Complications of Face and Neck Lift: Recognition, Treatment and Prevention: “You learn more from your failures than your successes.”

Bleeding

Hemostasis is a prime consideration of facelift surgery, and careful attention to bleeding must be observed throughout the entire procedure ( Fig. 9.19 ). Few cosmetic surgical experiences are more stressful than dealing with a postoperative expanding hematoma in the middle of the night. This is something that must be planned for in advance and anticipated for each case. Most novice surgeons have found themselves in the precarious position of having to take a patient back to the office surgery center after hours and the stress of not being able to reach their staff, the surgical instruments are still dirty in the sink, the anesthetic medications are locked up, and the surgeon is alone with an anxious patient and family. An ounce of prevention is definitely worth many pounds of cure in this situation. The key is to anticipate the complication. This involves having staff on call to respond, having sterile instruments available, and having access to anesthetic and medications and personnel. Having a proactive plan for dealing with hematoma or other emergent complications is a significant necessity.

Prevention of postoperative hemorrhage is critical. It is difficult to attempt to “catch up” with bleeding at the end of a case, before wound closure. The astute surgeon will continually control bleeding throughout each step of the facelift. Using a combination of bayonet bipolar forceps (large tip and fine tip), ball electrode, and indirect forceps coagulation allow the surgeon a multitude of means of addressing bleeding. I personally use 4.0 MHz radio wave surgery ( www.ellman.com ). In the discussion of complications, it is imperative to protect the delicate lipocutaneous flap from thermal insult when using electrosurgery. Any electrosurgical coagulation can produce heat, so cauterizing fat can create a heat sink that can remain very hot for several seconds. It is important for the assistant to prevent the skin flap from contacting the cauterized area until it is cool; otherwise a full-thickness thermal burn can occur ( Fig. 9.20 ).

Cauterization must also be used carefully around areas of motor or sensory nerves because lateral heat transmission can cause nerve damage.

Some anesthesia providers and or surgeons prefer hypotensive anesthesia to reduce bleeding. In these cases, the patient should be returned to a normotensive state before closure or bleeding points may be missed and contribute to postoperative hematoma.

Expanding Hematoma

As noted earlier, postoperative expanding hematoma is a true emergency in facelift surgery and although rare, can result in fatal outcome from airway compromise. An expanding hematoma also puts the delicate lipocutaneous flap under significant pressure and can compromise the vascularity of the flap. This can result in minor or major loss of flap viability, with resultant skin necrosis and full-thickness scarring. The points of prevention were addressed previously, but when an expanding hematoma does occur (statistics range from 0%–15% of facelifts in the published literature), the surgeon must be able to rapidly diagnose and treat the complication. Postoperative bleeding with hematoma can occur during the case where the surgeon has sutured the incisions on one side of the facelift and while working on the contralateral side, a hematoma forms on the first side. Hematoma can also occur while still on the operating table at the end of the case and is noticed when washing the hair or bandaging the patient ( Fig. 9.21 ). A minor amount of blood may be evacuated from the region by expressing through the suture or staple line or aspirated with a small liposuction cannula. If a collection of blood is evacuated and close observation shows no rebleeding, the patient may be transferred to the postanesthesia suite. If it appears that the area has continual bleeding, then the sutures and staples must be removed and the source of bleeding identified.

Expanding hematoma can also occur immediately after surgery, and I have personally seen two cases that occurred in the postanesthesia suite in the first hour after surgery ( Fig. 9.22 ).

Postoperative hematomas can be categorized into minor and major. A minor accumulation of blood can be aspirated when noticed and is sometimes resorbed without treatment. A major hematoma that is expanding in real time is an emergency. Because these frequently occur in the early postoperative period, it makes sense to recover the patient in your facility for several hours, although the next 24 hours still present a vulnerable period. Checking on the patient throughout the evening is time well spent. Also educating the patient and caregivers on the signs and symptoms of expanding hematoma can increase the chances of early treatment. Although most hematomas are unilateral, it is possible to have a unilateral bleeding source that dissects across the submental midline and affects both sides. Out of over 1200 consecutive facelifts, I have personally had 12 to 15 cases of major expanding hematomas that required emergent treatment. Two of these, although significantly distorting the patient's face, were not recognized by the patient or family and seen at the next morning's postoperative visit. All other hematoma patients called within 8 hours of their facelift, reporting unilateral pain, facial distortion, and bleeding. They were noticeably agitated and reported rapid-onset swelling with bleeding from the incision sites ( Figs. 9.23 and 9.24 ). One of these patients also reported difficulty closing her mouth. This resulted from dissection of blood into the buccal space, which expanded between the upper and lower teeth. When the surgeon is called by the caregiver saying there is pain, swelling, and bleeding, a presumptive diagnosis of expanding should be considered. In the rare case the patient would be in airway distress (I have never seen this), then the emergency medical technician (EMT) system should be activated.

This is an extremely stressful experience for patient, caregiver, and family. When the patient arrives at the office, they, and their caregivers or family must be reassured that as bad as this situation appears clinically, it will be rapidly treated, and the patient will do fine.

Although I have never encountered this, a patient with pending or acute respiratory distress should immediately have all sutures and staples removed to decompress the face.

I have experienced expanding hematoma in two patients who went unrecognized by the patient and caregiver and was not diagnosed until the next morning at 24-hour follow-up ( Fig. 9.25 ). This is unusual because the average patient and or caregiver would recognize such changes as they present.

As stated earlier in this chapter, expanding hematoma can occur from any event that increases blood pressure or produces a Valsalva situation. It is imperative that this is discussed in detail with patients and caregivers. The key to treating hematomas is not having them!

