Recognizing, Managing, and Guiding the Patient Through Complications in Facial Plastic Surgery.

Complications in facial plastic surgery can occur in both surgical and nonsurgical procedures. Many complications can be prevented through thorough preprocedural evaluation, patient counseling, and close postoperative monitoring. Despite the best efforts complications will happen and identifying them early is critical to prevent long-term sequelae. It is important to know how to both manage the complication and guide the patient through the recovery process.

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy.

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.

Analysis of Cervical Angle in the Submental Muscular Medialization and Suspension Procedure.

IMPORTANCE: The submental muscular medialization and suspension (SMMS) procedure is an option for addressing an obtuse cervical angle in select patients vs the use of traditional rhytidectomy techniques. OBJECTIVE: To compare the change in position of the cervical point between groups undergoing SMMS vs the traditional rhytidectomy technique. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was performed of 141 patients undergoing rhytidectomy in an accredited private surgery center between January 1, 2013, and December 31, 2014, comparing cervical point depth between patients undergoing SMMS vs those undergoing traditional rhytidectomy with platysma plication. Statistical analysis was performed from November 11, 2017, to January 5, 2018. INTERVENTIONS: Patients underwent either SMMS or traditional rhytidectomy with platysma plication. MAIN OUTCOMES AND MEASURES: The primary end point was change in the cervical point distance between preoperative and postoperative standardized profile photos. RESULTS: A total of 141 patients were included in the analysis. A cohort of 46 patients (43 women and 3 men; mean age, 63.5 years [range, 49.0-79.0 years]) underwent neck contouring with the SMMS technique and a cohort of 95 patients (90 women and 5 men; mean age, 61.0 years [range, 48.0-73.0 years]) underwent traditional rhytidectomy with platysmaplasty. The cervical point distance of the SMMS cohort had a mean (SD) postoperative increase of 2.0 (1.05) cm (95% CI, 1.73-2.28; P < .001) compared with 0.78 (0.82) cm in the traditional rhytidectomy cohort (95% CI, 0.54-1.02; P < .001). CONCLUSIONS AND RELEVANCE: The results of this study suggest that submental muscular medialization and suspension appears to be an effective option to address the obtuse neck in select patients. LEVEL OF EVIDENCE: 3.

Use of "Submental Muscular Medialization and Suspension" to improve the Cervicomental Angle.

Many techniques have been presented over recent decades to address the neck contour in facial cosmetic surgery. Despite advances, limitations remain when dealing with the obtuse cervicomental angle. The authors describe a technique for improving the obtuse cervicomental angle. Submental muscular medialization and suspension is a simple yet highly effective surgical technique that can result in dramatic and enduring improvement in the cervicomental angle.

Submental muscular medialization and suspension.

BACKGROUND: Many techniques have been presented over recent decades to address the neck contour in facial rejuvenation surgery. Despite advances, limitations remain when dealing with the obtuse cervical angle. OBJECTIVE: The authors describe a technique for improving the obtuse cervicomental angle. METHODS: The authors reviewed the charts of 295 patients who underwent the authors' submental muscular medialization and suspension (SMMS) technique to improve their neck contour, either alone or in combination with a facelift, between January 1, 2001, and December 30, 2003. The technique medializes and suspends the medial free edges of the platysma muscle and, when anatomy dictates, the anterior bellies of the digastric muscle to the deeper mylohyoid muscle. RESULTS: Eighty-seven (30.5%) of the 285 facelift patients examined underwent SMMS, and 10 additional patients underwent isolated SMMS. No patient required reoperation for hemostasis or evacuation. Three (1.05%) of the facelift with SMMS patients required reoperation for dehiscence of the submental suspension. None of the isolated SMMS patients had muscular suspension dehiscence or required reoperation. Seven (2.4%) patients (5 with SMMS and 2 without SMMS) with excessive facial and cervical tissue preoperatively developed a small amount of postoperative submental skin redundancy and subsequently underwent submental skin excision at 1 year postoperatively. CONCLUSIONS: Submental muscular medialization and suspension is a simple yet highly effective surgical technique that can result in dramatic and enduring improvement in the cervicomental angle.

Surgical manipulation of the periorbital musculature.

This article presents a review of the contribution of the periorbital musculature and brow depressors to the overall brow aesthetics. Special focus is given to the role of transblepharoplasty brow lift as well as myotomy of the corrugator and procerus muscles. The authors' preferred surgical technique and patient results are reviewed in detail.

Latest chemical peel innovations.

For decades, chemical peels have remained a trusted option for treatment of aging facial skin. However, emerging technologies are being adopted by many practitioners who may not have had sufficient opportunity to learn the art of chemical peeling. Properly performed peels can improve the condition of the skin, are less expensive than light-based machines, and exfoliate the skin without the thermal damage associated with light-based machines. This article presents a new variation of a trusted method, using a series of low-strength trichloroacetic acid peels and proper skin preparation that is cost-effective and produces excellent results in selected patients.

