin and
hold the redraped position and contour as early tissue healing and
adhesion take place, leading to long-term stability of results. This
technique is particularly useful in challenging cases of significant
lower neck laxity and redundancy by allowing the skin to be
advanced superiorly and contoured to define the cervicomental
angle and mandibular border. By removing the sutures in 48
hours, undesirable scarring is avoided.
54.5 Surgical Options for
Reoperative Rhytidectomy
Determining which procedure is best for a patient depends on
multiple variables. A good understanding of the patient’s goals
will help narrow options. Once this is done, determining what
techniques the previous surgeon used will help establish limita-
tions and potential reoperative risks.
Secondary Facelift Options
• Facial shaping and volume restoration with autologous fat
injection
• Facial lipocontouring with liposuction
• Threads/suspension suture technique
• Endoscopic approach to the midface
• Tuck-up procedure/mini-facelift
• SMAS procedures (complete, extended, or plication)
• “Closed” facelift with skin redistribution and hemostatic net
technique
• Isolated neck lift
• Ancillary procedures for periorbital (brow lift, blepharoplasty)
and/or perioral rejuvenation (lip augmentation, lip lift, DAO
weakening)
Fig. 54.11 (a,b,c) Intraoral excision of pseudoherniating buccal fat pads.
Fig. 54.10 (a–d) This patient developed a marginal mandibular
neuropraxia following primary rhytidectomy with superficial muscu-
loaponeurotic system (SMAS) elevation. Once recovered 3 years later,
she returned to address early recurrent neck laxity and prominent
facial folds. Due to her prior nerve injury, we preferred to stay away
from where the marginal mandibular and cervical branches of the facial
nerve are most prone to injury. Therefore, a plication of the lateral
border of the platysma was preferred over deep neck dissection.
a
c
b
d
a
b
c

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VIII Surgical Rejuvenation of the Face and Neck
54.5.1 Author’s Preferred Approach to
Secondary Rhytidectomy
The senior author has developed a simplified approach to the
primary and reoperative facelift using a rotation-advancement
SMAS plication approach with the ´Deltaµ technique. The neck
is carefully assessed, and an algorithmic approach is utilized to
address superficial and/or deep structures as needed.
Delta Facelift
Intraoperative markings before the plication can be seen. The
junction of the fixed and mobile SMAS has been demonstrated as
it transitions to the platysma more caudally. In this case, a platys-
mal window has been created prior to platysmal transection. A
triangular configuration, or ´Delta,µ design of the SMAS has been
marked with methylene blue, with a horizontal limb spanning
just anterior to the tragus, along the zygomatic arch, and ending
at the malar adipose mound. The hypotenuse of this triangle
follows the fixed–mobile SMAS junction caudally to 4 to 5 cm
below the mandibular angle, so as to minimize risk for injury to
the marginal mandibular branch of the facial nerve. The vertical
limb is marked, thus completing the Delta markings. At the
superomedial apex of the Delta, the malar fat pad is first secured
to the underlying periosteum and in turn to the overlying SMAS
using a figure-of-eight 2–0 polyglycolic acid (Vicryl; Ethicon,
Somerville, 1-) suture soaked in povidone–iodine (Betadine,
Avrio Health, Stamford, CT). Improvement in malar projection is
achieved immediately.
Suturing continues in this manner to plicate the hypotenuse of
the Delta toward the horizontal limb until tension becomes appar-
ent, at which point attention is redirected toward the platysma.
Neck Lift
The neck is carefully assessed for tissue hypertrophy, ptosis, and
laxity. The tissues are approached algorithmically depending
on the plane relative to the platysma. Supraplatysmal fat excess
and skin laxity can typically be corrected without a submental
incision. Conversely, correction of tissues deep to the platysma,
including the subplatysmal fat, SMGs, and anterior bellies of
the digastric muscles, may necessitate an ´openµ neck approach
through a submental incision.
Supraplatysmal Fat Liposuction
Supraplatysmal fat excess can be palpated and isolated by asking
the patient to contract the platysmal muscles. Cases of mild to
moderate fat excess isolated to the supraplatysmal space can
be treated with liposuction and/or direct fat excision from the
rhytidectomy incision. Care must be taken to avoid completely
denuding the subcutaneous layer and to maintain at least a
5-mm skin flap thickness to avoid irregularities and skeletoniza-
tion of the neck. Addition of subdermal energy through either
ultrasound-assisted liposuction or bipolar RF thermal energy,
can be utilized to achieve additional skin tightening and remod-
eling effects.
Fig. 54.12 (a) This patient, with significant sun damage and aging
changes in skin quality and facial morphology, presented for overall
facial rejuvenation. She underwent a facelift with autologous fat
transfer for volume restoration, delta superficial musculoaponeurotic
system (SMAS) plication, complete platysmal transection, and lateral
platysmaplasty. To achieve comprehensive facial rejuvenation, adjunc-
tive procedures, including bilateral upper and lower blepharoplasty
with ptosis correction, open rhinoplasty, bilateral earlobe reduction,
and erbium laser skin resurfacing, were also performed. (b) At 9
months postoperatively, she had insufficient correction of her neck
with ptotic deep neck structures including bilateral submandibular
glands as well as poor skin redraping in the cervicomental angle. (c)
One year following her initial surgery, she underwent revision necklift
through a submental approach with deep cervicoplasty, including
supraplatysmal and subplatysmal fat resection, bilateral excision of
ptotic submandibular glands, tangential debulking and plication of
hypertrophic and divergent anterior bellies of digastric muscles, hyoid
suspension, and medial platysmaplasty. No additional skin was excised;
rather, a hemostatic net was used to ensure proper redraping of the
skin against the defined cervicomental angle during the immediate
postoperative period and removed 48 hours later. At the same time,
she was also treated with a gliding brow lift and hemostatic net for
elevation of lateral eyebrows and second treatment of erbium laser
skin resurfacing. Results of the secondary procedure are shown 3
months postoperatively.

54 Reoperative Rhytidectomy
829
Platysmal Transection and Lateral Platysmaplasty
:e routinely treat the platysma through complete transection
and lateral platysmaplasty. A platysmal window is created by
scissor dissection. Insertion of a blunt instrument³in this case,
a electrocautery. The medial and lateral cut edges of the platysma
are secured with figure-of-eight 2–0 Vicryl sutures to the
sternocleidomastoid fascia and to Lore’s fascia, respectively.
The Delta plication is then completed with 2–0 Vicryl sutures
before smoothening the plication with a running, looped 4–0
barbed (4uill; Surgical Specialties, :estwood, MA) suture, pro-
ceeding from inferolaterally to superomedially. In cases of large
platysmal midline decussation and banding, additional midline
platysmaplasty is performed using a dual row of running 2–0
Vicryl sutures through a submental incision.
:ith aging, the anterior platysmal fibers undergo medial and
downward migration, whereas the posterior fibers are relatively
unchanged. Lateral traction on the anterior fibers therefore
restores the muscle to a more natural configuration. In isolation,
lateral platysmaplasty has been shown to cause greater adjust-
ment of the platysma and results in greater cranial pressure and
ptosis correction of nearby subplatysmal structures such as the
SMG or digastric muscle compared with the medial platysma-
plasty. Recurrence of platysmal banding is a common problem
that can be attributed to residual muscle fibers or reapproxima-
tion of previously transected fibers. Complete division of the pla-
tysma as well as suture repositioning of the muscular cut edge has
been shown to limit band recurrence. In our described technique,
further measures against recurrence are taken by repositioning
of platysmal fibers laterally, thereby intentionally eschewing the
anatomy to prevent muscle fiber reattachments as suggested by
Pelle-Cervaolo. Additional plication of the superior cut platysmal
edge to itself also prevents readhesion of the ´healingµ edges of
the muscle.
Subplatysmal Fat Excision
Adipose excess below the platysma can herniate through
platysmal decussation and obliterate the cervicomental angle.
Some authors have described debulking of the subplatysmal
fat with liposuction techniques. Our preference, however, is to
perform excision of the fat compartments below the platysma
under direct visualization and control. The medial edges of the
platysma are visualized along the decussation and carefully
elevated. The subplatysmal fat is then carefully excised with
monopolar electrocautery, taking care to debulk the central
prominence as well as the smaller lateral extensions below the
muscle. From this approach, additional deep cervicoplasty can
be performed as necessary to treat the SMGs, anterior bellies of
digastric muscles, and hyoid.
Partial Resection of Submandibular Glands
In cases of isolated SMG hypertrophy and ptosis, partial resec-
tion of excess gland protruding below the angle of the mandible
is performed effectively and safely through a lateral approach
from rhytidectomy incisions. After the platysma has been
divided, the SMG is visualized and bluntly dissected away from
surrounding tissues. The capsule is then opened with monopolar
electrocautery, and excess gland is trimmed. The raw surface of
the resected gland is cauterized, and the capsule is closed for
hemostasis and to minimize sialoma formation. The marginal
mandibular nerve and facial vessels lie posterolateral to the
SMG in the extracapsular space and are protected during this
approach. The lateral approach to the SMG avoids the need for
submental incision and extensive neck dissection and overcomes
the limited visibility, gland retraction, and instrument maneu-
verability often encountered with the submental approach.
Additional elevation of the SMG is achieved with plication of the
platysma with a barbed suture that is carried superiorly along
the SMAS delta plication.
In cases where a submental incision is utilized for approach
to other deep structures of the neck, the SMGs are dissected and
resected from the traditional medial approach. Given that the
inferolateral edge of the SMG is the portion that is most commonly
involved in protrusion below the mandibular border, excess gland
excision may still be visualized from the lateral approach and
further excision may be indicated.
Tangential Excision or Plication of Anterior Bellies
of Digastric Muscles with Hyoid Suspension
Hypertrophy and laxity of the anterior bellies of the digastric
muscles can contribute to submental fullness that is best visual-
ized in flexed lateral (Connell’s) view. Typically muscular bulging
is present in the posterior extent of the anterior bellies, which
can be corrected with tangential excision and debulking with
monopolar electrocautery as required. Diastasis of the anterior
bellies can then be corrected by plication of the medial edges of
the muscles together using 3–0 polydioxanone suture (PDS) to
create a more refined submental contour. :e anchor the first of
the plication sutures to the deep cervical fascia over the hyoid,
which helps further to define the cervicomental angle sharply.
The most caudal suture of a medial corset platysmaplasty can
additionally be anchored to this point for augmentation of an
acute neck profile.
Hemostatic Net
If there is significant skin laxity, a notable amount of subplatys-
mal fat has been excised, or deep cervicoplasty with treatment
of submandibular glands and/or anterior bellies of the digastric
has been performed, a hemostatic net is utilized to eliminate
deadspace, redistribute the skin, and contour the cervicomental
angle. Running 4–0 nylon transcutaneous sutures are placed
from the skin to the underlying platysma and SMAS only, where
skin undermining has been performed. The sutures are removed
at 48 hours.
54.5.2 Ancillary Treatment of Facial
Aesthetic Subunits
Periorbital Rejuvenation
The eyes are two of the most expressive subunits of the face,
second only to the mouth. The ongoing movements of the peri-
orbital mimetic muscles result in visible rhytids, particularly
in the forehead, glabella, and lateral periocular region, that can

830
VIII Surgical Rejuvenation of the Face and Neck
become permanently deep and static over time. Targeted muscle
denervation in these regions with neurotoxin is an excellent
method of prevention and can be used to smooth the appearance
of deep rhytids. It is an integral component of ´upkeepµ of results
and ongoing rejuvenation following primary rhytidectomy.
Deeper rhytids can be improved with skin resurfacing, judicious
use of HA fillers, or use of microfat or emulsified fat transfers. In
patients not willing to undergo repeat neurotoxin treatment for
glabellar rhytids, selective myotomy of the procerus, corrugator
supercilii, and depressor supercilii muscles can be performed
either through a transblepharoplasty approach or concurrently
with an endoscopic brow lift.
The orbit undergoes predictable volumetric changes with
aging, including infraorbital rim retrusion and expansion of the
superomedial and inferolateral rims. These changes in morphol-
ogy increase orbital volume and contribute to brow descent and
hooding, deepening of sulci, fat pad prominence, enophthalmos or
ptosis, and deepening of the nasojugal groove. Selective soft tissue
volume augmentation in the medial suborbital space, tear trough
and nasojugal grooves, and lateral brows can restore a youthful
appearance to the eye.
It is important to maintain a volume-preserving approach to
the eyelids as well. Laxity of skin and investing septum and fascia
over deep fat compartments can result in tissue malposition. In
upper blepharoplasty, the skin is excised and a thin strip of orbi-
cularis oculi muscle is removed to enable access to the underlying
septum and fat compartments. The septum is opened minimally
over the fat compartments as required, and conservative trim-
ming of only fat that herniates beyond the septum is performed.
Levator plication and/or advancement may be indicated to
correct a high-riding crease and senile attenuation of the levator
aponeurosis. Numerous approaches to the lower eyelid have been
described. Our preference in the older patient seeking a secondary
facelift is to use a transconjunctival approach to address fat hyper-
trophy or excess combined with skin pinch excision for treatment
of dermatochalasis. Mild skin laxity and crepey skin of the eyelids
may be addressed with ablative skin resurfacing including care-
ful chemical peel or laser (with or without coagulative thermal
tightening) in lieu of skin resection. In the lower eyelid, blending
of the lid–cheek junction and correction of deep tear troughs and
nasojugal grooves is paramount. Careful placement of fat grafts
along the infraorbital rim periosteum can correct hollowing in
this region. Additionally, nanofat grafts can be placed subdermally
along the lower eyelid to help blend the lid–cheek junction and
improve skin quality including dark circles and dyschromias.
Laxity of the lower eyelid can result in functional problems
as well as aesthetic concerns, including increased scleral show,
rounding out of the lower lateral eyelid, and apparent descent
of the lateral canthus. Cases of mild lower lid laxity can be suc-
cessfully treated with canthopexy, whereas moderate to severe
lid laxity may necessitate more reconstructive options, including
canthoplasty or tarsal strip procedure. In all cases, consideration
should be given to a ´Frostµ temporary tarsorrhaphy suture to
help support the lower eyelid during the initial phases of edema
and healing.
In most female patients, descent and brow malposition is
confined to the lateral tail of the brow. In mild cases, the lateral
brow descent can be corrected with autologous fat transfer to
restore support where underlying volume has been lost. Attention
should also be paid to the temples, which are specifically subject
to soft tissue loss as part of the aging process. Temporal hollowing
can markedly contribute to the aged periorbital appearance.
Moderate cases of lateral brow descent are best treated with
elevation through a temporal hairline incision with subfascial and
subcutaneous dissection and fascial suspending sutures. Lateral
brow elevation can also be achieved minimally invasively with the
gliding brow lift procedure, which utilizes blunt subcutaneous
dissection to just below the eyebrow and temporary transcuta-
neous sutures placed while superolateral tension is applied to
the skin (Fig. 54.13). In patients who also exhibit central brow
depression, an endoscopic brow lift is recommended for harmo-
nious brow elevation. The opposite can be done for patients who
show excessive central brow elevation or a ´surprisedµ look (Fig.
54.14). Direct brow lift is considered in selected cases, including
men with prominent eyebrows and receding hairlines.
Perioral Rejuvenation
Facial aging results from a complex interplay of volume loss and
tissue migration. Gravity is a major and constant external cause
of tissue descent. Internally, shear and tensile forces exerted by
the movement of mimetic muscles also contribute to laxity of
connective fibers, radial expansion of the soft tissues, and herni-
ation of fat compartments. The latter is perhaps most evident in
the perioral region: :ith aging, the malar fat pad and overlying
skin slides over the SMAS until it reaches the adherent nasolabial
crease, resulting in a prominent nasolabial fold. Similarly, descent
and juxtaposition of lower cheek fat compartments against
mandibular cutaneous ligaments result in marionette lines and
Fig. 54.13 (a) This 73-year old patient presented for facial rejuvenation
and underwent a secondary facelift with periocular rejuvenation with
autologous fat transfer, erbium laser skin resurfacing, and bilateral
temporal brow lift. (b) At 1 year postoperatively, she had improved
skin texture and fullness around the eyes, but the lateral tails of the
brows were not adequately elevated. (c) She underwent revisional
surgery with a gliding brow lift and hemostatic net as well as a second
treatment with laser resurfacing. (d) She is shown at 3 months postop-
eratively with satisfactory elevation of the lateral eyebrows and further
improvement of the skin quality around the eyes.

