Complications in FaceliftSurgery: Avoidance and Management

Richard A.K. Chaffoo, MD, FACS, FICSa,b,*

KEYWORDS

� Facelift � Rhytidectomy � Facelift complications � Cosmetic surgery � Facial rejuvenation

KEY POINTS

� Facelift surgery yields high satisfaction for most patients who have aesthetic surgery and mostwomen and men who seek facial rejuvenation surgery are generally well adjusted psychologicallyand have realistic expectations.

� Complications related to facelift surgery can be divided into 3 main areas: preoperative assessmentand surgical planning, intraoperative surgical maneuvers, and postoperative care.

� A methodical operative plan based on the patient’s aesthetic deformities executed in a meticulousmanner helps to limit intraoperative complications.

� Of all complications related to rhytidectomy, the so-called “done look” is perhaps the most com-mon and most difficult (or impossible) to correct.

� A thorough history and physical elicit evidence of prior complications associated with anesthesiaand surgery.

� Hematoma formation typically occurs within the first 24 hours following surgery, and is the mostcommon postoperative complication.

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INTRODUCTION

Rhytidectomy continues to be one of the mostcommon aesthetic procedures performed byplastic surgeons, as reported in the annual statis-tics by the American Society for Aesthetic PlasticSurgery. It consistently ranks within the top 10aesthetic surgical procedures performed in theUnited States each year, with more than 100,000performed in 2010, an increase of 28.5% since1997.1 Despite widespread public acceptance ofaesthetic surgery, complications related to faceliftsurgery persist. This article reviews the commoncomplications and proposes strategies to reduceor eliminate them wherever possible.

Complications related to facelift surgery can bedivided into 3main areas: preoperative assessmentand surgical planning, intraoperative surgical ma-neuvers, and postoperative care. Although some

Disclosures: None.a Division of Plastic Surgery, Department of Surgery, UCSPlastic Surgery, Scripps Memorial Hospital, Encinitas, CA,* Suite 480, Scripps Ximed Medical Building, 9850 GeneE-mail address: drc@drchaffoo.com

Facial Plast Surg Clin N Am 21 (2013) 551–558http://dx.doi.org/10.1016/j.fsc.2013.07.0071064-7406/13/$ – see front matter � 2013 Elsevier Inc. All

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complications are unavoidable and unforeseenwith any surgical procedure, patients are lessforgiving and tolerant of those associated with anaesthetic surgical procedure.

Some complications can be avoided during thepreoperative evaluation. A thorough history andphysical elicit evidence of prior complicationsassociated with anesthesia and surgery. Easybruising or postoperative bleeding should alertthe surgeon that a coagulation work-up may beindicated. Patients are instructed to avoid the useof aspirin and nonsteroidal antiinflammatory drugsfor at least 2 weeks before surgery. Smokingmust be discontinued for at least 4 weeks beforesurgery. All herbal preparations, vitamins, and ho-meopathic treatments should also be avoided for2 weeks before surgery because of the risk of post-operative bleeding and intraoperative anestheticcomplications, including arrhythmias (Box 1).

D School of Medicine, La Jolla, CA, USA; b Division ofUSAsee Avenue, La Jolla, CA 92037.

rights reserved. facialplastic.theclinics.

Box 1Herbal supplements to avoid before surgery

Dong quai, Ginkgo biloba, St. John’s wort(all types)

Echinacea, ginseng, valerian

Ephedra, glucosamine, vitamin C (>2000 mgdaily)

Feverfew, goldenseal, vitamin E (>400 mg daily)

Fish oils (omega-3 fatty acids)

