Complications of Facelift Surgery

Complications following facelift surgery, or rhytidectomy, can be devastating, particularly because of the elective nature of this procedure. As with all surgical procedures, complication prevention is paramount. ^[1]

Proper patient selection, mastery of pertinent anatomy, attention to meticulous surgical technique, and conscientious postoperative care are all important factors in preventing facelift surgery complications.

Complications include (1) hematoma, (2) nerve injuries, (3) infection, (4) skin flap necrosis, (5) hypertrophic scarring, (6) alopecia and hairline/earlobe deformities, and (7) parotid gland pseudocyst.

So-called minimally invasive procedures such as barbed suture lifts and thread lifts have emerged. ^[2] With these, new complications have been reported, including Stensen duct laceration and suture visibility and extrusion.

An example of facelift surgery complications can be seen in the image below.

Careful patient selection is paramount in preventing complications from facelift surgery or rhytidectomy. A comprehensive history often exposes potential risk factors for future complications.

Some relative contraindications for rhytidectomy include (1) smoking and/or alcohol abuse; (2) collagen vascular disorders; (3) poor nutritional status; (4) anticoagulation bleeding disorder; (5) use of Accutane, high-dose steroids, or immunosuppressants; and (6) poor medical condition (eg, uncontrolled hypertension, poorly controlled diabetes, significant chronic airway disease [CAD], significant chronic obstructive pulmonary disease [COPD]).

Using a prospective, multicenter US database, Gupta et al estimated the rate of major complications following facelift to be 1.8% (compared with 2% for other cosmetic surgeries), with hematomas and infections being the most common. The complication rate for patients undergoing facelift alone was 1.5%, versus 3.7% for those undergoing combined procedures. ^[3]

Out of more than 13,000 patients who underwent rhytidectomy, Chopan et al found the most frequent surgical complications to be hematomas and infections, with the overall adverse event rate calculated in this study as 5.1%. ^[4]

Hematoma

Hematoma is the most common complication after facelift surgery or rhytidectomy. Risk is higher in men (7-9%) than in women (1-3%). ^[5] Other factors that have been associated with increased risk of hematoma include anterior platysmaplasty, high systolic blood pressure, aspirin or NSAID intake, and smoking.

A literature review by Jacono et al found that among different superficial musculoaponeurotic system (SMAS) rhytidectomy techniques—specifically, the SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite procedures—the rate of major hematoma was highest in the SMASectomy/imbrication (1.92%) and deep plane (1.22%) operations. ^[6]

Nerve injury

Permanent motor nerve paralysis occurs at a rate of 0.5-2.6%. The marginal branch most commonly is injured, followed by frontal and buccal branches. Pseudoparalysis of the marginal mandibular nerve due to cervical branch injury can be distinguished from true marginal mandibular injury by the fact that the patient will be able to evert the lower lip because of a functioning mentalis muscle. The prevalence of cervical branch injury in SMAS facelifts is reported at 1.7%. Sensory nerve injuries are more common, with great auricular nerve injury reported in up to 7% of cases.

The above-mentioned study by Jacono et al found that among the different SMAS rhytidectomy techniques, the rate of temporary nerve injury was greatest in high lateral SMAS (1.85%) and composite rhytidectomy (1.52%). The various procedures did not differ with regard to the rate of permanent nerve injury. ^[6]

Infection

Severe infections (requiring intravenous antibiotics) are rare, affecting less than 0.2% of rhytidectomy patients.

Alopecia

Reported prevalence of alopecia is 0.2-1.8%.

Other complications are even rarer, and data are not available regarding prevalence of these complications.

In the above-mentioned study by Chopan et al, risk factors for adverse events in rhytidectomy included male gender, obesity, current engagement in smoking, duration of the procedure, the performance of combined procedures, the use of general anesthesia, and office-based surgery. ^[4]

Hematoma

Predisposing factors for hematoma include male gender, poorly controlled hypertension, and occult aspirin or nonsteroidal anti-inflammatory agent use. (Many postulate that hematomas are more common in men because of the greater vascularity of flaps secondary to hair follicles of the beard and its associated adnexal glands). Intraoperative factors include extensive skin undermining, use of general inhalational anesthesia, and failure to attain adequate hemostasis. Postoperative factors include poor control of nausea/vomiting accompanied by excessive retching or coughing.

