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Surgical Face Lifting: 10 Steps Nerve Injury & Complications Preventions

Understanding the Anatomy

Navigating the complexities of facial anatomy is a cornerstone of mastering face-lift procedures, demanding a comprehensive grasp of retaining ligaments and their intricate association with danger zones. Let's delve deeper into the nuances of each aspect to enrich our understanding.

1. Zygomatic to Upper Masseteric Ligaments (First Danger Zone)

Intricately dissecting the terrain from the zygomatic to upper masseteric ligaments demands heightened attention due to the superficial positioning of the zygomatic branch of the facial nerve, rendering it particularly susceptible. This zone, marked by the proximity of the zygomatic branch, underscores the critical nature of a nuanced approach. The zygomatic ligament's connection with facial expression and contour further accentuates the importance of preserving its integrity.

Technique: Delicate and deliberate movements are paramount in this phase. Employing microsurgical techniques and magnification tools provides the precision required to navigate through this intricate landscape, minimizing the risk of inadvertent nerve injury.

2. Transition from Superficial Lateral to Middle Cheek Fat Compartment (Second Danger Zone)

Navigating the intricate landscape during the transition from the superficial lateral to the middle cheek fat compartment requires a nuanced understanding of facial anatomy, particularly in the anterior parotid region. The emphasis in this zone lies on the dynamic shift between fat compartments, with a heightened risk to the buccal branch of the facial nerve. This region, characterized by a loose areolar plane, demands keen attention to preserve nerve structures and maintain facial harmony.

Technique: Optimal outcomes hinge on a technique that balances efficacy with delicacy. Gentle and controlled dissection, employing microsurgical instruments, helps safeguard the integrity of the buccal branch and minimize the risk of inadvertent injury.

3. Region of the Lower Masseteric Ligaments (Third Danger Zone)

In the nuanced exploration of face-lift procedures, the third danger zone unfolds in the region of the lower masseteric ligaments, demanding a focused and meticulous approach. This critical zone draws attention to the emergence of the marginal mandibular branch of the facial nerve from the tail of the parotid. Understanding the intricate interplay between ligaments and nerve branches in this region is essential for minimizing the risk of nerve injury and optimizing surgical outcomes.

Technique: The artistry of the surgeon shines through in the application of a nuanced approach. Avoiding undue tension and pressure during dissection is paramount. Surgeons leverage their expertise to delicately navigate this intricate region, ensuring the preservation of nerve integrity and minimizing the potential for postoperative complications.

4. Mandibular Ligament Region (Fourth Danger Zone)

In the intricate landscape of face-lift procedures, the fourth danger zone unfolds at the cheek-chin junction within the highly vascular mandibular ligament region, necessitating a strategic and measured approach. The focal point of attention lies in the dynamic interplay of structures at the cheek-chin junction, accentuated by the presence of the highly vascular mandibular ligament. Recognizing the intricacies of this region is pivotal for surgical success, as it involves navigating through a densely populated area with crucial vascular structures.

Technique: Surgical finesse takes center stage as surgeons adopt a slow and deliberate approach in this critical area. Ensuring precision and minimizing the risk of vascular complications demand a nuanced technique. Surgeons adept at managing the vascular intricacies of this region enhance the safety profile of the procedure, allowing for optimal outcomes.

What are the most common complications?

1) Hematoma

The occurrence of hematoma following rhytidectomy, or facelift surgery, is reported at varying rates, ranging from 0.9 to 4 percent. This phenomenon is particularly noteworthy in the male demographic due to their thicker and more vascular skin composition, placing them at an elevated risk compared to their female counterparts.

Immediate attention to hematomas is imperative as untreated cases can result in severe complications such as skin sloughing, fibrosis, or infection. Timely intervention is crucial to prevent these adverse outcomes. In instances of early acute hematomas attributed to generalized oozing rather than a specific bleeding source, a bedside approach may be considered. This involves the opening of the postauricular incision under local anesthesia, followed by the insertion of a small suction catheter for drainage and irrigation. This localized intervention can effectively address certain hematomas, but careful monitoring is essential.

However, for recurrent or large hematomas, a more formal surgical exploration becomes necessary. During this exploration, intraoperative hemostasis is a critical aspect, requiring meticulous attention under normotensive conditions. It is crucial to note that hypotensive anesthesia might obscure potential bleeding sites, emphasizing the importance of maintaining normotension throughout the surgical process.

How to Prevent Hematoma?

