The Laryngoscope
Lippincott Williams & Wilkins, Philadelphia
0 1999 The American Laryn ological,
Rhinological and Otological fociety, Inc.
Complications of Rhytidectomy in an
Otolaryngology Training Program
Christopher A. Sullivan, MD; Jeffrey Masin, MD; Anthony J. Maniglia, MD; David W. Stepnick, MD
ObjectiuesJHypothesis:Complications of rhytidec-
tomy have been widely reported in the literature. This
study examines the incidence of complications after
rhytidectomy in the hands of chief residents under ap-
propriate attending supervision in an otolaryngol-
ogy-head and neck surgery training program. Mated-
als and Methods: The charts of 96 consecutive SMAS
rhytidectomy patients were retrospectively reviewed.
Patients were selected for surgery from a clinic de-
signed exclusively for cosmetic facial surgery patients.
This clinic was run by the otolaryngology chief resi-
dent and was supervised by an attending staff surgeon.
Most patients elected local anesthesia and sedation ad-
ministered by the surgical team. Submental liposuc-
tion was performed followed by SMAS plication
rhytidectomy. Results: Follow-up ranged from 1 to 60
months. Complications included expanding hematoma
(l%), temporary facial nerve weakness (3%),pretra-
gdmastoid skin slough (4.2%), permanent ear numb-
ness (l%),hypertrophic scar (3.1%), wound infection
(l%), and dissatisfaction with result (4%). There were
no cases of permanent facial nerve injury. Concksion:
These complication rates compare favorably with re-
ported rates of larger studies over the past 30 years.
These data support the conclusion that rhytidectomy
can be performed safely by otolaryngology residents
with little morbidity and good patient satisfaction.
Words: Rhytidectomy, cosmetic surgery, residency
training.
Laryngoscope, 109198-203,1999
Presented at the Meeting of the Middle Section of the American
Laryngological, Rhinological and Otological Society, Inc., Minneapolis,
Minnesota, January 25, 1998.
From the Department of Otolaryngology-Head and Neck Surgery,
Case Western Reserve University, Cleveland, Ohio.
This study was supported by funds from the Head and Neck Medi-
cine and Surgery Foundation, University Hospitals of Cleveland, Cleve-
land, Ohio.
Send Reprint Requests to David W. Stepnick, MD, Department of
Otolaryngology, Head and Neck Surgery, University Hospitals of Cleve-
land, Room 7129, 11100 Euclid Avenue, Cleveland, OH 44106, U.S.A.
Laryngoscope 109: February 1999
198
INTRODUCTION
Facial plastic surgery is one of the most difficult ar-
eas in which to provide “hands on” experience for resi-
dents in otolaryngology-head and neck surgery. Facial
cosmetic procedures are elective surgeries often per-
formed under local anesthesia with sedation in a group of
patients who have a set of expectations that differ from
those encountered in nonelective surgical patients. Al-
though complications are an expected part of any surgical
practice, an unsatisfactoryresult is more unsettling to the
cosmetic surgery patient who has undergone elective
surgery in the absence of any prior illness or physiologic
compromise. Patient dissatisfaction, while disconcerting,
is inherent to facial plastic surgery in even the moat ex-
perienced hands. This review was carried out to see
whether the outcomes and complicationrates for rhytidec-
tomy performed by residents with attending physician
guidance are acceptable relative to reported outcomes in
the literature from the past 30 years. Consideration is
given to the model at our institution as a teaching tech-
nique for cosmetic surgery.
MATERIALS AND METHODS
The charts of 96 consecutive rhytidectomy patients were
retrospectively reviewed. Patient information included age, sex,
past medical history, smoking history, and length of follow-up
(Table I). Hematoma, seroma, facial nerve injury, skin slough,
sensory nerve injury, scarring, wound infection, patient dissatis-
faction, and anesthetic mishap were defined as complications.
Surgeon data included postgraduate level and number of
rhytidectomies performed (Table 11).
