The secondary and tertiary facelift patients tend to be older and often present with iatrogenic deformities from their prior rhytidectomy (Fig. 18). Furthermore, secondary facelifts require more volumization and minimal, if any, skin excision. Pixie ear deformity (ie, tethered appearing and anteriorly rotated lobule) is common and requires anatomic posterior lobule rotation, scar excision and avoidance of skin flap tension. Other deformities include sideburn distortion and the “windswept” deformity. Skin flap elevation is more difficult due to scarring of the tissue planes, making the use of infiltrating solution evermore critical for hydrodissection.58 The senior author (R.J.R) endorses the “five Rs” of secondary facelift which include resection of prior scar, release of the SMAS, reshaping via tissue stacking and volumization, and skin release and redraping to correct depressions, “windswept” and J-deformities.59
Prompt recognition is paramount as large hematomas can result in skin flap necrosis and airway compromise. Although smaller hematomas are not life threatening, failure to evacuate these results in scarring and contour irregularities that are difficult to treat secondarily. Large hematomas require return to the operating room. Small hematomas can be aspirated with a 16-guage needle 5–7 days after surgery in clinic, once the hematoma has liquified.
Use of a closed neck drain helps avoid most seromas as they usually occur the most gravity-dependent areas. A chin strap is also used as a compression garment to close dead space.60 If a seroma occurs, it should be serially drained by aspiration until resolved. For persistent areas of induration and if the seroma cannot be aspirated, injections of Kenalog 10 mg/ml diluted with 1% lidocaine injections are used.
Recurrent banding is most common medially. A low threshold for a submental incision and medial platysmal plication helps to decrease the incidence of recurrent platysmal bands. Despite appropriate operative interventions, platysmal bands may still recur. In these patients, either reoperation or Botox (Allergan, Inc., Irvine, Calif.) can be used.34
Persistent jowling can result from insufficient mandibular retaining ligament release and jowl fat pad lipodystrophy (Fig. 16). Extended skin undermining with release of the mandibular retaining ligament, with direct fat excision if necessary, is critical in patients with prominent jowls.61 Targeted liposuction and/or fat grafting is used for secondary jowl bulges or jawline scalloping, respectively.34
Avoiding surgery in high-risk patients (ie, nicotine product users) and maintaining at least 3 mm of fat on the skin flap undersurface prevent the majority of cases. Exacerbating factors such as excess skin tension is avoided and hematoma, if present, must be promptly addressed. Nitroglycerin ointment can be applied in the operating room over compromised appearing areas. Otherwise, areas of necrosis are conservatively managed with daily cleaning and triple antibiotic ointment application until the ischemic margins fully declare themselves and the eschar falls off. Areas that have healed by secondary intention can be addressed at a later date with scar revision.
Conservative management is used. Neuropraxia is the most common culprit and expected to resolve within 3 months of surgery. Contralateral depressor angularis oris neurotoxin injection can be used as a temporizing measure to improve smile symmetry.
The senior author (R.J.R.) avoids submandibular gland surgery as this risks sialocele formation and bleeding complications. Salivary leaks can be managed by serial aspiration, anticholinergics, and neurotoxin injection.
The modern facelift is a sophisticated operation that focuses on treating targeted areas of facial aging using an individualized and detailed approach to the SMAS, skin, and fat compartments. Maximizing patient safety and consistency is the key to this operation to deliver high patient satisfaction.
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