The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts

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 .

Safety and Outcomes in Multiplane Facial Rejuvenation with Tranexamic Acid: A Cohort Study

Background

Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and complications among patients undergoing facial surgical procedures.

Methods

A retrospective cohort study of patients who underwent multiplane facial rhytidectomy from January 2018 to September 2022 at the Clinica Ziegler, Lima, Peru. Patients were divided into two groups according to the use of intravenous plus local infiltration of TXA. We performed the chi square test to assess associations among categorical variables, the Student t test and Mann-Whitney U test for categorical with continuous variables, and Pearson correlation for quantitative variables.

Results

A total of 100 patients were included with 50 patients in each group. The median age was 59.5 years and the majority were women (88%). The median operative time was 288.5 minutes. The TXA group presented less intraoperative bleeding (40 versus 90 mL, P < 0.05) and shorter operative time (237 versus 353 minutes, P < 0.05); no differences in the development of hematoma (2% versus 12%, P = 0.11), less ecchymosis (2% versus 36%, P < 0.05), edema (2% versus 100%, P < 0.05), and time to drain removal (3 versus 6 days, P < 0.05).

Conclusions

TXA improves the short- and long-term outcomes of patients who undergo multiplane facial rhytidectomy. It also decreases intraoperative bleeding by more than half and reduces the operative time by one third. Moreover, patients receiving TXA presented significantly less ecchymosis, edema, and time to drain removal.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Top 50 Highly Cited Publications in Facelift Surgery: A 50-Year Bibliometric Analysis Review

INTRODUCTION

Facelift surgery, also known as rhytidectomy, is a commonly performed procedure to address aging-related changes in the face and neck. Over the years, its techniques and methodologies have evolved. This study aimed to provide a bibliometric analysis of the top 50 most cited publications related to facelift surgery over a fifty-year period (1973-2023).

METHODS

The authors obtained data from the Web of Science Core Collection on July 15, 2023. Using a predefined search strategy, the most cited articles from 1973 to 2023 on facelift surgery were identified. The publications were analyzed for their type of study, journal of publication, geographic origin, and primary outcomes. Furthermore, the authorship gender distribution was assessed.

RESULTS

The majority of the publications (34 out of 50) were published in the "Plastic and Reconstructive Surgery" journal. The USA contributed to 72% of the research, followed by the UK, Mexico, Australia, and Germany. The primary outcomes varied from surgical techniques, anatomical studies, risk factors, patient-specific outcomes, and facial rejuvenation techniques, to comparative and historical progression of techniques. Notably, male authors dominated the field with 47 out of 50 papers having both a first and senior male author.

CONCLUSION

Facelift surgery has seen substantial research development over the past fifty years. The USA has been at the forefront of this research, with a predominant focus on surgical techniques and anatomical studies. Male dominance in authorship indicates potential scope for increased gender diversity in this specialty. Annual updates are recommended for continued insights.

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 .

Evidence of Hematoma Prevention After Facelift

Hematoma is a common complication after facelift procedures. Multiple factors have been shown to increase the risk of hematoma formation, such as male gender, anticoagulant medication use, perioperative hypertension, increased intrathoracic pressure, and operative technique. The purpose of this manuscript is to provide an overview of existing literature to provide surgeons with evidence-based recommendations on how to minimize hematoma risk during facelift surgery. A literature search for hematoma and facelift surgery was performed that identified 478 unique manuscripts. Abstracts were reviewed, excluding articles not describing facelift surgery, those written before 1970, studies with a sample size of fewer than 5 patients, non-English studies, and those that did not provide postoperative hematoma rates. Forty-five articles were included in this text, with their recommendations. Measures such as the prophylactic management of pain, nausea, and hypertension, the use of fibrin glue tissue sealants, the use of local anesthesia rather than general anesthesia, and strict blood pressure control of at least <140 mmHg were found to significantly reduce hematoma formation. Quilting sutures has shown benefit in some high-risk patients. Measures such as drains, compression dressings, perioperative use of selective serotonin reuptake inhibitors, and perioperative steroids had no significant effect on hematoma formation. In addition to appropriate patient selection and careful intraoperative hemostasis, many adjunct measures have been shown to reduce postoperative hematoma formation in facelift procedures.