Eighty-four patients were enrolled in a resident facial plas-
tic surgery clinic as part of the Special Teaching Program of Uni-
versity Hospitals of Cleveland, Department of Otolaryngology-
Head and Neck Surgery between 1988 and 1996. The remaining
12 patients were evaluated and operated on at Case Western Re-
serve University affiliated hospitals under the guidance of the
same attending physicians. Chief residents (ORL-4) were as-
signed to a 4-month rotation in the special teaching clinic where
they did office consultations and perioperative management one
afternoon per week. From this clinic, patients were selected to
undergo appropriate facial cosmetic procedures. This gave resi-
dents the opportunity to see many of their own patients in follow-
up over a 4-month period, as well as to see and evaluate postop-
erative results from previous residents. Patients were evaluated
for surgery by the resident and scheduled for surgery after ap-
Sullivan et at.: Rhytidectomy Complications
 TABLE I. TABLE 111.
Patient Demographics. Simultaneous Cosmetic Procedures.
Demographic Number of Patients Procedure Number of Patients
Average age (y) 57 Cervicofacial liposuction 63
Women 78 Blepharoplasty 13
Men 18 Submentoplasty 8
Hypertension 1 Mentoplasty 6
Crohn's disease 3 Brow lift 5
Raynauds disease 1 Malar augmentation 2
Smoking history 16
Total 97
Average follow-up (mo) 13
Range of follow-up (mo) 1-60

The average duration for the procedures from the time

proval by an attending physician. Surgery was performed by
ORL-4 residents. Occasionally, when the chief resident was un-
available for surgery, the procedure was performed by a more ju-
nior resident. Virtually all procedures were performed under lo-
cal anesthesia with sedation administered by the surgical team
or by an anesthesiologist if deeper sedation was required.
Patients underwent standard SMAS plication or imbrica-
tion rhytidectomy usually with submental liposuction under the
supervision of the same two st& attending surgeons (D.w.s.,
A.J.M.) over the study period. Bulky pressure dressings were ap-
plied. Drains were not routinely used. Preoperative and postop-
erative antibiotics were administered for prophylaxis of wound
infection in all patients. Patients were seen frequently in the im-
mediate postoperative period for removal of their pressure dress-
ings, inspection of the wounds, rolling of the flaps to evacuate
hematoma, and replacement of their dressings. Patients were
generally seen on postoperative days 1,2,4,7,14, and 28. Before
undergoing surgery patients were encouraged to return regularly
for follow-up visits beyond the usual postoperative care period so
that long-term results could be observed by other residents com-
ing through the training program.
RESULTS
Seventy-eight women and 18 men between 45 and 73
years of age (mean, 57 y) underwent SMAS rhytidectomy.
Sixty three patients underwent submental liposuction a t
the time of their facelift. Thirty-four additional cosmetic
procedures were performed a t the same time including
blepharoplasty, submentoplasty, mentoplasty, browlift,
and malar augmentation (Table 111). Sixteen patients
were cigarette smokers, three patients had Crohn's dis-
ease, one had Raynaud's disease, and one had medically
controlled hypertension. Average follow-up was 13 months
(range, 1 to 60 mo). There were no anesthetic mishaps.
TABLE II.
Rhytidectomy Experience
by Otolaryngology Residency Level.
Residency Level
(in years) Facelifts (n) Facelifts ("A)
4 79 82
3 14 15
2 2 2 and three seromas. The expanding hematomas were bilat-
1 1 1
patients entered the operating room until they were
brought to the recovery area was 5 hours (range, 2.5-9
h). The longest case was a combination rhytidectomy,
submental liposuction, coronal browlift, and upper and
lower blepharoplasty. Expanding hematoma occurred in
one female patient (1%)and required return to the oper-
ating room for evacuation and control of hemorrhage.
