Research Article
Complication Rates of Facelift Alone Versus Facelift in Conjunction with Temporomandibular Joint Replacement
Patrick J. Louis1* and C Blake Smith2
1Department of Oral and Maxillofacial Surgery, University of Alabama, USA
2Department of Cosmetic and Facial Surgery, USA
*Corresponding author: Patrick J. Louis, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, School of Dentistry, USA
Published: 31 Mar, 2017
Cite this article as: Louis PJ, Smith CB. Complication
Rates of Facelift Alone Versus Facelift
in Conjunction with Temporomandibular
Joint Replacement. Clin Surg. 2017; 2:
1398.
Abstract
Purpose: The aim of this study was to evaluate the complication rates of rhytidectomy alone as
a primary procedure versus complication rates of rhytidectomy performed in conjunction with
temporomandibular joint replacement (TJR).
Materials and Methods: This study was a retrospective cohort study and consisted of chart review
only. The charts of all patients who had a superficial plane rhytidectomy procedure at our institution
during the specified time period (July 2000- July 2009) were reviewed. After exclusions were
determined, the patients were categorized into two groups, those that underwent the facelift operation
as the primary procedure (Facelift group), and those that had it performed as an adjunctive procedure
in conjunction with TJR (Facelift + TMJ group). After division of the two groups, the records were
examined and data collected on demographics and the complication incidence. The complication
categories were consolidated to include 1) Temporary facial nerve injury, 2) Permanent facial nerve
injury, 3) Hematoma, 4) Infection and 5) Early Wound Healing Complications (unaesthetic scar,
contour irregularities, and flap necrosis), 5) Minor Soft Tissue Complications (minor soft tissue
complications that do not fit in the other categories) and 6) Revision rate. A Fisher’s exact test was
used to analyze the data. The statistical significance was set at P<0.05.
Results: There were 31 patients in the Facelift group and 31 in the Facelift + TMJ group. The
mean age of the Facelift group and the Facelift + TMJ group was 58.6+10.82years (Range 30-79)
and 46.0+12.73 years (Range 24-76) respectively. In the Facelift group, the majority of cases were
bilateral rhytidectomies, with 2 unilateral cases for a total of 60 procedures. In the Facelift + TMJ
group, there were 16 bilateral cases and 15 unilateral cases for a total of 47 procedures. No statistical
significance was found between the two groups in any of these categories with the exception of
temporary facial nerve injury. A statistically significant (p<0.001) increased incidence of temporary
facial nerve injury was noted in the Facelift + TMJ group over the Facelift group.
Conclusion: Rhytidectomy can be safely performed in conjunction with temporomandibular joint
replacement. We did not find evidence to support that performing a facelift as an adjunct procedure
increased the complication rate. A much higher incidence of temporary facial nerve injury was
found in our patients undergoing facelift as an adjunct procedure when compared to the Facelift
group. The cause of this increased incidence is believed to be secondary to the simultaneously TMJ
operation, which has a well-known association with facial nerve injury.
Introduction
Rhytidectomy, or facelift, is one of the most commonly performed surgical procedures for
correction of age-related changes of the face. The surgical goals of the procedure are to restore
aspects of a youthful appearance through correction of skin laxity, ptosis of the subcutaneous tissues,
obliquity of the cervicomental contour, and deep nasolabial folds. A multitude of techniques have
been described and are currently in use, from skin only flaps to a variety of SMAS combination
procedures. The selection of technique is influenced by the patient’s particular area of concern,
surgeon preference, long-term stability, and complication rates.
While complication rates of rhytidectomy are relatively rare, certain major medical complications
can result in significant morbidity and poor outcomes. Knowledge of the potential complications and
proper management strategies can help the facial cosmetic surgeon avoid devastating consequences.
A list of some of the most common complications has been provided in Table 1.