Treatment of a major expanding hematoma requires removing the sutures and opening the flaps to explore and control bleeder(s). In general, these patients are scared, agitated, and in pain, and treatment is difficult without intravenous sedation because further manipulation and discomfort worsens the experience and increases blood pressure. Although any bleeding vessel or tissue can lead to a hematoma, I have never encountered an isolated bleeder in the neck. Almost always, the surgeon will find several major bleeding points and scores of minor bleeding points when the flaps are opened and inspected. One caveat is if the surgeon feels that the bleeder is only isolated to one flap, he or she should open both flaps on the affected side because no one wants to return to the office twice in one night for a missed bleeding point that could have been identified the first time. Once the patient is made comfortable, the sutures and staples are removed and large “currant jelly” clots are observed ( Fig. 9.26 ).

As the clots are removed, the surgeon is usually confronted with multiple bleeding points. Confined bleeding as seen in expanding hematoma is an “irritant” to the underlying tissue and encourages global bleeding and oozing of the entire raw surfaces. In some cases, the surgeon may see bleeding in an area that bled during the initial surgery and was aggressively treated and has reoccurred. More often, the bleeding occurs at sites that did not present any significant hemorrhage during the initial procedure. When the flaps are opened, the clots removed, and the tissues inspected, the common surgeon's response is “everything is bleeding”, and it usually is ( Fig. 9.27 ).

Critical blood loss is usually not a problem with postfacelift hematoma but could be a possibility and must be monitored. The treatment to this point can be very intimidating if not frightening to the novice surgeon facing his or her first hematoma. Initially, it may seem that the bleeding will never stop, and the surgeon can feel doomed. This is when the “inner surgeon” must kick in and manage the situation in a controlled manner with a cool head; the staff should be manage similarly. The first step after opening the incision and clearing the clots is to pack the surgical field with chilled saline gauze for 5 to 10 minutes ( Fig. 9.28 ).

Having bags of chilled saline requires forethought and should be part of the presurgical planning. The chilled saline gauze will generally slow bleeding significantly and allow the surgeon to begin exploring the surgical sites (neck and periauricular flaps) for active bleeding. I prefer to wear loupes for this process because many times bleeding occurs from small vessels or areas. If necessary, the chilled saline gauze packing is repeated. Selective cauterization with bipolar cautery is continued and most frequently a single offending vessel is located that produced the bleeding ( Fig. 9.29 ). This can be an arterial “pumper” or venous oozing. Once this vessel is controlled, the accessory bleeding points are addressed until hemostasis is achieved.

The introduction of kaolin treated hemostatic “combat” gauze used by the military for field wound management ( www.quickclot.com ) is useful in cosmetic facial surgery. After opening the wound and packing with iced saline, my protocol is to next pack the wound with hemostatic gauze for 5 to 10 minutes ( Fig. 9.30 ). Although this product assists in encouraging hemostasis, it will not suffice for cauterization or ligature of larger vessels. Once the iced saline, followed by the hemostatic gauze packing is completed, the gross bleeding is generally controlled and the offending “serious” vessels or bleeding points are easily identified.

The patient should be returned to a normotensive state before reclosing the incisions to confirm absolute hemostasis ( Fig. 9.31 ). One of the most disheartening points for the surgeon is that a lot of care and skill went into the initial trimming of the flaps and closing the incisions, and now the entire site has been disrupted. It continues to amaze me how well the flaps “reclose” and how well they heal after surgery, like nothing ever happened ( Fig. 9.32 and 9.33 ). Out of 12 to 15 hematomas I have experienced over a 20-year period that were returned to the operating room, I have never had one that was uncontrollable.

Topical thrombin is also used by some surgeons to control bleeding. If the aforementioned steps do not produce hemostasis, then the surgeon must consider external factors such as a bleeding diathesis. Appropriate laboratory tests should be drawn, and the patient transferred to a facility suitable for the diagnosis of bleeding disorders and the administration of blood factors, etc. In my experience, this is exceedingly rare because significant hemorrhage would have occurred at the initial procedure. This entire scenario enforces the point that no surgeon should undertake surgical procedures when he or she cannot manage the complications.

After the bleeding is controlled, the wound is closed in the same manner it was originally. A light compression dressing is placed on the patient and they are discharged and seen the following day. A vacuum drain would be valuable as well because posthematoma patients often develop seromas from the breakdown of the clotting blood. Even if the vast majority of clots were removed during the hematoma treatment, residual clots will always remain. Although major expanding hematomas require emergent treatment, minor, nonexpanding hematomas represent small collections of blood and can be simply aspirated with an 18-gauge needle. Although most critical hematomas occur early in the postoperative experience, in rare instances they can spontaneously occur at a later date. I have seen several patients with normal postfacelift healing develop spontaneous minor hematoma several weeks after surgery ( Figs. 9.34 and 9.35 ). Possible causes include over excretion, a cauterized vessel that becomes disrupted, or a suture that erodes into a vessel.

It is not uncommon for major hematoma patients to develop postoperative seromas as the residual clotted blood is metabolized. Seroma formation is not limited to posthematoma cases and can be common with routine facelift surgery. The incidence is higher with more aggressive lifts and less common with smaller lifts. As stated earlier, my seroma rate fell almost to zero when I began using catheter vents or vacuum drains. Early identification and treatment of seromas is critical. Fluid collections must be aspirated so they don’t delay healing or produce inflammatory changes which can delay healing ( Fig. 9.36 ). Some seromas only require a single aspiration whereas others require multiple evacuations. In rare cases, aspiration is required over several weeks.

Seromas are not true active bleeding or clotted blood but rather serum from the healing process and blood breakdown products. They are initially dark, then change to a serosanguinous color and finally to amore amber colored ( Fig. 9.37B ) and do not pose a threat other than delayed healing.