The patient subsequently suffered minimal postauricular
flap necrosis, which healed acceptably. There were five
small hematomas (5.2%)and three seromas (3.1%)which
were needle-evacuated or expressed by rolling the skin
flaps in the ofice without subsequent sequelae. Weakness
of a single branch of the facial nerve occurred in three pa-
tients (3.1%)and resolved in all patients ( at l, 3, and 9
mo). No patient experienced total nerve paralysis, either
temporary or permanent. Four patients suffered minimal
skin slough in the pretragal and mastoid area. ' b o of
these patients were smokers and one had Raynaud's dis-
ease. Six patients complained of ear numbness. Objective
findings were detected in only four (4.2%).All resolved ex-
cept one who still had numbness of the lobule at 18
months. Three hypertrophic scars (3.1%) developed that
were treated with steroid injections; one required revi-
sion. There was one postoperative wound infection in a
heavy smoker (1%).Three patients did not like the post-
operative appearance of their lobules but did not request
revision. Four patients (4.2%) expressed dissatisfaction
with their surgery (Table IV).
DISCUSSION
Well-recognized complications of rhytidectomy surgery
include hematoma, hair loss, skin slough, hypertrophic
scarring, infection, submental contour deformity, and motor
nerve or sensory nerve injury. Major complications includ-
ing cardiopulmonary emergency, anesthetic disaster, or
death are fortunately extremely rare. Complications and
patient satisfaction data were analyzed and compared with
the literature from the past 30 years.
Hematoma and Seroma
Acarefid analysis of this complication in our series re-
vealed one expanding hematoma, four small hematomas,
eral, occurred immediately after surgery in the recovery
area, and required return to the operating room for evacu-

Laryngoscope 109:February 1999 Sullivan et al.: Rhytidectomy Complications

199
 ~ ~~~
TABLE IV.
Complicationsof Rhytidectomy.
~~~
Complication Number of Patients % Residency Level
~ ~~~~~
Small hematomalseroma 8 8.3
Sensory nerve injury
Temporary 5 5.2
Permanent 1 1.o
Patient dissatisfied 4 4.2
Facial nerve injury
Temporary 3 3.1
Permanent 0 0.0
Hypertrophicscar
Resolved (steroid) 2 2.0
Revision 1 1.o
Wound infection 1 1.o
Anesthetidmedical 0 0.0
Death 0 0.0
ation. A search for accepted etiologic factors,l-ij including
preoperative history of hypertension, bleeding abnormal-
ity, medication use, intraoperative technical problem, use
of propofol, blood loss, postoperative hypertension, cough-
ing, retching, and agitation was carried out. Preoperative
hypertension and the use of propofol were identified in this
patient and may have contributed to hematoma formation.
Straith et al.4 have shown that preoperative hypertension
is the only relevant variable in predicting hematoma for-
mation. The primary hemodynamic effect of propofol is to
lower mean blood pressure and one would expect that this
would lower the risk for hematoma formation; however, a
recent review that controlled for technical variables and
preoperative hypertension found that patients undergoing
rhytidectomy with propofol sedation were more than twice
as likely to develop expanding hematomas than those who
were sedated with a combination of meperidine hydrochlo-
ride, diazepam, and methohexital sodium.3
Expanding hematoma is a feared complication of
rhytidectomy and occurs in 0% to 3.8%of SMAS rhytidec-
tomies.1-12 Unilateral swelling, bruising, or excessive pain
should alert the clinician to this diagnosis and needs to be
addressed immediately. In our case prompt return to the
operating room, inspection of the wound with prompt
achievement of hemostasis, placement of drains, and
reapplication of the pressure dressing resulted in control
without further significant bleeding. Despite prompt
recognition and treatment, asymmetry of the lobules oc-
curred from reclosure of the wound. This was unaccept-
able to the patient and was eventually revised to her sat-
isfaction. Our 1% incidence of major hematoma in
rhytidectomy performed by residents is well within the
accepted range reported in the literature. A review of 55
SMAS rhytidectomies performed by residents found no
major hematomas and a minor hematoma rate of 7%.13
Rees et al.1 have proposed that a typical learning curve
consists of 50 facelifis. After this, the risk of hematoma
formation decreases significantly. The ORL-4 resident
who performed the surgery was doing his fifth facelift as
Laryngoscope 109: February 1999
200
TABLE V.
