The Safety of Rhytidectomy in the Elderly:

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

Contemporary Analysis of Rhytidectomy Using the Tracking Operations and Outcomes for Plastic Surgeons Database with 13,346 Patients

BACKGROUND

Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking.

METHODS

A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors.

RESULTS

A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events.

CONCLUSIONS

This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) History: Its Role in Plastic Surgery Safety

From its origin cosmetic surgery was performed in facilities which were neither certified nor regulated. Recognizing that there was no formal oversight of facilities, a group of plastic surgeons saw the need to develop an accreditation program. This eventually evolved into the American Association for Accreditation of Ambulatory Plastic Surgery Facilities. The organization was started to implement and maintain a voluntary inspection accreditation program for qualifying surgical facilities. Its focus was to educate plastic surgeons on safety and became recognized as the gold standard for accreditation. Seeing the need for similar standards for all surgeons, it morphed into the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Comprehending that accreditation was in everyone’s best interest, AAAASF developed educational formats for plastic surgeons, testified at the US Congress suggesting potential ways that oversight of facilities could improve patient safety, functioned as a resource to numerous states in developing guidelines for oversight of facilities, continued to update its standards, and extended its accreditation program internationally. Recognizing the value of accreditation, proven by AAAAASF’s extensive database from its Internet-Based Quality Assurance Program, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) mandated that its members operate only in accredited or licensed facilities. Numerous studies documenting the safety of accredited plastic surgical facilities from AAAASF’s extensive quality assurance and peer-review reporting program are cited. AAAASF played a significant role and will continue to do that in producing better, safer environments for outpatient surgical procedures.

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

The Avoidance and Management of Complications, and Revision Surgery of the Lower Face and Neck

Complications are an inherent occurrence in surgery. In rhytidectomy, many complications are avoidable with thorough preoperative assessment and optimal intraoperative and postoperative care. Nevertheless, complications do occur. In certain situations, avoidance of risks is the best way to decrease the occurrence. Once complications do occur, there is a large body of literature to aid in the correction.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients

INTRODUCTION

Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure.

METHODS

We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates.

RESULTS

A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of - $1331 (95% CI - $2032 to - $631).

CONCLUSION

Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic Surgical Procedures in Men: Major Complications and Associated Risk Factors

BACKGROUND

The number of men undergoing cosmetic surgery is increasing in North America.

OBJECTIVES

To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures.

RESULTS

Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56).

CONCLUSIONS

Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures.

LEVEL OF EVIDENCE 2

Incidence and Risk Factors for Major Hematomas in Aesthetic Surgery: Analysis of 129,007 Patients

BACKGROUND

Postoperative hematomas are one of the most frequent complications following aesthetic surgery. Identifying risk factors for hematoma has been limited by underpowered studies from single institution experiences.

OBJECTIVES

To examine the incidence and identify independent risk factors for postoperative hematomas following cosmetic surgery utilizing a prospective, multicenter database.

METHODS

A prospectively enrolled cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major hematomas requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis was used to identify potential risk factors for hematomas including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.

RESULTS

Of 129,007 patients, 1180 (0.91%) had a major hematoma. Mean age (42.0 ± 13.0 years vs 40.9 ± 13.9 years, P < 0.01) and BMI (24.5 ± 5.0 kg/m2 vs 24.3 ± 4.6 kg/m2, P < 0.01) were higher in patients with hematomas. Males suffered more hematomas than females (1.4% vs 0.9%, P < 0.01). Hematoma rates were higher in patients undergoing combined procedures compared to single procedures (1.1% vs 0.8%, P < 0.01), and breast procedures compared to body/extremity or face procedures (1.0% vs 0.8% vs 0.7%, P < 0.01). On multivariate analysis, independent predictors of hematoma included age (Relative Risk [RR] 1.01), male gender (RR 1.98), the procedure being performed in a hospital setting rather than an office-based setting (RR 1.68), combined procedures (RR 1.35), and breast procedures rather than the body/extremity and face procedures (RR 1.81).

CONCLUSIONS

Major hematoma is the most common complication following aesthetic surgery. Male patients and those undergoing breast or combined procedures have a significantly higher risk of developing hematomas.

LEVEL OF EVIDENCE

2.

Age as a Risk Factor in Abdominoplasty

Background

Recent studies reviewing large patient databases suggested that age may be an independent risk factor for abdominoplasty. However, these investigations by design considered only short-term major complications.

Objectives

The purpose of this investigation was: (1) to compare the safety of abdominoplasty in an elderly and younger patient population; (2) to determine the complication rates across all spectrums: major, minor, local, and systemic; and (3) to evaluate complications occurring both short and long term.

Methods

Abdominoplasty procedures performed from 2010 to 2015 were retrospectively reviewed. Subjects were divided into two groups: ≤59 years old and ≥60 years old. Major, minor, local, and systemic complications were analyzed. Patient demographics, comorbidities, perioperative details, adjunctive procedures were also assessed.