LEVEL OF EVIDENCE: 3

Hemostatic Net in Facelift Surgery: A 5-Year Single-Surgeon Experience

BACKGROUND

The hemostatic net has been promoted as a safe and effective method to prevent hematoma formation following facelift procedures. To date there is little published evidence to validate the replicability and effectiveness of the technique.

OBJECTIVES

This study presents 2 cohorts of facelift patients from a single surgeon's practice to assess the impact of the hemostatic net on hematoma formation.

METHODS

The records of 304 patients were reviewed on whom the hemostatic net was placed following a facelift between July 2017 and October 2022. Data were collected and assessed for complications and compared with a control group of 359 patients who underwent a facelift procedure without placement of a hemostatic net by the same surgeon between 1999 and 2004.

RESULTS

A total of 663 patients were included. In this retrospective cohort study, analysis of available data showed a significantly reduced hematoma rate of 0.6% in the intervention group compared with 3.9% in the control group (P = .006722).

CONCLUSIONS

The use of the hemostatic net is a safe, reproducible, and effective technique in reducing the risk of hematoma in facelift surgery.

LEVEL OF EVIDENCE: 4

Can Vitamin D Levels Alter the Effectiveness of Short-Term Facelift Interventions?

Facelifting is increasingly popular among the population. It exceeded the limits of post-traumatic facia-reconstruction. Both the demand and the methods available are getting increasingly diverse. The minimally invasive technique revolutionized the facelift, although it took some time to completely comprehend the mechanics. The roles of vitamin D in numerous physiological processes in which it is involved have mostly been elucidated in the last decade. Our hypothesis is based on one of these roles, that is, vitamin D intervenes in changing the type of collagen by changing its location; therefore, collagen will have a supporting role for the subcutaneous tissue. A group of 156 patients with different facelifting methods was followed: 93 minimally invasive (NC), 49 classical surgery (C) and 14 with the combined technique (NC + C). The change in the subcutaneous tissue was monitored by an elastograph. The level of vitamin D was monitored in order to assess the immediate and long-term effects of vitamin D on the progression of subcutaneous fibrosis. It was proven that an optimal level of vitamin D has a beneficial effect in maintaining the volume of subcutaneous tissue in patients from the NC and NC + C groups, the best results being in the NC + C group. An increase in the subcutaneous volume was recorded, which leads to a decrease in elasticity (statistical significance p < 0.05) and the lowering of the subcutaneous tissue, and an increased amount of lowering corresponds to a lowering of vitamin D levels.

The Short Neck: Challenges and Techniques

Establishing a pleasant cervical contour in short-neck patients is of one the most difficult challenges for a facial plastic surgeon. Subplatysmal volume reduction, platysma tightening, and skin distribution adequately coupled with the middle third facelift are the pillars of the surgical approach. Additionally, treating the small chin, which is frequently observed in these patients, improves the overall result. In this paper, an objective method to define short-neck patients is offered. The applied surgical anatomy of the neck is revised. Innovative strategies to treat the supra and infrahyoid subplatysmal structures are presented, including the sternohyoid muscles plicature and the use of the interplatysmal/subplatysmal fat flap. A novel chin augmentation technique, using a subperiosteal en bloc fat graft is also introduced. A modified deep plane approach is described, including a continuous suture of the middle third fasciocutaneous flap. A combined lateral platysma tensioning with the sternocleidomastoid rejuvenation is demonstrated. Lastly, the hemostatic net is revisited as a critical approach to resolve the defying skin accommodation.

The Effect of Preoperative Gender Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation

BACKGROUND

Many providers require cessation of gender affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery due to concern for increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender affirming procedures.

OBJECTIVES

To compare adverse event rates in GAHT cessation versus GAHT continuation in patients undergoing masculinizing chest surgery.

METHODS

This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent masculinizing chest surgery between 2016 and 2020.