At our institution, we have a unique patient population who
undergo rhytidectomy simultaneously with other major maxillofacial
procedures, such as orthognathic surgery, temporomandibular
joint procedures, or post-traumatic reconstructions of the hard
and soft tissues. The majority of these patients are undergoing
temporomandibular joint procedures, as the rhytidectomy approach
affords superb access to the joint. The purpose of this paper is
to determine whether facelifts performed simultaneously with
temporomandibular joint arthroplasty procedures differ in their
complication rates than those performed as a primary procedure. We
postulate that complications of an adjunct facelift could be influenced
by a number of factors. The inherent complication rate of the primary
procedure, increased operative time, and patient expectations may all
play a role. In regards to this latter point, the incidence of subjective
complications such as contour irregularities and scar formation are
biased by patient perception. Therefore it is reasonable to assume
that a patient who seeks cosmetic surgery as a primary procedure for
esthetic goals may have more discerning criteria of success than those
who receive a facelift as a secondary or “bonus” procedure. In the
latter, the functional goals of the primary procedure may eclipse their
evaluation of esthetic outcomes.
While a large amount of literature on the common complications
of rhytidectomy has been published, no known studies of the
incidence of complications of rhytidectomy performed with a
simultaneous temporomandibular joint replacement (TJR) procedure
exist to the authors’ knowledge. The purpose of this Facelift + TMJ
is to determine the incidence of complication in patients undergoing
a superficial plane rhytidectomy concomitantly with TJR, and to compare this data to a Facelift group of patients undergoing elective
rhytidectomy as a primary procedure. The hypothesis is that the
performing a rhytidectomy in conjunction with TJR does not increase
the incidence of complications associated with rhytidectomy. Specific
aims of this study are to identify the incidence of facial nerve injury,
hematoma, and infection, early wound healing complications, minor
soft tissue complications and revision rate associated with the facelift
procedure in these two patient groups.
Materials and Methods
The office of the Institutional Review Board at the University
of Alabama at Birmingham granted approval for this study in June
2010. To address the research purpose, the investigators designed
and implemented a retrospective cohort study. The charts of all
patients presenting for superficial plane rhytidectomy procedure
at our institution during the specified time period (July 2000-
July 2009) were reviewed. Patients were excluded if complete
cervicofacial lift procedures were not performed (i.e. midface or
neck-only rhytidectomy), if there was no follow-up, or if insufficient
documentation at the time of the operation or follow-up existed.
Patients were also excluded if facial nerve injury existed from a prior
operation. Because of a change in patient information systems at our
institution, several older procedures were excluded due to insufficient
documentation.
The predictor variable in this study was operation type. After
exclusions were determined, the patients were categorized into two
groups, those that underwent the facelift operation as the primary
procedure (Facelift group), and those that had it performed as an
adjunctive procedure in conjunction with TJR (Facelift + TMJ
group). After division of the two groups, the records were examined
and data collected on demographics and the complication incidence.
The primary outcome variable was postoperative complication.
Complications included hematoma, infection, unaesthetic scar or
wound, flap necrosis or sloughing, contour irregularities, other minor
soft tissue complications and motor nerve deficits. Even though all
of the patients in the Facelift + TMJ group underwent a bilateral
rhytidectomy, some of them underwent a unilateral joint replacement.
For this reason the face was divided into sides. Unilateral procedures
counted as one side and bilateral procedures counted as two sides. For
the Facelift + TMJ group, only the side undergoing a rhytidectomy
in conjunction with TJR was included. The complication categories
were consolidated to include 1) Temporary facial nerve injury, 2)
Permanent facial nerve injury, 3) Hematoma, 4) Infection and 5)
Early Wound Healing Complications (unaesthetic scar, contour
irregularities, and flap necrosis), 5) Minor Soft Tissue Complications
(minor soft tissue complications that do not fit in the other categories)
and 6) Revision rate. The Fisher’s exact test was used to analyze the
risk of complications. The statistical significance was set at P<0.05. In
addition the Mantel-Haenszel chi-square test was used to compare
the total number of complications that occurred in each group of patients and a Student’s t test was used to analyze the demographic data and follow-up period.