Effectively addressing perioperative hypertension emerges as the pivotal modifiable risk factor in preventing hematomas, underscoring its significance in optimizing surgical outcomes. A stringent antihypertensive protocol is crucial for all patients, irrespective of their medical history. Patients with preexisting hypertension should maintain their routine antihypertensive medications perioperatively, with the exception of diuretics, which are typically withheld for 1 to 2 days post-surgery. Notably, aspirin and nonsteroidal anti-inflammatory agents should be discontinued at least 2 weeks prior to the surgical date to minimize the risk of complications.

Of particular importance is the observation that early postoperative hypertension, defined as systolic blood pressure exceeding 140 mm Hg, exhibits the strongest correlation with hematoma development. This underscores the significance of preventative measures targeted at mitigating postoperative hypertension. Preventing postoperative hypertension should initially focus on addressing potential contributing factors. Swift and proactive management of postoperative pain, anxiety, and nausea/vomiting using oral or intravenous medications is paramount. In cases of breakthrough hypertension, oral antihypertensive agents such as labetalol or nicardipine can be judiciously employed.

A noteworthy addition to the preventive arsenal is clonidine, a long-acting alpha-2 agonist. Administered preemptively, clonidine has demonstrated efficacy in reducing postoperative hypertension and hematoma rates. It stands out as a proactive measure, especially when administered preoperatively as an oral or transdermal form on the morning of surgery. This approach has proven safe in rhytidectomy patients, regardless of their hypertension status.

Considering its prophylactic potential, clonidine emerges as a valuable option in routine rhytidectomy patients or individuals at higher risk, such as men or those with preexisting hypertension. This tailored approach not only contributes to the prevention of hematomas but also aligns with the broader goal of optimizing patient safety and surgical outcomes.

2) Sensory Nerve Injury

Face-lift patients commonly report sensory changes at the six-month mark, encompassing sensations like facial numbness, tingling, or heightened sensitivity. While these alterations can be disconcerting, the majority are transient, typically resolving on their own within 6 to 12 months. However, particular attention must be given to potential injury to the great auricular nerve, as it can result in more profound consequences.

In certain cases, suture plication or partial severance of the great auricular nerve can lead to the development of a painful neuroma. Instances of unabated pain may necessitate early surgical exploration to address the condition. The great auricular nerve, responsible for sensory innervation to the posterior auricle and ear lobule, stands out as the most commonly injured nerve in rhytidectomy, with an estimated incidence of 6 percent.

The vulnerability of the great auricular nerve is particularly pronounced approximately 6.5 cm inferior to the external auditory canal, a location commonly referred to as the McKinney point. This point corresponds to the nerve's trajectory over the midbelly of the sternocleidomastoid muscle. Consequently, meticulous care during postauricular skin flap dissection is paramount. Performing the dissection under direct vision over the sternocleidomastoid muscle and keeping the fascia down over the muscle serve as preventive measures to avoid great auricular nerve injury.

Strategic considerations extend to the thickness of the skin flap directly under the ear lobule, emphasizing the importance of maintaining a relatively thin dissection. When platysmal suspension sutures are introduced, they should be strategically placed to span the location of the great auricular nerve, ensuring optimal support while minimizing the risk of injury. This comprehensive approach not only acknowledges the transient nature of sensory changes but also prioritizes the prevention of severe complications related to the great auricular nerve. By integrating these insights into surgical practices, practitioners can further enhance patient outcomes and minimize the potential for long-term sensory complications associated with face-lift procedures.

3) Motor Nerve Injury

In the realm of face-lift procedures, motor nerve injury, specifically involving the facial nerve branches, presents unique considerations, with the buccal branch being the most commonly affected. The buccal branch often experiences weakness, noticeable as diminished or asymmetric upper lip elevation during smiling. Fortunately, recovery in this region tends to be relatively quick due to substantial arborization between the buccal and zygomatic branches. This natural connectivity allows for a more rapid and comprehensive recuperation.

In contrast, the mandibular and temporal branches pose more significant challenges due to their limited interconnections. Weakness resulting from injury to the mandibular branch can cause the lower lip to remain elevated and flat on the affected side during smiling, reflecting weakness in the lower lip depressors. Temporal branch injury manifests as weakened eyebrow elevation and diminished transverse forehead rhytides on the affected side.

While concerns about permanent facial nerve injury are valid, the incidence remains extremely low, reported at less than 1 percent. Early recovery of some motion, even if slight, generally indicates incomplete injury, and gradual resolution is often observed within 6 months.

