Complications of Facelift Surgery

42.2 Complications

42.2.1 Asymmetry

Asymmetry usually results from excess excision of skin from one side of the face or from unequal pull on the flaps, not in the same direction, on each side. Distortion of the earlobe is common if the closure is performed under any tension around the bottom of the ear. Revision surgery may have to be performed.

42.2.2 Bleeding

Postoperative bleeding may occur if the vessels are not completely ligated or electrocoagulated.

42.2.3 Dehiscence

Tight wound closure with tension may result in wound dehiscence. This may require resuturing but if the tissues are friable, the wound may have to be allowed to heal with secondary intention.

42.2.4 Dog Ear

A dog ear may occur in the temporal region or the posterior neck or scalp. Most will tend to resolve over a few months. It is easier to repair the dog ear at the end of the surgical procedure but revision may be performed at a secondary surgery.

M.A. Shiffman

17501 Chatham Drive, Tustin, California 92780-2302, USA e-mail: shiffmanmdjd@yahoo.com

42.2.5 Ear Deformities

Excessive tension is the usual cause of ear deformity. Excision of skin around the ear should be performed after tension sutures have been inserted above the ear and behind the ear. Secondary surgery may be necessary to correct a deformity.

42.2.6 Edema

Edema usually subsides within the first few weeks. Chronic edema should be investigated for causes other than the surgery. Diuretics are not usually recommended.

42.2.7 Hair Loss

Hair loss can occur as the result of a tight closure and tension on the hair-bearing tissues. Most of the time the hair will regrow over time. Repair of the area of chronic hair loss may require excision (after 6 months) of the bare region or hair transplantation can be performed.

42.2.8 Hematoma

An expanding hematoma (pain and swelling of the side of the face) is a surgical emergency and requires early wound exploration with evacuation of the hematoma, ligation of bleeder, and probably needs to be drained at the time of closure [1].

42.2.9 Infection

Infection is rare (11 in 6,166 cases or 0.18% [2]). Inflammation may be treated with topical steroids and any infection should be treated with appropriate antibiotics. Heat applied locally is helpful.

42.2.10 Irregularities

Irregularities may be the result of coming too close to the skin in developing the facial flap. Indentations of the skin following face-lift surgery can be treated with a filler, preferably autologous fat. In one case indentation occurred from a very tight S suture in a modified face-lift (S-lift) (Fig. 42.1). This resolved over a

Fig. 42.1 This patient had an S-lift and 1 week after surgery began to develop a swelling of the right cheek. On examination there was a soft swelling that became an indentation when compressed by the finger. Simple observation with mild massage of the area allowed the problem to resolve that originated from too tight a closure of the purse string S suture in the parotid fascia

couple of months without treatment except massage of the area.

42.2.11 Necrosis

Necrosis can be the result of the flaps being too thin or the closure being too tight. Smokers are very susceptible to flap necrosis if the smoking is not completely stopped prior to and after surgery [3]. Especially dangerous is electrocoagulation of bleeders on the skin flap. The oozing of blood on the skin flap should be treated with compression only.

42.2.12 Neurological

Any of the facial sensory or motor nerves in the area of the face-lift may be injured. Especially susceptible are

the branches of the facial nerve and the anterior and posterior auricular nerves. Prevention is a necessity. The surgeon should understand facial anatomy and the three-dimensional relationship of the nerves.

Temporary paresis can occur with injection of local anesthesia into the area of the nerve or from traction on the nerve. This type of paralysis can be observed until it clears. If there is any question of motor nerve transection then studies should be performed to establish nerve conduction. Early repair of a transected nerve will aid in more complete and earlier return of function.

42.2.13 Pain

Persistent facial pain is rare. If acute following surgery this may suggest an expanding hematoma. If chronic branches of the sensory cervical nerves may have been injured. The pain will usually subside within 6 months. Nerve blocks may give temporary relief.

Fig. 42.2 Scar at the anterior inferior portion of the ear following S-lift. Surgical revision was necessary

42.2.14 Pigmentation Changes

Hyperpigmentation may follow facial ecchymoses even with full resolution of the bruising. Sunlight exposure may increase the possibility of hyperpigmentation.

Patients with telangiectasias may develop more after rhytidectomy.

42.2.16 Scar

Scars are usually a physiologic response to injury and may be hypertrophic or keloid. Keloid scars can be hereditary. Tight closure can contribute to a widened scar (Fig. 42.3).

There are a variety of treatments for keloids and hypertrophic scars including steroid injection, surgery, 5-fluorouracil injection, silicone gel sheeting, bleomycin injection, or a combination of these.

42.2.15 Salivary Fistula

Sutures placed deep in the parotid fascia (part of the SMAS) can result in a salivary fistula (rare) (Fig. 42.2). Treatment would require removal of the offending suture, bland diet, and Donnatol four times daily to reduce the salivary flow. The fistula usually heals very readily with this treatment.

42.2.17 Seroma

Seroma may occur following an unrecognized hematoma under the skin flap. Syringe with needle drainage followed by compression may resolve the problem. Open drainage with suction catheter can be used for persistent seroma.