Table 1
Table 2
Table 3
Table 4
Figure 1
Figure 2
Figure 3
Results
The results of demographics are summarized in Table 2. After
reviewing the records of over 200 patients that had prosthetic joint
replacement and/or facelift, only 62 patients met the inclusion criteria
for the study with adequate follow-up. There were 31 patients in the
Facelift group and 31 in the Facelift + TMJ group. The mean age of
the Facelift group and the Facelift + TMJ group was 58.6 + 10.82 years
(Range 30-79) and 46.0 + 12.73 years (Range 24-76) respectively. A
two-tailed Student’s t test was used to compare the ages of the patients
in the two groups and there was a significant difference between the
groups. In the Facelift group, the majority of cases were bilateral
rhytidectomies, with 2 unilateral cases fora total of 60 procedures.
In the Facelift + TMJ group, there were 16 bilateral cases and 15
unilateral cases for a total of 47 procedures. There was a statistically
significant difference in the number of bilateral cases between the two
groups. The average follow-up period was significantly longer in the
Facelift + TMJ group; 48.9 + 34.5 vs 11.1 + 16.30 months. This was
a statistically significant difference. The vast majority of procedures
were performed in female patients, with only one male, who was in
the Facelift + TMJ group.
Complications including facial nerve injury are summarized in
Table 3. All complications were infrequent except for temporary
facial nerve injury.
Facial nerve injury
In the Facelift + TMJ group, there were 15 sides (31.9%) that had
facial nerve injuries. There were no injuries in the Facelift group. A
statistically significant (p< 0.001) increased incidence of temporary
facial nerve injury was noted in the Facelift + TMJ group over the
Facelift group. Only 3 injuries (6.4% of all procedures) were present at
1 year and considered permanent, which was statistically insignificant
(p = 0.082).
Of these facial nerve injuries, 12 involved the temporal branch
and 3 involved the marginal mandibular branch. Only 3 of the nerve
injuries were permanent, all of which involved the temporal branch
of the facial nerve. There was a statistically significant difference
in which branch of the facial nerve that was involved in both the
temporary and permanent nerve injury categories (Table 4).
Of the 15 injuries, 5 sides required surgical intervention. Gold
weight placement for lagopthalmos was performed in 3 patients.
All of these were performed within a month of the initial procedure
for corneal irritation. These were later removed around 6 months
after placement due to resolution of the lagopthalmos. Endobrow
lift for residual brow ptosis was performed in 3 patients. These were
performed for brow ptosis that persisted for more than a year.
Hematoma
Hematoma occurred in 4 sides in the Facelift group only. All were
small and managed conservatively, and only 1 required intervention
by incision and drainage and pressure dressing at follow-up. No
major or expanding hematomas were encountered and none required
re-exploration in the operating room.
Infection
There was 1 infection in the Facelift group and 2 in the Facelift +
TMJ group. These infections were managed with surgical intervention
and antibiotics. There was no statistical difference between the two
groups.
Early wound healing complications
Unaesthetic scar formation including hypertrophic and widened
scars was noted in 4 sides (3 in the Facelift group), which usually
required localmanagement with steroid injection or scar revision.
Various contour irregularities were included under the heading
and were noted in 4 sides (2 in the Facelift group), most of which
required minor revisions. One of these cases represented a change
in earlobe position. Flap necrosis was noted in 2 sides (1 in the
Facelift group) and included only the flap tip in the postauricular
region. This was managed by observation and healed satisfactorily
without intervention. Due to the small number of sides, these
three categories were combined under the Early Wound Healing
Complicationscategory. There were a total of 10 sides in this category,
6 in the Facelift group and 4 in the Facelift + TMJ group.
Minor soft tissue complications
Four sides were classified as Minor Soft Tissue Complications
and included 1 postauricular stitch abscess in the Facelift group, 2
instances of preauricular hypoesthesia in the Facelift + TMJ group,
significant enough for patient complaint and 1 instance of protuberant
granulation tissue in the postauricular region in the Facelift + TMJ
group. In this category there were 1 side in the Facelift group and 3
sides in the Facelift + TMJ group.No statistical significance was found
between the two groups in any of these categories.