How to Prevent Nerve Injury?

1) Temperature Control

Effective temperature control is paramount to preventing sensory nerve injury during surgical face lifting. Surgeons should prioritize maintaining optimal tissue hydration and preventing thermal injury by leveraging advanced energy-based devices like lasers or radiofrequency with precise temperature control mechanisms. It is crucial to regularly assess the temperature of instruments, ensuring they remain within safe ranges. This practice minimizes the risk of thermal damage to surrounding nerves, enhancing overall safety during the procedure.

2) Customized Surgical Plans

Developing customized surgical plans is a key strategy to minimize the risk of unexpected nerve injury. Surgeons should craft individualized plans based on the patient's unique anatomy, taking into account variations in nerve pathways and branching patterns. Tailoring the surgical approach to each patient's specific needs, rather than adopting a one-size-fits-all mentality, is essential. This approach significantly reduces the likelihood of inadvertent nerve damage and contributes to enhanced patient safety.

3) Collaborative Approach

Facilitating collaboration between surgical specialties, particularly involving facial plastic surgeons and neurologists, is integral to collectively assessing and mitigating the risk of sensory nerve injury. Conducting multidisciplinary preoperative conferences further strengthens the collaborative approach. These forums provide opportunities to discuss complex cases and develop comprehensive strategies for nerve preservation. Such collaboration enhances the overall expertise applied to sensory nerve protection.

4) Preventive Medications

Considering the use of preoperative medications with neuroprotective properties is a proactive step in preventing sensory nerve complications. Surgeons may explore the potential benefits of administering anti-inflammatory agents or neurotrophic factors preoperatively. These medications aim to minimize inflammation and optimize nerve health, potentially supporting nerve regeneration and recovery post-surgery.

5) Patient Screening and Counseling

Thorough preoperative screening for conditions that may increase the risk of sensory nerve complications is crucial. Conditions such as diabetes or peripheral neuropathies should be identified early in the screening process. Additionally, engaging in detailed preoperative counseling is essential to educate patients about potential sensory changes. Emphasizing the temporary nature of most alterations and providing insights into the expected trajectory of recovery helps manage patient expectations.

6) Minimizing Operating Time

Efficiency in surgical techniques is vital to minimize overall operating time, thereby reducing the duration of exposure and potential stress on sensory nerves. Surgeons should adopt a team-based approach where each team member is well-coordinated to enhance procedural efficiency without compromising precision. This concerted effort contributes to a streamlined and safer surgical experience.

7) Advanced Imaging Technologies

Exploring emerging imaging technologies, such as 3D imaging or augmented reality, significantly enhances the visualization of anatomical structures and improves precision during surgery. Integrating real-time imaging modalities that provide detailed information on nerve location facilitates a more accurate and safer dissection. This high level of visualization contributes to precise surgical maneuvers, minimizing the risk of inadvertent nerve injury.

8) Continuous Professional Development

Continuous learning through attendance at conferences, workshops, and seminars dedicated to facial anatomy and nerve-preserving surgical techniques is essential. Surgeons should actively collaborate with leaders in the field to stay abreast of the latest research, innovations, and best practices related to sensory nerve preservation. This commitment to continuous professional development ensures that surgeons are equipped with the latest knowledge and techniques for optimal patient outcomes.

9) Innovative Nerve Protective Agents

Staying informed about ongoing research on novel pharmacological agents designed to protect nerves during surgery is crucial. Surgeons may explore the potential use of growth factors or nerve-specific protective coatings that contribute to minimizing nerve trauma. Incorporating these innovative nerve protective agents into surgical protocols represents a forward-looking approach to enhance sensory nerve preservation.

10) Outcome Audits and Analysis

Conducting regular audits of surgical outcomes, with a specific focus on sensory nerve complications, is a fundamental aspect of quality improvement. Analyzing cases with unexpected outcomes allows surgeons to identify areas for improvement, refine surgical protocols, and enhance overall patient safety. This commitment to ongoing analysis contributes to the continuous improvement of safety protocols and patient outcomes in surgical face lifting. By incorporating these strategies into their practice, surgeons elevate the standard of care for sensory nerve preservation, ensuring the best possible results for their patients.


Safety and Adjuncts in Face Lifting (2019)

Management of hypertension in the facelift patient: Results of a national consensus survey (2011)

Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls (1979)

Surgical approach to injuries of the cervical plexus and its peripheral nerve branches (2018)


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