RESULTS

There were 236 patients who met inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery (T-GAHT cessation), and 64 (27.1%) patients continued testosterone GAHT prior to surgery (T-GAHT continuous). Mean (SD) age at surgery was 25 (8) years, and mean (SD) BMI was 29.5 (6.6). Average duration of testosterone therapy was 18 months (range 0-300). There was no significant difference in tobacco use (p=0.73), diabetes (p=0.54), thrombophilia (p=0.97), or history of thromboembolism (p=0.39). Most patients underwent double incision free nipple graft technique (77.9%). There was no significant difference in surgical time (p=0.12), intraoperative complications (p=0.54), or postoperative complications (p=0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications.

CONCLUSIONS

There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively versus patients who undergo GAHT cessation for masculinizing chest surgery.

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery

BACKGROUND

Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients.

OBJECTIVES

This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes.

METHODS

A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed.

RESULTS

Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001).

CONCLUSIONS

TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

LEVEL OF EVIDENCE: 4

Face Lift after Facial Feminization Surgery: Indications and Special Considerations

SUMMARY

Iatrogenic jowling can be an unintended consequence of facial feminization surgery. Reduction of the mandible and chin without overlying changes to the soft tissue can lead to a redundant and deflated soft-tissue envelope, requiring a face lift to address jowling, cervicofacial laxity, and/or lower facial rhytids. Prospective quality-of-life outcomes data support this hypothesis, as patients who underwent mandible contouring with or without angle osteotomies were significantly more likely to express interest in face lift following facial feminization surgery on univariable analysis (90.0 percent versus 10.0 percent, p = 0.038). Patients with inherent skin laxity are at particularly high risk, such as those with advancing age, extrinsic skin damage (e.g., sun exposure, cigarette smoke), and history of massive weight loss. Before facial feminization surgery, the authors recommend comprehensive patient counseling that includes a discussion of the possible future need for a face lift, preferably around 1 year after facial feminization surgery. When performing a face lift after facial feminization surgery, technical considerations include those related to sequelae of prior facial surgery, anatomical differences between cismale and cisfemale facial soft tissue, and the mechanism of jowling after facial feminization surgery versus normal facial aging. The authors believe that these considerations can set more realistic expectations for facial feminization surgery patients, improve surgeons' ability to skillfully execute this procedure, and ultimately contribute to ongoing quality-of-life improvements in facial feminization surgery patients.

Facelift Part II: Surgical Techniques and Complications

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

LEVEL OF EVIDENCE: 4

Methods for Minimizing Bleeding in Facelift Surgery: An Evidence-based Review

INTRODUCTION

Bleeding and hematoma remain leading causes of postoperative complications and unsatisfactory patient outcomes in facelift surgery. Several methods have been implemented, and continue to be developed, to minimize bleeding in facelift surgery. These methods include perioperative blood pressure management, compression dressings, drains, tissue sealants, wetting solution infiltrate, and tranexamic acid.

METHODS

An evidence-based review of methods used to minimize bleeding in facelift surgery was conducted using the PubMed database according to PRISMA guidelines. Included studies were evaluated for the effects of implemented methods on bleeding outcomes in facelift surgery. Recommendations for each method evaluated were determined based on the amount, level, and heterogeneity of included studies.

RESULTS

Thirty-six studies were included in the evidence-based review. Effective strategies to reduce the time to hemostasis, postoperative drainage volume, and hematoma rate included perioperative blood pressure management, tissue sealants, and tranexamic acid. While the use of drains or wetting solution infiltrate did not demonstrate to significantly influence bleeding outcome measures, these methods may provide other advantages to facelift surgery. Compression dressings have not demonstrated a significant effect on facelift outcome measures.

CONCLUSIONS

Perioperative medical management of blood pressure, tissue sealants, and tranexamic acid are most effective in facilitating hemostasis and preventing postoperative hematoma in facelift surgery.

[Complications of head and neck expansion: Acting on modifiable factors. A study of 98 prothesis]

BACKGROUND

Tissue expansion is a key tool in the therapeutic arsenal that is proposed for repairing soft tissue losses of the head and neck. This technique, however interesting it may be, is not without its risks. The aim of this work is to identify the different steps of this procedure, determine the complications risk factors inherent to each step of the expansion and propose recommendations to improve functional and aesthetic results.

PATIENTS AND METHODS

We carried out a retrospective study on tissue expansion of the head and neck over a period of 10 years extending from January 2009 to December 2018, with at least one year follow-up for each patient. Our study counted 63 patients with the placement of 98 prostheses. We considered the various variables involved in the expansion process in order to determine those that increase the risk of complications.

