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 » Introduction
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 » Face-Lift
 » Fat Grafting
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 Table of Contents    
Year : 2013  |  Volume : 46  |  Issue : 2  |  Page : 359-364

Unfavourable results in facial rejuvenation surgery: How to avoid them

Senior Cosmetic Surgeon, Aesthetics Medispa, Ruby Hall Clinic, Oyster and Pearl Hospital, Pune, Maharashtra, India

Date of Web Publication21-Sep-2013

Correspondence Address:
Ashish Vijay Davalbhakta
E602, 1 Modibaug Ganeshkhind Road, Shivajinagar, Pune - 411 016, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-0358.118614

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 » Abstract 

Unfavourable results are the bane of most of the surgeons. Every surgeon tries hard to prevent them, but only proper foreknowledge of where things could go wrong will help in preventing them. For this article, a careful retrospective review of past facial rejuvenation cases passing through our clinic were done. Various common aesthetic unfavourable results, complications and steps to avoid them have been described.

Keywords: Blepharoplasty; complications; face-lift; fat grafting; prevention and correction; unfavourable results

How to cite this article:
Davalbhakta AV. Unfavourable results in facial rejuvenation surgery: How to avoid them. Indian J Plast Surg 2013;46:359-64

How to cite this URL:
Davalbhakta AV. Unfavourable results in facial rejuvenation surgery: How to avoid them. Indian J Plast Surg [serial online] 2013 [cited 2019 Jul 21];46:359-64. Available from:

 » Introduction Top

It is common knowledge that unfavourable results could be due to wrong analysis of the requirements, wrong technique and errors in execution of procedure and post-operative complications. In facial rejuvenation surgery, such unfavourable results are hard to miss. They stand out glaringly taunting the surgeon on his failure and frustrating the patient due to a disappointing result. Correcting these is often difficult if not impossible. Prevention of unfavourable results is the key.

In this paper, we retrospectively reviewed all facial rejuvenation cases, which presented in our clinic and present those which had unfavourable results from previous surgery elsewhere or surgery with us and discuss precautions one should take to prevent them.

 » Blepharoplasty Top

One of the first errors in the upper eyelid blepharoplasty is in doing the surgery in a patient who has eyebrow ptosis. Although rare, if this condition is not diagnosed and treated with a brow lift first, the blepharoplasty will fix the brow in a low position. Brow lift should be done either prior or at the same time. Although brow ptosis is rare, ensuring that the brow position has not sagged down below the supraorbital rim will ensure that excess skin of the upper eyelid is not resected.

Under correction or over correction is the most common error and it is better to under correct rather than over correct in upper blepharoplasty. Once the lower incision in the upper eyelid blepharoplasty is made along the upper edge of the tarsal plate, the lax upper eyelid skin is pinched with a forceps and the upper edge of the ellipse is marked. At least one cm of skin is left between the ellipse and the eyebrow to avoid over correction. The pinch should lead to a slight elevation of the lid margin. A skin muscle flap is excised. If only skin is excised, it leaves the upper eyelid a bit too full. Judicious removal of fat from medial and central upper eyelid pockets prevents residual fullness. We would err on not removing any fat, as removal of too much fat leads to a hollow eyes (A deformity) and makes the eye look older [Figure 1]a and b. [1] The excess skin and fat in the medial most corner of the upper eyelid ellipse is frequently left behind, marring the result and extra efforts should be made to remove that.
Figure 1

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Lower blepharoplasty is more likely to give unfavourable results than an upper eyelid bleph. [2] The lower eyelid incision should be taken flush below the eyelash line, any lower and it is visible as a scar under the eyelashes [Figure 2].
Figure 2: Improper lower bleph scar

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Lower eyelid ectropion results from excess or over exuberant removal of skin from the lower eyelid. [3] However, middle and inner lamellar scarring or fibrosis post-surgery can also give rise to an ectropion [Figure 3]. This is particularly problematic when dealing with a negative vector eye, a condition when the maxilla projection is behind the plane of the eye. If a blepharoplasty is attempted in these cases, there is a high risk of ectropion. To ensure that the latter does not happen, almost every case should have a canthopexy and/or canthoplasty incorporated as one of the steps. Orbicularis suspension also helps in preventing the midface from pulling the lower eyelid down. The level of fixation of the suspension suture has to be at the same level or it could lead to a difference in the shape of the two eyes. I usually fix it at the upper edge of the pupil of the eye, but it could vary according to the projection of the maxilla and the globe [Figure 4]a and b. A canthopexy suture bite should be taken from inside out of the globe rim to ensure that the lateral canthus sits flush with the eyeball. If taken at the rim or outside the rim, the lower lid may float away from the globe. A canthoplasty is done if the pre-operative lower eyelid distraction tests show more than 6 mm distraction in the lower eyelid. [1] Canthopexy and orbicularis suspensions are two very important steps in preventing lower eyelid ectropion, the most frequent complication after lower eyelid blepharoplasty.
Figure 3: Lower eyelid ectropion

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Figure 4

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Visual loss after blepharoplasty is a dreaded complication but fortunately very rare. [4] Retroseptal hematoma is the most likely cause. Ensuring that any retroseptal dissection is done with coagulating cautery, making sure there is absolute haemostasis and preventing post-operative hypertension can limit the incidence.

