All surgical procedures carry some uncertainty and risk. Even in the best hands, complications do occur. Fortunately, these are usually treatable. Patients vary in their anatomy, physical reaction to surgery and anesthesia, and healing capabilities, so that the outcome is never completely predictable. That’s just the nature of surgery. Surgeons know from experience that two operations in different patients, done almost exactly the same way, may have very different outcomes. Even operations on two sides of the same face or body can have different outcomes, particularly in terms of discomfort, bruising and swelling. Patients are often surprised at this. They think that both sides should heal at the same rate after surgery, but in reality one side always seems to take a little longer than the other, whether it’s the eyelids, face, breasts, or body.
It is best if patients anticipate having a complication, and if they don’t, that’s a bonus. There is a well worn phrase in surgery: “The only way to avoid complications is by not operating.” Experienced surgeons, particularly toward the end of their careers, are often very candid and admit that they’ve seen just about every complication in their practice over the years. If you are seeing an experienced surgeon, you are seeing a surgeon who has seen plenty of complications, their own complications, not just complications from other surgeons. That is why it is so important for the patient and doctor to have a mutual trusting relationship, to manage complications when they develop. One of my colleagues says he divides complications into two groups, those he has seen in his own practice and those he has not seen yet.
It is useful for patients to have a healthy degree of skepticism regarding complication rates quoted by surgeons. One well-known New York surgeon repeats at meetings, “Double any complication rate you see advertised, including mine.” Surgeons are human beings, after all. They don’t always remember all the complications they encountered and few keep a real-time tally. A complication rate of 1% is commonly quoted. It seems small, only one in a hundred, and perhaps this is a rate that is comfortable from a psychological standpoint, an event that sometimes happens to other people. But it should not be too reassuring, even if it is correct. If patients encounter a complication, it’s 100 percent as far as they are concerned. They have to understand that it could happen to them. They should have the surgery only if they can tolerate this risk.
A hematoma is a collection of blood under the skin that is usually removed by the surgeon. This is a possible complication of most surgical procedures that involve elevation of skin flaps (“undermining”), creating a potential space for fluid accumulation. A hematoma does not typically occur after liposuction because there is no sharp dissection and no creation of large spaces for blood to accumulate. In cases where there is substantial tissue undermining, such as facelifts (and abdominoplasties), a drain is inserted at the time of surgery. The drain helps draw off blood and fluid that would otherwise accumulate under the skin. Drains are usually removed the morning after surgery.
A hematoma typically develops within 24 hours of surgery. It can form in the recovery room, or is evident at the time of the postoperative visit the day after surgery. It is caused by bleeding from one or more blood vessels. Sometimes, hematomas are precipitated by spikes in blood pressure after surgery. For example, nausea and vomiting in the recovery room can cause the blood pressure to go up, which is one reason we try to prevent nausea by avoiding anesthetic gases (using intravenous medications instead) and routinely administering anti-nausea medications.
A short procedure is necessary to drain the hematoma. If it is not drained, the body will eventually absorb it, but this would take months and there would be prolonged bruising.
Patients and their caretakers are told to report any significant neck swelling after surgery, usually on one side, and usually the size of a lemon or larger. A small amount of swelling is normal. If there is any question, it is best for the patient to come in right away to be assessed.
Infection is uncommon because of the excellent blood supply of the face. Antibiotics are used to treat any infection.
Loss of feeling is normal, especially in front of the ears. Temporary numbness should be considered an expected outcome, due to surgical division of small sensory branches to the skin. Feeling gradually returns, but this can take months and may never be complete. However, sometimes a larger nerve which supplies feeling to the lower part of the ear (the great auricular nerve) is injured during a facelift, causing which numbness of the ear that will improve with time but may never return completely to normal.
Facelift scars are usually well hidden within the hairline or in natural creases around the ear. They fade with time and are usually barely noticeable. However, some patients are prone to forming raised, “hypertrophic” scars, which may require revision or steroid injectin.
The Effects of Smoking
Sometimes, healing of the skin is impaired due to compromised blood supply, seen most commonly in smokers. If the skin does not receive an adequate blood supply, it does not survive. Remarkably, the skin can put up with about 90% interruption of its blood supply from dissection. But, add the effects of smokingand this can tip the balance. The skin may appear red and blistered, then turns black and forms an unsightly scab (which surgeons call a “crust” or “eschar”). With time, the wound heals as new skin cells are created along the wound margins, which contract down, shrinking the wound. The final scar is typically much smaller than the original wound, although it will be thicker than it would otherwise have been without the delayed healing.
Usually, these areas of delayed healing and increased scarring are tucked behind the ears where they are not conspicuous. Remember, that blood supply has much to do with the severity of scarring. The skin in this area was at the end of the peninsula of tissue dissected at the time of the facelift, so its blood supply is farthest from the intact circulation and therefore most in jeopardy. Occasionally, there may be skin loss in front of the ear too.
Typically, areas of delayed healing are allowed to heal on their own and then revised as necessary, which means the scars are cut out and re-sewn. With no tissue undermining and minimal tension, they are likely to heal better the second time.
Facial Nerve Weakness
The facial nerve is responsible for making the facial muscles work. It branches out as it runs from a point just behind the ear to the facial muscles. It has five branches that may be stretched when a deep plane facelift is performed. They are usually not cut if: the operator is experienced, well versed in the anatomy of the facial nerve, wears proper magnification and illumination, and uses techniques that avoid cutting these nerve branches. These nerve branches are like tiny insulated electrical leads going to the muscles they supply. Stretching them temporarily interferes with their transmission. They do have the capability of self-repair, if not completely divided, but this takes time.
Injury to the facial nerve may be avoided by confining the dissection to a more superficial plane, a “skin only” lift. However, the drawbacks to a skin-only facelift are significant:
Most patients accept the risk of facial nerve stretching, that is associated with a deep-plane facelift, to maximize their results.
It is imperative that the corneas be protected from drying out. Normally, at night, the cornea is protected by the closed eyelids. However, after surgery, the eyelids may not close completely, due to swelling or weakness of the sphinter-lie orbicularis muscle than encircles the eyelids. In complete eyelid closure places the cornea at risk. Until eyelid function returns, it is imperative that the corneas be kept from drying out. Patients and caretakers do not leave the recovery room without being instructed in the use of lubricating ointment and eye drops.
The “pixie ear” is an unnaturally tethered ear. The earlobe is pulled down by the facelift scar. Usually this results from too much skin removal around the ear, so that there is tension on the skin closure, pulling down on the earlobe (See Patient C.B.). Experienced plastic surgeons avoid any skin tension in the area of the earlobe to prevent such a stigma of surgery.
The “lateral sweep,” is an unnatural, operated-on appearance that can happen after facelifts that draw back on the skin of the lateral face , while leaving the vertical descent of the cheek and jowl untreated. The skin form may form horizontal folds. It is not a harmonious or pleasing appearance. Another post-surgical problem is “joker’s lines,” unnatural lines of tension that extend from the corners of the mouth to the ears. Both problems may be prevented, and treated, with a deep-plane facelift that incorporates a cheek lift and vertical redraping..
Flattening of the tragus (the small bump just in front of the ear canal) may be avoided by using a pre-tragal incision, which is my preference. The tragus is a unique structure that is very difficult to recreate (See Patient J.R.) I reserve a post-tragal incision for patients who had this approach at the time of a previous facelift.