RESULTS

In our series we counted 66.3 % of complications and 22.4 % of failures. We found that a young age increased the risk of skin suffering and that smoking increased the risk of hematoma occurrence. Neck expansion was found to be the riskiest site of expansion followed by the scalp that increased the risk of exposure (especially the parietal section of the scalp). The face is considered as an interesting site for expansion. We found that the use of multiple expanders is an attractive alternative to iterative expansions and to the choice of large expanders.

CONCLUSION

Tissue expansion of the head and neck requires careful planning that takes into account each step of the process.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy

PURPOSE

Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy.

METHODS

A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed.

RESULTS

One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values.

CONCLUSIONS

Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Perioperative Approach to Reducing Hematoma during Rhytidectomy: What Does the Evidence Show?

BACKGROUND

Postoperative hematoma remains the most common complication in rhytidectomy, prompting surgeons to use a multitude of adjunctive measures to prevent its occurrence. The goal of this systematic review was to determine which of these measures are supported by strong evidence, and to highlight those that remain unsubstantiated and require further investigation.

METHODS

A systematic search was performed of the PubMed and Embase databases for English literature from 1975 to March of 2020 containing designated keywords, and focusing specifically on adjunctive measures aimed at preventing hematoma in rhytidectomy. The resultant articles were then systematically screened according to predefined inclusion and exclusion criteria to determine eligibility for inclusion in the study.

RESULTS

The keyword search yielded a total of 2391 articles. Title and abstract screening resulted in 103 articles that were eligible for full-text review. Ultimately, 48 articles met final inclusion criteria. The articles were categorized into their particular mode of intervention: fibrin tissue sealants, perioperative medications (anesthetics, antihypertensives, miscellaneous medications), and intraoperative maneuvers (hemostatic agents, preinfiltration, intraoperative maneuvers, and drains). Nine studies were indexed as evidence Level II and 24 as evidence Level III. The remainder of studies constituted Level IV evidence.

CONCLUSIONS

Adjunctive interventions have been borne out of necessity in efforts to reduce postoperative hematoma after rhytidectomy. Although many of these interventions have promising results, the current literature supports the senior author's (R.J.R.) experience that an evidence-based, multimodal approach is ideal to minimize the rates of hematoma after rhytidectomy.

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding

BACKGROUND

Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery.

OBJECTIVES

The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage.

METHODS

This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded.

RESULTS

The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications.

CONCLUSIONS

TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

LEVEL OF EVIDENCE: 2

Conservative Neck Rejuvenation

In the field of facial rejuvenation, among the recurrent topics, one of the most discussed is the return to less invasive techniques. Lower face rejuvenation is best achieved acting on the platysma muscle. Many techniques are used and usually include platysma section, redundancy reduction, and redraping. Platysma plication is also used especially in secondary cases because of the increased risk of nerve injury due to possible anatomical damage caused by previous operations. A technique that preserves the deep planes based on a new plication method is proposed (conservative neck rejuvenation). In this technique, the dissection plane is only subcutaneous to reduce the risk of nerve injuries. An effective neck contouring is possible using a simpler technique with very good results and a lower rate of morbidity.

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

The Role of Tranexamic Acid in Aesthetic Plastic Surgery: A Survey of the British Association of Aesthetic Plastic Surgeons

BACKGROUND

Tranexamic acid (TXA) can reduce intra- and postoperative bleeding as well as minimizing postoperative swelling and ecchymosis. It can be administered both intravenously and topically during surgery with minimal side effects.

OBJECTIVES

To assess the evidence of TXA use in aesthetic surgery and to complete a survey of current practice of full British Association of Aesthetic Plastic Surgeons members.

METHODS

The authors performed a literature review and online survey of full British Association of Aesthetic Plastic Surgeons members.

RESULTS

There is an increased indication of TXA utilization in aesthetic surgery. It provides multiple surgeon and patient benefits.

CONCLUSIONS

TXA is a useful adjunct in aesthetic surgery.