Revisions
A few patients did require revisions after the initial procedure
yielded less than satisfactory outcomes. All were performed
approximately 1 year after the initial procedure. There were 3 sides
revised in the Facelift group and 1 side in the Facelift + TMJ group.
Similarly, this finding was not statistically significant.
Total complications
The total numbers of complications in each group were
compared. The total number of complications in the Facelift group
was 12 out of 60 sides. In the Facelift + TMJ group the total number
of complications per side was 25 out of 47 sides. When the two groups
were compared, there was a statistically significant increase in the
occurrence of complications in the Facelift + TMJ group (p < 0.001).
In addition, the number of complications per patient in each group
was evaluated.
Using the Mantel-Haenszel chi-square test, in which the
independent unit of analysis is the patient, there was a statistically
significant increase in the number of complications in the Facelift +
TMJ group (p = 0.0257).
Figure 4
Figure 5
Figure 6
Discussion
The purpose of this study was to determine the incidence of
complication in patients undergoing a superficial plane rhytidectomy
concomitantly with TJR, and to compare this data to a Facelift group
of patients undergoing elective rhytidectomy as a primary procedure.
We specifically identified the incidence of facial nerve injuries,
hematoma, infections, wound healing complications and other minor
soft tissue complications in these two patient groups. The incidence
of temporary facial nerve injury in the Facelift group was 0%. In
contrast, the incidence of temporary nerve injury was 31.9%, which
was statistically significant. The incidence of permanent facial nerve
injury was 6.4%. The branches that were injured included the temporal
and the marginal mandibular. Only the temporal branch of the facial
nerve sustained permanent injury in the Facelift + TMJ group. The
incidence of hematoma, infection, early soft tissue complications and
other minor soft tissue complications were not statistically significant
among the patient groups. This study demonstrates that there the TJR
significantly increases the risk of temporary nerve injury during the
facelift procedure but does not increase the risk of other complications
associated with the superficial plane facelift.
Facial nerve injury is an uncommon complication in facelift
surgery, with an incidence of probably less than 1 percent [1]. Nerve
insult can result from a multitude of factors, including sutures
encircling the nerve, stretch injury, hematoma compression, heat
from electrocoagulation, crush injury from forceps, inflammation
or infection, or transection. In a review of over 7,000 superficial
plane rhytidectomies performed by multiple surgeons, Baker found
an incidence of 55 cranial nerve VII injuries (0.7%), only 7 of which
were permanent (0.1%). The most commonly injured branch was the
marginal mandibular (40%), followed by the temporal (33%), and
then the buccal (13%) [2].
A much higher incidence of facial nerve injury was found in our
patients undergoing facelift as an adjunct procedure when compared
to the Facelift group. Closer examination of the 15 nerve injuries
revealed that all cases occurred during TMJ replacement procedures.
There were no injuries in the Facelift group, which is consistent with
the literature. The cause of this increased incidence is believed to be
secondary to the simultaneously TMJ operation, which has a wellknown
association with facial nerve injury. This is usually a temporary
neuropraxia secondary to excessive retraction around the joint. This
was supported by a significantly higher incidence of temporal division
weakness when compared to other potentially affected branches.
The vast majority of these resolved within 6 months of the surgery.
This is consistent with the literature in patients undergoing TJR.
Sidebottom reported on 74 patients undergoing TJR. Of these, a total
of 31 patients had partial, and 2 had total weakness of the facial nerve.
They reported that all resolved fully except weakness of the temporal
branch in one patient, which required a brow lift [3]. Though the
surgical access for total joint replacement requires retromandibular
dissection to access the ramus, the incidence of marginal mandibular
involvement was low.