54 Reoperative Rhytidectomy
831
jowling. Perioral movement by the zygomaticus and risorius
muscles augment clotheslining of the malar fat pad against the
nasolabial crease, whereas that of the lateral platysma and DAO
accentuate marionette lines. Techniques aimed at weakening
mimetic muscles can be used as adjuncts for facial rejuvenation
and treatment of deep creases of the central face. Targeted
chemical denervation of the lateral platysma and DAO can be
used for prophylaxis against, and treatment of, mild to moderate
marionette lines and downturning of the oral commissures.
Additionally, conservative volume restoration just inferior to the
oral commissures with HA fillers or autologous fat transfer can
help support the commissure in a more neutral position. More
severe cases can be treated by selective surgical myotomy of the
muscles through external or mucosal approaches (Fig. 54.15).
The lip undergoes predictable changes in volume and structure
with aging. The white lip undergoes soft tissue volume loss as well
as loss of bony and possibly dental support, resulting in elonga-
tion of the upper lip and blunting of the Cupid’s bow. The red lip
itself also undergoes volume loss, resulting in overall decreased
vermilion show, fullness, and projection. Repetitive movement of
the orbicularis oris muscle results in formation of deep rhytids
around the lips, which are accentuated by activities that involve
pursing of the lips, such as smoking. All features of the aging lip
must be recognized and appropriately addressed to achieve a nat-
ural and youthful restored appearance. Lip volume can be restored
nonsurgically with the judicious use of HA fillers or surgically
with autologous fat injection. Care is taken to attain appropriate
ratio of upper to lower lip fullness (1:1.6 in Caucasian women).
A common mistake demonstrated by injectors is to attempt to
increase vertical red lip height with fillers alone, which results
in proportional anterior projection and the unnatural ´duck lipµ
appearance. In order to correct attenuation of the white lip with
aging, either subnasal lip lift or direct vermilion advancement
can be used. The subnasal lip lift is typically preferred due to
inconspicuous placement of the scar, preservation of the native
vermilion, and predictable improvement of the red–white lip
ratio (Fig. 54.16). Direct vermilion advancement may result in
a noticeable white scar in a prominent area of the face and is
typically reserved for partial elevation of the lateral lip, which can
become less visible with aging.
Deep perioral rhytids can be a prominent feature of aging and
environmental exposure. They can be treated with conservative
use of HA fillers (with lower G), taking care to avoid overfull in the
white roll, which can impart a simian appearance. Alternatively,
ablative skin treatments with or without the use of emulsified
intradermal fat grafts can be used to promote skin remodeling.
Earlobe Rejuvenation
The ear undergoes volumetric and morphologic changes
with aging that are most pronounced in the lobular segment.
Gravitational pull, augmented by weight of earrings, results in
elongation of the free caudal segment of the earlobe. Additionally,
the earlobe undergoes volume atrophy, which creates rhytids and
deep creases. During a secondary rhytidectomy, an elongated
earlobe can be easily corrected with inferior tangential excision
of the lobe along the caudal border to decrease the overall height.
A slight dog-ear deformity may result in the superolateral aspect
of the excision and will settle with time. Attempts to chase the
dog-ear can result in extension of the scar unnecessarily along
the helical border. In cases of a cleft deformity from piercing and
heavy jewelry, either tangential excision of the piercing, alone
or extended as a wedge resection to the inferior lobule border,
can be used to restore native ear anatomy. The ear can then be
repierced 6 weeks later away from the scar. Volume restoration
of the earlobe can be achieved with either the use of HA fillers or
autologous fat grafting with predictable results.
Fig. 54.14 (a) This 60-year-old woman had undergone endoscopic brow lift, mini-facelift, and lower lid blepharoplasty 4 years earlier. She was
displeased with her eyebrows’ appearance 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. (b,c) The patient was very pleased with the
improvement of the eyebrow shape; the medial portion of the brow had been moved more caudally, correcting her static “surprised” appearance.

832
VIII Surgical Rejuvenation of the Face and Neck
54.5.3 Preventing and Correcting the
“Overoperated” Look
Know When to Say No
If a surgeon has performed multiple facial aesthetic procedures
on a patient who is now requesting improvements that will
inevitably produce an unnatural, overoperated look, the surgeon
must exercise discretion and decline to proceed. The surgeon
must thoroughly explain why further surgical intervention
could cause an unnatural and uncorrectable appearance, lest
the patient seek ill-advised surgical correction elsewhere, which
inevitably leads to further patient dissatisfaction and could also
damage the reputation of the surgeon and the practice.
The Lateral Sweep
The term lateral sweep describes the unnatural appearance
of the cheeks after facial 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 rhytides establish an
obvious overoperated look.
The lateral sweep results from 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 midface, the central portion of the face,
is farthest from the skin anchoring and therefore has the least skin
tension.
:ith facial aging, skin descends as its tension diminishes. 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 a crisp jawline, and cervical laxity
with development of an obtuse cervicomental angle. However, in
a patient who has undergone facial rejuvenation surgery, tissues
descend at differing rates, because the skin and deeper tissues are
under different tensions postoperatively. As the postoperative face
ages, the midfacial areas under least tension begin to relax earlier,
whereas the inferolateral tissues retain their tensions longer, and
the lateral sweep becomes evident.
The culprit maneuver is skin elevation with a vector that is
too superior, rather than a more oblique, superolateral vector
(Fig. 54.17). Appropriate skin redraping during rhytidectomy is,
therefore, key. The surgeon can additionally minimize the risk of
a lateral sweep via deeper tissue manipulation using the SMAS
and by resuspending the midfacial tissue under appropriate ten-
sion. However, this tissue’s fixation point is less durable than the
skin’s and therefore ages earlier still. The composite rhytidectomy
described by Hamra involves repositioning the orbicularis oculi
muscle to attempt to strengthen midfacial support and minimize
periorbital bunching.
Tragal Distortion
Tragal distortion can be caused by excessive tragal skin tension
when the incision is brought behind the tragus to disguise the
scar. Preventing this finding entails placement of key sutures that
will hold the majority of skin tension at the superior extent of the
incision, at the root of the helix of the ear and the highest point
of the postauricular sulcus. After placement of these tension
sutures, excess skin can be excised judiciously near the tragus
to facilitate a tension-free closure (Fig. 54.18). An anteriorly dis-
placed tragus can be corrected by incision of the cartilage at the
base during reoperative rhytidectomy and temporary anchoring
of the tragus to the concha posteriorly using 5–0 nylon mattress
suture during the acute healing phase.
Fig. 54.16 This 61-year-old patient underwent perioral rejuvenation at
same time as facelifting with autologous fat injection in the nasolabial
folds and geniomandibular grooves, improvement of skin texture
and deep perioral rhytids with croton oil peel (two treatments), and a
subnasal lip lift to correct upper lip lengthening. (a) Preoperative view.
(b) View 20 months postoperative.
Fig. 54.15 (a,c) This patient presented at age 60 desiring facial rejuve-
nation for an irregular jawline contour and jowling. She first underwent
a short-scar facelift with fat grafting. Fifteen months postoperatively,
she desired additional correction of marionette lines at the oral
commissural region, and subsequently underwent depressor anguli
oris (DAO) division and fat grafting to the geniomandibular groove
(GMG). (b,d) After staged interventions, the lower third of the face
now appears more tapered and with a much softer look.

54 Reoperative Rhytidectomy
833
Hairline Distortion
Secondary rhytidectomy can cause hairline distortion, especially
at the sideburn level. If the previous rhytidectomy incision
extended into the temporal hair, then chances are that the
patient’s sideburn length has shortened. To mitigate the problem,
it is prudent to extend the incision just below the sideburn and
then cephalad anteriorly. The surgeon should bevel the incision
at a 30 to 45ƒ angle to the external skin surface to enable hair
growth through and anterior to the scar. The resulting scar can
be inconspicuous with less risk of hairline distortion (Fig. 54.19).
Pixie Ear and Earlobe Scar Migration
Secondary rhytidectomy presents an opportunity to correct
earlobe scar migration, which may occur after primary rhytid-
ectomy. Once the incision has healed and scar has maximally
matured, the scar malposition can be corrected in office under
local anesthesia. The scar tissue anterior and posterior to the
earlobe is deepithelialized; the skin is then rotated posteriorly
to secure the dermis to the conchal cartilage to provide added
support and recreate the natural aesthetic of the earlobe-cheek
junction (Fig. 54.20).
One can prevent pixie ear deformity by redistributing skin
tension appropriately with key 3–0 nylon sutures at the superior
extent of the pre- and postauricular incisions. Once the surgeon
places key sutures and removes tension from all portions of the
ear itself, one can excise skin judiciously. Always leave a little
more skin at the earlobe than you think is optimal with a trans-
verse cut, as opposed to a V-shaped skin removal that just delivers
the earlobe above the skin flap. To further reduce the potential of
developing a pixie ear, one can de-epithelialize excess skin at the
auricular base and suture it to the conchal base (Fig. 54.21). This
maneuver, espoused by Dan Baker, is especially helpful during
a short-scar facelift, where the postauricular incision stops just
posterior to the earlobe. :ith the short-scar approach, there is
no posterosuperior key suture to redistribute skin tension. The
described maneuver thus acts to minimize skin tension at the
earlobe inset base.
Obvious Scars
Visible scars betray a primary rhytidectomy but are amenable to
correction during revision surgery (Fig. 54.22). If the posterior
horizontal incision is placed low, the scar is quite obvious and
hinders the patient’s ability to hide it when his or her hair is cut
short or pulled back. One may be able to reposition these scars
higher if the incisions were placed low initially, or if tissue laxity
recurred and moved the incision lower. The surgeon should
not commit to the final scar location before having re-elevated
the entire skin flap and become cognizant of the posterior skin
excess. :ith this incision design, well-healed scars will be very
difficult to visualize.
Another rare complication of rhytidectomy is hypertrophic
or keloid scar formation. Surgeons should routinely ask patients
about prior posttraumatic or surgical scars to assess for a tendency
to form poor scars. Despite being counseled on the risks of obvious
scar formation, patients who have such a history may nonetheless
elect to proceed. :e have also encountered patients without a
poor scarring history who nonetheless later develop periauricular
hypertrophic scarring following rhytidectomy. Persistent or wors-
ening cases of keloid scarring may require formal scar revision
combined with steroid injection and/or radiation therapy. Tension
on the closure is the likely etiology and must be avoided.
Recognizing Body Dysmorphic Disorder
:hen discussing any reoperative aesthetic surgery, one must
recognize patients with body dysmorphic disorder (BDD). There
are three diagnostic criteria:
Fig. 54.18 (a,b) Removal of excess directly pretragal fascial tissue
to recreate a natural depression. The closure is secured using deep
dermal 4–0 polydioxanone suture.
Fig. 54.17 (a,b) This patient presented after undergoing rhytidectomy
elsewhere with telltale lateral sweep and excess skin tension. (c,d)
Upon animation, she had misdirected prominent horizontal rhytids.
a
b

834
VIII Surgical Rejuvenation of the Face and Neck
1. Preoccupation with an imagined or slight defect in appearance
2. Marked distress or impairment in social, occupational, or
other areas of functioning resulting from preoccupation with
appearance
3. Absence of another psychiatric disorder to which the preoccupa-
tion may be attributed
Patients with BDD may visit the plastic surgeon for correction
of their perceived deformities. The surgeon must recognize signs
of this disorder and refer patients with BDD to appropriate mental
health specialists. Patients with this disorder who have undergone
corrective surgery have high rates of dissatisfaction with their
results and have even turned violent. (See elsewhere in this book
for more detailed discussions of patient selection issues involving
this disorder.)
54.6 Management of Complications
from Primary Rhytidectomy
Facelifts, like any other aesthetic procedures, present risks for
early complications as shown.
Early Complications of Rhytidectomy
• Hematoma
• Infection
• Skin slough
• Nerve injury (sensory and motor)
• Dysphagia
• Emotional issues
54.6.1 Hematoma
Hematoma following facelift is a significant source of morbidity.
Various authors report the incidence among all patients to range
from 1 to 12.9. Risk factors associated with hematoma follow-
ing rhytidectomy include hypertension (especially if poorly con-
trolled preoperatively), male sex, bleeding disorders, and the use
of medications that interfere with coagulation. The incidence of
hematoma among patients undergoing facial rejuvenation with
local anesthesia and sedation alone may be slightly lower than
for those who are administered general anesthesia. However,
with either group, pre- and perioperative blood pressure control
is paramount in reducing the risk of postoperative hematoma.
If the patient’s blood pressure remains greater than a systolic
of 180 mm Hg or diastolic of 90 mm Hg after initial sedation,
we do not proceed until blood pressure has been normalized.
Persistent hypertension is an indication for referral and workup
by the patient’s primary physician or cardiologist. Clonidine is
an effective agent for preoperative control of blood pressure
at doses of 0.1 to 0.2 mg orally the morning of surgery. :e ask
our anesthetists to avoid spikes in blood pressure as the patient
emerges from general anesthesia, because this is a precarious
time for hematoma development.
Use of fibrin glue has also shown some benefits for rhytid-
ectomy. :hile sealant glue does not decrease the incidence of
hematomas, it does decrease drainage and ecchymosis. Drains do
not prevent hematoma but are nonetheless useful as a mechanism
for monitoring the amount of bleeding. Use of a hemostatic net
to eliminate dead space in regions that have been undermined
can help to prevent collections of fluids, including hematomas.
Head elevation, cool compresses, pain and nausea control, and
continued sedation are all useful for maintaining an acceptable
blood pressure.
Fig. 54.19 (a,c,e) This 47-year-old woman complained of continued
facial aging and prominent scars following an initial facelift at age 36
and a short-scar facelift at age 41. The presideburn scars were visible,
as was descent of the malar fat pad and minor jowling. We performed
a tertiary facelift that included an extended superficial musculoapo-
neurotic system technique to anchor the malar fat pad to the malar
periosteum. (b,d,f) Her results are seen at 1 year.
a
c
e
b
d
f

54 Reoperative Rhytidectomy
835
Men have a higher incidence of intraoperative bleeding than
women during rhytidectomy and more frequently develop
postoperative hematomas (between 4.0 and 12.9 of cases). This
phenomenon is probably attributable to the presence in men’s
faces of more sebaceous glands and hair follicles, each of which
is surrounded by a more extensive capillary network. As a result,
the vascularity of male skin is greater, in turn leading to greater
potential for blood vessel disruption. 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.
Hematomas developing after rhytidectomy can be generalized
into two categories: (1) small collections that are drainable at the
Fig. 54.21 (a) This 50-year-old patient developed a pixie ear deformity on the right side 2.5 months following a primary short-scar rhytidectomy.
(b) The pixie ear deformity was corrected with wide undermining of the skin anteriorly, inferiorly, and posteriorly to mobilize the skin adequately.
The dermis of the inferior skin apex was advanced superiorly and secured to the conchal fascia. The skin was then closed in a V-to-Y fashion. (c) The
patient is shown following the repair with correction of the deformity and a better-defined lobule.
Fig. 54.20 (a) Earlobe scar migration can also be a problem following primary rhytidectomy. Although the patient’s hair or makeup can hide most
scars, the earlobe scar can be very upsetting. After the scar has matured, one can easily treat this abnormality in the office under local anesthesia. (b)
The surgeon can deepithelialize scar tissue and suture it to the caudal portion of the conchal cartilage to provide added support. (c) Rotating the skin
posteriorly recreates the natural aesthetic of the earlobe-cheek junction.

836
VIII Surgical Rejuvenation of the Face and Neck
bedside without returning the patient to the operating room and
(2) large ones in which the cheek and/or neck must be reopened
and explored to control the bleeding source.
The key to successful hematoma management is early detection.
:hen detected early, it is more likely that the hematoma can be
managed without a return to the operating room. Bedside man-
agement is accomplished by removing sufficient sutures or staples
to be able to express clots and fresh blood manually. Preparation
for bedside evacuation should include oral pain medication or
sedation if the patient is overly anxious. Blood pressure must be
controlled. Chlorpromazine and nitroglycerin ointment are useful
agents for decreasing blood pressure by vasodilation. Towels are
spread beneath the patient’s head, and the area prepared with a
solution such as povidone–iodine (Betadine) solution. A suction tip or red Robinson catheter is helpful for evacuating all
the clots; the surgeon can then assess ongoing bleeding. The area
is irrigated with copious saline solution until the ȩuent runs
clear. 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 circumferential dressing applied.
If the hematoma is large and seems to involve both cheeks and the
neck, a return to the operating room is indicated (Fig. 54.23). Other
factors that should influence the surgeon toward a return to the
operating room are the following:
• An uncooperative patient
• An overly anxious patient
• A large, delayed hematoma
• Labile blood pressure
• Bilateral hematomas
• A compromised airway
If the patient is experiencing dyspnea, immediate suture
removal and decompression are essential. Since intubation and
airway control in the presence of a large hematoma can be exceed-
ingly difficult, we prefer to achieve initial situational control with
the patient under local anesthesia with minimal sedation. Often
very little premedication is required, because tissues are fre-
quently still numb from the initial procedure, and anxiolytic and
pain medications may already have been given. The surgeon must
attempt to locate the primary source of fresh bleeding and pack
that area while evacuating the remaining field. :ith large hema-
tomas, we usually remove most sutures to ensure that all bleeding
sources have been controlled. The worst scenario is to assume
that one has controlled the bleeding source only to find that the
hematoma has recurred after the patient has left the operating
room. Profuse irrigation with saline and dilute hydrogen peroxide
will usually reveal the bleeding source. Of course, the surgeon
can feel most confident about hemostasis when a single culprit
´pumperµ has been identified. :hen multiple bleeding vessels are
encountered, we prefer to keep the patient in the operating room
under observation until we are certain no further bleeding is
going to occur. Drains should always be replaced and their proper
functioning confirmed. Elimination of dead space with the use of
temporary transcutaneous sutures, as described earlier, is a useful
adjunct for prevention of hematoma formation. The hemostatic
net can also be used as an adjunct for in treatment of hematomas
to prevent recurrence, especially in instances where diffuse pin-
point bleeding is encountered.
If a patient presents with the results of a prior untreated hema-
toma, as with any significant deformity due to complications, the
mainstay of treatment is not to reoperate too soon and to avoid
additional traumatic injury by manipulation or injections. Release
of scar tissue and autologous fat grafting can ameliorate the dev-
astating effects.
Fig. 54.22 Most patients prefer to have their scars hidden from view.
(a) This patient had undergone a primary facelift 10 years earlier. She
now expressed concern about continued facial aging and obvious
scars. At the time of her reoperative rhytidectomy, the anterior
incision was designed adjacent to the anterior helix and earlobe and
at the tragal margin. (b) Posteriorly, the scar was continued in the
postauricular crease and continued superiorly to allow for elevation
of the postauricular scar higher behind the ear and to restore the gap
in the hairline. A carefully designed incision can create inconspicuous
anterior and posterior scars, regardless of patient hairstyle. One can
accomplish this goal by placing anterior incisions in or near the hairline.
Other helpful targets include natural rhytides. In continuing the
incision around the posterior aspect of the ear, one should do so within
the posterior auricular crease. The incision should continue high before
extending horizontally into the posterior hairline. The secondary
procedure 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; we also performed an endoscopic brow lift.
(c,d) She is seen 4 years postoperatively. Postauricular scars are also
vulnerable to migration and visibility. Surgeons should make every
effort in either primary or secondary rhytidectomies to place scars in
least-noticeable positions.

