Portuguese Version

Year:  2002  Vol. 68   Ed. 3 - (8º)

Artigo Original

Pages: 338 to 342

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Complications of rhytidectomy in an otolaryngology training program

Author(s): José Antônio Patrocínio(1),
Lucas Gomes Patrocínio(2),
Alexandre Soares Fogaça de Aguiar(3)

Keywords: rhytidectomy, facial plastic surgery, complications, training program, otolaryngology

Abstract:
Introduction: Facial plastic surgery is one of the most difficult areas on which to provide "hands on" experience for residents in otolaryngology. Complications of rhytidectomy have been widely reported in the literature. Aim: This study examines the incidence of complications after rhytidectomy in hands of residents under appropriate attending supervision in an Otolaryngology - Head and Neck Surgery Training Program. Study design: Chart analysis. Material and method: The charts of 62 consecutive SMAS rhytidectomy patients performed between March 1999 e March 2000 were retrospectively reviewed. It was obtained information regarding the patient, the surgical procedure, and post-operative complications. Results: Presented rates were 12,9% of the patients with one exclusive complication and 6,5% with more than one complication. These included 1 expanding hematoma (1,6%), 5 small hematomas (8,1%), 3 seromas (4,8%), 2 suture lost (3,2%), 1 wound infection (1,6%), 1 parotid salivary fistula (1,6%), 1 ear lobe deformity (1,6%) e 1 ear numbness (1,6%). There were no cases of facial paralysis, cardiopulmonary events nor deaths. Only one female patient expressed her insatisfaction with the surgery (1,6%). Conclusion: Although these data are clinically relevant, the sample size is small to make statistically significant conclusion. We can only suggest that the teaching of rhytidectomy in an academic setting is effective and safe, since it is performed carefully by a resident, with knowledge of technique and anatomy, under supervision of an experienced surgeon.

INTRODUCTION

Medicine has experienced fantastic advances throughout the past century, comprising different areas and including esthetical surgery, enabling subjects to grow old and still have great health and disposition together with a younger appearance. The action of gravity, associated with sun exposure and lack of skin elasticity owing to natural aging of human beings result in variable degrees of wrinkles on the face. Many procedures have been proposed to correct facial wrinkles, and everyone currently agrees that the best surgical option for the problem is rhytidectomy 12.

During the years, rhytidectomy technique was advocated by simple subcutaneous dissection. As of the 70's, dissection associated to SMAS (subcutaneous muscle-aponeurotic system) was introduced and considered as the second generation of rhytidectomy. In the 80's, the third generation started to dissect deep planes (deep-plane or three-plane rhytidectomy). In the new technique, a higher number of complications related to the facial nerve were noticed. Currently, subcutaneous rhytidectomy with SMAS is the most frequently used procedure12.

Facial plastic surgery is one of the most difficult areas to provide practical experience to residents in Otorhinolaryngology. They are elective procedures performed in patients that have different expectations from those undergoing non-elective surgeries. Although complications are expected in any surgery, dissatisfactory results are more difficult to cope with in patients submitted to cosmetic surgeries, that is, an elective procedure on patients with no previous diseases14.

Rhytidectomy also has complications, whose frequency depends on technique, philosophy and experience of the surgeon and associated adjunct procedures. Therefore, in a resident training program the likelihood of finding complications is higher taking into consideration the experience and skills of a novice surgeon.

The purpose of the present study was to review the medical charts of patients submitted to rhytidectomy performed by resident physicians under the supervision of an experienced surgeon in our Service of Otorhinolaryngology, assessing the results and complications and comparing them to data reported in the literature.

MATERIAL AND METHOD

The medical charts of 62 consecutive rhytidectomy procedures performed between March 1999 and March 2001 were retrospectively revised. We collected information about the patient (age and gender), surgical procedure (duration, anesthesia, surgical technique) and complications (hematoma, seroma, neural damage, healing, wound infection, flap necrosis, ear deformity, alopecia, salivary fistula and patient dissatisfaction).

All procedures were performed under local anesthesia. Sedation was performed under cardiac monitoring and peripheral oxymetry using 2m-phentanyl IV followed by 3mg midazolam diluted in 10ml saline solution IV, slowly injected. We conducted infiltration of lidocaine with adrenaline 1:100,000 at the incision site and lidocaine with adrenaline 1:200,000 at the flap detachment site.