Complicationsby Otolaryngology Residency Level (ORL).
(in years) Complications(n) Complications (%)
15 60
5 20
4 16
1 4
surgeon, although the attending surgeon had performed
far more than 50 facelifts at the time of this complication.
Small hematomas (2-20 mL) occur in 10%to 15%of
patients.l4 The small hematomas and seromas (3%-5%)
seen in our series were all diagnosed and addressed
within 72 hours of surgery. They were either observed,
needle aspirated, or rolled through openings in the inci-
sion within the postauricular hairline. Small unrecog-
nized hematomas may have been present in additional pa-
tients but went unrecognized owing to the relative
inexperience of the examining resident. All hematomas
resolved by 1 month follow-up without significant alter-
ations in contour noted by patient or surgeon. A recent
retrospective review of suction drains for the prevention
of hematomas and seromas suggests that although
seroma formation was significantly reduced, the occur-
rence of hematomas was not.6 Given the low incidence of
this complication in our series, we do not consider the
added expense and potential for drain complications to be
warranted and do not use them routinely.
Nerve In~*ury
Damage to the great auricular nerve is the most com-
mon neurologic injury in facelift surgery.15 Transient
numbness and hypesthesia of the lower two thirds of the
ear, preauricular area and the cheeks, usually lasting
from 2 to 6 weeks, is a result of disruption of small sensory
nerves and is unavoidable in rhytidectomy surgery. Per-
manent sensory loss in the lower portion of the ear and
postauricular area is usually due to injury of the great au-
ricular nerve when dissection is carried too deeply over
the midportion of the sternocleidomastoid muscle. One pa-
tient (1%) in the current series had numbness of the lower
third of the ear at 18 months. Review of the operative note
indicated injury to the great auricular nerve with imme-
diate repair at the time of surgery.
Injury to branches of the facial nerve in subcuta-
neous rhytidectomy occurs in 0% to 2.6% of cases. In
ShUS rhytidectomy permanent facial nerve injury occurs
in about 0.1%of patients.12 Temporary injury occurs in 0%
to 4.6% of cases.5.7-12 Temporary facial nerve palsy has
been reported in 1.8% of SMAS rhytidectomy cases per-
formed by residents.13 There were no cases of permanent
facial nerve injury in our series with three cases (3.1%) of
temporary paresis of the marginal branch that fully re-
covered at 1,3, and 9 months. This complication rate is not
dissimilar from rates reported by others in the literature.
Proposed mechanisms of facial nerve injury include
anesthetic infiltration, direct injection into the nerve, blunt
Sullivan et al.: Rhytidectomy Complications
dissection injury, edema of the nerve sheath, or cautery
trauma. For pareses caused by anesthetic infiltration, full
recovery should occur within hours once the anesthetic ef-
fect has disappeared. Temporary injury lasting 24 hours to
weeks is generally due to direct nerve trauma. The most
commonly injured branch varies fiom report to report, but
it is generally agreed that the frontal and marginal
branches are a t greatest risk for permanent dysfunction
owing to the lack of anastomotic branches.16 Mechanisms of
injury to the marginal branch include transection during
deep dissection of subplatysmal flaps, plication suture in-
jury, traction injury, and cervical liposuction in the sub-
platysmal plane. Of note, all of the facial nerve injuries en-
countered in this series involved the marginal branch.
Review of the operative notes for these cases did not reveal
known injury to the facial nerve at the time of surgery. Nei-
ther the SMAS nor the platysma was undermined in any of
these cases. Two of the three pareses occurred in the hands
of the same ORL-4 resident surgeon and were the first two
facelifts that he had performed as surgeon. The third case
occurred in a patient whose surgeon was at the ORL2 level
and was performing his first facelift. Surgeon experience
has been shown to be a factor in hematoma formation and
may have played a role in these cases of temporary facial
nerve paresis.'
