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

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

Overview

Age-Related Facial Changes

Facial Anatomy

Platysma

SMAS

Facial Nerve

Complications

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

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

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

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

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

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

Facial Landmarks

Facial Proportions

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

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

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

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

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

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

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

Platysma

Laxity in platysma

accounts for paramedian

vertical banding

Ptosis of platysma leads

to enhancement of

jowling

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

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

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

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

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

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

Complications

Hematoma

1-15% incidence

Consequences Partial flap loss

Infection

Pigmentation changes

Persistent facial edema

Prolonged convalescence

Scarring

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

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

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

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

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

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

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

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

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

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

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

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

Skin Flap Necrosis

Management

Conservative

Most partial-

thickness necrosis

will heal with little or

no visible scarring

or with

hypopigmented

scar

Scars

Most common in

postauricular region

Wounds under

tension

Appear within 12

weeks postop

Serial steroid

injections

Scars

Inappropriate skin

incisions

Camouflage

incisions

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

Hair Loss

Minoxidil treatment

postop for

prevention

Eremia et al. (2002)

60 rhytidectomies

L4

No permanent

alopecia

Temporary alopecia

in 1.7%

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

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

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

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

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

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

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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