In all cases, the surgery was performed by third year resident physicians, under the supervision of the physician responsible for the discipline of Facial Plastic Surgery of the Service of Otorhinolaryngology (the main author of the present study). The surgical technique used was as follows: pre-auricular incision, detachment of supra-SMAS flap involving skin and subcutaneous layers up to the face angle; submandibular detachment over the plastysma and up to the submentonian region; resection of a 2cm wide by 5cm long strap of SMAS starting immediately below the zygomatic arch and 1 cm anteriorly to pre-auricular incision, followed by inferior-posterior direction in L shape; fixation of the SMAS flap with 4 stitches of Ethibond thread 2-0, two stitches pulled over the mastoid and 2 stitches pulling it to the tragus; careful an comprehensive hemostases with electrocautery; resection of excessive skin; subcutaneous suture with Vicril 4-0; skin suture with Prolene 6-0 and Mononylon 4-0. We used Portovac drain and compressive dressing for 48 hours, in addition to prophylactic antibiotic for 7 days. Patients were assessed 1, 2, 7, 14 and 28 days and 3 and 6 months and 1 year after the surgery.

RESULTS

We performed 62 rhytidectomy procedures and 60 patients were females and 2 were males, aged from 38 to 63 years (mean age 48 years). Surgeries associated with neck liposuction, cervicoplasty, upper and lower blepharoplasty, eyebrow elevation, malar enlargement, and mentoplasty were not considered by the present study. The mean duration of surgeries was 4 hours (ranging from 2.3 to 6 hours). Follow-up ranged from 1 to 134 months (mean follow-up of 6 months).

Eight patients (12.9%) presented isolated complications in the surgical results; four patients (6.5%) presented more than one complication. As a whole, there were 16 complications (25.81%).

Expanding hematoma was noticed in one patient (1.6%), drained on the 2nd post-operative day. There were 5 small hematomas (8.1%) and 3 seromas (4.8%), which progressed to normality within 3 weeks, without sequelae. Two patients presented suture dehiscence (3.2%), with second intention healing, being that one was the case resultant from suture infection (1.6%) treated with antibiotic therapy and daily dressings. There was one case of parotid salivary fistula (1.6%) in which Penrose drain was used for 4 weeks. One patient presented ear deformity (1.6%), which regressed in 4 weeks. Another patient presented auricular pinna paresthesia (1.6%). There were no cases of facial paralysis. There was one female patient who expressed her dissatisfaction with the result of the surgery (1.6%).

DISCUSSION

Complications of rhytidectomy include hematoma, seroma, suture dehiscence, hypertrophic healing, alopecia, infection, facial nerve sensorial and motor damage, salivary fistula. Other more severe complications such as cardiopulmonary emergency, problems of anesthesia and death are fortunately extremely rare.

The complications and satisfaction levels of our patients were analyzed and compared with the data reported in the literature1-16. In general, the complication rates of our service of medical residence training in Otorhinolaryngology were compatible with those in other studies5, 6, 7, 14. There were 12.9% of patients with isolated complications after surgery and 6.5% with more than one complication. Sullivan et al14 presented rates of 13% and 7%, respectively.

Hematoma and Seroma

They are the most frequent complication and they can be small or large. Most of them are noticed within the first 12 post-operative hours. Small hematomas are noticed in 10 to 15% of the patients12, between the 7th and 10th days they are liquifyied or they can be easily aspirated with 5ml syringe and gauge 12 needle. In our series, small hematomas were detected in 8.1% of the cases, a figure within the expected normal range. Extensive hematomas are of concern and they may be detected in 0 to 3.8% of the cases14. Edema and unilateral ecchymosis or excessive pain should serve as warning signs to the diagnosis. In our sample, it was observed in only one case (1.6%), also within acceptable ranges. It was solved with drainage on the 2nd post-operative day. The possible predisposing causes for hematoma formation are: history of hypertension, abnormal bleeding, use of medication, problems in intraoperative technique, post-operative hypertension, cough, vomiting, agitation and use of propofol for sedation14. Hyperpigmentation may occur in hematomas by the deposit of hemosiderin and normally disappears 6 to 8 months later12.

The best treatment for hematoma is prevention. A good surgical technique, careful hemostasis, appropriate surgical drainage and compressive dressing are essential15. One of the main issues of rhytidectomy is that it should take longer to perform hemostasis than the surgery. Rees et al11 proposed that a typical learning curve takes up to 50 rhytidectomy procedures. After that, the risk of hematoma formation decreases significantly.

Suture infection

The incidence of infection after rhytidectomy is below 1%. It is a result of the excellent blood supply at the region. If present, we should order culture to define the infecting microorganism. The most common one is Staphylococcus aureus, which is manifested 72 hours after the surgery and normally responds to the appropriate antibiotic therapy7.

Sullivan et al14 reported only one case in 96 reviewed cases. Kramer et al3 reported 2 cases in 512 surgeries performed. In our sample, we found one case (1.6%), a figure compatible with the literature reports. We indicated removal of suture, cleaning of the area and application of topical antibiotic ointment. Real cellulitis and abscesses should be incised and drained. We recommend intensive antibiotic therapy and careful control of the wound, trying to minimize skin loss and improving the chances of having esthetically better scars5. In our case, the use of 1st generation cephalosporin associated to daily dressing was enough to solve the picture in 10 days.