Skin Slough
Skin slough in the postrhytidectomy patient is
caused by vascular compromise of the involved tissue. Full
thickness loss of skin can be a devastating complication.
Epidermal slough heals with little or no residual scarring.
Any condition that compromises the ability of the micro-
circulation to deliver oxygen and nutrients and carry
away carbon dioxide and waste products can result in flap
loss. Causes of skin slough are undiagnosed hematoma,
thin skin flap, traction injury during elevation, infection,
thermal injury, and wounds closed under tension. Any un-
derlying medical condition that compromises dermal
blood flow theoretically will increase the risk for skin
slough. It is estimated that the chance of developing skin
loss after rhytidectomy vanes from 2.7% in nonsmokers to
7.5%in smokers, with a 12-fold associated relative risk in
smokers.17 In the current review, of 16 patients who
smoked, 2 developed skin slough (12.5%). Of the remain-
ing 80 patients, 2 (2.5%) suffered skin loss. Of these 2, 1
had Raynaud's disease, and the other was taking steroids
for Crohn's disease. The resulting postauricular scar was
raised in this patient and required secondary revision.
Scarring
The postauricular incision is the most frequent site of
hypertrophic scarring.14 In general excessive tension and
subsequent vascular compromise lead to skin loss and
wide scars. This is problematic particularly in the pretra-
gal area and around the lobule, where wound contraction
is most noticeable. Vascular compromise of the hairline in-
cision may lead to unsightly hair loss. There were no cases
of hair loss in this series. However, three hypertrophic
scars (3.1%)developed. Two pretragal scars were treated
and flattened with injection of triamcinolone acetonide
(40 mg/mL). "he third scar occurred in a patient with
Laryngoscope 109: February 1999
Crohn's disease and required revision. Because Crohn's
disease is exclusively a mucosal disorder, it is unlikely
that this underlying inflammatory condition contributed
to this scarring. However, the patient did receive oral
steroids for a flare-up of his bowel disease just prior to
surgery. This may have interfered with the wound healing
process and contributed to subsequent scarring. There
were two other patients in the series with Crohn's dis-
ease, none of whom had wound complications.
Wound Infection
Of the 96 patients in this series, the one wound infec-
tion (1%)occurred-in a heavy smoker who had received
both preoperative and postoperative antibiotic prophylaxis.
The wound was culture positive for Staphylococcus aureus,
which was sensitive to cephalexin. The wound was opened
and drained, and a small Penrose drain was placed and ad-
vanced over 3 days. The patient was given oral cephalexin
for 10 days. At 9 month's follow-up there was no residual
asymmetry or objectionable scarring. Kamer et al.5 re-
ported 2 of 512 patients who developed wound infections
resulting in skin slough (0.39%)and 7 patients (1.36%)who
developed inflammatory reactions or suture extrusions.
Three of our patients (3.1%) developed similar inflamma-
tory reactions, all of whom responded to removal of the of-
fending foreign body and oral antibiotics.
Patient Satisfaction
Unlike any other type of surgery, cosmetic surgery can
be thought of as a consumer service for which a certain re-
sult is expected. Although physicians try to help patients
understand why complications occur, patients do not fully
expect that complications will happen to them. Indeed, any
complication detracts fiom the quality of the outcome. As
such, it is difficult for both surgeons and patients to accept
complications. It is equally difficult for attending surgeons
to allow residents to perform surgery in today's litigious en-
vironment, in which patients often ask, "Who will actually
be doing the cutting?" The special teaching model at our in-
stitution removes some of these factors by giving residents
full but supervised responsibility for preoperative evalua-
tion and management and valuable experience in dealing
with this unique patient population. Patients regard the
resident surgeon as their doctor and are generally happy
with their results. Although formal prospective evaluation
of satisfaction was not carried out, only 4.2%of patients ex-
pressed dissatisfaction with their result. This compares fa-
vorably with an earlier review of facial cosmetic surgery in
a residency training program, where 12.6% of patients ex-
pressed dissatisfaction.13 This model allows residents to
deal with the nuances of preoperative management and d e
cision-making that do not emerge during a brief initial en-
counter with the patient before the surgical procedure. Sur-
gical skills are developed, relationships are forged, and
long-term results are appreciated, as evidenced by our 13-
month average follow-up.
