There has been a marked increase in the number of face-lifts over the past 10 years.
The American Society for Aesthetic Plastic Surgery statistics estimate that there
were ∼100,000 face-lifts performed in the United States in 1999; by contrast, in 2008,
this number had jumped to over 130,000, an increase of over 30%.[1] Increasingly, as (particularly younger) patients undergo face-lifting procedures,
it is reasonable to anticipate a greater number of patients seeking secondary facial
rejuvenation. A brief review of the literature illustrates the lack of material published
on the subject of secondary rhytidectomy. A MEDLINE search of “rhytidectomy” returns
2132 references, whereas “revision rhytidectomy” yields only 29 results.[2]
There are several questions that need to be answered in the care of the revision face-lift.
What is the nature of the prior dissection plane and should it be re-utilized or should
a different plane be employed? Should the neck be reopened? How are deformities and
cosmetic issues from the first surgery corrected and prevented after the second procedure?
The clinical situations commonly encountered in revision rhytidectomy are reviewed
and treatment options discussed. For the sake of clarity, only face-lift surgery will
be reviewed; secondary brow lifts and neck lifts are beyond the scope of this discussion.
PATIENT EVALUATION
PATIENT EVALUATION
As with any patient presenting for facial rejuvenation, a standard preoperative analysis
of the face should be performed. A “top-down” approach has been systematized and well
described.[3] A history of previous rhytidectomy clearly adds a level of complexity to this assessment.
Incisional and soft tissue deformities from the primary rhytidectomy should be identified
and discussed with the patient, as these should be addressed for optimal secondary
outcome. Any preexisting deficits in sensation and facial animation must be thoroughly
searched for and documented.
During the preoperative consultation, the specific features the patient wishes to
address should be individually discussed. It is important to distinguish and classify
the global environment in which revision surgery is being performed. Is a once good
result now less than desirable due to the natural aging process or significant weight
fluctuation? Is the result of the original surgery still acceptable but other issues
of facial aging now cause an aged appearance? Was the original surgical result sub-par
because of random or preventable complications that now require repair?
Often, a disharmonious appearance, with adequate correction in some areas while other
regions remain tired and aged-appearing, is the primary concern. The nasolabial folds
are notorious for persistence despite corrective efforts.[4] It is crucial as a professional to resist the temptation to criticize the prior
surgeon's efforts, as several factors, including the patient's preoperatively stated
desires, may have limited the initial surgery only to lead to the patient's postoperative
regret. Previous operations may have been thoroughly planned, executed with great
artistry and resulted in excellent results. However, rhytidectomy does not arrest
the microbiological aging process or stop the effects of gravity. While the platysma
corset may have remained tight and the subcutaneous fat adequately treated, the submandibular
glands and anterior digastric muscles may now be ptotic, peeking through the overlying
soft tissue carpet.[5] In general, the face-lift surgeon is wise not only to examine the parts of the face
but also to compare their relative appearance and plan accordingly. Furthermore, the
genesis of the problem should be assessed: Is the patient suffering from re-ptosis
of previously lifted tissues, worsening of a disharmonious result, volumetric deflation,[6] or some combination of the above?
At the initial surgery, the sideburn and temporal and occipital hairlines may have
been distorted either by an overly aggressive resection or by poor hairline scar site
selection.[7] Loss of earlobe definition and blunting of the tragus are two aesthetic problems
with the ear that can be seen with improper design of the incision and/or too much
tension on the ear at the initial closure.[8] Additionally, the pixie ear deformity, characterized by caudal earlobe migration
and axis distortion, may develop as a result of excessive wound closure tension or
scar contracture.[9]
There are several soft tissue distortions possible after face-lift surgery: skin pleating[10]; lateral sweeps[11]; smile block (Lambros V, personal communication, October 2008); “joker's lines”[12]; hollow orbits[11]
[13]; commissural distortion; and flattening of facial contours.[14] Hamra has discussed the negative long-term effects of a face-lift flap pulled in
a completely lateral vector. This causes pleating in a lateral direction, which can
be unsightly. Additionally, when the upper portion of the cheek is undercorrected
with this vector of pull, as it continues to age, it may sag over the corrected lower
portion of the face, causing the stigmata of the lateral sweep. Stuzin and Lambros
have recently pointed out the appearance of the “joker's line,” or the cross-cheek
depression. This is a sequela of the face-lift in a patient who has submalar hollowing
preoperatively; this hollowing is exaggerated by the translation of the face-lift
flap, leading to a dysesthetic appearance in which the commissure appears to extend
onto the cheek. Commissural distortion, with a horizontal lengthening of the mouth,
when combined with the cross-cheek depression, can lead to an appearance that is quite
unsightly. Noting these deformities preoperatively can enable the surgeon to adequately
address these problems in the revision face-lift.