Scaring

Most of the scars are imperceptible. Keloids are rare. Hypertrophied scars are more common in the post-auricular region, in which skin tension is more marked. We can inject corticosteroid in them. Review of scars can be performed only after complete maturation of scaring8. The patient with infection presented suture dehiscence, similarly to another patient (3.2%), but fortunately the responses were good and there were no resulting hypertrophied scars or keloids.

Salivary Fistula

Salivary fistulae are noticed mainly after deep dissection of SMAS. The management is observation, since it tends to improve within 3 to 4 weeks. In more severe cases, we indicate drainage with incision and placement of catheter. We should administer bland diet and keep the patient under antibiotic therapy. The situation is resolved within 4 to 5 weeks of conservative clinical treatment, using atropine and compressive dressing for 2 weeks, so that the flap can adhere to the underlying tissue. Three to 4 weeks later, when the recess is reduced, there is a fistulous tract that may be dissected16. In our series, we found one case (1.6%) in which it was necessary to use Penrose drain, resolved within 4 weeks. As a result of the increased number of rhytidectomy every year and with the aggressive tendency of performing deeper SMAS dissections, the number of parotid gland damage tends to increase.

Ear Deformity

If the flap is anchored posteriorly and over the lobe, it retracts and pulls the earlobe downwards. In order to avoid it, the posterior flap should be anchored in the post-auricular region and not on the ear skin, and the contact of the ear in the region of the incision should be free of tension. If there is a change in lobe location, it should be repaired later7. There was one case of earlobe deformity in our sample (1.6%), but it regressed spontaneously after 4 weeks, which dispensed reintervention.

Sensorial nerve damage

Hyposthesia of the lower 2/3 of the ear, pre-auricular and maxillary regions for 2 to 6 weeks is the inevitable result of neural damage by the surgery10, 12. The numbness of the ear may be noticed in 1% of the cases, caused by section of the minor sensorial fibers over the malar and around the ear10, 14. Among our patients, one of them presented auricular paresthesia (1.6%), an acceptable figure based on the literature reports. It normally improves in weeks or months. Permanent anesthesia of the earlobe is a result of greater auricular nerve damage. This fact is not frequent, but if present, it should be repaired at the same surgical act.

Sensorial deficit may be caused by local anesthesia. Therefore, we recommend the use of small needles to prevent this problem6.

Motor nerve damage

Facial nerve damage in rhytidectomy is fortunately rare. In the pre-auricular region, the facial nerve runs deeply and it is protected by the parotid gland. In the absence of previous parotidectomy, damage of the proximal portion is extremely unlikely. However, it is anteriorly divided into segmented branches and becomes more superficial and subject to inadvertely damage6. Temporary paralysis of the facial nerve rates about 3%. Permanent damage of the nerve is present in 0.9% of the cases6. Frontal and marginal branches of the facial nerve are the most commonly affected. In our sample, there were no cases of motor nerve damage.

Deep plane dissection rhytidectomy, according to Rubin and Simpson13 (1996), analyzing the most frequent immediate post-operative neurological defects may cause: 1) frontal muscle paralysis; 2) lip and palpebral paralysis caused by damage to upper and lower buccal branches of the facial nerve; 3) diskinesia involving the lips and palpebrae after buccal branch damage; 4) lower lip paralysis by marginal nerve damage; 5) lower lip paralysis by platysma muscle surgery. In such type of deep plane surgery, the surgeon should follow the procedure with a nerve stimulator, have direct visualization and carefully dissect with scissors to prevent nervous damage4.

Most facial surgeons prefer to perform subcutaneous dissection with variable actions at the platysma and SMAS. Complications are minor and it may be performed with local anesthesia, the patient may be discharged from hospital the same day and it becomes a less costly surgery.

If a neural lesion is detected, it should be immediately repaired during the surgical act with nervous suture to prevent permanent paresthesia and the development of painful neuroma6.

Skin Necrosis

Tissue necrosis is caused by the vascular compromise of the tissue involved and may cause a small permanent scar12. When necrosis is superficial, only of the epidermis, sometimes there are no scars. The most common sites for damage are post-auricular and mastoid areas. They are present in 4.2% of the operated cases, probably because of thin skin and longer flaps. Fortunately, it may be more or less hidden by the ear and hair. Necrosis may be caused by undiagnosed hematoma, a highly traumatized flap during dissection, excessive tension upon closure, thermal damage by the cautery, very compressive dressing or by infection1. The resulting scar may be wide and require later repair.

