A 20-Year Experience with Secondary Rhytidectomy: A Review of Technique, Longevity, and Outcomes

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process.

METHODS

Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021.

RESULTS

Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001).

CONCLUSIONS

A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time.

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 .

Revision Rhytidectomy: Pearls and Pitfalls

While rhytidectomy can yield remarkable results, some patients may subsequently require revision rhytidectomy due to either unsatisfactory outcomes from primary surgery or the natural aging process many years later. Like most other secondary plastic surgical procedures, revision rhytidectomy is a complex undertaking and fraught with potential pitfalls. This can be attributable to natural or postsurgical alterations that can occur with the facial skin, superficial musculoaponeurotic system/platysma muscle, and/or facial nerve landmarks. Additionally, complications such as cobra neck deformity, pixie ear deformity, and synkinesis can add an extra level of complexity to revisional surgery. Furthermore, as more surgeons are performing deep-plane facelifts and more aggressive neck procedures, the risks are further amplified in revisional surgery. In this article, we review the challenges that a facelift surgeon may face when performing revision rhytidectomy and the technical considerations to overcome these obstacles.

Surgical or Nonsurgical Facial Rejuvenation: The Patients' Choice

Background

Patients seeking a pan-facial rejuvenation may not receive appropriate medical advice on surgical versus nonsurgical treatments, resulting in those who are best-suited for surgery receiving nonsurgical options, and vice versa. Patients who requested total-face, nonsurgical revitalization were surveyed to understand the factors influencing this decision-making.

Methods

Patients consulting for total facial rejuvenation were surveyed on their reasons for seeking nonsurgical versus surgical interventions by an investigator with 30 years of plastic surgery experience, practicing in a nonsurgical clinic alongside a dermatologist and aesthetic physician.

Results

Of the 92 patients surveyed, 78% completed the survey, 47% of whom had considered facelift surgery, and 14% of whom proceeded to inquiries or consultations with a plastic surgeon about facelift surgery. All respondents were women, and age was not an exclusion factor. Forty-four percent would still consider facelifts in later life. Among the most common reasons for choosing nonsurgical approaches were a desire for natural and subtle results, cost, having flexibility in treatment choice, concerns about surgical and anesthesia risks, downtime, the ability to distribute treatments over time, and scarring.

Conclusions

Many patients book nonsurgical treatments without prior professional advice, and consider these as a temporary solution, but may desire surgery later in life. Before conducting nonsurgical treatments, doctors should identify this group and avoid interventions that may interfere with optimal surgical outcomes later. Also, some patients desire surgical outcomes when surgery is not a feasible option, and thus seek nonsurgical alternatives. For this group, realistic goals must be set before treatment to avoid disappointment.

Analysis of the Outcome of Reoperative Face Lifts Using Sub-SMAS Techniques

BACKGROUND

Reoperative face lift can be technically more demanding than primary face lift because of altered anatomy and scarred tissue plane. This study was carried out to analyze the outcome of reoperative face lift using sub-superficial musculoaponeurotic system (SMAS) techniques, including facial nerve injury.

METHODS

Seventy reoperative face lifts using sub-SMAS techniques were studied. Data analysis includes the patients' demographic information, the interval between the previous face lift and the reoperative face lift, intraoperative findings of the SMAS-platysma anatomy, complications, and rate of revision. A separate group of 180 primary face lifts using sub-SMAS techniques during the same period was analyzed for the incidence of facial nerve injury only.

RESULTS

Intraoperative findings in the reoperative group consist of anatomical changes in the SMAS-platysma in 82.9 percent of the cases, including increased fibrosis, changes in thickness, limited movement, and increased adhesion on the undersurface. Sub-SMAS dissection was completed in 137 hemifaces. Complication consists of seroma (1.4 percent), delayed healing (1.4 percent), and temporary facial nerve injury (7.1 percent), which was not correlated with increased fibrosis or adhesion under the SMAS-platysma. The rate of revision within 18 months was 11.4 percent. There was a 2.2 percent incidence of temporary facial nerve injury in the primary face-lift group.

CONCLUSIONS

Sub-SMAS techniques, with few exceptions, were successfully used in a series of reoperative face lifts. Temporary facial nerve injury was the most frequent complication. Satisfactory outcome was obtained in all the cases. The incidence of facial nerve injury was higher than in primary face lift using sub-SMAS techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Evaluating Facelift Complications and the Effectiveness of the SMASectomy Technique: A Single Center's 15-Year Experience

BACKGROUND

Facelift continues to be one of the most common aesthetic procedures performed in the United States. Although there exist many techniques and variations, superficial musculoaponeurotic system (SMAS) manipulation, by way of plication, overlap, or SMASectomy, is common and has been shown to result in favorable cosmesis and durability. However, there is a lack of current complications data in the discussion of this technique.

