Give us a table of facelift complications. How would you treat each? Answers from Cummings:

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1 Give us a table of facelift complications. How would you treat each? Answers from Cummings: Hematoma The most common perioperative complication of rhytidectomy is hematoma, which occurs in 1% to 10% of patients and may be a major or minor collection of blood beneath the skin flap. Major and expanding hematomas usually occur within 24 hours of surgery and are heralded by increasing facial edema, bruising, and pain. Hypertension predisposes to this risk, and hematomas occur more frequently in men. Other factors related to hematoma are recent ingestion of aspirin, nonsteroidal antiinflammatory drugs, high doses of vitamin E, and certain herbal health supplements. Major hematomas require immediate wound exploration, evacuation of blood, and control of hemorrhaging. If not detected and treated within a few hours, there is risk of skin flap necrosis and subsequent scarring of the periauricular skin. Minor hematomas of 2 to 10mL of blood may not be detected until the first dressing change. These occur most frequently in the infra-auricular and postauricular region of the neck and can be evacuated in the office. Inserting a sterile slender suction device through the postauricular incision line enables complete evacuation of the blood. A compression dressing is applied to the neck, and the area is examined again in 24 hours. Typically, a small residual collection of blood is present and can be removed by percutaneous aspiration with a syringe attached to an 18-gauge needle. Seromas beneath the facial or cervical skin are usually apparent 5 to 7 days postoperatively and can similarly be treated with percutaneous aspiration. Skin Flap Necrosis Skin flap necrosis is associated with untreated major hematomas. It may also occur from ischemia related to the use of tobacco, certain systemic medical conditions, injury to the subdermal plexus during flap dissection, or closing the facelift incisions under excessive wound closure tension. Use of tobacco products increases the risk of flap necrosis by a factor of 12. To see any benefit of cessation of tobacco use, the patient must stop all tobacco products (including nicotine skin patches) for a minimum of 2 weeks before and after surgery. Conservative treatment of a skin slough is recommended. Typically, epithelialization of the affected area will occur. If flap necrosis is full thickness, subsequent healing may result in a hypertrophic scar. Partial thickness necrosis may heal with little or no visible sign of scarring or with a hypopigmented scar, depending on the depth of tissue necrosis. Nerve Injury When performing a rhytidectomy, the most common nerve injury is to the greater auricular sensory nerve and occurs in 1% to 7% of rhytidectomies. Damage to this nerve results in loss of sensation over the inferior half of the ear. Injury to the nerve can be prevented by a superficial dissection of the skin over the sternocleidomastoid muscle. The neck skin is firmly adherent to the muscle below the earlobe, and hydrodissection by injecting local anesthetic beneath the skin along the vertical axis of the muscle helps facilitate dissection of the skin flap. If the nerve is inadvertently injured, it should be repaired with 10-0 nylon perineural sutures placed under