Hematoma is well-recognized as the most common complication
associated with rhytidectomy, with rates most commonly published
in the range of 1-9% [1,2,1-8], and may represent up to 70% of all
rhytidectomy complications [1]. In a literature review of 9969 cases,
Baker noted a major or expanding hematoma incidence of 3.6%
(range 0.9-8.0%). Within this same study, he also stated the incidence
of small hematomas to be as high as 15% [2]. Poor perioperative
blood pressure control has been cited as the major cause of hematoma
occurence[1,8-10]. Male gender, the use of platelet-altering
medications, and inadequate intraoperative hemostasis are also
major contributing factors [8]. Multiple local measures to control
the incidence of hematoma have been described, and their use varies
from practitioner to practitioner. In a large retrospective series of
910 patients treated by the same surgeon, Jones and Grover found no
change in hematoma rate with the use of dressings, fibrin glue, drains,
or tumescence. They did however note a statistically significant
increase in incidence in those patients who were administered
epinephrine by tumescence compared to those without epinephrine,
which they contributed to reactive vasodilation in the post-operative
period which masked intraoperative recognition of potential bleeding
points [6].
In our study, an increased incidence of hematoma was noted in
the Facelift group (6.7% vs 0%). All of these hematomas were minor
and managed conservatively, and only 1 required intervention in the
form of drainage. The finding was not statistically significant, and
due to the low patient numbers, it is difficult to determine if a true
trend exists. One possible explanation is that although all patients
underwent superficial plane rhytidectomies, in the Facelift + TMJ
group deeper planes were often entered as a part of the concomitant
operation, for TMJ access. This may have served to provide a path of
drainage or masked the true incidence of hematoma due to increased
facial edema. Grover, et al [8] found no change in hematoma rate
when comparing various facelift techniques of different planes
of dissection. In contrast, in a review of 1236 consecutive facelifts,
Rees et al. found that the extent of SMAS dissection and elevation
influenced the rate of hematoma formation, with decreased incidence
with deeper planes of dissection. The incidence was 3.67% for SMAS
plication, 3.41% with moderate SMAS elevation, and 1.03% in
extensive SMAS elevation techniques (p=.002). The overall incidence
was 3.83% [7].
Perhaps the most feared complication in facelift surgery is flap
necrosis. This can range from a minor area of necrosis at the flap tip,
often in the postauricular area, to extensive tissue death requiring
debridement and skin grafting. Fortunately, this complication is rare.
Possible causes include unrecognized or undertreated hematoma,
pressure dressings that are too tight, and excess wound tension,
which can result in vascular compromise and tissue death. Smoking
[11,12] and poorly controlled diabetes can result in small blood vessel
disease and therefore contribute. There was only one incidence of
flap necrosis in our study, which occurred in the Facelift group. This
occurred in the tip of the postauricular flap bilaterally. This healed
by secondary intention without intervention and with satisfactory
cosmetic results.
Excess wound tension at closure can result in widened or
hypertrophied scar formation. This complication can usually be
managed by intralesional steroid injection, which result in softening and atrophy of the lesion. Occasionally, scar revision may be required. With either intervention, it is recommended to wait as long
as 6 months for the wound to stabilize. Some patients will develop
scarring, however, despite meticulous closure and postoperative
wound care. In our Facelift + TMJ, 4 cases of excess scarring occurred
(3 in the Facelift and 1 in the Facelift + TMJ group). There was no
statistical significance between the two groups. However, the increased
incidence noted in the Facelift group does invite the interesting
discussion of whether a true trend exists and what that may represent.
It could be argued that the primary cosmetic group may include a
larger percentage of esthetically conscious individuals who may be
more concerned with wound appearances. Therefore, as with any
retrospective study, the documentation of minor wound problems
may increase with patient complaint.The increased expectation of
patients in the cosmetic group would be expected to also influence
the “unaesthetic wound” category if it is truly an influencing factor.
This however was not found in our study, with 2 cases noted in each
group. Three of these represented contour irregularities requiring
minor revision or observation. One case of changed earlobe position
was noted in the Facelift + TMJ group. An alteration in the position
of the earlobe is a well-documented complication of rhytidectomy
and strategies to prevent its occurrence have been described [13-15].
