Complications of Rhytidectomy

Hematoma

The most common perioperative complication of rhytidectomy is hematoma, occurring with a frequency of 1% to 15% [1], [2], [3], [4], [5], [6], [7]. Hematomas can range in volume from a small collection of blood that is only detected after facial swelling regresses to a large expanding hematoma that can endanger skin flap survival. The incidence of large hematomas requiring surgical intervention ranges from 1.9% to 3.6% [2], [4].

Large and expanding hematomas usually occur within the first 24

Nerve injury

The most common nerve injury during rhytidectomy is to the great auricular nerve, occurring in 1% to 7% of procedures. Most patients undergoing rhytidectomy have transient numbness to the preauricular region and lower portion of the ear owing to the transection of small sensory nerves after dissection. Injury or transection of the great auricular nerve can cause permanent loss of sensation to the lower ear with paresthesias and pain.

The great auricular nerve emerges on the posterior border of

Skin flap necrosis

Skin flap necrosis is associated with ischemia caused by vascular congestion and arterial compromise secondary to unrecognized and untreated large hematomas and has a reported incidence ranging from 1.1% to 3.0% [Fig. 5] [1], [19]. Necrosis may also occur from ischemia related to the use of tobacco, certain systemic medical conditions (ie, Raynaud's disease [21]), or injury to the subdermal plexus during flap dissection or from closing the face-lift incisions under excessive wound closure

Scars

Hypertrophic scars occasionally occur in the retroauricular incision and usually appear within the first 12 weeks post rhytidectomy. The scars are most often observed in the portion of the incision extending from the postauricular sulcus to the scalp. The skin is thin in this region, and even moderate wound closure tension may result in scar thickening. If scar hypertrophy occurs, it usually responds rapidly to serial injections of triamcinolone in a concentration of 10 mg/mL. Hypertrophic

Hair loss

The incidence of alopecia after rhytidectomy is as high as 8.4% [25], with rates of permanent loss requiring surgical revision ranging from 1% to 3% [1]. Hair loss is more common in the temple region than the postauricular area and may be related to direct trauma to the hair follicles during dissection (transection of follicles or electrocautery), excessive tension on the skin flap during closure, or an expanding scar in which hair cannot grow. Patients with thinning hair preoperatively are at

Infection

Infection after rhytidectomy is rare. The incidence has been reported to be less than 1%. Leroy and colleagues [28] reviewed the records of 6166 consecutive face-lifts and found 11 infections (incidence of 0.18%) requiring hospital admission. Most of these infections occurred during the first week after surgery. The most common causative organism was Staphylococcus followed by Streptococcus, and 7 of the 11 patients had been given postoperative antibiotics. Interestingly, of the three patients

Parotid injury

Injury to the parotid gland during rhytidectomy is rare but is more likely to occur with current techniques that involve sub-SMAS dissections. Injury can occur to the parenchyma or the ductal system and may result in a parotid pseudocyst (sialocele) or fistula formation [29]. Salivary collections beneath the face-lift flap may delay the healing process by preventing the facial skin from adhering to the underlying tissue. They may prevent sealing of the injured glandular parenchyma and may

Pigmentary changes

Patients with Fitzpatrick skin types IV through VI may develop postinflammatory hyperpigmentation of scars or the skin flap. This hyperpigmentation may persist for many months but eventually fades. Sun exposure during the first few months postoperatively may accentuate the problem. Hypopigmentation of skin adjacent to face-lift incisions may also occur in patients of all skin types if there is excessive skin tension on the wound closure. Skin necrosis and electrocautery of the dermis may also

Contour deformities

Contour deformities can occur from overly aggressive liposculpturing, particularly in the submentum and neck. Nodules and skin puckering can result from organization of localized hematomas not aspirated postoperatively. Most of these smaller deformities will resolve over several months. The use of massage and steroid injections can speed their resolution.

A major contour deformity can occur in the submentum if excessive subcutaneous or subplatysmal fat is removed. This deformity is particularly

Depression

Short-term situational depression occurs in approximately 30% of women undergoing rhytidectomy [33]. These reactions are primarily correlated with a pre-existing, clinically detectable depression or a depression-prone personality pattern. Depression 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 following surgery, and

Deep venous thrombosis and pulmonary embolus

Deep venous thrombosis and pulmonary embolus account for as many as 5% of postoperative deaths occurring in the hospital setting and are thought to occur primarily in trauma, elderly, or immobilized patients. Reinisch and colleagues [34] reviewed the incidence of deep venous thrombosis and pulmonary embolus reported by 273 surgeons who performed 9937 face-lifts. Forty-nine patients had thromboembolic complications (0.49%), with 35 experiencing deep venous thrombosis (0.35%); 14 had pulmonary

Summary

As is true in any surgery, complications after rhytidectomy are unavoidable. The key to their minimization is a complete understanding of their causes and adherence to meticulous surgical technique. When complications occur, the surgeon must be willing to confront them honestly and openly. This care often requires frequent clinic visits for patient reassurance and occasionally revision surgery when conservative management cannot achieve an optimal cosmetic outcome.