2 magnification. Like the greater auricular nerve, the lesser occipital nerve and the spinal accessory nerve may be injured during elevation of the postauricular skin flap. These nerves are positioned considerably deeper than the greater auricular nerve, and injury to these structures is rare. Injuries of motor nerves during rhytidectomy may result in complete paralysis of a facial nerve branch or mild paresis. The incidence of motor nerve injury ranges from 0.3% to 2.6%. [27] The most commonly affected nerves are the temporal and marginal mandibular branches of the facial nerve. The temporal branch is particularly prone to injury when combining forehead and facelifting. Above the zygomatic arch, the nerve travels in the temporoparietal fascia. To avoid injury when dissecting in the temple and lateral orbital areas, the plane of dissection for the lateral portion of the forehead lift is in the subgaleal plane below the temporoparietal fascia. The facelift dissection anterior to the hairline in the temple is in the superficial subcutaneous tissue plane. Therefore, there are two planes of dissection overlapping in the lateral orbital and temporal region. Dissection beneath the lateral border of the platysma below the angle of the mandible is at risk for causing injury to the marginal mandibular nerve, because the nerve is located immediately beneath the muscle in this region. Surgeons who develop a posterior platysmal flap in the superior aspect of the neck to correct platysmal laxity must take care to remain just ventral to the muscle during dissection. The buccal branch of the facial nerve may be injured when performing midfacelifting. This is most likely to occur with subperiosteal dissection rather than supra-smas dissection of the mid-face. Release of the periosteum from the inferior border of the zygoma necessitates dissection over the masseter muscle tendon in the vicinity of the buccal nerve. Mid-facelifting also increases the risks of injury to the zygomatic branch of the facial nerve. The zygomaticofacial and infraorbital sensory nerves are also at risk for injury during mid-facelifting (see discussion on mid-facelifting). Fortunately, injury to motor nerves during rhytidectomy does not usually lead to permanent paresis in most cases. When injury does occur, in most cases it probably represents neuropraxia from traction, heat injury from electrocautery, or needle injury. Scars Hypertrophic scars occasionally occur in the retroauricular incision. This is most often observed in that portion of the incision extending from the postauricular sulcus to the scalp. The skin is thin in this, the apex of the mastoid skin, and even moderate wound closure tension may precipitate scar thickening. Fortunately, if scar hypertrophy occurs, it usually responds rapidly to serial intralesional injections of triamcinolone in a concentration of 10mg/mL. Hypertrophic scars occurring in the preauricular and temple incisions are exceedingly rare. Wound closure tension and subsequent scar contracture of the incisions around the earlobe may produce a variety of deformities, including displacement of the earlobe, obliteration of the sulcus between earlobe and cheek, and downward traction causing a satyr ear. These problems are best avoided by carefully trimming the skin flap beneath the earlobe, so there remains a slight redundancy of flap skin. This redundancy of skin provides

3 a safety against scar contracture and subsequent downward migration of the earlobe. Mild traction deformities of the earlobe can be corrected as soon as 6 months after facelift by direct excision of the scar, creating a rounded lobule, and closing the triangular-shaped defect primarily. This in essence represents a V-Y advancement of the earlobe. For more severe deformities, repair should be delayed for 1 year from the time of the facelift and requires wide undermining of the inferior periauricular cheek skin, so that the area of the excised scar can be moved behind the ear and closed in the postauricular sulcus by advancement of the infra-auricular skin. Hair Loss Hair loss is more common adjacent to temple incisions than postauricular scalp incisions. This may occur even when the dissection is performed well below the level of the hair follicles and is known as telogen effluvium. In such circumstances, hair regrowth will occur within 6 months. Electrocautery in the vicinity of the hair follicles and excessive wound closure tension may cause permanent hair loss. This may require excision of the scalp devoid of hair. Micrografting of the area of alopecia is an alternative. Distortion of the natural hairline may occur if the postauricular flap is not pivoted anteriorly sufficiently to realign the hairline. Stair stepping of the postauricular hairline is more difficult to prevent when there is marked advancement of the cervical skin during rhytidectomy. The temporal hair tuft may be elevated to an unnatural height when trimming the facial flap in the temple. This deformity can be completely prevented by the use of a horizontal sideburn incision beneath the tuft to facilitate trimming of the vertically lifted facial skin. Parotid Injury Injury to the parotid gland parenchyma is likely to occur more frequently than in the past because of the popularity of SMAS flaps and sub-smas dissections. Injury can occur either to the parenchyma or the ductal system and may result in a parotid pseudocyst or fistula formation. Salivary collections beneath the facelift flap may delay the healing process by preventing the facial skin from adhering to the underlying tissue. This may prevent sealing of the injured glandular parenchyma and may eventually lead to the development of a pseudocyst. When dissecting beneath the SMAS over the parotid gland, it is important to recognize that parotid tissue has a gray or pink color and should not be confused with the more yellow fat that may be in the vicinity. If parotid gland parenchyma is inadvertently injured, it should be cauterized in an attempt to seal any ductules that have been violated. After SMAS dissection is completed, a secure closure of the SMAS over the area of parotid injury is performed. If a pseudocyst develops, then serial percutaneous aspirations can be performed. Large pseudocysts greater than 3cm and persistent salivary fistulas should be treated with closed suction drainage. Pigmentary Changes Darker complexioned individuals may have postinflammatory hyperpigmentation of scars or of the skin flap. This may persist for many months but eventually fades. Sun exposure during the first few months postoperatively may accentuate this problem. Hypopigmentation of skin adjacent to facelift incisions may occur if there is