A comparison of the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing hematoma and seroma in rhytidectomy: A randomized, double-blind, controlled study

BACKGROUND

One of the most feared complications of rhytidectomy is the formation of hematoma and seroma, which may harm patients' health and compromise the surgical outcome.

OBJECTIVE

To compare the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing surgical complications such as hematoma and seroma following rhytidectomy procedures.

METHODS

A prospective, randomized, double-blind, controlled study was conducted to compare the efficacy of the two interventions. Seventy-two patients were selected and divided into two groups of 36 (autologous fibrin glue versus suction drainage). Forty-eight hours after the procedures, all patients underwent ultrasound examination, always by the same radiologist, to measure the volume of exudate under the facial skin flaps.

RESULTS

The mean total volume of exudate was 3.21 mL in the suction drainage group and 1.02 mL in the fibrin glue group, with effect size of 68.1% and confidence interval of 55.3 to 77.2 (P < 0.001).

CONCLUSIONS

Results significantly favor the use of fibrin glue and show that it was 68.1% more effective than suction drainage in preventing hematoma or seroma in rhytidectomy procedures.

Quilting Sutures in Rhytidectomy: A Systematic Review of the Literature

BACKGROUND

Different technical variations exist for the utilization of quilting sutures (QS) in rhytidectomy. No systematic review or meta-analysis of the studies describing the use of QS in facelifts has been published to date to the authors' knowledge.

OBJECTIVES

The objective of this study was to summarize all the published data regarding the utilization of QS in rhytidectomy, compare QS techniques, and evaluate their effect on postoperative complications.

METHODS

On April 1, 2019, a systematic search of the Medline, Embase, and Cochrane databases was conducted. All the studies describing the usage of QS in facelifts were included in this review. Studies reporting hematoma rate in a QS group and a control group were included in the meta-analysis part of this study.

RESULTS

The initial search of the databases yielded 93 results. Four trials were included in the systematic review and 2 were included in the meta-analysis. The total number of included patients with QS was 527. Two studies employed internal QS and the remaining studies utilized external QS. The meta-analysis found a lower rate of hematoma in the QS group (relative risk, 0.02; 95% confidence interval = 0.00-0.13; P < 0.0001).

CONCLUSIONS

QS can be applied either internally or externally and are very effective in reducing hematomas after facelifts. QS could be a great asset in facelifts but should be utilized with caution because additional work is needed to confirm their safety and efficacy.

LEVEL OF EVIDENCE: 2

The Male Facelift

Rhytidectomy techniques have evolved significantly since the procedure was first described in the early twentieth century. Techniques vary based on surgeon preference, patient characteristics, and the desired outcome. As facelifts are embraced by the general public and the frequency of rhytidectomy increases, attention to male patient-specific technique is critical. Male and female facelift techniques are fundamentally similar; however, there are nuances to patient selection and technique in males that guide the surgeon to improved postoperative outcomes. Attention to incision placement, trichophytic technique, and adjunct procedures will improve overall cosmesis in the male patient. Understanding of potential risks and their likelihood in the male patient will also minimize complications and allow for rapid recovery.

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.

Differences in Female and Male-to-Female Transgender Facial Skin Micro-Vessel Density

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind this gender-associated risk is poorly developed and requires further investigation. Objective: The objective of this study was to compare facial skin micro-vessel density of female and male-to-female (MTF) transgender patients undergoing rhytidectomy to better understand the mechanism of gender-correlated hematoma risk factors. The authors hypothesized that transgender patients would have higher micro-vessel density compared with female patients. Design, Setting, and Participants: This was a prospective histopathological analysis of pre- and post-auricular facial skin samples from patients undergoing primary rhytidectomy. Patient clinical data and skin samples were collected. Histopathological slides were prepared and stained with CD-31, a marker of vessel endothelium, followed by image analysis allowing for micro-vessel stained pixel counts and calculated pixel density comparisons at a single academic hospital. Female, MTF transgender, and male patients >18 years of age were studied. Exposure: Patients undergoing primary rhytidectomy between 2015 and 2018. Main Outcomes: Gender-associated pre- and post-auricular micro-vessel pixel density. Results: Forty-one patients contributed skin samples for analysis. Post-auricular micro-vessel pixel density was greater than pre-auricular density (mean difference post-pre 0.359 percentage points [p.p.], standard error [SE] = 0.135, p = 0.009). The mean post-auricular micro-vessel pixel density was 1.60% (SE = 0.13 p.p.), 2.16% (SE = 0.19 p.p.), and 2.77% (SE = 0.34 p.p.) for female, transgender, and male patients, respectively (p = 0.016). Pre-auricular micro-vessel pixel density showed no difference among females, males, and transgender patients (p = 0.30). Gender was a strong predictor of increased post-auricular micro-vessel pixel density on stepwise linear regression, but it did not predict pre-auricular micro-vessel density. Both preoperative hair removal and a history of hypertension were associated with increased pre-auricular micro-vessel density. Conclusions and Relevance: Facial skin micro-vessel density differs by gender, in addition to pre- and post-auricular locations in patients undergoing rhytidectomy.