Chemical face peeling.

Chemexfoliation is an excellent method to reduce facial rhytids. For 25 years, we have used the traditional formula as described by T. J. Baker but with a moist healing technique rather than a tape mask. We have found the peel to be inexpensive and easy to perform, with results that are excellent and consistent, with minimal side effects.

Transblepharoplasty brow suspension with a biodegradable fixation device.

BACKGROUND: Brow droop, eyelid tissue excess, and hyperfunction of the muscles of forehead facial expression may contribute to the aging diathesis of the upper one-third of the face. Many approaches to the brow have been described, including coronal or pretricheal incisions, direct incision of the suprabrow or forehead, and endoscopic techniques. A less frequent technique, the transblepharoplasty browlift (TBBL), has a role in rejuvenating brow position, especially in patients in whom both the eyelids and brows need to be addressed. The Endotine forehead device has been reported to increase speed and ease in providing operative support to the brows, but little has been written about its function with the TBBL approach. OBJECTIVES: The authors describe their results with Endotine brow fixation for browlift through a TBBL approach. METHODS: Between November 2005 and January 2008, 20 patients presented to the senior author (PRL) for browlift and were treated with a TBBL approach and placement of the Endotine device in one of three sizes (3 mm, 3.5 mm, or 4 mm). The surgeon completed an operative questionnaire immediately postoperatively, as well as a satisfaction questionnaire at one and three months postoperatively. Nineteen of the 20 patients were followed up also completed satisfaction questionnaires at one and three postoperative months. The results were tabulated to assess the safety and efficacy of the Endotine device. RESULTS: A 3-mm Endotine browlift device was placed in most patients (13; 68%). The surgeon was satisfied with the performance of the Endotine device, its ease of insertion, and the fixation provided in all cases. The Endotine was always palpable under the skin but visible in only roughly half of patients. At one month, 5% of the fixations were judged by the surgeon to be fair in appearance; the remainder of cases were satisfactory or better. At three months, all fixations were judged as satisfactory or better. Patients reported being very satisfied with the results of the surgery initially (53%), and satisfaction improved with time (74%). After three months, 79% of patients would recommend the procedure to others, an increase from 63% after one month. CONCLUSIONS: The Endotine device provides an effective lift for the brows, allows for easy repositioning, and is much quicker to apply than the sutures placed in a traditional browlift.

Upper lid transconjunctival versus transcutaneous approach for fracture repair of the lateral orbital rim.

The use of the lower eyelid transconjunctival approach in the setting of orbital trauma has becoming increasingly popular in recent years. However, experience has found that access to the lateral orbital rim can be somewhat limited with this type of incision. Many authors supplement the approach with a lateral canthotomy in order to gain adequate access laterally. Although usually well tolerated, there can be side effects associated with this incision. We examine the upper lid transconjunctival approach to the lateral orbital rim. Furthermore, we compare this technique to the more traditional transcutaneous approaches used for orbital trauma. We have found this technique to be safe, effective, and to cause no more complications than the more traditional approaches.

Transblepharoplasty brow suspension: an expanded role.

Brow position and hyperfunction of the muscles of forehead facial expression contribute to the aging diathesis of the upper one third of the face. In many cases, the eyelids and brows are addressed together to achieve a satisfying rejuvenation effect. Many different approaches to the brow are used, including the long coronal or pretricheal incisions, direct incision of the suprabrow or forehead, and finally the use of smaller incisions with an endoscopic technique. Another technique, deserving of further consideration, is the transblepharoplasty brow lift (TBBL). Though generally reserved for occasional use, this technique is easy to perform, minimizes facial incisions and operative time, and can achieve results comparable to other, more extensive, approaches.

Transconjunctival approach to the zygomatico-frontal limb of orbitozygomatic complex fractures.

Fractures of the orbitozygomatic complex represent one of the most common injuries of the facial skeleton. Repair of the fractures often requires multiple surgical access points and the necessity for skin incisions. As surgeons attuned to aesthetics, we strive to minimize the signs of injury and treatment. We propose an approach designed to treat orbitozygomatic fractures without the use of skin incisions. The objective of this article is to outline the surgical technique designed by the senior author (PRL) to address the zygomatico-frontal fracture component of orbitozygomatic complex fractures through an upper lid lateral transconjunctival approach. Relevant anatomy and technique is described. The combination of previously described lower lid transconjunctival and gingivobuccal sulcus incisions with this new upper lid lateral transconjunctival approach provides adequate access for rigid fixation of all major components of orbitozygomatic fractures without skin incisions.