54 Reoperative Rhytidectomy
837
54.6.2 Skin Slough
Skin slough usually occurs because of closure under excessive
WHQVLRQ %ORRG XQGHU WKH ÁDS, WLJKW GUHVVLQJV, ÁH[HG QHFN SRVL-
tioning, smoking, and diabetes are all contributing factors to skin
compromise. If one diagnoses impending tissue necrosis in the
early postoperative period by flap cyanosis or lack of capillary
refill, sutures should be removed immediately and the skin
should be allowed to retract. The open wound can be covered
with a nonadherent petrolatum gauze dressing (e.g., Xeroform;
various manufacturers) 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, once- or
twice-daily treatments for 5 days can help salvage underper-
fused skin flaps.
If skin necrosis is clearly demarcated, conservative treatment is
usually indicated. If the patient is a smoker, the surgeon should
ensure that the patient has complied with smoking cessation. These
patients require repeated reassurances, because this complication
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. :hen spontaneous separation begins to occur, any
nonviable tissue is dpbrided and wound dressing changes initiated.
Allowing the wound to heal secondarily and contract usually gives
a result that is a better color and texture match than a skin graft
would be. If possible, flap advancement and reclosure is the best
Fig. 54.23 (a,b) Preoperative views of a 59-year-old woman who underwent a facelift, endoscopic brow lift, and upper and lower blepharoplasty.
(c) Four hours postoperatively, she developed an obvious hematoma involving both cheek pockets and the neck. Exploration revealed two arterial
bleeding points in the neck, which were controlled. All regions were washed out and the skin was reclosed. (d,e) The patient was seen 4 months
postoperatively with near-complete resolution of this complication. This complication can be prevented with the application of hemostatic net over
undermined areas.

838
VIII Surgical Rejuvenation of the Face and Neck
option. However, there is usually too much tension to accomplish
this approach in the acute period (Fig. 54.24).
54.6.3 Infection
Fortunately, infection following rhytidectomy is rare, but it can
have devastating consequences. As with other complications,
prevention is key. Our patients wash their faces at least three
times with an antibacterial soap on the morning of surgery. It is
difficult to maintain a strict sterile field with facial rejuvenation
surgery because of the presence of hair and inclusion of the oral
and nasal cavities, as well as the endotracheal tube or other
airways and oxygen sources, within the field. 1evertheless,
every attempt must be made to avoid contamination, especially
when the procedure is prolonged. :e have found that soaking
braided sutures in povidone–iodine before use has decreased
small suture infections, especially in the region of the platysma
plication. In addition, before closure of the cheek dissection, we
meticulously irrigate all open areas with dilute povidone–iodine
to wash out any debris, particularly loose fat globules.
Infections may arise from undrained hematomas or seromas and
are often seen as collections in dependent portions of undermined
areas. Overlying skin erythema is usually the first sign, but there
may be little to no associated pain or fever. Drainage is paramount,
and cultures should be obtained to guide antibiotic therapy. If the
combination of drainage and antibiotic agents fails to resolve the
problem rapidly, one should consider operative exploration to rule
out an infected foreign body. External auditory meatus plugs (e.g.,
cotton or petrolatum gauze) have been known to drop into the
wound and should be accounted for in sponge and needle counts.
In severe facial infections, thorough irrigation, dpbridement of non-
viable tissue, and wide drainage are generally effective, in addition
to administration of an appropriate antimicrobial. Hospitalization
and intravenous medication are rarely required, but they may be
indicated if rapid resolution of the infection is not achieved with
aforementioned treatments (Fig. 54.25).
54.6.4 Salivary Gland Problems
Parotid Fistula
Parotid injury has become a more common event with facelift
techniques that involve dissection in the sub-SMAS plane.
Unfortunately, injury is even more likely when the SMAS has
Fig. 54.24 Although superficial skin resurfacing (to a depth of no more than 20–30 micrometers) of undermined skin can be performed safely,
deeper skin resurfacing should not be performed, as it can result in skin necrosis, especially in patients with possible skin vascular compromise. (a)
This patient had diabetes mellitus and underwent primary rhytidectomy and erbium laser resurfacing, resulting in frank necrosis of the malar skin.
(b) Skin necrosis was managed conservatively. (c) Good secondary healing in progress. (d) Scar contraction is substantial. (e) Immediately following
revisional surgery. (f) The patient exhibits excellent healing with a barely visible scar.

54 Reoperative Rhytidectomy
839
been previously elevated, as encountered in some secondary
facelifts. :ith secondary rhytidectomy, the parotid is at greater
risk of injury because of altered anatomy and scarring. The
gland is at highest risk over its superficial lobe and just at the
mandibular angle. The superficial fascia can usually be separated
from the parotid fascia, unless the plane has already been oblit-
erated surgically. However, raising both the superficial fascia
and the parotid fascia in continuity can be advantageous when
the superficial fascia is thin, because the combined fasciae add
strength for deep tissue fixation. If this approach is undertaken,
one is dissecting directly superficial to the glandular lobules of
the parotid, which can be confused with sub-SMAS fat and thus
susceptible to injury. This misidentification is how most parotid
injuries occur. The parotid duct is rarely injured but can be
obstructed if one torques the gland with suture fixation.
Management of parotid injury hinges on immediate recognition
so that the dissection plane is promptly corrected. The injured
parotid is coagulated with electrocautery or, rarely, oversewn with
fine sutures if the injury appears to involve the terminal ductules.
A drain is left in situ, and compression is applied for 48 hours.
If there is frank saliva in the drainage, the drain should remain
in place until output is minimal. Generally, as long as the duct is
unobstructed, these salivary fistulas are self-limited. Sialography
or duct endoscopy can be helpful if ductal obstruction is sus-
pected. Injuries late in the postoperative period are diagnosed by
swelling and fluid collection over the parotid that, on aspiration,
yields a high amylase titer. Generally, the patient is afebrile, and
eating often exacerbates the swelling. Mainstays of management
include insertion of a closed suction drain, placement of a pres-
sure dressing, and administration of antibiotics. Botulinum toxin,
atropine, glycopyrrolate, and scopolamine have been reported to
be helpful as antisialagogues.
Submandibular Gland Sialoma
Incidence of sialocele formation following SMG resection is
infrequent. During surgery, preventative measures to decrease
fluid collection postoperatively include cauterization of the
Fig. 54.25 (a,b) This 61-year-old patient presented for facial rejuvenation. (c,d) Four weeks after undergoing a primary rhytidectomy with Delta
superficial musculoaponeurotic system plication, fat grafting to face, endoscopic browlift, upper and lower blepharoplasties, depressor angulis oris
division, and erbium laser resurfacing, she presented with a hemifacial rash that was initially attributed to cellulitis. On further consideration and an
infectious workup, the rash was revealed to be trigeminal herpes zoster (shingles), consistent in its dermatomal nerve distribution. She went on to
heal after expectant medical management and without further sequelae. (e,f) One year later, she had persistent neck laxity and deep perioral rhytids,
which were addressed with revision necklift with medial and lateral platysmaplasty and croton oil facial chemical peel. (g,h) Final results are shown 2
years postoperatively.

840
VIII Surgical Rejuvenation of the Face and Neck
raw gland surface and closure of the capsule with one or two
suture mattresses to minimize drainage into the subcutaneous
space. Placement of a temporary subplatysmal drain for 1 week
following surgery can further help to decrease the incidence of
sialomas. If a clear fluid collection presents in the submental
space following surgery, a sialocele can be diagnosed and distin-
guished from seroma by fluid aspiration and testing for amylase.
Sialomas can be treated conservatively with needle aspiration(s)
and compression. Pharmaceutical treatment with intraglandular
injection of botulinum toxin type A is effective for decreasing
secretions and has replaced traditional treatment with scopol-
amine, which carries untoward anticholinergic side effects.
54.6.5 Nerve Injury
Any branch of the facial nerve can be injured during a facelift.
:ith altered anatomy from primary rhytidectomy, deeper dis-
section beneath the SMAS during secondary rhytidectomy risks
injury to the facial nerve. Although nerve branch transections
do occur, injury more typically results from traction or thermal
damage from nearby electrocautery use. Motor nerve dysfunc-
tion presenting immediately postoperatively is typically due to
local anesthetic, and patients should be reassured accordingly.
1erves still in continuity recover well without intervention. Most
neuropraxias recover within 2 weeks to 3 months, although this
process can take up to a year or more, and patients should be
counseled accordingly. In case of nonimproving nerve injuries,
one should consider obtaining electrodiagnostic studies at 6
weeks to 3 months postoperatively, with surgical exploration
reserved at 3 months, including neurolysis and neurorrhaphy.
:hen facial nerve injury does occur, the buccal branch is most
commonly affected. However, the frontal branch of the facial
nerve is the most commonly injured nerve with notable clinical
significance, followed by the marginal mandibular branch. :hen
frontal branch weakness is observed postoperatively and persists
beyond 1 month, and if the patient is agreeable, we favor admin-
istering botulinum toxin to weaken the unaffected side of the
face for symmetry while the injured side recovers. Commonly, by
the time the botulinum toxin effect wears off, the injured nerve
has recovered, and symmetric motor function is reestablished.
If the nerve has not recovered by 1 year postoperatively, a more
permanent solution is to perform a brow lift on the affected side,
either directly or endoscopically, as well as on the unaffected side
if indicated (Fig. 54.26).
A similar strategy can be used for the marginal mandibular
branch with weakening of the DAO on the unaffected side with
botulinum toxin (Fig. 54.27). Resection of the DAO muscle has
been described for perioral rejuvenation and could also be consid-
ered if the smile remains asymmetric beyond 1 year.
The great auricular nerve is the nerve most commonly recog-
nized as injured in up to 7 of cases. Injuries to the great auricular
nerve are typically managed conservatively, and sensation will
often return spontaneously with resolution within 12 months.
Nonetheless, we recommend that any acute nerve transection
be repaired primarily in a tension-free manner if diagnosed
intraoperatively.
54.6.6 Dysphagia
Dysphagia is attributable to platysmal tightening, which is a
dramatic change for patients accustomed to their lax necks. In
fact, we are routinely pleased to hear the patient mention neck
tightness in the first week following facelift. Diazepam is an
effective relaxant for early symptoms, and surgical intervention
is not indicated, as the muscle invariably relaxes with time.
Patients are reassured and otherwise managed expectantly.
Fig. 54.26 (a,b) This patient had undergone primary facelift and presented with a desire for further rejuvenation. She underwent secondary facelift-
ing with fat grafting and genioplasty. Additional temporal scalp incisions and temporal undermining were performed to redrape the skin better.
Bleeding was encountered along the left temporal dissection, requiring significant electrocautery use for hemostasis. (c,d) Frontal branch injury on
the left was readily apparent postoperatively, which was treated with nerve stimulation, coupled with neurotoxin treatment to the unaffected right
side for symmetry. (e) The patient went on to recover motor nerve function by 6 months postoperatively.

54 Reoperative Rhytidectomy
841
54.6.7 Emotional Issues
Recovery from a facelift can be an emotional rollercoaster for
some. Effects of anesthesia, steroids, and other medications,
combined with anxiety over their eventual appearance, can take
a serious toll on patients’ emotional well-being. Anticipatory
guidance can help prepare patients for depressive symptoms
that frequently accompany the recovery process. Having an
established relationship with a reliable and local clinical psychol-
ogist can pay great dividends if both referral and an intervention
seem necessary. For most patients, reassurance is sufficient until
swelling and associated tissue distortion have resolved. A recent
long-term patient satisfaction study demonstrated that an over-
whelming majority of our patients described their improvement
in facial appearance postrhytidectomy as ´very goodµ or ´beyond
expectations.”
54.7 Concluding Thoughts
Facial reoperative conditions vary, depending on the patient’s
concerns and altered anatomy. One may include the need to
correct complications such as hematoma and nerve injury.
Today, adjunctive procedures are becoming more prevalent and
being used to a much greater extent. One can anticipate staged
procedures in which the patient may need early intervention
or can use them to delay more definitive facelifting. Improving
the results for dissatisfied primary rhytidectomy patients can
present more challenging cases. In secondary rhytidectomy, the
surgeon may struggle to achieve results that both surgeon and
patient will accept. The most common reasons for reoperation
are persistent or recurrent stigmata of aging.
The surgeon must make an accurate preoperative diagnosis and
design an appropriate reoperative plan. One can retain patients in
the practice by advising them on maintenance strategies such as
skin care, neurotoxin therapy, dermal fillers, laser skin resurfac-
ing, and ultimately, additional surgery.
Clinical Caveats
• The surgeon must educate the patient that a facelift 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 result-
ing from the primary procedure combined with anatomic
differences. The facial nerve may be in a different place.
• It is very helpful to determine exactly what was performed in
the previous surgery and in what tissue plane.
• Because increasing emphasis on the midface and volumetric
shaping has happened more recently, these issues might not
have been addressed in the initial facelift.
• 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 postoperative hematoma than
women do, probably due to increased facial skin vascularity.
Suggested Readings
[1] Akers -O, Mascaro -R, Baker SM. Mycobacterium abscessus infection after facelift
surgery: a case report. J Oral Maxillofac Surg 2000;58(5):572–574, discussion
574–575
>2@ Ali M-, Ende ., Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast
Surg Clin North Am 2007;15(4):491–500, vii
>3@ Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe
method for preventing hematoma in 405 consecutive patients. Aesthetic Plast
Surg 2014;38(1):1–9
>4@ Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas.
Plast Reconstr Surg 2005;115(7):2119–2122, discussion 2123
>5@ Baker DC, Stefani :A, Chiu ES. Reducing the incidence of hematoma requiring
surgical evacuation following male rhytidectomy: a 30-year review of 985 cases.
Plast Reconstr Surg 2005;116(7):1973–1985, discussion 1986–1987
>6@ Baker -L -r. Dermabrasion. In: 1ahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques, Vol. I. St. Louis, MO: 4uality Medical Publishing; 2005
[7] Barron R, Margulis A, Icekson M, =eltser R, Eldad A, 1ahlieli O. Iatrogenic parotid
sialocele following rhytidectomy: diagnosis and treatment. Plast Reconstr Surg
2001;108(6):1782–1784, discussion 1785–1786
[8] Bravo FG. Reduction neck lift: Importance of the deep structures of the neck to
successful neck lift. Clin Plast Surg 2018;45(4):485–506
Fig. 54.27 (a) This patient was referred for management of marginal
mandibular nerve injury and smile asymmetry 4 years following
a primary rhytidectomy performed elsewhere. (b) She has been
managed conservatively with restoration of smile symmetry and high
patient satisfaction with routine chemical paralysis of the contralateral
lower lip depressor using botulinum toxin.