Resident Surgeon Experience
Eighty-two percent of the rhytidectomy surgeries
were performed by fourth-year otolaryngology residents
(ORL-4). Fourteen percent, 2%, and 1% of the facelifls
Sullivan et al.: Rhytidectomy Complications
201
were performed by ORL-3, ORL-2, and ORL-1 residents,
respectively. Of 25 total complications, seventeen (68%)
occurred in the hands of ORL-4 residents (Table V).
Twenty percent of the complications occurred in patients
whose surgeon was a t the ORL-3 level; only 15% of the
surgeries were performed by this group. Two of the 25
complications (8%)occurred in the hands of ORL-2 resi-
dents who performed only 2% of the facelift surgeries.
Only 1facelift was performed by an ORL-1 resident. A hy-
pertrophic scar occurred in this patient but resolved with
steroid injection. There was a 100% complication rate for
ORL-1 and ORL-2 residents, a 33% complication rate for
ORL-3 residents, and a 22% complication rate for ORL-4
residents. This trend toward higher complication rates
with junior residents is intuitive; however, the sample size
is too small to draw statistically relevant conclusions.
Surgical lkchnique
Surgical results tend to be technique- as well as sur-
geon-dependent. The following discussion of our surgical
method describes the technical points that we consider
important in avoiding major complications.
Skin incisions and the extent of submental liposuc-
tion are marked and hair is placed in rubber bands or bar-
rettes in the preoperative holding area. A peripheral in-
travenous catheter is placed. Prophylactic antibiotics,
analgesia, and sedation are given and the patient is
brought to the operating room. No hair is shaved, as this
does not appear to decrease the risk for infection. The pa-
tient is prepped with anti-infective solution into the hair-
line and draped in the usual sterile fashion. A mixture of
lidocaine, bupivacaine, epinephrine, and sodium bicarbon-
ate is injected for anesthesia and vasoconstriction.As the
procedure progresses successive regions are infiltrated to
accomplish hydraulic dissection and to allow sufficient
time to pass for maximal vasoconstrictive effect.
Submental liposuction is done first. A 1-to 2-cm skin
incision is made in a suitable submental crease. Using
blunt dissection with the cannula tip facing away from
the skin, liposuction is then carried out widely in the sub-
dermal fatkupraplatysmal plane, thus avoiding injury to
the marginal branch of the facial nerve as well as the
mental nerve. The extent of liposuction is about two thirds
of the way back along the mandible toward the angle, well
up over the body, thus addressing the jowls, and down in-
feriorly to approximately the prelaryngeal region. Accu-
racy of depth is confirmed by palpation of the skin thick-
ness overlying the cannula with the free hand. Feathering
is done at the periphery to avoid sharp step-offs between
areas of liposuction and nonliposuction.
For the rhytidectomy, skin incisions are made and
flaps elevated. In hair-bearing areas care is taken to place
incisions parallel to the direction of the hair follicles. The
depth of undermining varies based on the specific location
on the face. In hair-bearing areas the plane is the deepest
to ensure that hair follicles are raised with the flap. Inter-
mediate thickness is accomplished by creating a plane that
splits the subdermal fat, leaving fat on the undersurface of
the skin (ensuring maximal perfusion) and some fat on the
SMAS. The relative paucity of fat in the postauricular area
necessitates creation of an immediate subdermal flap,
Laryngoscope 109: February 1999
202
which also helps to protect the great auricular nerve from
accidental transection. As the transition from one plane to
another may be dimcult and may result in dissection at the
wrong depth, each area is elevated separately, creating tun-
nels. Blunt scissors are then used to take down the connec-
tions between each tunnel, thus joining the deep, interme-
diate and superficial planes of dissection. Flap elevation
extends anteriorly no W h e r than the anterior border of
the parotid gland, which is marked by a line drawn per-
pendicular to a point midway between the lateral orbital
rim and the external auditory canal. Below the mandible,
dissection proceeds in the preplatysmal plane no further in-
feriorly than Erb’s point to avoid injury to the great auric-
ular nerve. The platysma is not undermined. Dissection of
the flap is accomplished with relatively blunt scissors using
both direct vision and tactile information from above and
below the skin to monitor flap thickness.