Finally, with the advent of laser resurfacing as an adjunctive or stand-alone procedure,
it is important to assess the color of the patients face relative to their neck. Hypopigmentation
is not uncommon, and redraping darker, sun-beaten skin above the jawline will leave
an unsightly demarcation on the face.[15]
A comprehensive preoperative discussion with the patient is absolutely mandatory.
What is and (more importantly) what is not possible to correct must be frankly and
specifically outlined to the patient. It is important to emphasize to the patient
the limitations imposed on the revision procedure by the prior surgery.
GENERAL MANAGEMENT
GENERAL MANAGEMENT
Four potential presentations for the secondary face-lift can be described: (1) a poorly
performed primary procedure with limited results; (2) a poorly selected face-lift
procedure with limited results; (3) a poorly executed or well-executed primary face-lift
with postoperative sequelae; or (4) a well-selected and executed primary face-lift
procedure with good results lost over time as a result of continued aging. It is important
to review preoperative and postoperative photographs and the operative report of the
primary face-lift, and an assessment should be made as to whether the proper technique
was used. If results of a properly performed primary procedure are limited, a more
aggressive technique should be used in the secondary procedure. If limited improvement
occurred after a properly selected but poorly performed technique, it is not unreasonable
to proceed with a more thoroughly performed but similar procedure secondarily. If
initial results were good but failed to persist, alternative forms of facial aging
(e.g., soft tissue or bony volume loss) should be sought, and procedures ancillary
to the revision face-lift should be considered. Patient expectations should be assessed
and actively managed, as patients will bring to this secondary procedure preconceived
notions of wound care, postoperative course, and surgical results.
Surgery in any region that has undergone previous operation is always more complicated
than venturing into uncut tissue. Scar decreases the facility of dissection, both
by distorting planes and by increasing the rigidity of the tissues. Improved postoperative
vascularity of the rhytidectomy flap has never been demonstrated; however, if the
same flap is dissected, it should be theoretically “delayed” with improved perfusion.[16] Additionally, tension on the flap should improve the nature of its vascularity.[17] Conversely, chronoaging of the skin in the time between the initial and revision
surgeries, as well as the process of the prior surgery and wound healing, may have
left the skin considerably less elastic than before the first procedure.
A comprehensive medical evaluation is essential, as a patient who had an uncomplicated
course after a long surgery in her forties may not be as healthy 15 years later. It
is important to ascertain whether the patient has begun taking any new medications
or herbal supplements over the time since the first surgery. Guyuron et al demonstrated
through patient survey data that a significant number of patients will have started
a new medication between their first and second face-lift procedures.[5] Moreover, a significant number of patients will have developed a new medical condition
during this time period. Whereas patients may have stopped tobacco use at the time
of the first surgery, Guyuron notes that 60% of patients who smoked before their first
procedure will continue to smoke after their secondary rhytidectomy. This makes it
imperative that a thorough preoperative medical evaluation is obtained. In the senior
author's practice, the nature and extent of the planned procedure are discussed with
the patient's primary care physician, and documented recommendations for perioperative
medical management are requested.
INCISIONS
INCISIONS
In general, the secondary face-lift is performed using the prior incisions and excising
the existing scars. Exceptions to this rule include:
-
Any well-healed and inconspicuous portion of the scar from the initial procedure that
is not necessary for flap elevation and superficial muscular aponeurotic system (SMAS)
manipulation is not touched.
-
In women with pretragal scars and sufficient skin laxity, a retrotragal incision is
used and the pretragal scar excised along with redundant skin.
-
Standard incisions are used in cases of obviously malpositioned scars that can be
mobilized sufficiently to allow excision and closure in more appropriate locations.
Attention should be paid to the quality of wound healing from the prior surgery, and
although poor scarring may have been due to poor technique in the initial surgery,
it behooves the surgeon to anticipate scarring after revision rhytidectomy no better
than those from the primary procedure.
THE PLANE! THE PLANE!