4 excessive skin tension on the wound closure. Skin necrosis and electrocautery of the dermis may also cause hypopigmentation. The severest postoperative pigmentary skin changes are observed in areas that have suffered partial or full-thickness skin necrosis. Facial skin telangiectasias are frequently increased in the skin undermined during dissection of the facelift flap. Patients prone to this problem should be advised of the possibility of accentuating telangiectasias. Contour Deformities Nodules and skin puckering can result from organization of localized hematomas not aspirated postoperatively. Most of these deformities will resolve with time, but resolution is hastened by use of warm compresses, massage, and subcutaneous injections of triamcinolone. A more diffuse but permanent depression or irregularity may result from suction-assisted liposculpturing. If severe, contour irregularities may require autogenous fat grafting. A major contour deformity can occur in the submentum if excessive subcutaneous fat or subplatysmal fat is removed. This is particularly accentuated if the platysmal muscles are not sutured together in the midline. In such instances, a hollow depression occurs above the hyoid in the midline of the upper neck and is referred as a cobra deformity. Depression Short-term situational depression occurs in approximately half of women undergoing rhytidectomy. This develops within the first month postoperatively and is related to the distorted unnatural appearance of the face from edema and bruising. Patients should be given emotional support by reassuring them that depression is common after surgery and that they will improve as facial architecture returns to normal. Occasionally, a short course of antidepressant medication may be indicated. Rhytidectomy complications Rate Treatment Risk factors Hematoma 1-10% Immediate exploration, evacuation of blood and control of hemorrhage Asa, anticoagulants Skin flap necrosis Conservative tx generally reepitheliazation will will occur Hematoma, injury to subdermal plexus too high tension on skin Nerve Injury Greater auricular 1-7% Repair with 10.0 nylon Facial nerve % Most commonly temporal and marginal mandibular Scars Intralesional injections of triamcinolone Most commonly retroauricular - rare preauricular/temporal Hair loss Excision of hairless skin or micrografting if permanent Commonly telogen effuvium - regrowth in 6 months Parotid Injury Small collection - serial aspirations Large pseudocysts greater than 3cm closed suction drain Contour deformities Resolve with time - aided by warm compresses, massage, sub q injections of steroids Depression 50% of women - short term

5 4. A patient seeks your expert opinion on the management of her deep nasolabial folds. What are her options? First article by Robertson et al. Expanded polytetraflouroethylene Augmentation of Deep Nasolabial Creases Retrospective review of 100 consecutive patient who underwent Gore-Tex Augmentation of nasolabial creases with 1 year follow up. Patient varied in grade subjective scale 1-4. The higher the grade usuall the more procedured required Safe effective treatment Complication rate 4.5% - superficial placement and infection Second article Rudkin et al. Aging Nasolabial fold and treatment by Direct Excision Describes using superficial direct excision as a treatment for the aging nasolabial fold. This treatment is recommending only in cases where traditional treatments such as rhytidectomy have had less success specifically in patients with sun damaged skin they have less elasticity causing abnormal appearing rhytids after rhytidectomy Other options in the literature Extended SMAS with periosteal fixation, subperiosteal lift, liposuction, check fat excision, malar fat pad lift, fat sculpturing and fat grafts, direct undermining, injection/implantation of silicone (nolonger available) Collagen, fat, dermal fat grafts. 6. What are the retaining ligaments of the face and why are they important? Plast Reconstr Surg 1192;89: These ligaments are important because they support the facial soft tissue in its normal anatomic locations. Facial skin is supported in normal anatomic position by retaining ligaments the run from deep fixed facial structures to the overlying dermis. Two types of ligaments are: True osseocutaneous ligaments run from periosteum to dermis. And Ligaments formed by the coalescence that occurs between the superficial and deep facial layers (e.g parotidocutaneous, masseteric cutaneous ligaments) Connent both superficial and deep layers of the facia to the skin. Zygomatic ligaments periosteum of malar region begin laterally. They extend through the malar fat pad to the overlying skin. Mandibular ligaments prarsymphyseal skin to underlying mandible Medial cheek fibrous bands from the anterior border of the masseter to the skin. Begin at the malr portion of the muscle and extend inferiorly to the mandible.