OBJECTIVES

To assess the benefits and risks of the SMASectomy technique.

METHODS

The records of all patients who underwent a facelift procedure between December 2004 and March 2019 were reviewed for this study. All procedures were performed at an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)-accredited outpatient facility in Marina Del Rey, California. This represents data on 241 total patients. Retrospective chart review was performed to include data on patient characteristics, operative technique, and complications.

RESULTS

Average operative time of 152.68 ± 51.50 minutes and anesthesia time of 175.00 ± 54.07 minutes were observed among those patients who underwent SMASectomy. This was significantly lower (P < 0.000001) than those who did not undergo SMASectomy (average operative time of 265.25 ± 85.25 minutes and anesthesia time of 294.22 ± 85.31 minutes). There were no observed facial nerve injuries among patients who underwent SMASectomy. No deep vein thrombosis (DVT) events were observed in this patient population.

CONCLUSIONS

In the hands of an experienced surgeon, the SMASectomy facelift technique offers the unique advantage of significantly reducing operating time and anesthesia time and can provide extremely favorable and long-lasting aesthetic results.

LEVEL OF EVIDENCE 3

Revision Facelift and Neck Lift

Facial rejuvenation procedures have become more commonly performed due to an increasing elderly population and greater general public acceptance. As a result, patients are now increasingly undergoing secondary and tertiary rhytidectomies to treat natural aging and/or to correct complications from prior procedures. Revision face and neck lifts are more complex by nature of the procedure and require a comprehensive preoperative assessment for enhanced outcomes. In this review, we discuss the preoperative evaluation, surgical challenges encountered, primary face and neck lift deformities, and their surgical management for patients undergoing secondary face and neck lifts.

Revision and Secondary Facelift: Problems Frequently Encountered

Revision facelift is a very challenging operation. The goal of our study was to examine the most common problems that the facelift surgeon has to face in a revision case and to suggest ways of solving them.

Methods

A review of all patients from 2012 to 2017 in whom rhytidectomy was performed by the senior author was conducted.

Results

During the 5-year study period, the author performed 552 face lifts. After the review to confirm revision procedures, a total of 72 revision facelifts were found. On reviewing the most common problems encountered in our facelifts, we found that in addition to the stigmata of the primary facelift, which are thoroughly analyzed in our article, a new type of stigmata has been added nowadays to the revision facelift-that of the various noninvasive interventions that patients undergo after their first facelift, in their effort to postpone or avoid a second operation. In all the abovementioned cases, the surgeon has to modify his basic surgical plan accordingly, to be able to improve or solve all of those problems during the revision surgery.

Conclusions

The modern facelift surgeon often has to face much more than the stigmata of the primary facelift or the natural aging process. Thus, he/she should be appropriately trained to solve any problem we might encounter in a revision case.

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.

Local Infiltration of Tranexamic Acid With Local Anesthetic Reduces Intraoperative Facelift Bleeding: A Preliminary Report

BACKGROUND

Rebound bleeding as a result of loss of epinephrine effect is a common problem encountered during facelift surgery. Tranexamic acid (TXA) is an anti-fibrinolytic agent whose safety and efficacy in reducing bleeding are well documented. We have found that local infiltration of TXA combined with a lidocaine with epinephrine solution during facelift surgery has been effective in decreasing rebound bleeding and the time required to gain hemostasis.

OBJECTIVES

The authors sought to share their local infiltration protocol of TXA combined with epinephrine solution in facelift.

METHODS

Patients who underwent facelift received subcutaneous injection of TXA-lidocaine 0.5% solution following the authors' protocol. After completing both sides of the facelift and the submental platysmaplasty, the first and second sides were sequentially closed. The time to gain hemostasis on each side prior to closure was prospectively measured.

RESULTS

Twenty-seven consecutive patients who underwent facelift surgery received local infiltration of TXA-lidocaine solution. In 23 of the 27 patients, the time required for hemostasis was prospectively recorded. The mean age was 62.1 years (±9.3) and all were females. The average time spent achieving hemostasis on the right, left, and both sides of the face was 6.5 (±2.7), 6.3 (±2.1), and 12.9 (±4.2) minutes, respectively. The total surgical time saving is approximately 25 to 60 minutes. Although primary facelift [13.6 (± 4.3)] exhibited a longer time of hemostasis compared with the secondary group [10.2 (± 2.8)], this was not statistically significant (P = 0.09).

CONCLUSIONS

Local infiltration of TXA with local anesthetic prior to a facelift appears to decrease bleeding, operative time, and postoperative facelift drainage output.

Level of Evidence: 4.