842
VIII Surgical Rejuvenation of the Face and Neck
[9] Broughton G II, Crosby MA, Coleman -, Rohrich R-. Use of herbal supple-
ments and vitamins in plastic surgery: a practical review. Plast Reconstr Surg
2007;119(3):48e–66e
>10@ Christian MM, Behroozan DS, Moy RL. Delayed infections following full-face CO2
laser resurfacing and occlusive dressing use. Dermatol Surg 2000;26(1):32–36
[11] Coleman SR. Structural fat grafting. In: 1ahai F, ed. The Art of Aesthetic Surgery:
Principles & Techniques, Vol. I. St. Louis, MO: 4uality Medical Publishing; 2005
>12@ Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast
Reconstr Surg 1997;100(6):1513–1523
>13@ Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic
surgery. Plast Reconstr Surg 2006;118(7):167e–180e Review
>14@ Daane SP, Owsley -4. Incidence of cervical branch injury with ´marginal mandib-
ular nerve pseudo-paralysisµ in patients undergoing face lift. Plast Reconstr Surg
2003;111(7):2414–2418
>15@ De Cordier BC, de la Torre -I, Al-Hakeem MS, et al. Rejuvenation of the midface by
elevating the malar fat pad: review of technique, cases, and complications. Plast
Reconstr Surg 2002;110(6):1526–1536, discussion 1537–1540
>16@ de la Cruz L, Berenguer B, de la Plaza R. Thromboembolism after face lift because
of mutation of the prothrombin gene. Plast Reconstr Surg 2005;116(2):682–683
[17] de Pina DP, 4uinta :C. Aesthetic resection of the submandibular salivary gland.
Plast Reconstr Surg 1991;88(5):779–787, discussion 788
[18] Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM 5Š). :ash-
ington, DC: American Psychiatric Association; 2013
[19] Feingold RS. Parotid salivary gland fistula following rhytidectomy. Plast Reconstr
Surg 1998;101(1):245
>20@ Fogli AL. Skin and platysma muscle anchoring. Aesthetic Plast Surg
2008;32(3):531–541
>21@ Friel MT, Shaw RE, Trovato M-, Owsley -4. The measure of face-lift patient
satisfaction: the Owsley Facelift Satisfaction Survey with a long-term follow-up
study. Plast Reconstr Surg 2010;126(1):245–257
>22@ Gassman AA, Pezeshk R, Scheuer -F III, Sieber DA, Campbell CF, Rohrich R-. Ana-
tomical and clinical implications of the deep and superficial fat compartments of
the neck. Plast Reconstr Surg 2017;140(3):405e–414e
>23@ Giampapa V, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty
for neck rejuvenation revisited: technical fine points for improving outcomes.
Aesthetic Plast Surg 2005;29(5):341–350, discussion 351–352
>24@ Grover R, -ones BM, :aterhouse 1. The prevention of haematoma follow-
ing rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg
2001;54(6):481–486
>25@ Gupta V, :inocour -, Shi H, Shack RB, Grotting -C, Higdon ... Preoperative risk
factors and complication rates in facelift: analysis of 11,300 patients. Aesthet Surg
J 2016;36(1):1–13
>26@ Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg 2004;114(3):797–800
>27@ Guyuron B, Bokhari F, Thomas T. Secondary rhytidectomy. Plast Reconstr Surg
1997;100(5):1281–1284
>28@ Guyuron B, Majzoub R.. Facial augmentation with core fat graft: a preliminary
report. Plast Reconstr Surg 2007;120(1):295–302
>29@ Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin
Plast Surg 2001;28(4):621–638
>30@ Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause
and repair. Plast Reconstr Surg 1998;102(5):1658–1666
>31@ Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity.
Plast Reconstr Surg 2010;125(2):699–708
>32@ Hodgkinson D-. The fate of Fogli’s Lore’s fascial platysma fixation optimalising
the results of Fogli’s neck lift procedure. Aesthetic Plast Surg 2018;42(4):1002–
1012
>33@ Hollmig ST, Struck S., Hantash BM. Establishing the safety and efficacy of simul-
taneous face lift and intraoperative full face and neck fractional carbon dioxide
resurfacing. Plast Reconstr Surg 2012;129(4):737e–739e
>34@ -allali 1, Lamberty BG. A rare and nearly fatal complication of rhytidectomy. Plast
Reconstr Surg 2004;114(1):279–280
>35@ -ones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a person-
al 8-year quest. Reviewing 910 patients. Plast Reconstr Surg 2004;113(1):381–
387, discussion 388–390
>36@ .amer FM, 1guyen DB. Experience with fibrin glue in rhytidectomy. Plast Recon-
str Surg 2007;120(4):1045–1051, discussion 1052
>37@ .amer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch
Facial Plast Surg 2000;2(4):240–242
>38@ .aoutzanis C, :inocour -, Gupta V, et al. Incidence and risk factors for major
hematomas in aesthetic surgery: analysis of 129,007 patients. Aesthet Surg J
2017;37(10):1175–1185
>39@ .aufman MR, Miller TA, Huang C, et al. Autologous fat transfer for facial recon-
touring: is there science behind the art" Plast Reconstr Surg 2007;119(7):2287–
2296 Erratum in Plast Reconstr Surg 2010;125(2):759
>40@ .nize DM. Periauricular face lift incisions and the auricular anchor. Plast Reconstr
Surg 1999;104(5):1508–1520, discussion 1521–1523
>41@ Labbp D, Guerreschi P. Cervical lift: an update >in French@. Ann Chir Plast Esthet
2017;62(5):461–473
>42@ Lambros V, Stuzin -M. The cross-cheek depression: surgical cause and effect
in the development of the ´joker lineµ and its treatment. Plast Reconstr Surg
2008;122(5):1543–1552
>43@ Lapid O, .reiger <, Sagi A. Transdermal scopolamine use for post-rhytidectomy
sialocele. Aesthetic Plast Surg 2004;28(1):24–28
>44@ Larson -D, Tierney :S, Ozturk C1, =ins -E. Defining the fat compartments in the
neck: a cadaver study. Aesthet Surg J 2014;34(4):499–506
>45@ Lawson GA III, .reymerman P, 1ahai F. An unusual complication following rhyt-
idectomy: iatrogenic parotid injury resulting in parotid fistula/sialocele. Aesthet
Surg J 2012;32(7):814–821 Erratum in: Aesthet Surg J 2012;32(8):1040
>46@ Le Louarn C, Buis -, Buthiau D. Treatment of depressor anguli oris weakening
with the face recurve concept. Aesthet Surg J 2006;26(5):603–611
>47@ Little -:. Applications of the classic dermal fat graft in primary and secondary
facial rejuvenation. Plast Reconstr Surg 2002;109(2):788–804
>48@ Little -:. Hiding the posterior scar in rhytidectomy: the omega incision. Plast
Reconstr Surg 1999;104(1):259–272, discussion 273–276
>49@ Marten T-. Discussion. Preauricular facelift incisions and the auricular anchor.
Plast Reconstr Surg 1999;104(5):1521–1523
>50@ Matarasso A. Managing the buccal fat pad. Aesthet Surg J 2006;26(3):330–336
>51@ Matarasso A, Elkwood A, Rankin M, Elkowitz M. 1ational plastic surgery survey:
face lift techniques and complications. Plast Reconstr Surg 2000;106(5):1185–
1195, discussion 1196
>52@ Mendelson B, :ong CH. Changes in the facial skeleton with aging: impli-
cations and clinical applications in facial rejuvenation. Aesthetic Plast Surg
2012;36(4):753–760
>53@ Mendelson BC, Tutino R. Submandibular gland reduction in aesthetic surgery of
the neck: Review of 112 consecutive cases. Plast Reconstr Surg 2015;136(3):463–
471
>54@ Mowlavi A, Majzoub R., Cooney DS, :ilhelmi B-, Guyuron B. Follicular anatomy
of the anterior temporal hairline and implications for rhytidectomy. Plast Recon-
str Surg 2007;119(6):1891–1895, discussion 1896
>55@ Mowlavi A, Meldrum DG, :ilhelmi B-, Russell RC, =ook EG. The ´pixieµ ear defor-
mity following face lift surgery revisited. Plast Reconstr Surg 2005;115(4):1165–
1171
>56@ Moyer -S, Baker SR. Complications of rhytidectomy. Facial Plast Surg Clin North
Am 2005;13(3):469–478 Review
>57@ Mulholland RS. Radio frequency energy for non-invasive and minimally invasive
skin tightening. Clin Plast Surg 2011;38(3):437–448, vi
>58@ 1iamtu - III. Expanding hematoma in face-lift surgery: literature review, case
presentations, and caveats. Dermatol Surg 2005;31(9 Pt 1):1134–1144
>59@ Paul MD, Calvert -:, Evans GR. The evolution of the midface lift in aesthetic
plastic surgery. Plast Reconstr Surg 2006;117(6):1809–1827
>60@ Pelle-Ceravolo M, Angelini M, Silvi E. Complete platysmal transection in neck
rejuvenation: a critical appraisal. Plast Reconstr Surg 2016;138(4):781–791
>61@ Pezeshk RA, Sieber DA, Rohrich R-. 1eck rejuvenation through the lateral
platysma window: a key component of face-lift surgery. Plast Reconstr Surg
2017;139(4):865–866
>62@ Pitanguy I. Facial cosmetic surgery: a 30-year perspective. Plast Reconstr Surg
2000;105(4):1517–1526, discussion 1527
>63@ Reinisch -F, Bresnick SD, :alker -:, Rosso RF. Deep venous thrombosis and
pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast
Reconstr Surg 2001;107(6):1570–1575, discussion 1576–1577
>64@ Rohrich R-, Ghavami A, Lemmon -A, Brown SA. The individualized component
face lift: developing a systematic approach to facial rejuvenation. Plast Reconstr
Surg 2009;123(3):1050–1063
>65@ Rohrich R-, Mahedia M, Shah 1, Afrooz P, Vishvanath L, Gupta R.. Role
of fractionated fat in blending the lid-cheek junction. Plast Reconstr Surg
2018;142(1):56–65
>66@ Rohrich R-, Pessa -E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
>67@ Rohrich R-, Rios -L, Smith PD, Gutowski .A. 1eck rejuvenation revisited. Plast
Reconstr Surg 2006;118(5):1251–1263

54 Reoperative Rhytidectomy
843
>68@ Shaw RB -r, .atzel EB, .oltz PF, et al. Aging of the facial skeleton: aesthetic impli-
cations and rejuvenation strategies. Plast Reconstr Surg 2011;127(1):374–383
>69@ Slavin B, Beer -. Facial identity and self-perception: an examination of psychoso-
cial outcomes in cosmetic surgery patients. J Drugs Dermatol 2017;16(6):617–
620
>70@ Stuzin -M. Reoperation and refinements after rhytidectomy. In: 1ahai F, ed. The
Art of Aesthetic Surgery: Principles & Techniques, vol II. St Louis: 4uality Medical
Publishing; 2005
[71] Stuzin -, Baker T-, Baker TM. Discussion. Hiding the posterior scar in rhytidecto-
my: the omega incision. Plast Reconstr Surg 1999;104(1):273–276
>72@ Stuzin -, Baker T-, Baker TM. Discussion. Volumetric facelifting. Plast Reconstr
Surg 2001;108(5):1371–1379
>73@ Sundine M-, .retsis V, Connell BF. Longevity of SMAS facial rejuvenation and
support. Plast Reconstr Surg 2010;126(1):229–237
>74@ Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H.
1anofat grafting: basic research and clinical applications. Plast Reconstr Surg
2013;132(4):1017–1026
>75@ Trepsat F. Volumetric face lifting. Plast Reconstr Surg 2001;108(5):1358–1370,
discussion 1371–1379
>76@ Viterbo F, Auersvald A. Abstract: Gliding brow lift (GBL). Plast Reconstr Surg Glob
Open 2017; 5(9, Suppl)186–187
[77] =oumalan R, Rizk SS. Hematoma rates in drainless deep-plane face-lift surgery
with and without the use of fibrin glue. Arch Facial Plast Surg 2008;10(2):103–
107

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VIII Surgical Rejuvenation of the Face and Neck
55 Avoidance and Management of Complications in Facial
Aesthetic Surgery
Foad Nahai
Abstract
Reported rates of complications following facelifts range from 1
to 10. I classify the complications as common, rare, devastating,
or craftsmanship issues. By far the most common complication
is hematoma. All classes of complications are represented, and
their avoidance and management are discussed.
Keywords
hematoma, nerve injuries, skin slough, seroma, motion distor-
tion, scars, ear deformities, hair line changes, infection, contour
irregularities, parotid fistula, sialocele, overgrafting of fat
55.1 Introduction
The 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 compli-
cations. The overall complication rate for facial aesthetic surgery
is reported to range from 1 to 10; this rate is a little higher in
men. Pitanguy’s 2012 review of close to 9,000 facelifts reported
an overall complication rate of 4.5.
Data from the American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF) reported by .eyes et al in
2008 included four deaths from facelifts and related procedures.
These deaths were caused by venous thromboembolism (VTE) or
oversedation and were associated with facelifts in combination
with other procedures. Updated AAAASF data in 2012 confirmed
the earlier numbers. Our Paces Plastic Surgery 4-year review
of 468 facelifts showed a complication rate of 3.6 in patients
who underwent facelifts and blepharoplasties. However, when
an additional procedure was performed, this incidence almost
doubled to 6.2, and if two or more procedures were added to the
facelift, the incidence more than quadrupled to 14.9.
The list of potential complications includes the following:
• Hematoma
• Hair problems
• Skin necrosis
• Scars
• Contour irregularities
• Ear deformities including the lobe and tragus
• Nerve injury
• Seroma
• Infection
• Parotid fistula
• Deep venous thrombosis/VTE
• Facial distortion
• Overfilling with fat
• Death
Hematoma is by far the most common complication, accounting
for almost 70 of all facelift complications. Some complications
are rare, some are devastating, and still others are not true com-
plications but rather quality or craftsmanship (´finesseµ) issues.
Facelift Complications
• Common
• Rare
• Devastating
• Craftsmanship “finesse” issues
Common complications include hematoma and temporary
nerve paralysis. Rare complications include infection parotid
fistula and sialocele. Devastating complications include
unrecognized or untreated hematomas, skin slough, perma-
nent nerve injury, VTE, facial distortion, and overgrafting of
fat. 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, unsightly scars,
ear distortions, hairline distortions, hair loss, and contour
irregularities. In terms of litigation, facelift ranks fifth among
aesthetic procedures, representing 9 of the total number of
lawsuits filed, according to data from The Doctor’s Company
(1apa, CA) for 1997 to 2002.
55.2 Hematoma
The incidence of hematomas with facelifts (Fig. 55.1) ranges
from 1 to as high as 10. According to data from the AAAASF,
hematoma after a facelift and related procedures managed on an
outpatient basis ranked only second to hematoma after breast
augmentation and revision and second to abdominoplasty for
hematomas managed on an inpatient basis. Pitanguy’s 2012
series reported a 3 hematoma rate, and more recent publi-
cations, reporting on CosmetAssure (Birmingham, AL) data,
included a very low rate of 0.7. The incidence in men and in
patients with a history of hypertension is significantly higher.
Steps to minimize the risk of hematoma are taken before,
during, and immediately after the operation as discussed in the
following subsections.
55.2.1 Preoperative Measures
Preoperative measures include a workup and control of blood
pressure and instructing the patient to avoid medications, dietary

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
845
supplements, and herbal remedies that may affect bleeding (Fig.
55.2). There have been recent reports that some antidepressants
may play a role in the development of hematomas after facelifts.
:e advise our patients to stop all vitamins other than C and to
stop all nutritional supplements of all kinds. :e do allow them
to continue on antidepressants. All men are questioned about
prostatic symptoms, and it is essential that such symptoms be
controlled before a facelift operation.
The lists shown in Fig. 55.2 are only a sampling of medications
to be avoided, and lists of aspirin-containing products and nonste-
roidal anti-inflammatory drugs (1SAIDs) will vary from country
to country.
55.2.2 Intraoperative Measures
Intraoperative measures to avoid hematoma include close coop-
eration between the anesthesiologist and the surgeon. :hen
these two work as a team, the incidence of hematoma can be
significantly reduced. Rigorous control of blood pressure during
the procedure is important. The actual blood pressure, whether
high or normal, is not as important as avoiding fluctuations in
blood pressure. A report by -ones 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 vasoconstric-
tors and rely on meticulous hemostasis. Appropriate fluid man-
agement during the procedure is also important. :e 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 facelifts under general anesthesia, and
I do not initiate clonidine therapy before the operation. All male
patients are routinely treated in the recovery room with oral
clonidine and, if need be, with parenteral antihypotensive agents
until the clonidine becomes effective. :omen are given clonidine
on an individual basis.
Recently there have been reports that the administration of
Tranexamic acid (TXA) systemically or locally will significantly
reduce intraoperative bleeding. Any effect on post op hematoma
is yet to be proven.
55.2.3 Immediate Postoperative
Measures
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 hematomas (up to 3 weeks)
have been reported, these are most likely caused by bleeding
from the superficial temporal or other relatively large vessels.
Close monitoring and observation in the recovery room and
during the first 12 hours postoperatively are the key to minimiz-
ing hematoma.
Patients are monitored for pain, anxiety and agitation, blood
pressure elevation, restlessness, nausea and vomiting, and a
full bladder. Aggressive control and treatment of each of these
will significantly reduce the incidence of hematoma (Fig. 55.3).
Therefore, in all our male patients, in addition to clonidine, we
administer postoperative sedation and antianxiety medication.
:e do the same selectively in female patients. 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.
:hen I was first in practice at a university medical 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 recov-
ery room. During that time, the incidence of hematoma in my
patients was 6; over my time in private practice and again in an
academic aesthetic center always working with the same team,
the incidence has been lowered to less than 1. This parallels the
experience reported by Baker et al in private practice, after they
instituted the guidelines that we have since adopted.
55.2.4 Sequential or Repeat Hematomas
Sequential or repeated hematomas may indicate an underlying
deficiency in the blood-clotting system. Even a bilateral hema-
toma may point to blood-clotting problems. :e routinely review
the patient’s platelet count and solicit a history of bleeding
tendencies, hematoma, or prolonged bleeding associated with
previous dental or surgical procedures. In patients with unusual
bleeding during the procedure or those with sequential or
bilateral hematoma, administration of desmopressin acetate
(DDAVP; Ferring Pharmaceuticals, Saint-Prex, Switzerland) has
proved effective. The recommended dose is 0.3 mcg/kg given
intravenously over a 10-minute period. More recently there has
been interest in tranexamic acid. Although it has proven to be
effective in resulting in a drier field during surgery, as yet it has
not proven to reduce hematoma rates.
55.2.5 Management of Hematoma
Expeditious and appropriate management of hematoma will
minimize its consequences. Immediate decompression of an
Fig. 55.1 Large expanding and bilateral hematoma following facelift
and laser resurfacing.

846
VIII Surgical Rejuvenation of the Face and Neck
Fig. 55.2 Medications to avoid before surgery.

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
847
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 tension, pain, and anxiety.
It is important to assure the patient that the blood pressure, anxi-
ety, and pain are all under control. Baker and colleagues advocate
not only drainage but also complete management of facelift
hematomas at the bedside. I prefer to take the patient 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 operating room. In
the operating room, with the patient under general anesthesia (if
appropriate), 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 dilute 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.
Management of Hematoma
• Control blood pressure
• Control anxiety and pain
• Remove sutures
• Evacuate all clots
• Irrigate with dilute peroxide to break up clots
• Close over drains
The patient shown in Fig. 55.4, whose primary facelift 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, regardless of size, to minimize these sequelae.
In the final analysis, it is unlikely that hematomas can be totally
eliminated. However, experienced surgeons, anesthesiologists,
and operating room and recovery room nurses can reduce the
incidence of hematoma to 1 or less by focusing on details.
55.3 Skin Slough
Skin slough most commonly results from tension on the skin
rather than direct vascular 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 skin loss include smoking, acne scarring,
and diabetes. I do routinely ask all patients interested in facial
rejuvenation whether they have had fillers and, if so, what type
Fig. 55.3 Key conditions to avoid to prevent postoperative hematoma.
Fig. 55.4 (a,b) Contour irregularity of the right cheek that developed at the site of a localized hematoma after a facelift, managed nonoperatively.
a
b

848
VIII Surgical Rejuvenation of the Face and Neck
of filler and any barbed suture lift, which may rarely aeffect the
subdermal circulation. Unusual and devastating infections may
also lead to skin necrosis (Fig. 55.5).
55.3.1 Avoiding Skin Slough
Skin sloughs are minimized through measures taken before,
during, and after the operation. High-risk patients, including
smokers and those with acne scars, are identified preoperatively.
Smokers are advised to stop smoking 3 or 4 weeks before and after
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 patients 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. :henever possible,
skin incisions are minimized and modified to avoid long retroau-
ricular flaps. Skin undermining is limited, and deeper planes of
dissection, such as subperiosteal, subgaleal, and sub-superficial
musculoaponeurotic system (SMAS), are preferred. I have found
that the short-scar facelift, 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 postponed for a later time.
Heavy or tight dressings are avoided, and the tissues are kept moist
through the judicious application of petrolatum-based ointments.
Postoperatively, a strict no-smoking policy is strongly emphasized.
55.3.2 Treatment of Skin Slough
The early treatment of skin ischemia or a pending slough is
reduction of tension by removing the sutures. If necessary,
nitroglycerin ointment (1itrol; Paladin Labs, Montreal, Canada)
is applied to the compromised 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 facelift flap compromise and necrosis. This may well be
an option, especially in a patient who smokes. Long-term treat-
ment of skin slough requires patience from the surgeon and the
patient. The surgeon must show a great deal of understanding
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 compression,
topical agents, steroid injection, and eventually scar revision or
even secondary procedures.
The patient shown in Fig. 55.6 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 epithelialization by 6
weeks. The resultant scar matured sufficiently, so no scar revision
was necessary.
55.4 Nerve Injuries
Motor branches of the facial nerve and sensory nerves, mostly
branches of the trigeminal nerve, are at risk during facelifts.
Rarely, injuries to the accessory nerve have also been reported.
55.4.1 Sensory Nerves
Sensory nerve injuries in facial aesthetic surgery are uncommon
and are rarely of serious consequence. The great auricular nerve
is at risk during standard facelift procedures; the supraorbital,
supratrochlear, and zygomaticotemporal nerves are at risk
during brow lifts; the infraorbital nerve is at risk during subperi-
osteal 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 (Fig. 55.7).
The great auricular nerve is most at risk during face- and neck
lifts. It emerges around the posterior border of the sternocleido-
mastoid muscle at Mc.inney’s point, 6.5 cm below the external
Fig. 55.5 Skin slough following facelift.
Fig. 55.6 (a) Full-thickness skin loss after a staphylococcal infection.
(b) Near-complete healing by secondary intention at 6 weeks.
a
b