The flap is gently retracted by an assistant who
avoids placing digital pressure or excessive tension on the
flap in order to minimize the risk of flap ischemia. Metic-
ulous hemostasis is maintained using bipolar cautery.
Monopolar cautery is not used. The SMAS layer is then
more clearly defined using the liposuction cannula, with
the surgeon always cognizant of the expected position of
branches of the facial nerve as they emerge from the
parotid gland. The vast majority of patients underwent
SMAS suspension by plication; that is, the SMAS was not
incised or undermined at all, since this technique places
the facial nerve a t greatest risk for injury. Undermining of
the SMAS was carried out in less than 10% of the patients
in this series. Buried 2.0 white braided polyester sutures
are placed, with the medial sutures parallel to the course
of the facial nerve where it is most superficial and the lat-
eral sutures perpendicular to the nerve where it is several
centimeters from the surface. This maneuver minimizes
the risk of traction injury to the nerve while maximizing
pull on the flap at the ear. Once several suspension su-
tures have been placed, hemostasis is again assured and
the skin is redraped for excision of the excess.
Ear lobules are routinely detached and repositioned
to avoid a “pixie ear” deformity. In those few cases in
which a posttragal incision is chosen, the skin overlying
the tragal cartilage is carefully thinned of subdermal fat
to approximate the thickness of skin that normally over-
lies the cartilage. Buried 5.0 polyglactin sutures are used
to tack this skin down into the pretragal area. Care is
taken to eliminate tension here since it will pull the tra-
gal cartilage forward, distorting the normal pretragal and
tragal contour. A nontension closure of the pretragal skin
incisions is carried out with interrupted 5.0 and 6.0
monofilament suture. The postauricular incision is closed
with a running 4.0 monofilament suture. The hair-bearing
areas are closed using skin staples, leaving 1-cm portions
of these incisions open for drainage. Flaps are rolled to al-
low any accumulation of blood to be expressed from the in-
cisions in the hairline. Drains are not used. Hair and skin
are then cleaned with peroxide and saline, Xeroform
dressing is placed over the wounds and a bulky pressure
dressing consisting of fluffs, cotton batting, Kerlix
(Kendall Health Care Products, Co., Mansfield, MA), and
Coban (3M Healthcare, St. Paul, MN) is applied firmly but
Sullivan et al.: Rhytidectomy Complications
not tightly enough to compromise the blood supply to the
flaps.
Dressings are removed, wounds rechecked for
hematoma, flaps rolled, and dressings reapplied at post-
operative days 1 ,2, and 4.Suture removal begins at post-
operative day 4 in the pretragal area and is completed
with removal of the skin staples in the hairline between
postoperative days 10 and 14.An elastic bandage support
is worn daily for 14 days and then nightly for 1month.
CONCLUSION
Complication rates for SMAS rhytidectomy in our
training program compare favorably with those in the lit-
erature. Thirteen percent of patients undergoing rhytidec-
tomy experienced a single complication as a result of their
surgery; 7% of patients experienced more than one com-
plication. There were no cardiopulmonary events, deaths,
or anesthetic disasters. Only 4% of patients expressed dis-
satisfaction with their surgery. Although these data are
clinically relevant, the sample size is small and therefore
lacks the power to make statistically relevant conclusions
about resident surgeon experience as a factor in complica-
tion rates. The overall complication rates compare favor-
ably with those in the literature, suggesting that the spe-
cial teaching model at our institution is an effective and
safe way to teach rhytidectomy and other facial cosmetic
procedures in a n academic setting.
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