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The Aging Face and
Complications of Rhytidectomy
Murtaza Kharodawala, MD
Faculty Advisor: Francis B. Quinn, MD, FACS
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
October 3, 2007
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Although the effects of aging are normal and ubiquitous, not all people choose accept these changes
A youthful appearance is valued in society
An aged appearance may carry the persona of being unattractive, undesirable, and helpless
The demand for facial rejuvenation has increased with a greater aging population
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Overview
Age-Related Facial Changes
Facial Anatomy
Platysma
SMAS
Facial Nerve
Complications
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The Aging Face
Facial Anatomy Skin
Greatest elasticity in infancy
Soft tissue
Underlying skeletal elements that provide the basic shape of the face
Softer curves in youth, and gradual weakening and resorption in older age
Age is the most significant factor determining facial structures Gender and Ethnicity
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The Aging Face
Intrinsic Factors Genetic factors
Ethnicity
Hormonal and biochemical changes effecting skin, subcutaneous tissue and facial skeleton over time
Extrinsic Factors Gravity
Sun exposure
Smoking
Pigmentary changes, rhytids, texture irregularities
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The Aging Face
Epidermis and subcutaneous fat thins
Effacement of dermal-epidermal junction
results in a flattened rete ridge pattern
Elastosis: progressive loss of organization
of elastic fibers and collagen
Weakening of underlying muscles
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The Aging Face
3rd Decade Eyebrows begin to descend to
create the appearance of smaller eyes
4th Decade Excess eyelid skin laxity appears
Pseudoherniation of orbital fat through weakened orbital septum occurs in upper and lower eyelids
Glabellar frown lines appear
Nasolabial folds become more prominent
Continued brow descent
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The Aging Face
5th Decade: Forehead rhytids deepen
Glabellar furrows deepen
Crows feet develop
Excess skin over upper eyelids due to lost elasticity
Vertical lines in the perioral region form
6th Decade: Perioral and neck rhytids become more prominent
Nose begins to droop
Lateral canthi weaken resulting in downward slant
Glabellar and forehead rhytids deepen
Midfacial descent leads to prominence of nasojugal fold and lower eyelid
Submental fat excess , platysma banding and jowl formation is highly visible
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The Aging Face
7th Decade:
Skin thins
Subcutaneous fat resorbs
Palpebral aperture narrows due to severe hooding of brows and upper eyelid excess
8th Decade and beyond:
Changes are exaggerated as skin continues to thin
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Facial Landmarks
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Facial Proportions
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Upper Third
Brow Anatomy
The female and male
ideal brow differ
In women, the brow
should arch superiorly at
least 1cm above
supraorbital ridge
The brow is not as
arched and located just
over the supraorbital
ridge
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Aging of Upper Third
Forehead elongation as hairline moves upward and brow descends
Brow ptosis
Lateral brow hooding
Crow’s feet
Fine and deep rhytids of forehead and glabella
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Eyelid Aging
Greater laxity of upper and lower lids
Narrowing of horizontal and vertical dimensions of palpebral fissures
Canthal angles become more obtuse
Weakened orbital septum with pseudoherniation of orbital fat
Entropion
Ectropion
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Middle Third Aging
Nose Nasal skin, bone, muscle,
fibrous tissue, and cartilage become thin and weakened
Underlying nasal skeleton may become visible
Nasal tip ptosis
Lengthening of nasal dorsum
Separation of upper and lower lateral cartilages resulting from splaying of fibrous attachments at scroll
Narrowing of nasal valve
Interdomal ligaments may weaken and stretch
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Middle Third Aging
Midface
Loss of orbicularis
oculi muscle tone
Descent of malar
soft tissue
Illusion of excess of
fat in lower lid
Nasolabial crease
deepens
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Lower Third Aging
Chin ptosis
Resorption of mandibular height
Thinning of subcutaneous fat
Excess of skin
Jowl formation
Platysmal banding
Loss of cervicomental angle
Submental fullness
Upper lip lengthening
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Anatomy
Platysma Paired rhomboidal subcutaneous
sheet of muscle
Extends from lower cheek to 2nd rib crossing the entire length of mandible
3 Anatomic variations at medial borders
Type I: medial fibers interdigitate 1-2 cm below chin (75%)
Type II: interdigitation of fibers extends to level of thyroid cartilage (15%)
Type III: fibers are completely separated through entire length (10%)
Continues into cheek as superficial aponeurotic fascia
Extends over the inferior aspect of the parotid gland but dissipates into fascia over most of the gland
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Platysma
Laxity in platysma
accounts for paramedian
vertical banding
Ptosis of platysma leads
to enhancement of
jowling
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SMAS
Superficial Musculoaponeurotic System
1976 Mitz and Pyronie Landmark paper Tessier