Garlic, licorice

Kava

Licorice

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Chemotherapeutic agents and oral steroid usagecan alter wound healing and must be discontinuedseveral weeks before elective surgery. In addition,close communication and clearance with thepatient’s primary care physician and specialistis needed to determine suitability for electiveaesthetic surgery.The initial consultation must include a thorough

assessment of the patient’s signs of facial aging.This assessment includes an evaluation of skintone and laxity, facial rhytids, dyschromia, previ-ous facial scars, skin atrophy, telangiectasia(worsened with facial surgery), and presence orabsence of facial fat. Facial fat is important inthat care must be taken during flap elevation toavoid perforation of the superficial muscularaponeurotic system (SMAS) and facial nerveinjury. Furthermore, aggressive liposuction insuch patients may result in visible and/or palpablecontour irregularities of the face and neck.Facial nerve paresis or paralysis must be docu-

mented and demonstrated to the patient. Subma-lar hollowing, microgenia, and facial asymmetryneed to be recognized and discussed with the pa-tient. Submandibular gland ptosis, low-riding hy-oid, and platysmal bands are also documented.Deep neck rhytids, perioral rhytids, and nasolabialfolds are unaffected by rhytidectomy so alternativetreatment plans can be discussed at the initialconsultation. The hairline needs to be inspectedcarefully. The position of the frontal and temporalhairlines should be noted along with any alopecia.Patient expectations and goals should be dis-

cussed. It may be possible to identify a particularlydifficult or manipulative patient before the consul-tation based on the patient’s interactions with theoffice staff. The aesthetic deformities must becorrectly identified during this consultation, andthe surgeon needs to develop an appropriate sur-gical plan to manage each deformity. It is

paramount that an open and honest dialogue oc-curs between surgeon and patient as to the defor-mities that will be improved at the time ofrhytidectomy. Realistic goals need to be agreedon with the patient in advance because a thoroughpreoperative discussion and explanation of thelimitations of rhytidectomy are interpreted by thepatient as a sign of a meticulous and ethical plasticsurgeon. If this discussion occurs only after sur-gery, it is viewed with suspicion by the patientand interpreted asmaking excuses for an outcomethat the patient perceives as suboptimal.An evaluation of the skin is critical in the

aesthetic analysis of every patient. Extensive skinlaxity may alert the surgeon that a minor touch-up or further skin excision may be needed severalmonths after the initial rhytidectomy, especially inelderly patients and those with prior extensivesun exposure or steroid use. Facial dyschromiaand telangiectasia can be exacerbated byrhytidectomy.Facial asymmetry is common in patients who

present for aesthetic surgery. This asymmetrymay be the result of, among other things, priorfacial surgery, trauma, facial nerve injury, soft tis-sue atrophy, skeletal abnormalities, brow ptosis,or alopecia. It is necessary to point out this asym-metry to the patient in a mirror and explain that itmay persist after rhytidectomy. Submalar atrophymay respond to soft tissue augmentation per-formed at the same time as the rhytidectomy,especially in the case of fat transfer. Microgeniacan be corrected concurrently and creates amore youthful jaw and neck contour.Submandibular gland ptosis is not improved by

most rhytidectomy techniques and may even beaccentuatedwith aggressive liposuction in the sub-mandibular area. This limitation needs to be dis-cussed with the patient at the initial consultation.Techniques are available to remove the subman-dibular glands causing this ptosis but the author(an otolaryngologist and plastic surgeon) does notadvocate such an approach. Such surgery canresult in significant morbidity, including facialnerve, lingual nerve, and hypoglossal nerve injuryand hemorrhage from the facial and lingual arteries,which might compromise the patient’s airway.Platysmal laxity should be noted at the consulta-

tion and a surgical plan formulated to improve thisdeformity. In general, platysmal laxity can beimproved with plication. However, overly aggres-sive surgery, including extensive subplatysmal li-pectomy and digastric muscle resection, canproduce an unnatural and overly operated-onappearance to the neck, including witch’s chin,cobra deformity, and a skeletonized and cadavericneck, which does not look rejuvenated.

Fig. 1. Preoperative rhytidectomy. (A) Masseteric cuta-neous ligament. (B) Mandibular cutaneous ligament.