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
849
auditory meatus, and courses almost directly upward to the
earlobe (Fig. 55.8). The surgeon can avoid injury to this nerve
through knowledge of its anatomy and cautious flap elevation over
the sternocleidomastoid muscle. Leaving the sternocleidomastoid
fascia intact will usually protect this nerve. It is advisable in sec-
ondary face- and neck lifts to perform this dissection under direct
vision rather than blindly, because the preexisting scar tissue may
distort the planes of dissection. Injury to the nerve will lead to
numbness of the lower two-thirds of the ear. This sensory loss is
not debilitating, but a painful neuroma of the greater auricular
nerve can be. If an injury to the nerve is recognized, the surgeon
should attempt to repair it with the aid of magnification. If this is
not possible, the proximal stump should be buried well within the
sternocleidomastoid muscle to prevent a neuroma. Painful great
auricular nerve neuromas are rare, and even more rarely these
neuromas may present as a neck mass and be mistaken for an
enlarged lymph node.
The supraorbital nerve emerges from the orbit through a notch or
a foramen, usually in the midpupillary line, and provides sensory
innervation to nearly half of the forehead and anterior scalp. The
lateral branch, which courses along the temporal crest, is respon-
sible for most of the innervation of the anterior scalp. Injury to the
supraorbital nerve during endoscopic brow lift is rare. However,
the surgeon must be aware that this nerve can emerge through
a foramen up to 2 cm above the orbital rim, so blind dissection
should be limited to a distance of 2 to 4 cm above the orbital rim,
and the orbital rim should be approached endoscopically to avoid
nerve injury. The lateral, sensory branch of the orbital nerve is
almost always divided during a transcoronal brow lift, resulting
in forehead sensory loss, paresthesias, and dysesthesias. These
Fig. 55.7 Sensory nerves at risk during facial aesthetic surgery.
Fig. 55.8 (a,b) Anatomy of the great auricular nerve.
a
b

850
VIII Surgical Rejuvenation of the Face and Neck
sensory changes, fortunately, are usually temporary but can be
permanent.
The supratrochlear nerve has multiple branches, emerges
through the orbit medially within 1 or 2 cm of the midline, and
usually courses within the corrugator muscle. It provides sensory
innervation for a narrow strip of medial forehead and brow on
each side. During an endoscopic brow lift, one or two branches of
the supratrochlear nerve may be disrupted during the corrugator
muscle excision. This is rarely of any clinical significance.
The zygomaticotemporal nerve is a very small nerve that
emerges through the temporal fascia, usually accompanying the
more lateral of the two sentinel veins. :hen viewing this nerve
during an endoscopic brow lift, I make every attempt to preserve
it, although injury to the nerve is of little consequence.
The infraorbital nerve emerges through a foramen 1 or 2 cm
below the inferior orbital rim in the midpupillary line and inner-
vates the cheek, lips, and teeth. It is rarely at risk during subcuta-
neous or sub-SMAS facelift procedures. It is at greatest risk during
subperiosteal midface dissections, whether through the mouth,
lower eyelid, or temporal area. However, injury to this nerve is
extremely rare because it is very large, easily identified with or
without an endoscope, and difficult to injure with a periosteal
elevator.
The zygomaticofacial nerve is a small nerve that emerges through
a foramen 1 to 2 cm lateral to and below the lateral canthus. It is
at risk only during subperiosteal dissection of the periorbital area.
Unlike the infraorbital nerve, the zygomaticofacial nerve is very
small and very easily divided. It is always accompanied by a small
blood vessel, and often the only indication that the nerve has
been divided is the bleeding. I make every attempt to identify and
preserve this nerve during subperiosteal midface lifts. Division
of the nerve is of little consequence in terms of sensory loss, but
irritating discomfort in the area has been attributed to division of
the nerve.
The mental nerve emerges through the mandible in the midpu-
pillary line at the level of the second premolar. This nerve is at risk
during subperiosteal dissection for placement of chin implants.
Fortunately, it is a large nerve that is easily identified and not
easily injured with a periosteal elevator. Injury to the nerve results
in debilitating sensory loss in the lips and teeth.
55.4.2 Facial Nerve
One of the most devastating and long-lasting complications after
facial rejuvenation surgery is permanent injury of a branch of the
facial nerve. Fortunately, the incidence of facial nerve paralysis
is fairly low. In a reported series of 6,500 patients, facial nerve
paralysis was seen in 0.7, with only 0.1 permanent. :ith
endoscopic brow lifts, the incidence of temporary paresis to the
frontal branch of the facial nerve has been consistently reported
at 1, with permanent injury of 0.1. My personal experience
parallels these reported series, but I have been fortunate enough,
in over 41 years, not to have permanent paralysis in any of my
patients.
The facial nerve branches most at risk include the buccal,
frontal, and marginal mandibular branches. Recently concern has
been raised about the zygomatic branches in association with
complex periorbital procedures (Fig. 55.9).
Most commonly reported injuries involve the buccal branches;
however, because these are multiple branches rather than a single
nerve, recovery is usually seen within 3 to 4 months. The frontal
branches are the next most frequently reported injured nerves,
and these are also multiple branches rather than a single nerve,
so recovery is the rule; however, recovery takes longer than after
buccal branch injury. The marginal mandibular branch is a single
nerve, and complete recovery after injury is rare. Fortunately, the
resulting asymmetry of the mouth can be improved through the
judicious administration of botulinum toxin on the opposite side.
Buccal Branches
The buccal branches are multiple, and injury to all branches is
rare. Dissection below the SMAS, beyond the parotid gland and
masseter muscle, puts these nerves at risk. Therefore, in any
facelift procedure necessitating sub-SMAS dissection beyond
the parotid gland and the masseter, the dissection should be
performed bluntly and with caution. These branches are readily
visible, and injury is easily avoided. Blind or sharp dissection
beyond the parotid gland and masseter should be avoided.
These branches all run deep to the zygomaticus major muscle,
so dissection beyond the zygomaticus major toward the nose
and nasolabial fold is safe as long as it is in a plane above the
zygomaticus major (Fig. 55.10).
Temporal and Zygomatic Branches of
the Facial Nerve
The temporal and zygomatic branches of the facial nerve are at
risk not only during forehead lifts (coronal and endoscopic) but
also with sub-SMAS facelifts, especially techniques requiring a
Fig. 55.9 Anatomy of the facial nerve.

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
851
high SMAS dissection. Classically the landmark for identifying
the course of this nerve has been a diagonal line drawn from a
point 5 mm below the tragus to a point 2 cm above the lateral
brow. However, I have found that if the sentinel vein is visible
through the skin, a point 5 mm above the vein will usually mark
the course of the vein. I then draw a diagonal line toward the
tragus and use this as the guideline. Because this nerve runs
under the temporoparietal fascia above the zygoma and very
deep to the SMAS below the zygoma, the surgeon can avoid
injury to the nerve by performing the temporal dissection of
any forehead lift well below the temporoparietal fascia. In fact,
I make a point of placing all of my instruments directly over the
deep temporal fascia, pushing on the fascia as I dissect toward
the zygoma and orbital rim. Below the zygoma, injury is avoided
by staying above the SMAS. However, if high sub-SMAS dissec-
tion is undertaken, injury to the nerve is avoided by dissecting
just below the SMAS. Recent anatomic data demonstrate that
the nerve lies much deeper and closer to the periosteum of the
zygoma rather than just below the SMAS. During a combined
temporal and facial dissection, the development and mainte-
nance of a “mesotemporalis” made up of the temporoparietal
fascia and SMAS will ensure the safety of this nerve (Fig. 55.11).
Marginal Mandibular Branch
Although the marginal mandibular branch is deep to the SMAS
and the platysma along all of its course, it is still susceptible to
injury, especially as it courses over the facial vessels at the level
of the mandibular notch. The two factors contributing to this
area of risk are (1) the thinning of the SMAS and platysma in that
area and (2) the presence of perforating branches of the facial
vessels. The thinning of the SMAS and platysma puts the nerve
at risk during blind dissection, where the scissors can easily
slip through the thin platysma and injure the nerve. The other
mechanism of injury is the use of electrocautery in an attempt
to control bleeding from the perforating vessels. As a general
rule, I prefer to use bipolar rather than the unipolar coagulat-
ing current for hemostasis during facial rejuvenation, because
there is less electrocautery current that can damage the nerve.
In thin individuals I prefer to perform the dissection along the
mandibular border under direct vision to minimize the risk of
subplatysmal penetration (Fig. 55.12).
:hen performing subplatysmal dissection of the neck, the
surgeon must keep in mind that the relationship of the marginal
mandibular branch to the inferior border of the mandible is
variable; in fact, it can run 1 to 2 cm below the mandible along
its entire course, not just proximal to the facial vessels and the
mandibular notch.
Although permanent injuries to the branches of the facial nerve
are rare, it is vital that the surgeon be familiar with the anatomy
of these branches, their relationships to the various layers of
the face, their specific danger zones, and the risk afforded each
branch by the more complex and deeper dissections. Familiarity
with specific techniques is essential to minimize risk and avoid
complications. I encourage anyone performing facial rejuvenation
Fig. 55.11 Path of the frontal (temporal and zygomatic) branches of
the facial nerve.
Fig. 55.12 (a,b) Anatomy of the marginal mandibular branch of the
facial nerve.
Fig. 55.10 (a) The buccal branches of the facial nerve course deep to the superficial musculoaponeurotic system (SMAS) beyond the parotid gland.
(b) Medial to the zygomaticus major, the nerve branches run deep to the muscle.
a
b
a
b

852
VIII Surgical Rejuvenation of the Face and Neck
to dissect the layers of the face and branches of the facial nerve in
the cadaver laboratory (Fig. 55.13).
55.4.3 Accessory Nerve
Although extremely rare, injury to the accessory nerve and a
resultant shoulder drop have been reported. The nerve is most
at risk during posterolateral dissection in the neck. The nerve
emerges behind the posterior border of the sternocleidomastoid,
almost at Mc.inney’s point or just above, coursing posteriorly
and laterally toward the trapezius (Fig. 55.14).
55.5 Deep Venous Thrombosis
Venous thromboembolism (VTE) and its consequences, deep
venous thrombosis (DVT) and pulmonary thromboembolism
(PE), are devastating, life-threatening, and fortunately uncom-
mon. The exact incidence of DVT in facial aesthetic surgery is not
known. Reinisch et al reported an incidence of 0.35 for DVT and
0.14 for PE in facelifts. A 4-year review of 468 facelifts at Paces
Plastic Surgery revealed two patients with DVT, an incidence of
0.4, with no PE. Our 0.4 compares to the 0.35 reported by the
Reinisch group. Spring and Gutowski surveyed 3,797 plastic sur-
geons in the United States, who reported 15 DVT and PE events
associated with facial cosmetic procedures. Every precaution
should be taken to minimize the risk of DVT. Factors increasing
the risk include the following:
• Age
• :eight (BMI)
• Length of procedure
• Family history
• Use of oral contraceptives
• Type of anesthesia
• Underlying risk factors such a Factor V Leiden mutation
The Caprini scale remains the standard for risk assessment for
surgical procedures.
In my practice almost all patients undergoing facial rejuve-
nation fall into the high-risk category. All of these patients are
operated on under general anesthesia; support is placed behind
their knees, and intermittent pneumatic compression garments
are used in all of them (Fig. 55.15). Stuzin et al have reported zero
incidence of DVT in over 10,000 facelifts spanning 30 years, all
of which were performed under local anesthesia with sedation.
They comment that patients operated on with intravenous seda-
tion moved during the procedure, thus reducing the tendency of
venous stasis and DVT.
Risk factors are summarized in Table 55.1.
55.6 Craftsmanship Issues
Some postoperative concerns are not true complications; I prefer
to call them issues of finesse, quality, or craftsmanship. However,
they are the issues that make all the difference in the patient’s
Fig. 55.14 Anatomy of the accessory nerve (called spinal accessory
nerve here). The nerve is at greatest risk as it emerges behind the
posterior border of the sternocleidomastoid muscle.
Fig. 55.13 Facial danger zones where motor and sensory nerves are at
greatest risk during aesthetic facial surgery.
Fig. 55.15 (a) Standard pneumatic pressure garments extending from
knee to ankle. (b) PlexiPulse intermittent pneumatic compression
devices (Kinetic Concepts, Inc., San Antonio, T;) placed on feet.
a
b

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
853
perception of the quality of the result. In this category I include
the following:
• Scar placement and scar quality
• Ear distortion
• Hair loss and hairline distortion
• Contour irregularities
55.6.1 Scar Placement and Scar Quality
I regularly talk to patients to explain where the incisions and
scars will be. Occasionally the patient looks back at me and
comments, ´:ell, there won’t be any scars, will there" This is
plastic surgery, after all.µ I reply that all incisions leave scars and
that the best I can offer them is to place the scars where they will
be imperceptible or at least less noticeable, and that I will make
every effort to ensure the quality of the scars, although this will
depend as much on the location, the tension, and the patient’s
biology as it will on surgical technique.
The key to avoiding undesirable scars is to manage tension
appropriately. Special attention is required in those who are prone
to hypertrophic scarring, especially redheaded individuals with a
ruddy complexion and patients who are keloid prone.
The man shown in Fig. 55.16 underwent a minimal-access
cranial suspension (MACS) lift elsewhere and has hypertrophic
scars in front of and behind his ear, most likely related to tension.
Note that the horizontal scar below his sideburn has healed well.
Table 55.1 Venous thromboembolism risk factors for plastic surgeons to consider
Solid, consistent evidence that these are the most important risk factors*
• Prior history of VTE (DVT or PE)
• Malignancy (active or in patient history)
• Thrombophilia disorders (inherited or acquired)
• Factor V Leiden mutation (makes factor V resistant to activated protein C)
• Prothrombin 20210A mutation (found exclusively in whites)
• Antithrombin deficiency
• Protein S and protein C deficiency
• High levels of fibrinogen or plasminogen, factor VIII, factor I;, factor ;I, thrombin activatable fibrinolysis inhibitor (TAFI), or protein C inhibitor
• Low levels of tissue factor pathway inhibitor (TFPI)
• Hyperhomocysteinemia (plasma homocysteine level ! 18.5 mmol/L)
• Dysfibrinogenemia and polycythemia vera
• Antiphospholipid antibodies (lupus anticoagulant and anticardiolipin)
• Obesity (risk may be highest for those < 40 years of age)
• Use of oral contraceptives, tamoxifen, hormone replacement therapy, or other estrogen-containing drugs
Known to be risk factors but probably not in the top tier; do not disregard as unimportant
• Age ≥ 40 years (risk rises as age rises)
• General anesthesia (risk rises with each hour in surgery, regardless of procedure)
• Varicose veins
• Inflammatory disease (inflammatory bowel disease, rheumatologic diseases, especially systemic lupus erythematosus)
• Abdominal surgery (carries higher risk than most other types of surgery)
• Pregnancy, abortion, or miscarriage within 3 months
• Smoking
• Recent hip or knee replacement or hip fracture
• Recent surgery of any kind
• Prolonged travel by air, train, or car
• Recent physical trauma
*Important risk factors that are rarely encountered in plastic surgery practices include prolonged immobilization, ischemic stroke, heart failure, chronic lung disease,
respiratory failure, serious infection, pneumonia, central venous catheterization, paralysis, and spinal cord injury. Some risk factors are permanent (such as a history of VTE or
cancer, chronic disease, thrombophilia, age) and some are transient (such as surgery, travel, estrogen use, pregnancy).
Fig. 55.16 Hypertrophic preauricular scar following minimal-access
cranial suspension (MACS) lift.