Treatment should be observation and no surgery. Smokers, diabetes mellitus and previous head and neck radiated patients are more likely to have complications with hematomas and/or skin necrosis and difficult scaring. We should avoid extensive displacements in smokers2.

There were no cases of skin necrosis in our sample of patients.

Alopecia

It may affect 3% of the cases. It is more common in the temporal region, owing to the excessive tension on the flap or the destruction of hair follicles by dissecting too superficially or by electrocauterization 12. Temporal extension of the incision of rhytidectomy should be 4 to 5 cm behind the hairline and it should be incised at the follicle orientation. The hair may regrow within 4 to 6 weeks. We did not observe patients with alopecia.

Dissatisfactory Results

Dissatisfaction with the results is variable, described by some authors as present in 4.23% to 12.6% of the patients9, 14. Even though we have not performed prospective assessment of satisfaction, only one patient (1.6%) expressed dissatisfaction with the results of the surgery. However, we could not conclude that the rhytidectomy performed in our Medical Residence Program in Otorhinolaryngology has more success in satisfaction rates than the ones performed in other services. We believe that the differences may be a result of cultural issues and diverse expectations.

Dissatisfaction may be avoided by having efficient medical-patient relationship, with a detailed pre-operative visit in which the patient is informed about the surgery, results and possible sequelae. We should explain pre-operatively what can be improved, avoiding making promises beyond those the surgeon thinks he/she is capable of fulfilling. Corrections should be performed only 6 months after the first surgery. Psychological support to the patient is required up to the next surgery.

CONCLUSIONS

Complication rates in our Medical Residence Program in Otorhinolaryngology are compatible with those reported in other studies. We presented 12.9% of patients with isolated complications after the surgery and 6.5% had more than one complication. There was one expanding hematoma (1.6%), 5 small hematomas (8.1%), 3 seromas (4.8%), two suture dehiscence (3.2%), one infection (1.6%), one parotid gland fistula (1.6%), one ear deformity (1.6%), one auricular pinna paresthesia (1.6%). There were no cases of facial paralysis, cardiopulmonary disease or death. There was one female patient who was dissatisfied with the surgical results (1.6%).

Even though these data are clinically relevant, the size of the sample is too small to allow statistically significant conclusions. We can only suggest that the teaching of rhytidectomy in the academic setting is safe and efficient, provided that it is carefully performed by the resident physician who knows the technique and the anatomy and under the supervision of an experienced surgeon.

REFERENCES

1. Braddock SW. Cutaneous necrosis after rhytidectomy [letter]. Plast Reconstr Surg 1984;73(6):998.
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3. Kamer F, Damiani J, Churukian M. 512 Rhytidectomies: a retrospective study. Arch Otolaryngol Head Neck Surg 1984;110:368-70.
4. Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison. Plast Reconstr Surg 1998;102(3):878-81.
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8. Mélega JM, Zanini SA, Psillakis JM. Cirurgia plástica reparadora e estética. In: Psillakis JM. Face Senil: tratamento pela ritidoplastia subperiostal. Rio de Janeiro: Medsi, 1988. cap.59, p.185-193.
9. Osguthorpe J, Lomax W. Facial plastic surgery in an otolaryngology training program. Laryngoscope 1985;95:1255.
10. Pitanguy I, Cervollo MP, Degand M. Nerve injuries during rhytidectomy: consideration after 3,203 cases. Aesthet Plast Surg 1980;4:257-65.
11. Rees T, Barone C, Valauri F Ginsberg G, Nolan W. Hematomas requiring surgical evacuation following facelift surgery. Plast Reconstr Surg 1994; 93(6):1185-90.
12. Rees TD, Aston SJ, Thorne CHM. Blepharoplasty and Facialplasty. In: Maccarthy J. (ed.) Plastic Surgery. Philadelphia: W.B. Saundres, 1990. vol.3, cap.43, p.2320-414.
13. Rubin LR, Simpson RL. The new deep face lift dissections versus the old superficial techniques: a comparison of neurologic complications. Plast Reconstr Surg 1996;97(7):1461-5.
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[1] Faculty Professor, Head of the Service of Otorhinolaryngology, Federal University of Uberlândia.
[2] Undergraduate, Medical School, Federal University of Uberlândia.
[3] Resident Physician, Service of Otorhinolaryngology, Federal University of Uberlândia.
Service of Otorhinolaryngology, Hospital de Clínicas, Federal University of Uberlândia, Minas Gerais, Brazil.

Address correspondence to: José Antônio Patrocínio - Rua XV de Novembro, 327 / aptº. 1600 - Bairro Centro - Uberlândia - MG - 38.400-214

Tel/Fax: (55 34) 3215-1143 - E-mail: lucaspatrocinio@triang.com.br

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