Fibromuscular fascial extension of the platysmal muscle that arises superiorly from the fascia over the zygomatic arch and is continuous in the inferior cheek with the platysma
Facial nerve lies deep to the SMAS
Functions to transmit the activity of facial mimetic muscles to the facial skin
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SMAS
Posteriorly, the SMAS fuses with the fascia overlying the sternocleidomastoid muscle, but it is a distinct layer superficial to the parotid fascia
Anterosuperiorly, the SMAS invests the facial mimetic muscles of the mid-face (i.e., orbicularis oculi, zygomatic major/minor, levator labii superioris)
Anteriorly, the SMAS invests the superficial portions of the orbicularis oris and gives off fibrous septae that insert into the dermis along the melolabial crease and upper lip
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Scalp
galea
Upper face
continuous with frontalis and orbicularis oculi
Temporal region
temporoparietal fascia (superficial temporal fascia)
Parotid region
dense fibrous layer overlying parotid gland
Cheek
thin layer invests superficial mimetic muscles
Lower face
continuous with platysma
SMAS
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Facial Nerve
Protected by parotid tissue and lower branches are deep to masseter fascia
Potential space exists between SMAS and masseter fascia in inferior cheek Important in
deep/composite rhytidectomy techniques
Innvervates midfacial mimetic muscles from undersurface
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Facial Nerve
Temporal branch is
most superficial
Crosses junction of
anterior 1/3 and
posterior 2/3 of
zygomatic arch
Above the arch it
travels in the
temporoparietal fascia
to innervate frontalis
and orbicularis oculi
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Facial Nerve
Marginal division descends from the inferior parotid to 1-2 cm below the mandibular body and returns above the inferior border of the mandible anterior to the facial artery
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Complications
Hematoma
1-15% incidence
Consequences Partial flap loss
Infection
Pigmentation changes
Persistent facial edema
Prolonged convalescence
Scarring
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Hematoma
Major/expanding hematomas occur within 24 hours of operation and early signs include sudden sharp pain, followed by swelling and ecchymosis Hardness/tightness of facial skin
Trismus
Anxiety and dyspnea
Late signs: swelling and discoloration of lips and buccal mucosa
1.9-3.6% of large hematomas require operative intervention
Prevention and early recognition Compression dressing
Aspiration/evacuation
Persistent ecchymosis and prolonged edema usually resolves after treatment without compromise to aesthetic result
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Hematoma
Risk factors Hypertension
Berner et a. (1976) 202 rhytidectomies L4 Preop and Postop BP within first 2 hours were similar
Reactive hypertension in subsequent 3 hrs
Medications were less effective
Pain and anxiety affected BP
Striath et al. (1977) 500 rhytidectomies L4 9.2% hematoma rate when SBP preop >150mm Hg
1.6% overall rate
Grover et al. (2001) 1078 rhytidectomies L4 Multivariate analysis indicated strong association of hematoma
formation when preop SBP >150mm Hg
Close association of hematoma with postop hypertension
Effective diagnosis and management by internist
Anxiolytics and analgesics
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Hematoma
Risk Factors
Male gender
Baker et al. (1977) 137 males L4
Major hematoma rate 8.7%
Overall rate 3.26%
Lawson et al. (1993) 115 males: 9.6% L4
Grover et al. (2001) L4
12.9% in males (8/62)
3.6% in females (32/1016)
Possibly related to increased blood supply to
beard and sebaceous glands in males
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Hematomas
Risk Factors
Aspirin or other NSAID use
Grover et al. (2001) L4
ASA/NSAID use within 2 weeks of rhytidectomy had
higher hematoma rate
Vitamin E, Gingko, Ginger, Ginseng, Garlic
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Hematoma
Deep-plane Technique
Kamer et al. (2000) 451 rhytidectomies L3
2.2% with major hematoma
6.65% with minor hematoma
All occurred in subcutaneous plane
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Hematoma
General anesthetic is not a risk factor Rees et al. (1994) 1236 rhytidectomies L4
1.1% hematoma rate with GETA
0.9% with conscious sedation
Suction drain Perkins et al. (1997) 222 rhytidectomies L4
Drain use does prevent seroma formation but minimal impact on hematoma formation
Fibrin glue Marchac et al. (1994) 200 rhytidectomies L4
Reduction in hematoma rate from 9% to 2%
Grover et al. (2001) 1078 rhytidectomies L4 No difference in treated (4.4%) or untreated (4.4%)
Fezza et al. (2002) 48 rhytidectomies L3 No hematoma formation in those treated with fibrin glue but not statistically different from non-treated
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Sensory Nerve Dysfunction
Most common nerve injury
is to great auricular nerve
1-7%
Should be repaired with
10-0 nylon perineural
sutures
Lesser occipital
Dissection should remain in
subcutaneous plane
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Facial Nerve Deficits
Paresis to complete paralysis
0.3% - 2.6% incidence
Baker (1993) 7000
rhytidectomies L4
(0.7%) 55 paralysis
0.1% permanent
Marginal mandibular 22/55
Temporal (frontal) 18/55
Buccal 7/55
Neuropraxia, heat injury, needle
injury, transection
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Facial Nerve Deficits
Marginal mandibular nerve “Danger zone” from angle