Tranexamic Acid in Aesthetic Facial Plastic Surgery: A Systematic Review of Evidence, Applications, and Outcomes

Background

Tranexamic acid (TXA) is an antifibrinolytic that has become widely used in aesthetic facial plastic surgery, although its efficacy has not been well investigated.

Objectives

To evaluate the existing evidence for use of TXA in aesthetic facial plastic surgery, highlighting routes of administration, dosing, surgical applications, and clinical outcomes.

Methods

Systematic review of primary literature evaluating TXA in aesthetic facial plastic surgery.

Results

Eleven studies met inclusion criteria: 8 prospective randomized controlled trials, 2 retrospective case series/cohort studies, and 1 clinical opinion. Six studies evaluated TXA in rhinoplasty, 4 in rhytidectomy, and 1 in blepharoplasty. Significant reductions in intraoperative blood loss were found in 5 rhinoplasty studies. Three rhinoplasty and 2 rhytidectomy studies found significantly reduced postoperative edema and ecchymosis. One rhinoplasty and 1 rhytidectomy study reported reduced operative time and time to achieve hemostasis. One rhytidectomy study reported reduced postoperative drain output and faster time to drain removal. No studies reported an adverse outcome directly related to TXA.

Conclusions

Existing literature investigating TXA in aesthetic facial plastic surgery is sparse with varying levels of evidence and heterogeneous data. Literature suggests systemic TXA reduces intraoperative blood loss during rhinoplasty, although the clinical significance of this blood loss reduction is unclear. TXA may also reduce postoperative edema and/or ecchymosis in rhytidectomy and rhinoplasty, although the lack of validated grading scales yields insufficient evidence to support this claim. Topical and subcutaneously injected TXA are emerging administration routes in rhytidectomy, with evidence suggesting TXA mixed with tumescent may reduce postoperative drain output, thereby expediting drain removal.

Level of Evidence: 2

From the Deep-Plane Rhytidectomy to the Vertical Platysma Advancement

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

Nuances in Superficial Musculoaponeurotic System Rhytidectomy

Rhytidectomy techniques have evolved since the early 1900s. As the understanding of facial anatomy and the aging process expanded, the superficial musculoaponeurotic system (SMAS) became a focal point in developing longer-lasting, natural results. Further evolution led to various approaches in repositioning the SMAS layer, including subperiosteal, composite, and deep plane rhytidectomies. This article describes the nuances of SMAS rhytidectomy, the biplanar SMAS imbrication technique, and adjuvant procedures used. This biplanar SMAS technique has been refined over more than 25 years and has proved to be a reliable and safe technique that leads to high patient satisfaction with minimal complications.

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.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Triple-S Lift for Facial Rejuvenation

BACKGROUND

Since the beginning of the last century, when the aesthetic rejuvenating surgery was first described, there have been great changes in tactics and methods for solving the problems of age-related facial changes. Since the first description of the superficial muscular aponeurotic system (SMAS), there have been two main approaches to influencing this structure. These are various types of SMAS plications and different in-depth and technique sub-SMAS liftings. Each of these approaches has its advantages and disadvantages.