The Minimal Access Cranial Suspension Lift

The minimal access cranial suspension (MACS) facelift is a minimally invasive face and neck lift that uses the understanding of the changes in facial anatomy as it relates to facial aging. The MACS facelift uses a shorter incision with limited subcutaneous undermining. It achieves a resuspension of the underlying neck and midface soft tissues with the use of looped, purse-string sutures in the superficial musculoaponeurotic system and platysma. These attenuated structures are anchored to the deep temporal fascia. In the properly selected patient, the MACS facelift is an effective technique with high levels of physician and patient satisfaction.

Getting Better Results in Facelifting

The facelift has significantly evolved over the past several decades. What was once considered a skin only operation is now a sophisticated, elegant procedure that requires meticulous preoperative analysis, understanding of underlying anatomically based aging changes, and extreme attention to detail. According to the American Society of Plastic Surgeons, 125,697 facelifts were performed in 2017. It is not surprising that given these advances that facial rejuvenation surgery is still a very common procedure with a high degree of patient satisfaction despite the increase in nonsurgical facial aging treatments. With an improved understanding of facial anatomy including the facial retaining ligaments and intervening superficial and deep fat compartments, the modern facelift requires an anatomically targeted approach. Furthermore, the modern facelift surgeon must achieve consistently excellent results with reasonably little downtime while being aware of methods to improve the safety of this popular elective procedure. Hematoma is the most common complication after rhytidectomy with an incidence between 0.9% and 9%, with a higher incidence in males. Other potential complications include seroma, nerve injury, skin flap necrosis, siaolocele as a consequence of submandibular gland debulking, and skin flap rhytid and hairline distortion. This review aims to discuss safe, consistent, and reproducible methods to achieve success with facelift.

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 .

Platysma Motor Nerve Transfer for Restoring Marginal Mandibular Nerve Function

BACKGROUND

Injuries of the marginal mandibular nerve (MMN) of the facial nerve result in paralysis of the lower lip muscle depressors and an asymmetrical smile. Nerve reconstruction, when possible, is the method of choice; however, in cases of long nerve gaps or delayed nerve reconstruction, conventional nerve repairs may be difficult to perform or may provide suboptimal outcomes. Herein, we investigate the anatomical technical feasibility of transfer of the platysma motor nerve (PMN) to the MMN for restoration of lower lip function, and we present a clinical case where this nerve transfer was successfully performed.

METHODS

Ten adult fresh cadavers were dissected. Measurements included the number of MMN and PMN branches, the maximal length of dissection of the PMN from the parotid, and the distance from the anterior border of the parotid to the facial artery. The PMN reach for direct coaptation to the MMN at the level of the crossing with the facial artery was assessed. We performed histomorphometric analysis of the MMN and PMN branches.

RESULTS

The anatomy of the MMN and PMN was consistent in all dissections, with an average number of subbranches of 1.5 for the MMN and 1.2 for the PMN. The average maximal length of dissection of the PMN was 46.5 mm, and in every case, tension-free coaptation with the MMN was possible. Histomorphometric analysis demonstrated that the MMN contained an average of 3,866 myelinated fiber counts per millimeter, and the PMN contained 5,025. After a 3-year follow-up of the clinical case, complete recovery of MMN function was observed, without the need of central relearning and without functional or aesthetic impairment resulting from denervation of the platysma muscle.

CONCLUSIONS

PMN to MMN transfer is an anatomically feasible procedure for reconstruction of isolated MMN injuries. In our patient, by direct nerve coaptation, a faster and full recovery of lower lip muscle depressors was achieved without the need of central relearning because of the synergistic functions of the PMN and MMN functions and minimal donor-site morbidity.

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.

Are There Differences Between the Upper and Lower Parts of the Superficial Musculoaponeurotic System? A Preliminary Biomechanical Study

BACKGROUND

The superficial musculoaponeurotic system (SMAS) becomes thinner and gradually disappears from the midface. In rhytidectomy, manipulation of the SMAS occurs in the lateral area, and previous research has focused primarily on the SMAS region as a whole.

OBJECTIVES

In this preliminary study, the authors compared the viscoelasticity of the upper and lower regions of the SMAS using biomechanical techniques.

METHODS

Two adjacent projection regions of the SMAS were designated: region 1 and region 2, representing the upper and lower parts, respectively. The SMAS tissues from 8 fresh-frozen cadaver heads were cut into 64 samples before biomechanical testing, and the following variables were recorded for subsequent analysis: stress-strain curve, elastic modulus, ultimate strength, and elongation at break.

RESULTS

The stiffness of region 1 was markedly greater than that of region 2. Energy dissipation was greater in region 2. Elastic modulus and ultimate strength were significantly higher for region 1, and elongation at break was longer in region 2. The fit curve of the 2 regions deviated markedly.

CONCLUSIONS

The biomechanical properties of the upper and lower regions of the lateral SMAS are functionally different. Such knowledge will help refine the planning and design of facial surgery and improve outcomes for patients who undergo rhytidectomy.