of mandible to facial artery
More commonly injured when dissection performed to correct platysma laxity
Platysma atrophy or hypoplasia will increase risk of injury
Revision rhytidectomy
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Facial Nerve Deficits
Temporal (frontal)
branch
At greater risk when
forehead procedure is
combined with
rhytidectomy
Forehead procedures
should remain subgaleal
at level of superficial
layer of deep temporal
fascia to avoid injury
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Facial Nerve Deficits
Buccal branch Injury from subperiosteal
dissection for midface-lift
Release of periosteum from inferior border of zygoma requires transition over masseter tender near buccal branch
Sub-SMAS dissection over cheek places nerve at higher risk than more superficial dissection
Careful dissection is needed deep to SMAS and superficial to masseteric fascia
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Skin Flap Necrosis
Ischemia from vascular congestion and arterial compromise Unrecognized and untreated hematoma
Tobacco use (12 times more likely) Cessation
Vasculitis
Subdermal plexus injury
Excessive tension at closure
1.1-3% incidence
Most common in postauricular region where flap is the thinnest and closure is greatest with most distal arterial supply
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Skin Flap Necrosis
Management
Conservative
Most partial-
thickness necrosis
will heal with little or
no visible scarring
or with
hypopigmented
scar
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Scars
Most common in
postauricular region
Wounds under
tension
Appear within 12
weeks postop
Serial steroid
injections
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Scars
Inappropriate skin
incisions
Camouflage
incisions
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Hair Loss
Up to 8.4% incidence
1-3% require surgical revision
Most common in temporal region
Poorly placed incisions in respect to hair follicles, excess tension on closure, heat injury
May be prevented with carefully planned incisions along follicles
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Hair Loss
Minoxidil treatment
postop for
prevention
Eremia et al. (2002)
60 rhytidectomies
L4
No permanent
alopecia
Temporary alopecia
in 1.7%
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Pixie Ear Deformity
Excessive skin
excision at earlobe or
excessive tension
across skin incision
May be avoided by
incising flap prior to
SMAS dissection or
placement of
suspension sutures
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Infection
1% incidence
Leroy et al. (1994) 6166 rhytidectomies L4
11 (0.18%) required hospitalization
Occurred within first week postop
Staphylococcus and Streptococcus most common
7/11 given postop Abx
IV Abx and I&D
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Parotid Injury
Rare
More common in sub-SMAS techniques
May delay healing and possibly lead to
psuedocyst
Prevented by cauterization of exposed
ductules
Serial aspirations and compression
dressings with anti-sialogogues or Botox
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Pigmentary Changes
Fitzpatrick types IV-VI may develop
hyperpigmentation postop
May persist for months, but gradually
fades
Avoid sun exposure, sun block use
Telangectasias may develop in areas
dissection in those prone
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Depression
Short term situational depression occurs in 30% of women
Related to a pre-existing detectable depression or in depression-prone personality pattern
Within first month postop and related to unnatural appearance
Reassurance and possible short course of antidepressant
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DVT and PE
Account for up to 5% of postoperative morbidities
Reinisch et al. (2001) 9937 L4 0.49% with thromboembolic
complications
0.35% DVT
0.14% PE
83.7% in patients who underwent GETA
Decrease in incidence noted in patients in whom SCDs were used
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Costs
Most facial plastic surgery
procedures are expensive
and are not covered by most
insurances
Newer less invasive and
less expensive techniques
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Sources
Moyer JS, Baker SR. Complications of rhytidectomy. Facial Plast Surg Clin NA 2005;13:469-78.
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Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg 1983;10(3):543–62.
Grover R, Jones M, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg 2001;54:481–6.
Rees TD, Barone CM, Valauri FA, et al. Hematomas requiring surgical evacuation following face lift surgery. Plast Reconstr Surg 1994;93(6): 1185–90.
Perkins SW, Williams JD, Macdonald K, et al. Prevention of seromas and hematomas after face-lift surgery with the use of postoperative vacuum drains. Arch Otolaryngol Head Neck Surg 1997;123(7):743–5.
Kamer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast Surg 2000;2(4):240–2.
Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg 2004;13(1):381–7.
Straith RE, Raju DR, Hipps CJ. The study of hematomas in 500 consecutive face lifts. Plast Reconstr Surg 1977;59:694–8.
Berner RE, Morain WD, Noe JM. Postoperative hypertension as an etiological factor in hematoma after rhytidectomy: prevention with chlorpromazine. Plast Reconstr Surg 1976;57:314–9.
Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast Reconstr Surg 1977;60: 514–22.
Lawson W, Naidu RK. The male facelift: an analysis of 155 cases. Arch Otolaryngol Head Neck Surg 1993;119(5):535–9.
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