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It is important to evaluate the patient’s hairlineand look for evidence of alopecia. The present po-sition of the temporal and mastoid hairlines needsto be respected in the design of any rhytidectomyincisions. The temporal hairline must not beelevated or narrowed as the result of a poorly de-signed incision. The upper end of the rhytidectomyincision should be placed along and parallel to thelower end of the temporal hairline and should notextend above the upper edge of the pinna. If itdoes, the temporal hairline is raised and narrowed,compromising the final aesthetic result and mak-ing reconstruction of this valuable landmark diffi-cult. Hairline incisions in the mastoid and postauricular area should be avoided because theyoften result in hypopigmented and quite obviousscars that prevent the patient from wearing herhair up, which might expose them. If it is necessaryto extend the incision behind the ear, then it is pru-dent to continue it into the hair-bearing scalp.

INTRAOPERATIVE COMPLICATIONSPositioning and Preparation

Careful patient positioning following anesthesiaand before surgery improves patient visibility andoutcome and reduces complications. Suturingthe endotracheal tube to the lower central incisorsstabilizes the airway and avoids the use of tape onthe face, with its subsequent distortion of sur-rounding structures. The head is positioned in asmall donut for occipital support and the armstucked at the patient’s sides. It is sometimes help-ful to place a small roll between the shoulderblades to extend the neck adequately. The eyesare lubricated, taped, and checked frequentlythroughout the procedure to prevent corneal dry-ing. Local anesthesia is infiltrated before thesurgical prep to allow the epinephrine effect tooccur by the time of the surgical incision. Thehair is prepped in the surgical field because it isan important aesthetic landmark but may requirerubber bands to keep it off the field. Cotton ballsare placed in the ear canals to reduce blood pool-ing here.

Incision and Flap Dissection

The skin incision is created with a #15 blade andthe skin flaps elevated a short distance with theknife and single-toothed Addison forceps. Next,the flaps are first elevated using double skinhooks and then Deaver retractors to avoid traumato them. The flaps are then elevated with tenot-omy scissors for about 2–3 cm while the assistantretracts the skin medially. The overhead surgicallights are shone on the outer surface of the skinflaps and not directly into the surgical field for

transillumination. This method allows the surgeonto ensure the proper plane of dissection of theskin flaps. The light should shine through theflaps, indicating that a small amount of fat is onthe undersurface of the flaps, the so-called peaud’orange effect. If the light becomes dim or ab-sent, it indicates that the surgeon is in too deepa surgical plane and adjustment needs to bedone to avoid perforation of the SMAS. Deeperdissection may result in inadvertent injury to theparotid fascia and underlying gland, increasingthe possibility of parotid fistula.

After the initial 2–3 cm of dissection with tenot-omy scissors, the flap dissection continues withflat, long-bladed facelift scissors by bluntly raising2 tunnels and connecting them under directvision. The dissection of the flap continues alongthe mandible to release both the masseteric cuta-neous and mandibular cutaneous ligaments (Figs.1 and 2).

Parotid duct injuryInjury to the parotid duct may occur along theanterior border of the masseter on a line from theexternal auditory canal to the upper lip. If it isinjured, the distal end of the duct is cannulatedwith a small catheter and passed retrograde intothe field and then passed into the proximal sev-ered end. The duct can be sutured with 6-0 nylonsutures and the catheter left in place for about2 weeks.

Fig. 2. Postoperative rhytidectomy.

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Facial nerve branch injuryInjury of branches of the facial nerve can occurduring flap dissection if the dissection is toodeep. If recognized during the surgery, the nerve

Fig. 3. Erb point.

can be repaired with 6-0 nylon sutures after iden-tification of the distal severed branch by nervestimulation and a lack of paralytic anestheticagents. The temporal branch is most vulnerableanterior to the temporal hairline so dissectionhere must be superficial with observation of theoverlying hair follicles in the skin flap to ensureproper plane position. Marginal mandibular andcervical branch injuries are possible if the dissec-tion below the mandibular border extendsbeneath the platysma. Bipolar cautery is helpfulin areas where the facial nerve branches aresuperficial, such as the temporal and cheekregions.

Auricular nerve and jugular vein injuryThe posterior neck flap dissection must be donesuperficially but without buttonholing the skinflap. Care is taken to avoid exposing the fasciaoverlying the sternocleidomastoid muscle andrisking injury to the great auricular nerve andaccompanying external jugular vein. If injured,direct repair of nerve and suture ligature of veinshould be undertaken.