THE PLANE! THE PLANE!
Every effort should be made to obtain the initial operative report in an effort to
understand what was done in the previous surgery so that intraoperative findings can
be anticipated and potential pitfalls avoided. Several issues should be specifically
addressed:
-
How far was the skin flap elevated?
-
To what extent was the SMAS elevated/manipulated?
-
Was any liposuction performed?
-
What was done to the platysma?
-
Was there any inordinate bleeding or anatomic anomalies?
As previously stated, it is believed by some that the secondary face-lift flap should
be more resistant to vascular embarrassment due to the delay phenomenon. Despite this,
there is a theoretical disadvantage to using the same dissection plane. Scar tissue
is less elastic[18] and flap excursion may be diminished,[19] although this idea has been challenged.[5] Additionally, the connective tissue fibers in the flap are oriented parallel to
the direction of the previous vector,[20] and theoretically this may lead to earlier relapse after secondary surgery, as the
weaker fibers are subjected to new tension and stress.[21] Moreover, it is possible that the facial nerve branches might be tethered more superficially
and hence more exposed and vulnerable during a secondary surgery if dissection is
performed in the same plane. Finally, prior injury to some peripheral branches of
the facial nerve (especially involving the zygomatic and buccal innervation to orbicularis
oculi and the lip elevator muscles[22]
[23]) may not be readily apparent because of cross-innervation between these two branches.
However, previous injury to some of these branches may have reduced their redundancy,
and any additional injury during a sub-SMAS dissection may produce a clinically apparent
lower lid or midfacial hypotonicity. In the senior author's experience, gentle blunt
dissection with vertically oriented Reynolds scissors and limited sharp dissection
can reliably re-elevate the SMAS without causing nerve injury.
MANAGING THE NECK
MANAGING THE NECK
Similar to the decision regarding the management of prior incisions, treatment of
the neck should be based on preoperative findings. If the neck shows good form, no
intervention here is necessary. A poorly healed submental scar should be excised,
at a minimum. If submental fat is excessive, liposuction or direct lipectomy is necessary.
Platysmal banding, if present, is treated by corset platysmaplasty, which can also
(partially) treat cobra neck deformity. Jowling, new or insufficiently treated by
the initial procedure, may be due to submaxillary gland ptosis, and in addition to
corset platysmaplasty oblique mattress sutures to tighten the paramedian platysma
should be considered. It is important to carefully redrape the cervical skin when
complete, as the reduced skin elasticity may require more extensive skin elevation
than expected.
REVERSING SOFT TISSUE DEFORMITIES
REVERSING SOFT TISSUE DEFORMITIES
Hamra observed that lateral sweep results from excessive tension and a lateral vector
when using a SMAS flap for facial rejuvenation.[11] It is his estimation that over time as the flap loses tension, descent occurs along
this lateral vector, leading to disharmony over time. The use of a more superior vector
during the secondary rhytidectomy has been shown to reverse this deformity.
Lambros and Stuzin pointed out how the secondary rhytidectomy patient might present
with something they call the “cross-cheek depression” or “joker's lines,” which appears
as a shadow from the oral commissure to the ear.[12] They believe that this distortion is seen in patients who are morphologically prone
because of strong malar prominence and a submalar hollow. These patients preoperatively
have a mild version of this deformity, and it is likely unmasked by the correction
of aging. Although a strong cheek ogee and submalar hollow are youthful and pleasing,
this shadow can be very disharmonious. Correction of this deformity is achieved by
soft tissue augmentation of the shadow to restore some submalar fullness.[24]
Smile block is a recently described entity in which the patient appears to have a
hypodynamic cheek mound or facial fat that does not move appropriately with animation.
It is unclear whether this is due to plication sutures placed too anteriorly, tethering
the SMAS and zygomaticus major muscle, or blocking of facial fat and fascia by sutures
and scar tissue.[25] Similar to the “joker line,” treatment of smile block is achieved with soft tissue
augmentation around the area that appears “blocked,” creating a more smooth appearance.[26]
CORRECTION OF HAIRLINE DISTORTION
CORRECTION OF HAIRLINE DISTORTION
A posttrichial temporal incision with aggressive superolateral flap advancement can
distort or obliterate the sideburn and temporal hair tuft (Fig. [1]). Though hairstyling can camouflage this deformity, a pretrichial incision could
have prevented it. Secondary rhytidectomy must avoid exacerbating this situation by
utilizing a pretrichial incision, and postoperative microfollicular hair transplantation
should be incorporated into the treatment plan to maximally reconstruct a proper hairline.