METHODS

We have developed and applied a face-lift technique that combines the advantages of both approaches. We call it the triple-S lift, which is based on three basic principles: 1. A short scar technique; 2. The safety SMAS (limited sub-SMAS dissection to anterior border of the masseter muscle); 3. The support system (a complex of ligatures in the sub-SMAS layer, which allows lifting and plication of the medial part of the SMAS simultaneously) According to this method, there were 93 operations performed on 8 men and 85 women aged 38 to 72 years.

RESULTS

The first clinical applications produced good results. The patients noted a high degree of satisfaction, and the level of complications was quite low. Since the technique has been performed for a short period of time, we demonstrate results of the 2-year period.

CONCLUSION

The described technique requires further study, but the first results suggest that this type of a surgical intervention is safe, easy to execute, and may be an option to choose for surgical correction of facial aging changes.

LEVEL OF EVIDENCE IV

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 .

Neck Rejuvenation: Anatomy and Technique

An aesthetically pleasing neck contour remains the cornerstone for facial rejuvenation. In this article a detailed description of the anatomy pertaining to the necklift surgery is provided, with supplemental cadaver video dissections going over the most common and novel necklift techniques.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

The Extended Superficial Musculoaponeurotic System

The extended superficial musculoaponeurotic system (SMAS) facelift targets the 2 cardinal signs of facial aging: (1) descent of the malar fat resulting in deepening of the nasolabial folds as well as accentuation of the palpebral malar groove and tear trough deformity; (2) formation of jowls, which also obscure the definition of the lower mandibular border. In this article the authors describe the concepts behind the extended SMAS operation, importantly the extent of skin dissection and SMAS elevation. They present a brief history of the operation and landmark papers and supplement with fresh cadaver dissections.

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.

Facelift Performed Safely With Local Anesthesia and Oral Sedation: Analysis of 174 Patients

BACKGROUND

Anesthesia for elective ambulatory procedures must provide appropriate pain control while minimizing perioperative risk. Local anesthesia in combination with oral sedation provides a safe office-based method of anesthesia for rhytidectomy.

OBJECTIVES

The purpose of this analysis was to identify the incidence of traditional outcome parameters in ambulatory rhytidectomy performed with local anesthesia and oral sedation.

METHODS

A retrospective chart review was performed on all patients who underwent office-based rhytidectomy under local anesthesia with oral sedation from February 2011 to May 2017. A total of 174 patients were included. The data collected included patient medical and surgical history, medications, body mass index, tobacco use history, operative time, technique, and concurrent procedures. All intraoperative and postoperative complications were recorded.

RESULTS

One hundred and sixty-five patients were female (94.8%) and 9 were male (5.2%) a mean age of 57.6 years (SD ± 7.90). There were 46 complications, including 23 hematomas (13.2%), 6 seromas, 6 episodes of emesis, 5 infections, 4 scar deformities, and 2 ear deformities. Of the 23 hematomas, only 2 required operative evacuation with local anesthesia in the office procedure room. Twenty-one hematomas were small and managed with percutaneous needle aspiration, followed by surveillance. The 5 infections resolved after oral antibiotics only. There were no thromboembolic events or hospitalizations.

CONCLUSIONS

The use of only local anesthesia in combination with oral sedation safely permits the performance of rhytidectomy with similar incidence of rhytidectomy-related complications without the risk related to general anesthesia.

LEVEL OF EVIDENCE: 4

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

Management of the Submandibular Gland in Neck Lifts: Indications, Techniques, Pearls, and Pitfalls

Neck contour deformities are common among patients who present for facial rejuvenation. A thorough physical examination and photographic analysis, including an upward view of the flexed neck, enable the surgeon to determine which structures should be treated. Common causes of neck concerns include hypertrophy of the subplatysmal fat, the anterior belly of the digastric muscle, and/or the submandibular salivary glands. Partial removal of the submandibular salivary glands requires advanced knowledge of subplatysmal anatomy and surgical expertise but can be performed safely and reliably to yield favorable results of neck rejuvenation.

The Avoidance and Management of Complications, and Revision Surgery of the Lower Face and Neck

Complications are an inherent occurrence in surgery. In rhytidectomy, many complications are avoidable with thorough preoperative assessment and optimal intraoperative and postoperative care. Nevertheless, complications do occur. In certain situations, avoidance of risks is the best way to decrease the occurrence. Once complications do occur, there is a large body of literature to aid in the correction.