854
VIII Surgical Rejuvenation of the Face and Neck
Incisions are planned so that they will be inconspicuous and
allow appropriate distribution of tension. Meticulous closure
under minimal tension and aggressive early management of scar
problems are important. Incisions in the hair are made parallel
to the hair roots; the use of cautery is judicious and limited to
preserve hair roots. Closure must avoid excessive tension, which
damages the hair roots. Incisions along the hairline are also made
in the direction of the hair roots to preserve and encourage hair
growth through the resulting scar.
The preauricular incision should never be a straight line. It
should be broken up above and below the tragus. I prefer the
intratragal incision whenever possible. This incision is made in
such a way that the tragus has a beginning and an end. Far too
often this is not done, and the tragus blends into the lower face,
with a telltale sign of a face lift. The incision behind the ear is
placed either within the sulcus or 1 to 2 mm on the posterior
surface of the ear. My preference is to make it on the ear rather
than within the sulcus (Fig. 55.17).
The woman shown in Fig. 55.18 underwent a facelift by a non-
surgeon who left her with a hypertrophic straight-line scar in front
of her ear and little in the way of facial rejuvenation. I saw her in
consultation and performed a secondary facelift with appropriate
placement of the incisions. Seven years later, the tragus appeared
natural and there was no hypertrophic scarring or distortion.
Distribution of tension during the closure defines the quality
of the resultant scar. Tension should usually be placed at the level
of the concha, behind the earlobe, and behind the ear, never in
the preauricular or tragal area or the earlobe. Once the skin
tension has been appropriately distributed, the excess skin along
the preauricular area and behind the ear is excised and closed in
two layers under no tension. Usually this closure will not require
a suture any larger than a 6–0. If sutures stronger than 6–0 are
required for this closure, there is too much tension and the scar
will widen unacceptably (Fig. 55.19).
The patient shown in Fig. 55.20 had a facelift with the full classic
incision including preauricular intratragal incisions; scars are
inconspicuous in early postoperative and late postoperative views.
Preoperative and 4-year postoperative views of a patient who
underwent a short-scar facelift with a preauricular intratragal
incision ending at the earlobe are shown in Fig. 55.21.
Closure of the retroauricular incision requires as much atten-
tion to detail as, or perhaps even more than, the preauricular
incision. It is very unusual to see hypertrophic scarring in front
of the ear; however, it is not so uncommon to see it behind the
Fig. 55.17 (a–c) The preauricular incision should be broken up above and below the tragus and should never be a straight line.
Fig. 55.18 (a,c) Hypertrophic straight-line preauricular scar. (b,d) Seven-year postop photos following secondary facelift demonstrate a normal-ap-
pearing tragus and favorable scar.
a
a
b
b
c
d
c

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
855
Fig. 55.19 (a) Excess skin is excised only after tension is distributed at key sutures. (b,c) The incision is closed in two layers and under no tension.
Fig. 55.20 (a) Preop, (b) early postop, and (c) late postop photos following facelift with the full classic incision including preauricular intratragal
incisions.
a
b
c
a
b
c

856
VIII Surgical Rejuvenation of the Face and Neck
ear. I think this is related to excessive tension and overresection
of retroauricular skin. Another problem is scar migration in an
outward direction from the retroauricular sulcus. This is avoided
by anchoring the posterior ear skin and the facelift flap skin to the
mastoid fascia with every bite or every other bite when closing
the retroauricular portion of the incision.
Treatment of undesirable scars includes intralesional injection
of steroid medications and the application of topical creams,
silicone gels, or 5 Fluorouracil (5FU). Scar revision may also be an
appropriate treatment.
55.6.2 Ear Distortion
Very often, close observation of the tragus and earlobe will
reveal telltale signs of a facelift. 1ot only the appearance of the
scar but distortions of the tragus and earlobe attract the eye and
scream out: ´The tragus must have a beginning and an end, and it must
project outward from the face and external auditory meatus with
a gentle posterior tilt. Forward displacement renders the external
auditory meatus more visible, creating the impression that it has
been enlarged. This is a result of excessive tension with no break
above or below the tragus. An extreme example is the ablation
of the tragus. This is avoided by deepening the pretragal sulcus,
especially in secondary face lifts, and, if necessary, by suturing the
pretragal skin into the sulcus.
The patient shown in Fig. 55.22 had had a previous facelift that
resulted in near-complete ablation of her tragus with wide-open
external auditory meatus. Her earring conceals the pixie ear
deformity. On the right, her ear is seen on the operating table
before a secondary facelift.
Earlobe problems are related to improper closure around the
earlobe. I prefer to leave the earlobe hanging free rather than
suturing it to the skin flap. This allows the natural ´angle of the
dangleµ described by Connell. Suturing the earlobe leads to pixie
earlobe deformity and a migration of the earlobe into the neck,
another telltale sign of a facelift.
Another finesse issue with the earlobe is the concomitant
reduction of the earlobe at the time of a rhytidectomy. This is
especially important in older patients who have large, pendulous,
creased earlobes. The addition of autologous fat or filler into
the aging earlobe will eliminate the creases and render a more
youthful appearance.
55.6.3 Hair Loss and Hairline Distortion
Hairline distortion is one of the most common stigmata of a
facelift. Possible distortions include the following: elevation or
elimination of the sideburns, irregular retroauricular hairline or
a stepoff, and frontal hairline elevation. The most common prob-
lem, however, is scar alopecia. This is also the simplest problem
to resolve.
Elevation or Elimination of Sideburns
Sideburn elevation or elimination is avoided by appropriate
placement of the incision. In a primary facelift in a patient with a
short sideburn, I will make a prehairline incision, and in all patients
undergoing secondary facelifts I will also make a prehairline inci-
sion. This affords ample exposure for the facelift without any change
in sideburn position. An alternative is to continue the preauricular
incision into the temporal area and to take out the skin triangle
below the sideburns. This will also maintain sideburn length.
After a previous facelift, the woman shown in Fig. 55.23 had
elevation of the hairline, with elimination of sideburns and a
wide, depigmented preauricular scar.
In Fig. 55.24, preoperative and postoperative views are shown
of a patient who had a secondary facelift. Hairline distortion and
sideburn shortening were avoided through a prehairline incision
extending into the preauricular, intratragal, and retroauricular areas.
Irregular Retroauricular Hairline
Retroauricular hairline stepoffs and distortion are avoided by
aligning the occipital hairline first and then resecting the excess
retroauricular skin and scalp. A certain amount of tailoring is
needed in patients with excess or loose neck skin.
Frontal Hairline Elevation
The high-forehead hairline is seen more commonly with coronal
rather than endoscopic brow lifts, although brow elevation is
Fig. 55.22 (a) Nearly ablated tragus and wide-open external auditory
meatus from a prior facelift. (b) Intraop view prior to surgical
correction.
Fig. 55.21 (a) Preop and (b) 4-year postop views following a short-scar
facelift with a preauricular intratragal incision ending at the earlobe.
a
b
a
b

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
857
Fig. 55.23 Elevated hairline, absent sideburn, and wide preauricular
scar following facelift.
also seen with the endoscopic approach. This problem is best
avoided by techniques that allow shortening of the forehead; all
of these techniques entail an incision in the frontal hairline, an
incision that some patients are not willing to accept.
Scar Alopecia
Hair loss is avoided through minimization of tension and with
gentle tissue handling. Overuse of the electrocautery, tight
sutures, and staples will damage hair roots. The most common
scar alopecia that I have encountered has been at the external
screw fixation site associated with the endoscopic forehead
lift. All of these problems are relatively easy to correct through
simple excision of the bald spots under local anesthesia.
Very rarely, after facial aesthetic surgery and brow lift (notably
endoscopic brow lift), there may be partial or full alopecia of the
entire scalp. Fortunately, most of these are self-limiting. Topical
use of minoxidil (Rogaine) and steroids may accelerate the
recovery. In patients with thinning hair, as a preventive measure
I encourage the preoperative and postoperative use of Rogaine on
the scalp.
55.6.4 Contour Irregularities
Contour irregularities result from improper defatting, SMAS
plication, and mismanaged hematoma. By far the most common
cause is injudicious or excessive fat grafting.
Oversuction or suction too close to the dermis, especially in
the neck, will lead to banding and skin adhesion to the platysma.
These irregularities may not be visible at rest but are very
distracting on animation of the facial muscles, especially the
platysma. This is best avoided by leaving 3 to 5 mm of fat on
the deep surface of the skin, keeping the suction cannula hole
pointed away from the dermis, and limiting the number of passes
in each tunnel.
Excessive fat removal in the subcutaneous plane to mask or
correct problems deep to the platysma is a common error that is
often difficult to reverse, as is seen in Fig. 55.25. Overaggressive
fat removal from her neck and submental area has unmasked
platysma bands and prominent digastric muscles.
SMAS plication with or without SMAS resection can lead to
contour irregularities. These are best avoided by inspecting and
ensuring a smooth subcutaneous contour before closure. Multiple
sutures should be placed to ensure that the plication and suture
lines are smooth without any discernible irregularities.
Even the smallest hematoma, if inadequately drained, will lead
to prolonged swelling, subcutaneous scarring, and irregularities.
These irregularities are best treated through lymphatic drainage
Fig. 55.24 (a) Preop and (b) postop photos following secondary
facelift. Hairline distortion and sideburn shortening were avoided
through a prehairline incision extending into the preauricular, intratra-
gal, and retroauricular areas.
Fig. 55.25 (a–d) Excessive fat removal in the neck and submental area
has unmasked platysma bands and prominent digastric muscles.
a
a
c
b
b
d

858
VIII Surgical Rejuvenation of the Face and Neck
and skin massage. I have also found external ultrasound useful,
especially with the banding in the neck. Steroid injections may
also be helpful. Reoperation is also an option.
Some patients refer to these contour irregularities as ´waves.µ
There are some patients, however, in whom the waves are seen
only on animation, representing what I think is an imbalance of
the mimetic muscles of the cheek after deep and subperiosteal
procedures. These are difficult problems to correct and may be
related to disruption and reattachment of muscle origins and
partial denervation.
55.6.5 Motion Distortion
One of the more difficult problems to correct following a facelift
is the distortion observed on animation, especially in the cheek
area. The cause of such distortions is not fully understood, which
makes the problem difficult to correct. It is thought to be related
to a change in the relationship of the muscles of facial expres-
sion with the overlying soft tissues and/or the underlying bony
skeleton.
55.7 Infections
Infections after facial aesthetic surgery are extremely rare,
because the face has a plentiful blood supply. Recent data from
CosmetAssure report a 0.2 incidence of surgical site infection
with facelifts. However, the sequelae of infection can be serious
and include skin slough and scarring. All patients undergoing
facial aesthetic surgery should have their faces washed and hair
shampooed with antiseptic shampoo on the day of the proce-
dure. The face and hair should be prepared and draped as with
any other surgical procedure. I still use perioperative antibiotics
on all patients undergoing facial aesthetic surgery, although this
is controversial.
Very rarely, Pseudomonas infection of the face is seen in swim-
mers who harbor this organism in their auditory canals. As a pre-
caution, we always soak the earplugs in povidone-iodine solution
(Betadine, Avrio Health, Stamford, CT) before placing them in the
external auditory meatus.
55.8 Other Rare Complications
Although perforation of the parotid gland capsule or even the
gland itself is encountered with sub-SMAS dissections, such
violations of the gland and its capsule are very rarely of any
consequence. However, a few cases of parotid fistula and even
parotid cysts have been reported after rhytidectomy. The fistula
may present as serous drainage through the wound, often mis-
taken for a seroma. Evaluation and definite diagnosis includes
testing the drainage for amylase. Sialoceles present as ´swell-
ingsµ along the mandibular angle, typically 10 days to 2 weeks
postoperatively. The swelling may well be mistaken for a delayed
hematoma, but, in contrast to a hematoma, there is no bruising
and it is insidious in origin, enlarging slowly. If encountered,
these problems are usually self-limiting and will resolve spon-
taneously. However, it is important to ensure that the parotid
duct is intact. If the problem does not resolve spontaneously,
exploration and open drainage will be required. Scopolamine,
which decreases salivary secretion, may be helpful in managing
this problem. Injections of botulinum toxin A into the parotid
gland will reduce its secretions and is the preferred treatment.
55.9 Concluding Thoughts
The results of a facelift are at best temporary. The consequences of
complications may be permanent.
³Claudio Cardoso de Castro
Although complications cannot be totally eliminated, careful
patient selection and preparation, attention to surgical and
anesthesia detail, and attentive postoperative management by
an experienced team will significantly reduce complications.
In contrast to any other field of surgery, or even to other areas
in aesthetic surgery, complications and unfavorable results
affecting the face and neck cannot be concealed or otherwise
protected from public view. The problems are out there, not only
for you and the patient to see, but for the entire world! This is
especially true for the patient’s family and close friends and hair
stylist. It is vital to understand that, regardless of how minor or
inconsequential the problem may seem to the surgeon, these
problems are significant for the patient. The patient’s concerns
must be openly discussed, the patient must be reassured, and
every attempt should be made to rectify the problem as expedi-
tiously as possible with minimum or no expense to the patient.
After evacuation and closure of facial hematomas, I routinely
reassure the patient that the hematoma will in no way affect
the quality of the result but may delay the recovery, especially
the resolution of the ecchymosis. Patients with temporary facial
nerve paresis are reassured that in all likelihood the weakness
is temporary and that permanent facial nerve weakness is
extremely rare. None of us is happy about complications, least
of all me. I make every attempt to see and take care of all my
patients personally whenever possible. This becomes even more
important with patients who have a complication. It is their own
surgeon they want to see, not the surgeon’s partner, assistant, or
nurse. Their own surgeon should see them on every visit, and it is
important that the visits become more frequent. Anything short
of this will lead patients to believe that at best their surgeon is
avoiding them and at worst their surgeon has abandoned them.
Complications and patient dissatisfaction with results test
not only the established doctor-patient relationship but also
our abilities as physicians and compassionate human beings.
The confidence and trust of the patients gained over a period of
weeks, months, or even years is threatened or lost very easily if
the situation is not handled sensitively.
Do not hesitate to consult partners or colleagues when dealing
with complications, especially in patients who express anger or
even undue concern that their problems have not been as self-
limiting as you have indicated. In patients who will need extensive
revisions, it is important to seek the advice of partners and other
colleagues and to resolve financial issues up front and as soon as
possible.
The best way to deal with complications is to avoid them. If
we cannot avoid them, we must remedy them expeditiously and
effectively.

55 Avoidance and Management of Complications in Facial Aesthetic Surgery
859
Clinical Caveats
• Preoperatively, patients should be given a list of medications,
herbal remedies, and dietary supplements to avoid.
• Appropriate blood pressure management should be initiated
before, during, and after the operation to reduce the risk of
hematoma.
• The perioperative use of clonidine is recommended.
• Pain, anxiety, nausea, and blood pressure elevation must be
treated aggressively in the recovery room.
• An expanding hematoma must immediately be decom-
pressed; it is a potential disaster.
• Excessive tension on the skin should be avoided.
• The surgeon should be familiar with the anatomy of the
sensory and motor nerves at risk.
• Sub-SMAS dissection beyond the parotid gland should con-
tinue under direct vision.
• Blunt instruments are best for sub-SMAS dissection beyond
the parotid gland.
• If possible, bipolar is preferred over unipolar coagulation of
bleeders below the SMAS.
• Preventive measures should be taken to avoid DVT in all
patients.
• The surgeon should be an artisan, taking the time necessary
to produce a satisfactory result.
• The sideburns and hairline should be respected, keeping
changes minimal.
• A natural-appearing tragus and earlobe should be maintained.
• The surgeon should be kind to the hair roots.
• Oversuction of neck fat should be avoided.
• A smooth facial contour must be left under the skin flap.
• Complications must be treated expeditiously.
• Autologous fat grafting should be judicious, avoiding
overgrafting.
• It is important to remember that the patient’s facial compli-
cation is on view all the time.
Suggested Reading
[1] Abboushi 1, risk of venous thromboembolism: a single center’s experience. Aesthet Surg J
2012;32(4):413–420
>2@ Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas.
Plast Reconstr Surg 2005;115(7):2119–2122, discussion 2123
>3@ Baker DC, Stefani :A, Chiu ES. Reducing the incidence of hematoma requiring
surgical evacuation following male rhytidectomy: a 30-year review of 985 cases.
Plast Reconstr Surg 2005;116(7):1973–1985, discussion 1986–1987
>4@ Baker DC, Conley -. Avoiding facial nerve injuries in rhytidectomy. Anatomical
variations and pitfalls. Plast Reconstr Surg 1979;64(6):781–795
>5@ Baker T-, Gordon HL. Complications of rhytidectomy. Plast Reconstr Surg
1967;40(1):31–39
>6@ Baker T-, Gordon HL, Mosienko P. Rhytidectomy: a statistical analysis. Plast
Reconstr Surg 1977;59(1):24–30
[7] de Chalain T, 1ahai F. Amputation neuromas of the great auricular nerve after
rhytidectomy. Ann Plast Surg 1995;35(3):297–299
[8] Connell BF. Correcting deformities of the aged earlobe. Aesthet Surg J
2005;25(2):194–196
[9] DDAVP: official FDA information, side effects and uses. Drugs.com.
drugs,com/pro/ddavp.html Accessed December 4, 2019
>10@ Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after
platysmal face-lift operation. Plast Reconstr Surg 1979;63(3):364–368
[11] Freilinger G, Gruber H, Happak :, Pechmann U. Surgical anatomy of the mimic
muscle system and the facial nerve: importance for reconstructive and aesthetic
surgery. Plast Reconstr Surg 1987;80(5):686–690
>12@ Grover R, -ones BM, :aterhouse 1. The prevention of haematoma follow-
ing rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg
2001;54(6):481–486
>13@ -ones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a person-
al 8-year quest. Reviewing 910 patients. Plast Reconstr Surg 2004;113(1):381–
387, discussion 388–390
>14@ -ones BM, Grover R. Reducing complications in cervicofacial rhytidectomy by
tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts.
Plast Reconstr Surg 2004;113(1):398–403
>15@ .eyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety
using an Internet-based quality improvement and peer review program. Plast
Reconstr Surg 2004;113(6):1760–1770
>16@ .eyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Recon-
str Surg 2008;122(1):245–250, discussion 251–253
[17] .aoutzanis C, Gupta V, :inocour -, Shack B, Grotting -C, Higdon .. Incidence
and risk factors for major surgical site infections in aesthetic surgery: analysis of
129,007 patients. Aesthet Surg J 2017;37(1):89–99
[18] Lawrence :T, Murphy RC, Robson MC, Heggers -P. The detrimental effect of
cigarette smoking on flap survival: an experimental study in the rat. Br J Plast
Surg 1984;37(2):216–219
[19] Lawson GA III, .reymerman P, 1ahai F. An unusual complication following rhyt-
idectomy: iatrogenic parotid injury resulting in parotid fistula/sialocele. Aesthet
Surg J 2012;32(7):814–821
>20@ McDevitt 1B; American Society of Plastic and Reconstructive Surgeons. Deep
vein thrombosis prophylaxis. Plast Reconstr Surg 1999;104(6):1923–1928
>21@ Mc.inney P, .atrana D-. Prevention of injury to the great auricular nerve during
rhytidectomy. Plast Reconstr Surg 1980;66(5):675–679
>22@ Patronella C., Ruiz-Razura A, 1ewall G, et al. Thromboembolism in high-risk
aesthetic surgery: experience with 17 patients in a review of 3871 consecutive
cases. Aesthet Surg J 2008;28(6):648–655
>23@ Pitanguy I, Machado BH. Facial rejuvenation surgery: a retrospective study of
8788 cases. Aesthet Surg J 2012;32(4):393–412
>24@ Peterson RA, -ohnston DL. Facile identification of the facial nerve branches. Clin
Plast Surg 1987;14(4):785–788
>25@ Rees TD, Barone CM, Valauri FA, Ginsberg GD, 1olan :B III. Hematomas
requiring surgical evacuation following face lift surgery. Plast Reconstr Surg
1994;93(6):1185–1190
>26@ Reinisch -F, Bresnick SD, :alker -:, Rosso RF. Deep venous thrombosis and
pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast
Reconstr Surg 2001;107(6):1570–1575, discussion 1576–1577
>27@ Rees TD, Lee spective study. Plast Reconstr Surg 1973;51(2):149–153
>28@ Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap surviv-
al in the face lift patient. Plast Reconstr Surg 1984;73(6):911–915
>29@ Schwember G, Rodrtguez A. Anatomic surgical dissection of the extraparotid
portion of the facial nerve. Plast Reconstr Surg 1988;81(2):183–188
>30@ Spring MA, Gutowski .A. Venous thromboembolism in plastic surgery patients:
survey results of plastic surgeons. Aesthet Surg J 2006;26(5):522–529
>31@ Stuzin -M, :agstrom L, .awamoto H., :olfe SA. Anatomy of the frontal branch
of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg
1989;83(2):265–271
>32@ Trinei FA, -anuszkiewicz -, 1ahai F. The sentinel vein: an important reference
point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32
>33@ Medical Publishing; 2009
>34@ is in plastic surgery. Aesthet Surg J 2006;26(2):157–175