Widened and visible temporal scars can also be treated with hair transplantation when
scar excision is not feasible.
Figure 1 Visible occipital and temporal scars 15 years after rhytidectomy by a noted surgeon
that required specific hairstyling for camouflage. Note the distorted appearance caused
by posterosuperior transposition of temporal hair and loss of sideburn.
Occipital hairline deformities (Fig. [2]) include widened scars in hair-bearing skin, visible hairline scars, or hairline
step-offs. These can be corrected by scar excision, appropriate flap advancement/rotation
to restore the normal visual continuity of the hairline, and meticulous layered closure.
Focal hair transplantation postoperatively should be reserved for persistent deformities.
Figure 2 (A) Obvious step-off of the occipital hairline after rhytidectomy caused by poor
alignment of the transposed face-lift flap. (B) Hypertrophic scar with sublobular
portion.
CORRECTION OF EAR DEFORMITIES
CORRECTION OF EAR DEFORMITIES
Ear deformities are not uncommon after rhytidectomy. It has been shown by retrospective
reviews of plastic surgery practices that auricular displacement occurs in 64% of
rhytidectomy patients postoperatively.[27] It is likely that excess tension on the ear during healing leads to the caudal and
sometimes anterior malposition of the ear.[28] These problems are exacerbated by the fact that redraping of the facial soft tissues
in a more youthful position causes a disharmonious contrast between the corrected
face and the ptotic ear position. Pixie ear deformity describes the loss of ear lobule
definition, with the helical curve blending directly into the cheek.[29]
[30] Many methods have been devised to correct it: simple wedge excision and lobule re-creation[31]; triangular excision with wedge closure [32]
[33]; lobular suturepexy with no tissue excision.[34] Prevention of these ear deformities has also been discussed: McKinney et al advised
cephalad overrotation of the lobule during inset at the closure of the incisions[35]; Barton recommends dividing the excess SMAS flap and replacing it behind the ear
to brace the ear in addition to further definition of the jawline.[36] In the authors' experience, this transposition of a portion of the SMAS flap posteriorly
with anchorage to the mastoid periosteum can provide significant superior flap support
during healing. Additionally, a semipermanent suture placed between the inferior portion
of the SMAS incision and the deep aspect of the conchal cartilage can assist in defining
the lobular notch. To this can be added cephalad overrotation of the earlobe during
skin closure, as described by McKinney et al (Fig. [3]).
Figure 3 (A) For correction of a pixie ear deformity, a perilobular incision is made and a
small flap (limits shown by markings) is elevated inferiorly and posteriorly. (B) A suture is passed from the SMAS/scar
inferiorly and anchored to the perichondrium of the inferior portion of the conchal
bowl superiorly. (C) Tightening of this suture advances the flap superiorly, providing
stability as well as generating sufficient redundancy to allow overrotation of the
earlobe during closure.
In some cases where a retrotragal incision is used, the tragus can become anteriorly
rotated, especially in patients with soft and pliable tragal cartilage, leading to
an unsightly exposure of the external auditory meatus and canal. Additionally, the
tragus can become bulky and blunted. Retrotragal incisions should not be used in any
patient with a pliable or anteriorly rotated tragus. The lateral cheek skin redraped
over the tragus at the end of the case is always thicker than the natural tragal skin
and should be carefully defatted prior to closure to avoid a “plump” tragus. Finally,
prior to tragal skin closure, an absorbable “tacking” suture should be placed between
the dermis and soft tissue just anterior to the tragal root to better define a pretragal
sulcus that visually distinguishes the lateral cheek from the tragus.
CONCLUSION
CONCLUSION
Patients may seek revision rhytidectomy as a result of operator failure, technique
failure, or simply because of the inexorable progression of aging. Revision face-lift
can be performed but may present additional problems and challenges compared with
primary face-lifts. It is critical preoperatively to help the patient determine appropriate
and achievable goals and expectations. Correction of face-lift stigmata with modest
rejuvenative changes may be a more appropriate goal than aggressive skin redraping
with persistent surgical deformities. An approach of “Underpromise, Overdeliver” is
certainly appropriate for the typical revision rhytidectomy. However, with thoughtful
planning, excellent and reliable results are obtainable.