Spinal accessory nerve injuryMore posteriorly, injury to the spinal accessorynerve can occur if the dissection becomes toodeep. A good superficial landmark to keep inmind is Erb’s point (Fig. 3), which is a point alongthe posterior border of the sternocleidomastoid

Complications in Facelift Surgery 555

muscle midway between the mastoid and clav-icle. It can be estimated by drawing a horizontalline from the thyroid notch to the posterior borderof the sternocleidomastoid muscle. It is the pointfrom which the nerve roots of C5 and C6converge. It is also the location of the greaterauricular nerve. Most importantly, the spinalaccessory nerve exits from the posterior borderof the muscle within 2 cm superior or inferior tothe Erb’s point.

Jowl Liposuction

Once flap elevation is completed, direct liposuc-tion of the jowls can be performed gently with a1-mm or 2-mm liposuction cannula keeping theopen end of the cannula down away from the un-dersurface of the flap to avoid contour deformities.Liposuction must be done gently to avoid paresisof the marginal mandibular nerve. Liposuctionposterior to the mandibular angle helps definethis area and create a more youthful jawline.

SMAS Plication

Plication of the SMAS is done using 4-0 Mersilenesutures, with care taken to avoid penetration of theparotid fascia and parotid gland. The plicationshould include just the SMAS or a parotid fistulamay occur, resulting in postoperative gustatoryswelling and erythema, which may necessitatewound exploration and suture removal. If the plica-tion results in tissue elevation, these irregularitiesshould be carefully trimmed flush with the sur-rounding tissue to avoid noticeable contour defor-mities after surgery. The decision to use a drain ismade now based on the appearance of the opera-tive field. If the field appears wet, small rounddrains are placed through a small stab incision inthe postauricular sulcus and typically removedthe following day. The drains are useful to reducepostoperative edema and ecchymosis in such sit-uations but not to reduce hematoma formation.

Skin Excision and Wound Closure

Meticulous hemostasis is paramount at this pointbefore skin removal and wound closure. Pinpointbipolar cautery is useful and reduces trauma tothe underlying facial nerve branches, therebylimiting postoperative facial nerve neurapraxia.Skin flaps are redraped and checked for signs ofvascular compromise. Excess skin is removedand closure performed first at the temporal hair-line. Most tension on the flaps occurs herebecause of the lifting nature of the flap redrapingversus posterior pulling with its subsequent wind-swept look. Several 4-0 monocryl sutures areplaced in the subcutaneous/deep dermal position.

Further skin excision is done down to just abovethe tragus with no tension to avoid distortion ofthe auricle. All further skin excision must be con-servative. The tragal flaps are conservatively de-fatted and conservatively trimmed to eliminateany widening of the ear canal. The skin aroundthe ear lobes is carefully removed so that theear lobes are free with no tension. The same con-servative approach is used in the postauricularsulcus. Skin closure is with interrupted 5-0 mono-cryl dermal sutures and 5-0 nylon skin sutures,except 5-0 fast-absorbing gut for the tragalclosure. The submental incision is closed last,with final inspection of the submental area forhemostasis.

Immediate Postoperative Procedures

Placement of a compressive dressing for the first24 hours after surgery may reduce the extent ofedema and ecchymosis. Fluffs are placed aroundeach ear for padding and to prevent inadvertentfolding over of the external ears. Kerlix andbias are wrapped around the face and neck as afigure-of-eight dressing. Communication is impor-tant between the surgeon and anesthesiologist toavoid excess coughing and straining during extu-bation, which could cause hematoma formation.The head of the bed is elevated with the kneesflexed and ice applied to the central face in the re-covery room. Postoperative nausea is monitoredand treated promptly in the recovery room andduring the first several days after surgery with anti-emetic agents to reduce ecchymosis.