(Trang không có chữ)

Part IX
Rejuvenation of
the Cheeks, Chin,
Lips, and Ears
IX

(Trang không có chữ)

56 Rejuvenation of the Aging Mouth
863
56 Rejuvenation of the Aging Mouth
Christopher D. Knotts, Byron D. Poindexter, Robert K. Sigal, and George W. Weston
Abstract
Evaluation of the perioral region is an absolute requirement when
talking to patients about facial rejuvenation. An aged mouth left
surgically untouched in the setting of rejuvenating the rest of
the face will leave the patient looking out of proportion, ´done,µ
and unnatural. In this chapter we present how to evaluate the
aging mouth, the most common surgical procedures to correct
normal perioral aging, and clinical pearls relevant to both sea-
soned plastic surgeons and those starting to implement perioral
rejuvenation into their aesthetic practice. :e provide photo-
graphs, videos, and insight accumulated over 40 years of private
aesthetic practice borrowed from five board-certified plastic
surgeons with over 100 years of combined clinical experience.
Keywords
lip lift, corner mouth lift, vermilion advancement, direct excision
56.1 Introduction
Perioral rejuvenation has a certain degree of subtlety compared
to other areas of aesthetic plastic surgery. Foremost, many ideal
patients do not know they are candidates for the procedures.
:hile a breast augmentation patient will often present with
most of an operative plan already developed, and facial rejuve-
nation patients will often present knowing they want a facelift,
seldom does a patient request around-the-mouth surgery. The
burden falls on the surgeon to broach the subject. Leaving an
untouched mouth in the setting of surgically addressing the rest
of the face leaves the patient looking disharmonious, unnatural,
and operated-on.
Perioral surgery may be a small part of a larger discussion
about total facial rejuvenation. In that context, patients readily
understand that the mouth ages along with the rest of the face,
and that if they want an overall youthful look, the mouth will
also need correction. However, some patients lack facial harmony
simply because of an imperfection in their perioral anatomy, and
like the patient who requires an isolated chin implant to balance
the face, some patients require only a perioral operation to restore
proportion. The procedures outlined in this chapter are most
often used to make an aged mouth look younger in the setting of a
full facial rejuvenation, but each can also be used as a stand-alone
procedure.
As regular speakers at plastic surgery meetings over the last
several decades, we have observed a trend of aesthetic surgeons
at our talks to embrace perioral surgery as a key component of
total facial rejuvenation. This chapter is intended to offer the
experienced surgeon some nuances developed over years of
experience and also to offer the plastic surgeon inexperienced
with around-the-mouth surgery a thorough understanding of
how and when to use these operations safely. In the current era
of social media, instant gratification, and the industry-driven
hordes of noncore practitioners armed with hyaluronic acid (HA)
fillers, adding volume to the lips is touted to patients as a solution
for all that ails the perioral region. :hile volume has a place in
rejuvenation, we will discuss how to address the mouth in terms
of both shape and size.
56.2 Pertinent Anatomy
The aging mouth has several predictable anatomic changes, each
carrying its own symbol. :ith time, the upper lip lengthens,
covering the upper incisors like a curtain and concealing the
attractiveness of dental show. This is particularly evident in
the nonvermilion skin between the nasal sill and the upper lip
vermilion, known as the ergotrid. As the soft tissue support of
the lips becomes lax and atrophic, the corners of the mouth
droop and widen, mimicking displeasure or disgust. :ith bony
loss, the vermilion falls into the mouth, which looks gaunt, aged,
and ill. The vermilion thins and deflates. Lines form and deepen
around the mouth and in the nasolabial and marionette regions,
symbolizing advancing age.
:hile patients may not recognize the specific anatomy, they
are astute to the symbols their face conveys to others. It is this
incongruency between external facial symbolism and internal
emotional state that leads some patients to seek plastic surgery
(Fig. 56.1). Perioral surgery aims to align the internal state with
the desired external symbolism.
Fig. 56.1 This patient with an aging mouth exhibits the typical charac-
teristics of a long upper lip, loss of maxillary dental show, downturned
corners, numerous perioral rhytids, vermilion deflation, deepening
folds, and lower lip vermilion falling into the mouth.

864
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
56.3 Preoperative Assessment
The preoperative assessment involves two main parts: first,
choosing the right patient for surgery and second, choosing
the right surgery for that patient. The ideal patient is willing to
accept a facial scar, typically imperceptible at conversational dis-
tance, for a more youthful appearance. This is an easy discussion
in the full facial rejuvenation patient preparing for incisions on
the forehead, eyelids, around the ears, and so on. In all patients,
high-quality pre- and postoperative photographs are a critical
part of the process. :e routinely show patients photographs and
also have the luxury of multiple staff members and surgeons
who have had procedures performed themselves and can show
the patients exactly what a real and mature scar looks like in
person.
Specific anatomic considerations to note for perioral surgery
include presence of nasal sill, nasolabial angle, condition of teeth,
occlusion class, incisor show in repose, oral commissure position,
perioral rhytids, deflation changes, existing scars, nasolabial lines,
marionette folds, and philtral effacement.
56.4 Surgical Procedures
56.4.1 Lip Lift
The lip lift is used to shorten a long upper lip and involves a
final surgical scar under the nasal base. The procedure was
first presented in the 1970s by the Brazilians, and we have been
perfecting this procedure since the early 1980s in our group
practice. There have been several adaptations of the procedure
and different names employed by others to describe essentially
the same operation, but the general concept of removing excess
skin from below the nasal sill to shorten a long upper lip is the
same. This procedure is indicated for patients with an aged and
long upper lip in the setting of a normal bite and good dentition.
Caution should be exercised in patients with a long lip and max-
illary dental show in repose, as shortening the lip can worsen the
appearance of maxillary excess. Lip lifts in these patients should
be conservative. If a patient has a lip shorter than 10 mm or a
highly arched Cupid’s bow before surgery, the lip lift should be
minimal or combined with a corner mouth lift. Similarly, in the
setting of downturned corners and a long lip, the corners should
be addressed concomitantly, as a lip lift can make the corners
look more drooped if they are not also addressed.
Markings
The markings of the lip lift vary based on patient anatomy (Fig.
56.2). The ideal upper lip is short enough to reveal several milli-
meters of incisor show, and this is generally no shorter than 10
mm when measuring from the nasal sill to the vermilion. The
ideal candidate has a well-defined nasal sill. Often patients may
show effacement of the nasal sill below the nostrils, and in these
patients the markings are done as a ´bull’s hornsµ so that the
final scar is concealed cephalad, inside the floor of the nostril.
The lateral extent of excision is the nasal ala. Extending the
scar out beyond the ala in the region of a :eir excision makes
the scar more visible with minimal improvement in result and
is not recommended. Caution is exercised in patients with
an obtuse nasolabial angle, as the scar will be more visible. In
these patients, altering the nasolabial angle by taking down the
nasal spine at the time of lip lift can be beneficial. A lip lift is
not recommended in patients with poor condition of maxillary
dentition, as a shortened lip in the setting of unattractive teeth
leaves a poor aesthetic result.
Fig. 56.2 Some of the varieties of lip lift that can be performed based on patient anatomy.

56 Rejuvenation of the Aging Mouth
865
Operative Technique
An isolated lip lift can be performed under local or general anes-
thesia. Local 1 lidocaine with epinephrine is infiltrated beneath
the surgical marks. After adequate time for the anesthetic to take
effect, the upper and lower incisions are made straight down
through dermis. The muscle is not disturbed or manipulated. A
conservative undermining of 1 to 2 mm is done inferiorly, and
hemostasis achieved with electrocautery. The temptation to
undermine farther distally to release perioral rhytids should
be avoided, as this can result in a tethered and irregular final
scar with unnatural orbicularis oris movement postoperatively.
Closure is carried out in two layers: 6–0 polyglactin (Vicryl,
-ohnson -ohnson, 1ew Brunswick, 1-) suture is placed in an
everting, interrupted, buried fashion and at least three sutures
are used. This suture can be used to grasp the nasal spine supe-
riorly to minimize inferior scar migration. The skin is closed
with everting mattress polypropylene (Video 56.1). A good result
will look overdone in the early postoperative period but relaxes
significantly (Fig. 56.3).
56.4.2 Corner Mouth Lift
The corner mouth lift comes in several varieties depending on the
degree of aging present. Attention should be paid to preoperatively
assessing the upper vermilion and commissure. :ith normal
aging, the upper lip vermilion can disappear as it approaches
the oral commissure (Fig. 56.4a). :ith more advanced cases, the
commissure itself may also droop (Fig. 56.5a), and occasionally
the droop will continue on as a marionette fold (Fig. 56.6a).
Depending on the deformity and on the patient’s tolerance for
a facial scar, the operative plan may include a standard corner
mouth lift, a wraparound corner mouth lift, or a boomerang
corner mouth lift. All of these procedures involve placing a surgical
Fig. 56.3 (a) This patient is deemed a good candidate for a lip lift with a long lip, revealing her mandibular dentition in repose. (b) Because her
nasal sill is effaced below the nostril, her markings are taken up into the nasal floor in a “bull’s horns” pattern. (c) At day 1 postop, the patient has an
overdone result. (d) Lip relaxes significantly by 1 week. (e) Result is socially acceptable by 3 weeks. (f) By 3 months, the scar is fading and the result
shows restored facial harmony.
Fig. 56.4 (a) This patient underwent a traditional corner mouth lift with fat grafting and no other perioral surgery. Note that her upper lip vermilion
disappears several millimeters before the oral commissure. This is a sign of normal aging. (b) The markings for a standard corner lift terminate in
the oral commissure and should extend no farther medially than the philtral column. (c) In her 3-month postop photograph, the vermilion has been
rolled up and out, so it now extends to the commissure, giving a more natural and youthful appearance.

866
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
scar from the lateral commissure extending medially along the
upper lip vermilion edge. 1onvermilion tissue from the ergotrid
is excised and removed to advance the vermilion into an aesthetic
location. This is essentially an upward advancement of vermilion
near the oral commissure.
The differences in the three types of corner mouth lift are in
what happens with the scar near the commissure. For a standard
corner mouth lift, the scar terminates at the commissure. For a
wraparound, the final scar continues around the commissure
and extends into the lower vermilion border. For a boomerang,
the scar continues down into the beginnings of a marionette fold,
essentially combining the corner mouth lift with a direct excision,
which is discussed later on. In cases where the commissure
requires lifting, a wraparound corner mouth lift can be a powerful
tool in lifting this tissue to its normal anatomic location. A boo-
merang will also alter the commissure position.
It is not recommended that the scar along the upper lip vermil-
ion edge traverse any farther medially than the philtral column, as
this can distort the delicate anatomy in this region.
Another version of the corner lift, which left a final scar
extending out straight laterally from the commissure as a small
´whiskerµ line, has essentially been abandoned (Fig. 56.7). This
sometimes scarred quite well, but in the cases where it did not,
the scar became a lipstick bleed line in an unnatural location and
was difficult to correct.
In planning the corner mouth lift, the excision should be
planned with the expectation of some postoperative relaxation.
:hile the degree of relaxation is not as dramatic as in a lip lift,
the result on the table should be slightly overdone to allow for
relaxation.
Markings
A standard corner mouth lift is performed by hovering the
marker over the commissure and then using the nonmarking
hand to simulate the degree of lift desired. The hovering marker
is then touched to the skin and the nonmarking hand is removed,
dragging the skin across the marker tip to leave behind a vertical
line that shows the extent of the skin to be removed. The inferior
marking edge is the vermilion border, and the marks are tapered
out to allow for closure without standing deformity (Video 56.2).
Examples including markings of the three types of corner
mouth lifts are demonstrated in Fig. 56.4b, Fig. 56.5b, and Fig.
56.6b, respectively.
Operative Technique
An isolated corner mouth lift can be performed under local
or general anesthesia. As in a lip lift, the incisions are made
down to but not through muscle. Minimal if any undermining
is undertaken before two-layer closure with interrupted 6–0
Fig. 56.5 (a) This patient underwent a wraparound corner mouth lift with lip lift, dermabrasion, fat grafting, and neuromodular treatment of
depressor anguli oris and mentalis muscles. Note the symbolism in her preoperative state of looking grumpy and disappointed. (b) The markings
show the new location of the oral commissure will be toward the blue dot. (c) In her postoperative photograph, there is a dramatic improvement in
her facial symbolism.
Fig. 56.6 (a) This patient shows minimal commissure descent preoperatively, but her vermilion begins to disappear approaching the commissure,
making her a good candidate for a boomerang corner mouth lift. (b) In this case, the loss of vermilion continues on as a marionette fold, and thus the
markings connect a corner mouth lift to excise the fold as well. (c) In her postoperative state the scar is nearly imperceptible.

56 Rejuvenation of the Aging Mouth
867
polyglactin and skin polypropylene. The sutures are removed
before 7 days, and the scar is typically excellent by 3 months.
For a wraparound corner lift, conservative undermining is done
over the commissure to allow the tissues to lift into their new
location with minimal tension. A boomerang marries a corner
mouth lift to the direct excision, discussed later in the chapter.
Results of the three types are shown in Fig. 56.4c, Fig. 56.5c, and
Fig. 56.6c, respectively.
56.4.3 Vermilion Advancement
A vermilion advancement is a lower lip procedure used to pull
collapsed vermilion that has fallen into the mouth with aging
and bone loss back to its normal anatomic location (Fig. 56.8a).
This is done by excising nonvermilion tissue below the lower lip
and advancing the vermilion into its place. The final surgical scar
is along the red vermilion junction.
:e do not recommend performing a vermilion advancement
of the upper lip, as the necessary peaks and valleys of the final
scar traversing the Cupid’s bows can distort terribly if the scar
contracts at all. This is unnatural and difficult to manage, though
other surgeons have reported convincing results. In the patient
with severe collapse of upper lip vermilion, there is almost always
a long upper lip, and substantial improvement can be achieved
with a lip lift, fat grafting, and often also a corner mouth lift.
Markings
The markings for vermilion advancement span the length of
the lower lip. The superior marking is at the edge of pigmented
vermilion, and the inferior edge of the marking is placed just
below the desired final border to account for the small amount of
relaxation of tissues that typically occurs (Fig. 56.8b).
Operative Technique
Vermilion advancement is almost always performed in conjunc-
tion with other perioral procedures. This means scars will be in
close proximity. :hen combining this procedure with a corner
mouth lift, it is generally recommended to allow for a gap of sev-
eral millimeters of untouched tissue between the two final scars
to minimize the risk of scar contracture around the corner of the
mouth. This means a wraparound corner mouth lift is seldom
performed with a full lower lip advancement, or that a gap is left
between the lower limb of the wraparound and the start of the
vermilion advancement.
A vermilion advancement can be performed under local or
general anesthesia. If under local anesthesia, mental nerve blocks
are performed as well as direct injection of local for hemostasis.
The upper and lower incisions are made, and the lower lip skin
is excised without manipulating the muscle. After hemostasis is
achieved, closure is carried out with a single-layer skin closure
(Fig. 56.8c).
Sutures are removed before 7 days, and the scar is typically well
concealed. Any scar irregularities can be touched up with revision,
but that is a rare occurrence, and the scars typically are acceptable
to patients (Fig. 56.8d).
56.4.4 Direct Excision
The difficult area of facial rejuvenation between the commissure
and cheek led us to extend the incisions from around the mouth
down onto the bare cheek skin. This courageous endeavor has
now been undertaken thousands of times in our practice and
matured from being a ´backup planµ or staged secondary proce-
dure after primary facelift and fat grafting to being now part of
the primary facelift.
It is a matter of experience to determine whether deep folds
can be remedied with fat grafting and a facelift alone or whether
direct excision will be required. One useful tool is to mimic the
tension of a facelift preoperatively and carefully assess the naso-
labial region. If the folds are still deep or unchanged, it is unlikely
they will be eliminated with facelift alone. That being said, we are
still sometimes surprised with the results obtained without direct
excision (Fig. 56.9).
Often patients may be reluctant to have a direct excision
because of the concern for a poor scar, and surgeons unfamiliar
with direct excision techniques are unable to disabuse them. It is
a reasonable option to stage a direct excision until after facelift
and fat grafting. If the patient is counseled preoperatively about
the chance of requiring a later excision of nasolabial or mario-
nette tissue under local, they will not find it surprising if that
happens.
If the decision is made to perform the direct excision at the time
of primary facelift, however, it is our recommendation to do the
direct excision first, partially close it, and then perform a slightly
more conservative facelift than usual. If the facelift is performed
Fig. 56.7 Original corner mouth lift with final resulting “whisker” scar, now abandoned due to patient concern for lipstick bleed postoperatively.