With the use of current perioperative antibiotics and skin
preparation techniques, the incidence of infection is fortunately
very low. When infection does occur, it is usually managed with oral
antibiotics without undue sequelae. More serious infections, however,
may require IV antibiotics or local drainage if abscess occurs. In a
large series by Leroy et al., 6166 consecutive facelifts were performed
resulting in 11 cases of infection requiring hospital admission
(0.18%). Seven required drainage of an abscess and 4 were treated
with antibiotics alone for cellulitis. Past medical history, the use of
perioperative antibiotics, surgical equipment used, complexity of the
surgical dissection, drains, or hematoma formation did not influence
the infection rate. In our Facelift + TMJ, 3 total infections(4.92%)
were noted between the two groups, all of which required some
type of intervention. Only 1 case, however, appeared to be strongly
related to the facelift procedure, which resulted in an accumulation
of purulence beneath the subcutaneous flap requiring drainage. This
occurred in the Facelift + TMJ group. One case in the Facelift group
appeared to be localized to a hemoclip in the submandibular region
from a previous procedure, and the other case was associated with
an infected total joint prosthesis placed simultaneously. In either
of the latter two cases, it is assumed that the facelift procedure was
only associated with the infection secondarily, and were considered
for exclusion entirely. They remained included, however due to
the difficulty in separating out causality in the case of infection.
Regardless, the incidence remained low.
Due to its superficial location in the posterior aspect of the
flap, the greater auricular nerve is the most common sensory
nerve injured during rhytidectomy. This can result in paresthesia,
numbness, and even pain of the postauricular region, which can be
quite troublesome. Careful superficial dissection under direct vision,
particularly over the sternocleidomastoid muscle can help prevent
this complication. If transection of this nerve occurs, direct repair
under magnification is recommended. In contrast, the small nerve
fibers in the preauricular region are often transected, which usually
results in numbness of the cheek and preauricular area. This is often
transient due to the small caliber fiber regeneration and arborization
in this area. Two patients were documented with this complaint, both
in the Facelift + TMJ group. However, since no objective method of
evaluation of sensory innervations was used in our Facelift + TMJ, the
true incidence is unknown. It is assumed that all patients likely have
some sensory nerve deficit after rhytidectomy.
Only three major revisions (repeat full facelifts or focused surgical
revisions) were required in our Facelift + TMJ. This can be viewed
as a complication or general barometer of patient satisfaction, but
either way, the incidence was low, and required in two patients in the
Facelift and one in the Facelift + TMJ group. These were performed
for residual ptotic tissue requiring various levels of skin and SMAS
recontouring for correction. All three were performed after 1 year
from the previous rhytidectomy, and no third revisions were required.
There are several weaknesses to this study worth discussing. First
is the inherent problem of a retrospective design, some of which was
discussed previously. The true incidence of complications cannot be
ascertained with this type of Facelift + TMJ, which depends upon
strict documentation for accurate results. The use of a prospective
study with strict observation and measurement criteria would be
more desirable. In addition, the small patient numbers make true
trends and statistical analysis problematic. This information could be
valuable, however, to notice potential trends to develop prospective
studies in the future.
In conclusion, we did not find evidence to support that performing
a facelift as an adjunct procedure increased the complication rate.
However, due to the retrospective design and small patient sample,
we were unable make a definitive comparison of the two groups.
While we feel that empiric evidence supports our finding, further
research is required. A large study would be ideal for comparing
complications with low overall incidence, and a prospective design
a stronger level of evidence. We do recommend that any patient
undergoing TMJ surgery simultaneously with rhytidectomy be fully
aware of the potential for facial nerve injury associated with access to
the temporomandibular joint, and at the same time educated about
its likely transient nature. Proper education can help alleviate postoperative
anxiety associated with facial nerve weakness in a patient
with cosmetic objectives, and thus improve subjective outcomes.
While we feel the evidence supports our findings, further work would
be required, preferably a prospective study with a large patient sample.
Figure 7
Figure 8
Figure 9
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