A study by Maricevich et al specified preoperative systolic blood pressure of greater than 160 mmHg as a risk factor for postoperative hematoma in patients undergoing facelift. The study involved 229 patients who underwent the procedure, with postoperative hematoma being the second most common complication (6.5%) after unfavorable scar (7.4%). Increased perioperative peak systolic blood pressure was also identified as predictive for hematoma. ^[7]

In a retrospective study by Ramanadham et al, an antihypertensive protocol that included the routine use of transdermal clonidine, close perioperative hemodynamic monitoring, and a target systolic blood pressure of 140 mmHg or less was used in 1089 rhytidectomy patients, with postoperative hematoma developing in only 10 individuals (0.9%). ^[8]

Nerve injury

Transient motor nerve paralysis is more common and may be due to local anesthetic effect, excessive traction of the SMAS, infection, or hematoma. Permanent nerve injury can be prevented by detailed understanding of the anatomy of facial danger zones (see the images below). Nerve injury may result from inadvertent clamping, tying, or electrocauterization of the nerve during an attempt to control brisk hemostasis.

Infection

Predisposing factors for infection include diabetes, immunosuppression, or other systemic illnesses. Postoperative factors include undetected hematoma and wound contamination. The aforementioned study by Gupta et al found combined surgeries and a body mass index of 25 or greater also to be risk factors for infection. ^[3]

Skin flap necrosis

This condition is more common in smokers and in patients with longer and thinner flaps. Unrecognized hematoma may lead to skin flap necrosis.

Hypertrophic scarring

Predisposing factors for hypertrophic scarring include race, ethnicity, and skin type or family history. Hypertrophic scarring is most common in postauricular areas and areas of previous partial-thickness or full-thickness skin slough. The condition may be related to excessive tension on suture lines and may be prevented by careful incision planning, adequate SMAS suspension, accurate skin flap redraping, and judicious use of deep sutures. ^[9]

Alopecia and hairline/earlobe deformities

Alopecia may be caused by excessive tension on suture lines and is often transient because of the shock to the hair follicles. Recovery usually occurs within 3 months. Hairline distortion results from poor incision planning and improper redraping of the skin flap. Earlobe distortion results from poor incision placement, inaccurate reapproximation of the earlobe to the redraped skin flap, or excessive tension on the skin closure.

Parotid gland pseudocyst

This condition may occur after trauma to the parotid gland when raising the SMAS flap.

Hematoma

Patients with major hematoma (see the image below) present with pain, agitation, hypertension, neck/facial swelling, buccal mucosa ecchymosis, and skin ecchymosis. Major hematoma occurs within 12 hours postoperatively. Pain is the sine qua non of major hematoma. Patients with minor hematoma present with localized swelling or bogginess. The condition occurs within 1-14 postoperative days (POD). Hematoma may predispose patients to infection or skin flap necrosis if not treated.

Nerve injury

The physician must distinguish transient paralysis from permanent paralysis. Transient paralysis due to local anesthetic effect or underlying hematoma formation must be excluded. Cases of painful neuroma formation following inadvertent transection of the great auricular nerve have been reported.

Infection

Patients with infection may present with fever, chills, facial swelling, erythema, pain, fluctuance, and drainage.

Skin flap necrosis

Cyanosis of the skin precedes necrosis and is potentially reversible (see the image below). Patients may present with underlying hematoma or infection.

Parotid gland pseudocyst

This condition is usually detected during POD 3-10 and is characterized by recurrent facial swelling following repeated aspiration of clear fluid. A parotid gland pseudocyst may be the cause of a persistent seroma overlying the angle of the mandible following rhytidectomy.

Frontal branch of the facial nerve

The frontal branch of the facial nerve (see the first image below) exits the parotid gland and courses deep to the SMAS layer as it approaches the zygomatic arch. The branch then enters the temporal fossa by crossing superficially over the middle portion of the zygomatic arch. It travels in the temporoparietal fascia layer and then exits the temporal fossa to course along the deep aspect of the frontalis muscle.

Injury occurs when dissecting too superficially in the temporal region. The correct dissection plane in the temporal region lies below the temporoparietal fascia and directly above the superficial layer of the deep temporal fascia (see the second image below).

Marginal branch of the facial nerve

The marginal branch of the facial nerve exits the parotid gland and courses deep to the SMAS layer as it approaches the angle of the mandible. The branch then courses 2-3 cm below the lower border of the mandible, deep to the platysma and superficial to the facial artery and vein, before heading more superiorly toward the oral commissure. Injury often occurs when attempting to obtain hemostasis from inadvertent injury to the facial artery or vein.

Buccal branch of the facial nerve

This branch exits the parotid gland and courses deep to the SMAS layer. Injury occurs when dissecting anterior to the parotid (eg, as in deep plane facelifts). Direct visualization of the nerve branch is essential to avoid injury when beyond the anterior border of the parotid gland.