868
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
first, the swelling of the flap will give the impression that there
is no excess tissue in the nasolabial region, and the surgeon will
lose the courage to perform the direct excision. Once the swelling
begins to subside in the weeks following surgery, the excess tissue
will again manifest itself.
The prediction of which patients would benefit from direct
excision as well as facelift comes with experience and choosing
the right patients. In those with multiple or very deep nasolabial
and/or marionette lines, direct excision is a powerful addition to
the traditional facelift (Fig. 56.10).
Markings
The markings for direct excision extend across the area of
deformity (Fig. 56.11). Ideally the distal ends of the excision fall
into a tissue depression to hide any dog-ears. The excision may
encompass an entire nasolabial fold, an entire marionette fold,
a combination of both, or be combined with a corner mouth
lift as a boomerang corner mouth lift (Fig. 56.6b). A video of a
patient being marked for direct excision and corner mouth lift is
provided (Video 56.3).
Operative Technique
Direct excision can be performed under local anesthesia or as
part of facial rejuvenation. As in the other perioral procedures, the
incisions are through dermis only. Because the direct excision is
more prone to having some fullness at the tapered ends, superfi-
cial fat may require removal beneath the tapered incision ends.
Closure can be with temporary staples if this is performed at the
time of primary facelift, as this allows the tension of the facelift
to be set so facelift skin can be excised, and then formal closure
of all incisions can be done at the end of the case. The closure
of the direct excision is ultimately done in two layers with 6–0
polyglactin in the deep dermis and polypropylene in the skin. The
scars in the region of direct excision are pinker for longer than
those of other perioral surgeries, and patients should be coun-
seled regarding this. By 3 months the scars are well concealed at
conversational distance.
56.5 Postoperative Care
After perioral surgery, patients are continued on antibiotics
for less than 24 hours and placed on a short course of antiviral
to prevent a herpetic eruption. :e encourage the use of topical
bacitracin ointment to keep any scabs soft and make the suture
Fig. 56.8 (a) This patient shows severe collapse and thinning of the
lower lip in the setting of facial aging. (b) The markings are shown for
lower lip advancement among other perioral procedures. Note that
the lower lip markings do not extend all the way to the commissure,
as she is having a concurrent corner mouth lift. (c) The immediate
postoperative suturing is shown with a single-layer closure. (d) The
postoperative result at 3 months shows a rejuvenated perioral region
as part of a full-face rejuvenation. Procedures performed include brow
lift, upper blepharoplasty, lower blepharoplasty, midface lift, lip lift,
corner mouth lift, lower lip advancement, facelift, neck lift, facial fat
grafting, and fractionated laser resurfacing to face, neck, and chest.
Fig. 56.9 (a) This patient shows disappearing vermilion near the
commissure and also a deep marionette fold. (b) She declined any
direct excision at the time of primary facelift and was still able to
achieve a good result in the marionette region from facelift, fat
grafting, lip lift, and standard corner mouth lift.

56 Rejuvenation of the Aging Mouth
869
removal process easier. The sutures are removed before 7 days
and patients can wear makeup 24 hours after suture removal.
Scars are treated with topical silicone cream and reassessed at 6
weeks for evidence of hypertrophy. In this rare instance, a dilute
injection of steroid and 5-fluorouracil (5-FU) typically arrests the
condition. Management of other postoperative complications has
been detailed elsewhere.
56.6 Ancillary Surgical Procedures
56.6.1 Mucosal Advancement Flaps
If there is inadequate red upper lip vermilion to accept fat
grafting, and the lip is too short, an intraoral V-< mucosal
advancement flap can be performed, but this is rarely used in
our practice. In the patient with adequate upper lip vermilion
volume and an already short lip without the appropriate amount
of incisor show, cosmetic dentistry to lengthen the incisors can
be used if the teeth are short, or a LeFort operation can be used
to lengthen a short maxilla.
56.6.2 Fat Grafting
Fat grafting is performed in the vast majority of our facial reju-
venation procedures. It is first line for adding volume to lips and
perioral rhytids during facial surgery. Although the lips seem
to be a challenging area for consistent graft ´take,µ it remains a
workhorse thanks to low cost, availability, and ease of use. :e
also routinely freeze fat for later “touchups” in the immediate
postoperative course. Although cell culture research we have
performed shows loss of viability with freezing, we see results
with the frozen fat and believe this to be achieved through the
scarring process. In patients with deep folds and unwillingness
to undergo excision, we will use sharp subcision, fat grafting,
and horizontal mattress sutures removed at 4 days to allow the
fat a space to heal while minimizing suture train tracking.
56.6.3 Dermis Grafts
In patients resistant to fat grafting, or those with significant
collapse and unwillingness to tolerate a lip scar, we use de-
epithelialized dermis threaded through the lip with a tendon
passer. :e have used this technique below very deep perioral
rhytids as well with limited success.
56.6.4 Alloplastic Implants
The use of implants for lip augmentation has lost favor in our
practice. The unnatural movement, occasional migration, and
asymmetry have led us to use the methods previously outlined
to create an ideal lip aesthetic.
56.6.5 Perioral Resurfacing
For patients with severe and numerous perioral rhytids, skin
resurfacing using dermabrasion, chemical peels, or lasers can
be a useful addition to the surgical plan. Often patients with
the worst perioral skin conditions are the least likely to tolerate
the significant recovery associated with complete skin resur-
facing. These kinds of skin changes take a lifetime of neglect to
accumulate, and patients may find it difficult to hear that the
damage cannot be simply undone without significant tradeoffs.
Perioral resurfacing methods are seldom used in our practice as
Fig. 56.11 Some of the varieties of direct excision that can be tailored
to excise existing facial creases.
Fig. 56.10 (a) This patient exhibits preoperative findings of the loss of upper lip vermilion near the commissure, a deep marionette fold, multiple
perioral rhytids, and a relatively well-defined Cupid’s bow with a slightly long upper lip. (b) She is shown marked for corner mouth lift and direct
excision of a marionette fold as well as fat grafting to rhytids. (c) At 3 months, the scars are near invisible. Her lip aesthetics are drastically improved,
and the stern symbolism is improved compared to preoperatively.

870
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
a stand-alone solution and are typically coupled with excisional
procedures.
Care must be taken in treating any areas that have been sub-
sequently undermined. Another limitation to the use of perioral
resurfacing is the associated pigmentation changes. In attempts
to eliminate fine rhytids completely, there is often a residual
pinkness or hypopigmentation that we have found to be an unac-
ceptable tradeoff. :e generally lean toward undertreating and
leaving some lines rather than creating a pigmentation problem
that may be impossible to correct.
For relatively superficial lines, we employ dermabrasion by
painting the skin with methylene blue and using a coarse dia-
mond fraise to remove all the blue pigment, occasionally cleaning
the fraise with a brush and hydrogen peroxide to maintain a
consistent epithelial removal.
In patients with deeper rhytids, we use a tunable full-field
erbium laser at a depth of up to 800 microns ablation to induce
peel or use several sessions of fractional treatment in the post-
operative period. For those with the most sun damage and deep
lines, we will use phenol/croton oil peels and do not treat any
undermined areas simultaneously.
56.7 Ancillary Nonsurgical
Procedures
56.7.1 Alloplastic Fillers
:e use HA fillers almost exclusively to add volume to young
patients simply wanting more fullness. In the aging mouth, fillers
work up to a certain point for such areas as nasolabial folds, but
when the effect is no longer as good, or if we worry the patient
will look overplumped and ´odd,µ we have the conversation about
surgically correcting the shape of the perioral region and then
going back to fillers and volume as a maintenance treatment.
Fillers are also used as a “touchup” in the instance of poor fat
graft survivability. Fillers are best used in lips that have been
already made youthful using the excisional techniques described.
:e find a volumized lip that is still long, downturned, or collapsed
to be a dead giveaway the practitioner did not appreciate the
anatomy and used the wrong procedure to treat the patient. In
these instances, the filler often requires dissolving so that the
underlying structure can then be addressed properly.
56.8 Results
The excisional procedures outlined in this chapter have been
used in thousands of patients and are a component of the surgical
plan in over half of the hundreds of facial rejuvenation cases we
perform annually. :ith astute preoperative analysis and patient
counseling, we have found no better substitute.
56.9 Concluding Thoughts
Much as the periorbital region cannot be rejuvenated without
making incisions around the eyelids, the aging mouth cannot be
successful without the addition of direct surgical excisions. This
ethos is gaining acceptance in aesthetic plastic surgery, and we
believe the tradeoff of a well-planned surgical scar for a shapely
perioral region is worthwhile and necessary.
Clinical Caveats
• The ideal upper lip height is no shorter than 10 mm.
• A lip lift relaxes significantly and should be overdone on the
operating table.
• A corner mouth lift relaxes some and should be only slightly
overdone.
• Vermilion advancement is recommended chiefly for the lower
lip.
• Vermilion advancement combined with corner mouth lift
should have an untouched gap of tissue between the final
scars.
Suggested Reading
[1] Austin H:. The lip lift. Plast Reconstr Surg 1986;77(6):990–994
>2@ Austin HA. Rejuvenating the aging mouth. Perspect Plast Surg 1994;8:27–56
>3@ Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip. In: Heuston -T, ed. Trans-
actions of the Fifth International Congress of Plastic and Reconstructive Surgery.
Butterworth, Australia, 1971
>4@ Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg
2006;33(4):567–577
>5@ Fanous 1. Correction of thin lips: ´lip liftµ. Plast Reconstr Surg 1984;74(1):33–41
>6@ Guerrissi -O, Sanchez LI. An approach to the senile upper lip. Plast Reconstr Surg
1993;92(6):1187–1191
[7] Haworth RD. Customizing perioral enhancement to obtain ideal lip aesthetics:
combining both lip voluming and reshaping procedures by means of an algorith-
mic approach. Plast Reconstr Surg 2004;113(7):2182–2193
[8] .notts CD, Poindexter BD, Sigal R., :eston G:. Perioral aesthetic surgery. In:
Cohen M1, Thaller SR, eds. The Unfavorable Result in Plastic Surgery: Avoidance
and Management, 4th ed. 1ew [9] .notts CD, Sigal R., :eston G:. Rejuvenation of the aging mouth. Presented at
the American Society of Plastic Surgeons. Boston, MA, October 16, 2015
>10@ Penna V, Iblher 1, Bannasch H, Stark GB. Proving the effectiveness of the lip lift
for treatment of the aging lip: a morphometric evaluation. Plast Reconstr Surg
2010;126(2):83e–84e
[11] :eston G:, Poindexter BD, Sigal R., Austin H:. Lifting lips: 28 years of experi-
ence using the direct excision approach to rejuvenating the aging mouth. Aesthet
Surg J 2009;29(2):83–86

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871
57 5eÀnemenWV in 2WRSODVWy 7eFKniTueV
Kayvan Shokrollahi and Jamie Barnes
Abstract
This chapter describes an approach to otoplasty that is patient
focused and, to a certain extent, patient led. The request for treat-
ment is introduced as a new concept in consent, and emphasis
is placed on patient wishes over strict anatomic descriptions of
the aesthetic ear, in keeping with published evidence supporting
this concept.
In recent years, suture-based otoplasty techniques have been
augmented by use of the postauricular fascia system. Evidence-
based scar placement, the use of fascia both to detension sutures
and to protect them from extrusion and also to provide further
repositioning of the ear, and the use of glue as a dressing charac-
terize the approach described. This facilitates a safe, reproducible
technique with a low complication rate and can obviate the need
for head bandages, with simple gluing of the helical rim adequate
for wound closure and cover.
A considerable amount of focus is placed on the patient
experience, from consultation through the procedure to the
postoperative stage and healing process. :ith technically sound
outcomes achievable in a reproducible manner, these previ-
ously secondary considerations now come to the fore. Prone
positioning is discussed to facilitate teaching, dual operating,
and optimization of the patient experience by using hand-held
devices as distraction. Discharge from the operating theater
with an open, optional follow-up appointment is proposed
as a potential option for this low-risk and low-maintenance
technique.
Keywords
otoplasty, postauricular fascia, fascial flap, request for treatment,
head bandage
57.1 Introduction (Philosophy)
The oft-quoted principles of A. -. McDowell have guided the
myriad approaches to otoplasty that have been developed over
the last 50 years. These include correcting all aspects of upper
pole protrusion, a smooth helical rim, an intact postauricular
sulcus, symmetry to within 3 mm, acceptable predetermined
distances between pinna and head (10–12 mm, 16–18 mm, and
20–22 mm in the upper, middle, and lower thirds, respectively),
and, finally, that both helices should lie lateral to the antihelices
when viewed from the front.
These goals have been widely accepted and targeted and cer-
tainly have significant merit, yielding consistently aesthetically
pleasing results where they are met. However, while ´under-
correction” is obviously unsatisfactory, “overcorrection” or “an
operated lookµ is equally to be avoided. The standard definition
of this phenomenon, however, is slightly dogmatic in origin and
possibly contrary to clinical evidence.
A small clinical study has demonstrated that, for example,
an ear with a prominent antihelix can be quite aesthetically
pleasing to many independent observers and actually prefera-
ble to a more traditional ´McDowellµ ear. This study also noted
that some observers who were plastic surgeons critiqued ears
as “overdone” only to discover that in fact they had not been
operated on. This variation in the natural appearance of ears
is to be expected, but the aesthetic acceptance of the general
public can lie in contrast with traditional teaching about ideal
parameters.
:ith this in mind, the search for a ´naturalµ-looking ear widens
and, while deviating wildly from McDowell’s principles is unlikely
to yield pleasing results, it is possible to be slightly less rigid in the
pursuit of a pleasing and natural result.
The key question for surgeons remains, of the numerous
otoplasty techniques, which one should they adopt, or at least
which are the key principles they wish to incorporate into their
own practice" Our advice is that the answers to these questions
should be formulated based on the patient experience with a
holistic view, rather than based on anatomy. For example, will the
patient need head bandages with this technique" :hat are the
risks of this technique over another" How many appointments are
required" Is local anesthesia possible" How quick is the recovery"
How much does it cost to do it this way" And so forth.
57.2 Indications and
Contraindications
There are several anatomic, psychological, and logistic consider-
ations to be taken into account when planning otoplasty surgery.
The pliability of neonatal ear cartilage has been demonstrated
clinically with successful correction of deformity using splints
in the first few weeks or months after birth. Later interventions
require longer splintage times and offer more variable results.
After the first few months of life, splintage is unlikely to be suc-
cessful, and for those that employ it, it can be traumatizing for an
infant and parents.
The ear is expected to reach 85 of adult size between ages 3
and 6, and indeed, growth restriction has not been demonstrated
in comparisons of ear growth between operated and nonoperated
ears of children as young as 9 months old. It is worth noting that
most authors advocating for surgery in children under 5 years old
advocate suture-based techniques, and this may play a role in the
lack of growth restriction.
Anatomic parameters for an aesthetic ear are well described
but are rarely used in the assessment stage as an indication for
surgery. In general terms, a reasonable case would present as a
prominence of the ear that is noticeable and undesirable to the
patient with or without underdevelopment of the antihelical fold,
which the surgeon feels can be reasonably corrected to within
socially acceptable proportions to the patient’s satisfaction. The

872
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
´normalµ morphology of the ear has been demonstrated to vary
widely in the relative positions of the anatomic components, and
ultimately an anatomic change is sought that can be impactful
enough to enact a psychological benefit.
The psychological benefit may be sought by parents or the
patient themselves. Of course, a patient-driven consultation with
a clear anatomic problem is straightforward. A parent-driven
consultation can present challenges that must be dealt with sen-
sitively. Parents are often anxious about potential for bullying or
social exclusion because of ear prominence, sometimes based on
personal experience.
Evidence abounds for the social benefit of otoplasty surgery;
however, evidence for avoiding the onset of social difficulties
by pre-emptive surgery, as opposed to surgery after the onset
of social difficulties, is lacking. :hile many children with ear
prominence may go on to live happy and successful lives without
intervention, others will receive comments that inspire them to
seek surgical intervention. In the absence of evidence that delayed
surgery yields inferior benefits, early surgery may result in unnec-
essary procedures being carried out and can risk resentment in
adulthood in the case of an unfavorable aesthetic result.
:hile some advocate waiting for children to be ´sensitizedµ to
their ear prominence before carrying out surgery, the ´sensitiza-
tion” of the child by parents can possibly be predicted based on
the strength and nature of their assertions.
A patient presenting with minimal anatomic abnormality and
high levels of distress should raise alarm bells. This is true of any
aesthetic patient, and with the increasing pervasiveness of social
media, it seems that ever younger children are under increasing
levels of pressure to seek a physical perfection that may be beyond
reach.
Logistics in our practice mandate that a patient should be able
to comply with postoperative instructions to avoid complications
such as hematoma and wound healing problems. In general terms
this usually means delaying surgery until around the age of 6
to 7. A delay in surgery to a timepoint where local anesthesia is
feasible is also another important consideration to be discussed
with parents and children.
57.3 Pertinent Anatomy
The anatomy of the external ear is illustrated in Fig. 57.1.
57.3.1 Cartilaginous Framework
The main anatomic contributor to ear prominence is the concha.
The concha can be large and/or effaced, causing underdevelop-
ment of the antihelical fold. Many excisional surgical strategies
have been proposed to reduce the size of the enlarged concha;
however, combing a posterior rotational movement of the concha
with recreation of the antihelix by folding can almost always pro-
duce a pleasing result without the need for excision of the ´excessµ
concha. True ´macrotiaµ is vanishingly rare, and in fact, promi-
nence rather than size is the cause of offense in most instances.
57.3.2 Postauricular Fascia
The postauricular fascia has come into common consciousness
for its use as a flap both to provide structural support while
reshaping the ear and also to provide soft tissue cover to under-
lying sutures, aiming to reduce the risk of recurrence and suture
palpability or extrusion.
The anatomic basis of this tissue has recently been described
in detail. The posterior auricular fascia is characterized by a
well-defined and reliable blood supply as well as being thin and
strong. It has been used in otoplasty as a posteriorly based flap
that is sutured to the helical rim simply to provide suture cover
and, more recently, a flap based on the helical rim and sutured
to the mastoid periosteum to provide the same cover with the
added benefit of holding the ear in its retroverted position, either
destressing the other sutures used to reposition the cartilage or
indeed to provide further repositioning. Use of this fascial flap can
therefore contribute to shape, resilience of repair, and avoidance
of recurrence as well as fine tuning of the end result.
The postauricular fascia has an intrinsic and an extrinsic compo-
nent. The intrinsic postauricular fascia (IPF) consists of fibrofatty
tissue, vessels and nerves, and perichondrium and covers the back
Fig. 57.1 Anatomy of external ear.