Results

A total of 129 patients were included in the study: 43 in the older and 86 in the younger age group. The median age of The elderly and young groups was 65.0 and 41.5 years, respectively (P < .001). No statistically significant differences in major, minor, local, or systemic complications were found when both age groups were compared. Major local, major systemic, minor local, and minor systemic in the elderly were 6.9%, 2.3%, 18.6%, and 2.3%, while in the younger patients were 9.3%, 4.7%, 10.5%, and 0.0%, respectively (P > .05). Median follow-up time of the elderly (4.0 months) was no different than the younger (5.0 months) patients (P > .07). Median procedure time in the elderly (4.5 hours) was no different than the younger group (5.0 hours) (P = .4). The elderly exhibited a greater American Society of Anesthesiologist score, median body mass index (28.7 vs 25.1 kg/m2), and number of comorbidities (2.7 vs 0.9) (P < .001).

Conclusions

There was no significant difference in either major or minor complications between the two groups. This suggests that with proper patient selection, abdominoplasty can be safely performed in the older age patient population.

Level of Evidence

2.

Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients

BACKGROUND

Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies.

OBJECTIVES

This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures.

METHODS

A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility.

RESULTS

Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥ 25 (relative risk 2.8) increased infection risk.

CONCLUSIONS

Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥ 25, and combined procedures are independent risk factors. LEVEL OF EVIDENCE 2: Risk.

Objective Assessment of Facial Rejuvenation After Massive Weight Loss

BACKGROUND

While the literature is replete with articles about body contouring after bariatric surgery, little information exists regarding the outcomes of facelift following massive weight loss (MWL). A case report and a technique article are the only sources available addressing this issue. This pilot study objectively examines the effects of MWL in the cervicofacial region and results after facelift.

METHODS

A retrospective review of seven patients who underwent facelift after MWL (>100 pounds) was performed. Patient's change in appearance was objectively evaluated using an apparent age model. Forty blinded reviewers assessed pre- and postoperative photographs of seven MWL and eleven non-MWL female patients. The reviewers estimated the apparent age for each subject. Reduction in apparent age was calculated by comparing patient's apparent age against actual age.

RESULTS

The preoperative apparent age of MWL patients was 5.1 years older than their actual age (p < 0.02) compared to the increased preoperative apparent age of 1.2 years in non-MWL subjects (p > 0.05); suggesting MWL patients appear older than their actual age. Post-operatively, the apparent age reduction in MWL patients was 6.0 years; and their apparent age after surgery was 0.9 year less than their actual age (p > 0.05). In contrast, the control group exhibited an apparent age reduction of 5.4 years and a postoperative apparent age 4.2 years younger than their actual age (p < 0.01). Apparent age reduction was not significantly different for the two groups (p > 0.05). Age, BMI, and follow-up were similar between groups (p > 0.05).

CONCLUSIONS

MWL may accelerate apparent cervicofacial aging. Facelift following MWL enhances cervicofacial appearance and significantly reduces apparent age. We hope this study stimulates further interest in the study of facial esthetics in this increasing population.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Safety of Cosmetic Procedures in Elderly and Octogenarian Patients

BACKGROUND

The proportion of elderly patients in North America is increasing. This has resulted in an increased number of elderly patients undergoing cosmetic procedures.

OBJECTIVES

The purpose of this study was to determine the incidence of postoperative complications in elderly patients (age ≥65) undergoing elective aesthetic plastic surgical procedures compared with younger patients.

METHODS

A total of 183,914 cosmetic surgical procedures were reviewed using the prospectively enrolled cohort of patients in the CosmetAssure database. Comorbidities and postoperative complications in elderly and younger patient groups were recorded and compared. A separate analysis of postoperative complications was performed in the octogenarian subgroup (age ≥80).

RESULTS

A total of 6786 elderly patients who underwent cosmetic procedures were included in the study. Mean ages (±standard deviation) in elderly and younger patients were 69.1 ± 4.1 and 39.2 ± 12.5 years, respectively. The elderly patient population had more men, a higher mean body mass index (BMI), a higher prevalence of diabetes mellitus (DM), and fewer smokers compared with the younger patients. The overall postoperative complication rate was not significantly different between elderly and younger patients. When stratified by type of cosmetic procedure, only abdominoplasty was associated with a higher postoperative complication rate in elderly compared with younger patients. The most common postoperative complications in elderly patients were hematoma and infection. The overall postoperative complication rate in octogenarians was 2.2%, which was not significantly different from the younger population.

CONCLUSIONS

Cosmetic procedures in elderly patients, including octogenarians, remain safe with an acceptable complication rate compared to younger patients.

Evaluation of Face Lift Skin Perfusion and Epinephrine Effect Using Laser Fluorescence Imaging

Supplemental Digital Content is available in the text.

Face lift dissections are believed to compromise skin flap circulation, possibly leading to wound healing complications. To reduce blood loss, plastic surgeons commonly inject a solution of local anesthetic that contains epinephrine. However, the effect of surgery on skin perfusion and the degree of vasoconstriction caused by the epinephrine have not been quantitated. Little information is available to guide the selection of epinephrine concentration.