Great auricular nerve

The great auricular nerve courses deep to the platysma, along the sternocleidomastoid muscle fascia, after exiting from the Erb point. The nerve courses posterior and parallel to the external jugular vein. Injury to the nerve often occurs when attempting to obtain hemostasis from inadvertent injury to the external jugular vein.

Laboratory Studies

No additional laboratory or radiological workup is necessary for most of the above complications. Diagnoses of parotid gland pseudocyst can be confirmed by checking amylase levels of the aspirate.

Surgical Therapy

Hematoma

Major hematomas are a true emergency. Immediate surgical drainage is necessary to avoid flap necrosis. Often no discrete bleeding vessel is identified during surgical exploration.

Direct evacuation of minor hematomas is preferred if the hematoma is detected early and is easily reachable through an existing incision. Otherwise, minor hematomas may be treated with serial needle aspirations and pressure dressing. Antibiotic prophylaxis is suggested.

According to a study by Cason et al, the literature supports the use of an evidence-based, multimodal approach to reducing the incidence of post-facelift hematomas. This approach includes the following ^[10] :

• Strict control of blood pressure perioperatively
• Expectant management of pain, nausea, and anxiety (to inhibit postoperative hypertensive spikes)
• Intraoperative tumescent use
• Employment of intraoperative tranexamic acid and platelet-rich plasma
• Meticulous hemostasis achieved via the second-look technique

The second-look technique involves performing dissection and temporary closure on first one side of the facelift and then the other, followed by a return to the first side and then the second for hemostasis and closure. This method combats delayed bleeding. ^[10]

Nerve injury

If a motor nerve is knowingly transected, immediate microscopic neurorrhaphy is indicated. If nerve injury is noted postoperatively, institute expectant management. Eliminate anesthetic effect. Transient paralysis is more likely than permanent paralysis.

The literature indicates that during rhytidectomy, maintenance of the auricle’s sensory function is better accomplished through preservation of the great auricular nerve’s lobular branch than through protection of its posterior branch. A cadaveric study by Sharma et al analyzed variations in the position of the lobular branch as a means of helping surgeons to avoid it during rhytidectomy dissection. The investigators found the lobular branch to be present in all 50 cadaveric necks, with the branch being directly inferior to the antitragus in 85% of specimens and directly inferior to the tragus in the other 15%. Thus, according to the report, the predicted location of the lobular branch can be determined through preoperative markings, specifically, vertical lines running from the tragus and antitragus to the McKinney point. ^[11]

Infection

Major infections requiring intravenous antibiotics are rare. The predominant organisms causing infection are staphylococci. Patients with minor hematomas may warrant oral antibiotic prophylaxis.

Skin flap necrosis

Treat partial-thickness injury with moist surgical bandage, occlusive ointments, or both. These injuries may result in normal healing, hypertrophic scar formation, or abnormal pigmentation. Treat full-thickness injury with conservative debridement and healing by secondary intention.

Hypertrophic scarring

This condition may be treated with intralesional corticosteroid injections or silicone topical therapy (eg, Cica-Care, Kelo-cote gel). Perform scar revision only after complete wound maturation.

Alopecia and hairline/earlobe deformities

Transient traumatic alopecia is likely to normalize in 3 months. Permanent alopecia may be corrected with local flaps or micrografts and minigrafts. Observe earlobe distortion for spontaneous improvement. Surgical correction with local advancement flaps may be used for persistent deformity.

Parotid gland pseudocyst

Treat this condition with frequent needle aspirations and suction drain insertion.

Hematoma

Ischemic changes of the skin flap are reversible, and skin flap necrosis and scarring are avoidable, if major hematoma is detected early. Chance of infection increases upon reexploration of wounds.

Minor hematoma usually resolves without sequelae after evacuation or after serial aspiration. Slight soft tissue contour irregularity may result, however.

Nerve Injuries

Motor nerve paralysis

Intraoperative neurorrhaphy improves facial paralysis to House-Brackman Grade IV status. For postoperatively diagnosed paralysis, rule out local anesthetic effect. If paralysis remains, manage initially as neurapraxia. Monitor with serial examinations and electrical testing. Adjunctive measures to assure corneal protection include lubrication and gold weight.

Permanent sensory nerve injury

Great auricular nerve injury is usually permanent, but the affected sensory area typically decreases in size over time. Painful neuromas may result with transection.

Infection

Most infections resolve without sequelae if detected and treated early. Some soft tissue contour deformity may result if infection is severe or undetected.

Skin flap necrosis

Healing by secondary intention often results in a satisfactory scar, although hypertrophic scarring may result.

Parotid gland pseudocyst

This problem often resolves without sequelae within 1-3 weeks upon repeated aspiration or drain insertion.