POSTOPERATIVE COMPLICATIONSHematoma

Hematoma formation typically occurs within thefirst 24 hours following surgery, and is the mostcommon postoperative complication, occurringin 3% to 8% of cases according to multiplestudies.2–6

Before discharge, the dressings are inspectedand flaps viewed with a flashlight while lifting upthe Kerlix wrap from each cheek. If there is signif-icant pain or asymmetric swelling, the dressingsare immediately removed and the flaps inspected.The patient is returned to the operating room if ahematoma is discovered because further delayplaces the flaps at risk, and an expanding hema-toma can compromise the patient’s airway if notmanaged immediately. The incision is opened,clots evacuated, bleeding controlled, and the inci-sions closed over an active drain. Early andprompt intervention reduces the risk of furthervascular compromise to an already compromisedflap.

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Infection

Infection is unusual following rhytidectomy butmay occur as the result of a stitch abscess or,more rarely, a suture passed through the tragalcartilage. The offending suture(s) should be re-moved and local wound care with an antimicrobialointment often clears the problem. Significant ery-thema and tenderness to the auricular cartilagewarrants oral antibiotics to cover Staphylococcus,Streptococcus, and Pseudomonas to preventpermanent cartilage damage.

Nerve Injury

Nerve injury is rare but has been reported at ratesfrom 0.7% to 2.5% in large series.7 If noted duringsurgery, primary repair results in the best outcome.Mild facial paresis is usually temporary but maypersist for 12 hours after surgery, caused by theprolonged duration of local anesthetic agents oredema of the nerve. Permanent nerve injuriesmay involve sensory and motor nerves. The greatauricular nerve is the most frequently injured sen-sory nerve and results in numbness. If the nerve isrepaired during surgery, return of sensation is com-mon but may be delayed for 12 to 18 months andresult in localized areas of persistent anesthesia.The temporal branch is the most frequently injuredmotor nerve inmost series; the delay is usually tem-porary, reported as 0.8% in a review of more than12,000 rhytidectomies. Permanent injury wasnoted in 0.1% of the cases in this large retrospec-tive study. Temporal nerve injurymay resolvewithin18 to 24 months of onset but the resultant asym-metric brow can be improved with careful use ofparalytic agents like Botox or Dysport on the non-paralyzed side. If the forehead paralysis is perma-nent, treatment is dictated by the extent of thesubsequent deformity and disability. Mild asymme-try is best managed by the paralytic agentsmentioned earlier, whereas significant brow ptosismay require a brow lift on the affected side.Other nerve injuries may include marginal

mandibular, zygomatic, buccal, or cervicalbranches of the facial nerve, and permanent dam-age was less than 1% in a large study.7 Temporaryinjury is dictated by paresis versus paralysis andlength of time since surgery. Permanent injury islikely if no return of function occurs after 2 years.Long-term management of paralysis depends onthe branch injured, subsequent deformity, andfunctional deficits.

Systemic Complications

Major systemic complications are unusual inpatients undergoing facelift surgery, reported

as 0.1% in a large facelift survey by the AmericanSociety of Plastic Surgeons. Major complicationsincluded deep vein thrombosis (DVT), pulmonaryembolism, stroke, blood transfusions, majoranesthetic complications, and death. A morerecent report by the American Society forAesthetic Plastic Surgery discussed a singlecenter’s experience with venous thromboembo-lism in which 630 patients underwent rhytidec-tomy and 3 cases of DVT were identified.8 Riskfactors included operative time more than5 hours and combining rhytidectomy with otherprocedures. DVT diagnosis was established byultrasound and confirmed by computed tomog-raphy. Patients were admitted and received anti-coagulation therapy followed by warfarin for6 months. All patients recovered with full resolu-tion of their symptoms.

Skin Slough

Skin slough is a rare occurrence following rhyti-dectomy. The skin flaps are monitored closelyduring the postoperative course. Vascularcompromise is usually noted in the periauricularregion and may appear as a distinct area ofecchymosis. Local application of nitropaste orDMSO 2 to 3 times daily may be beneficial toreduce the chance of full-thickness skin loss.More often, there is a superficial epidermolysisthat heals uneventfully. Nevertheless, the areaof concern is allowed to demarcate fully into aneschar before conservative debridement is donein the office. The debrided area is protectedwith an antimicrobial ointment until secondaryhealing has occurred. Excision of scars andclosure are delayed until full maturation of thewound and scars has occurred to prevent furthercompromise of the flaps and ultimate aestheticresult.

Scarring

Noticeable scars are unusual following a well-designed and well-executed facelift. Hypertrophicscars are injected with a dilute concentration ofKenalog 2% to 5% every 6 weeks once noted,along with the use of silicone sheeting or gels.Persistent scars may respond to pulsed dye lasertherapy if resistant to the aforementioned mea-sures and usually require multiple treatments.The laser also reduces the telangiectasia that oc-curs following prolonged steroid injections. Hypo-pigmented scars are most common along theposterior hairline when incisions have been placedalong the hairline instead of behind it. These scarscan be reduced by medical tattooing or the inser-tion of hair grafts into the scar.

Fig. 4. Preoperative rhytidectomy.

Fig. 5. Postoperative rhytidectomy with normal peri-auricular architecture and preserved temporal tuft.

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Alopecia

Alopecia occurs following damage to the hair folli-cles from electrocautery, excess traction of ten-sion on the skin flaps, and inadvertent elevationor elimination of the temporal hair tuft and tempo-ral hairline. Temporary loss may be shortened withthe use of topical minoxidil. Permanent alopeciarequires the insertion of single-hair follicular unitsinto the areas of alopecia or the replacement orlowering of the temporal hairline. Definitive hairreplacement surgery should be delayed until it iscertain that the loss is permanent, which oftenrequires 12 months to ascertain.

Contour Deformities

Contour deformities are common immediately af-ter rhytidectomy. Most of these are temporaryand related to postoperative edema and ecchy-mosis and occur in the preauricular and submen-tal regions. As the swelling subsides, most ofthese resolve, and resolution may be hastenedwith gentle local digital massage. Persistent con-tour deformities may be seen for several monthsand require no further treatment. If localized areasof depression persist after 6 to 12 months, theycan be improved by injections of dermal fillersor fat.

SUMMARY

Despite the complexities and challenges, faceliftsurgery continues to yield high satisfaction formost patients who have aesthetic surgery. Mostwomen and men who seek facial rejuvenation sur-gery are generally well adjusted psychologicallyand have realistic goals and expectations. As anaesthetic plastic surgeon ages and matures, sodoes his patient base and community reputation.The natural outcome is for surgeons to see morepatients for facial rejuvenation when they areseasoned surgeons, which is fortunate for bothpatient and surgeon.

Complications related to rhytidectomy are aninevitable outcome of a busy aesthetic plasticsurgery practice. It is imperative that the surgeonconstantly strives to reduce the incidence andseverity by a proactive approach. The initial his-tory and physical examination must be overseenby the responsible surgeon to elicit informationthat might be overlooked by a nurse or other of-fice assistant. The patient’s demeanor and inter-action with the surgeon may either reinforce thatof the office staff or contradict it. When in doubt,it is always prudent to defer surgery and allowthe patient to choose another, less fortunatecolleague.

Fig. 6. Preoperative rhytidectomy.

Fig. 7. Postoperative rhytidectomy.

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A methodical operative plan based on thepatient’s aesthetic deformities executed in ameticulous manner helps to limit intraoperativecomplications. Vigilant postoperative care bythe surgeon and trained staff are vital to recog-nize and treat any postoperative complications.Once a complication is recognized, the surgeonmust maintain good communication with the pa-tient along with frequent office visits to managethe subsequent physical and psychologicaleffects.Overall, what patients fear most is the so-called

“done look.” Of all the complications related torhytidectomy, this is perhaps the most commonand most difficult (or impossible) to correct. Allpatients have seen examples of this in their com-munities, and it is what they most fear. The hall-marks of this include an overly stretched, pulled,or tightened face with distortion of the mouth.The hairline is distorted or raised and scars areevident around the ears and hairline. The resultsare neither youthful nor aesthetic. In men, theend result is feminization of the face, which mightbe why men are initially more reluctant thanwomen to consider rhytidectomy. Patients arerelieved when assured that great plastic surgeryis natural looking and often goes unnoticed byfamily and friends (Figs. 4–7).

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