 » Face-Lift Top

Subsmas face-lift has to be planned very meticulously from start to finish before even beginning the procedure as there are many chances of getting unfavourable results. [5] It is only when all steps of the procedure are carefully executed can you get a good result [Figure 5]a and b.
Figure 5

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A poorly placed incision is easily seen and is a dead giveaway. The incision in the hairline should be parallel to the hair follicles to prevent hair loss on either side of the scar [Figure 6]. If it is passed behind the tragus, it makes the scar less visible [Figure 7]. However, in men, if a lot of skin is likely to be excised, the incision should be pretragal. This helps to prevent hair bearing beard skin from moving on to the tragus. Going too close to the earlobe groove can result in a drag on the earlobe, giving it a typical face-lift look. The incision should be a couple of mm below the ear lobe and neck skin groove. Another glaring error can be in adjusting the extra neck skin in the post auricular region. It is important to align the mastoid hairline satisfactorily and prevent a step.
Figure 6: Scar visible in the temporal hair line

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Figure 7: Proper placement of the incision

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If the skin flaps are raised thicker than ideal, you could find that the submuscular aponeurotic system (SMAS) is not tough strong enough to be moved as a flap. [6] The whole exercise of raising the SMAS becomes futile if it develops holes or weaknesses. It cannot then raise the jowls properly and defeats the whole purpose of doing a face-lift. Tumescent infiltration with a local anaesthetic adrenaline mixture gives excellent visibility while raising the skin flap. Positioning a light to transilluminate from the other side of the skin flap and another direct behind the surgeon allows you to raise the skin flap in a plane, which reveals a clear marbled fat appearance. Cloudy fat or thicker fat globules mean that you are too deep. Thinner skin flaps, especially in the preauricular area, could lead to ischemia of the skin flaps and necrosis.

Sub SMAS face-lifts allows you to limit the subcutaneous dissection to the level of the lateral angle of the eye. You do not have to take it all the way forward up to the nasolabial fold. This again saves devascularisation of the skin. [7]

Raising the SMAS too deep is also fraught with danger due to the heightened risk of inadvertent damage to the facial nerve branches. If the SMAS is tumesced with saline adrenaline solution beforehand, elevation of the SMAS becomes easier. A clear plane presents itself that allows gentle dissection above the parotidomasseteric fascia and flush under the fibrous layer of SMAS [Figure 8]. The facial nerve branches lie below this fascia and are safe if this fascia is not breached. However, if the dissection goes slightly deeper beyond the parotid, you may encounter the facial nerve branches. While elevating the SMAS near the angle of the mandible, the marginal mandibular is most vulnerable. Ensuring that the dissection is done all the time under vision, with gentle opening of the scissors can save from damaging the nerve. Another area where the facial nerve is vulnerable is where the zygomatico-cutaneous ligaments have to be divided. Following the same principles, not blindly clamping any bleeding vessel and exploring any fibre like structure before dividing helps in preventing damage.
Figure 8: Raising the SMAS as a sheet

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I take the upper incision for the SMAS dissection on the upper border of the zygomatic arch and take the dissection up to and beyond the zygomaticus major and minor origins, then upward vertical traction on the SMAS causes a cone effect on the malar prominence. [8] This adds to the fullness of the malar prominence post-operatively. It also effectively causes a malar fat pad lift [Figure 9]a and b. [7] Here only the weight of the knife should be used to make the initial incision, Further dissection is with scissors to avoid injuring the frontal branch of the facial nerve, although the nerve here is deep against the zygomatic arch.
Figure 9

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The vectors of the lift of both the SMAS and the skin differ. The SMAS should be lifted in a more vertical direction while the skin is pulled superolaterally perpendicular to the nasolabial fold. Any error in this or inadequate tension of closure will lead to unfavourable results.

Another possibility of unfavourable result is if the maximum tension of closure is placed on the skin instead of the SMAS. [9] Not only it affects the vascularity of the skin, but it also leads to scar hypertrophy and stretching. It also can give rise to the deformity called lateral sweep, where the skin of the face looks windswept. [10] This appearance can also result from repetitive face-lifts. A thin skin flap with tension increases the risk of skin necrosis. A subsmas face-lift allows one to limit the extent of skin undermining, thus reducing the risk of devascularisation.

Haematoma is a serious complication that should be avoided by meticulous haemostasis before closure. The reported incidence of hematomas post-operatively extends from 7.9% to 12.9%. A strict peri-operative blood pressure control regime was able to bring it down to incidence of 3.9. [11] In my series, I have had a post-operative haematoma in one case in which a neck vein had got nicked. It did not bleed on the table due to hypotensive anaesthesia and elevated position of the head, but rapidly increased post-operatively. A low threshold for re-exploration can salvage the situation; otherwise necrosis of the thin skin flaps is certain.

 » Fat Grafting Top

Stem cells from adipose tissue are fast developing in to very reliable and potent filler. As a thumb rule, by the current techniques and principles about 50% survives, but whatever survives, survives permanently [Figure 10]a and b. The issues we get after fat transfers are overfilling, underfilling or resorption, nodularity and lumpiness. Fat embolisation or migrations are issues that happen if the basic principles of fat grafting are not followed properly. [12],[13]
Figure 10

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For facial fat to survive and do well, one has to use microfat grafting principles. Fat should ideally be harvested using cannulas of 2.1-2.4 gauge and injected with 0.7 to sub brow region, 1.2 for lower eyelid, 1.4 to mid-cheek, temporal and marionette or pre-jowl area. Injecting through larger cannulas leads to larger globules of fat and these lead to more central necrosis, less fat survival and more irregularities. The thinner the skin you are injecting under, the smaller the cannula. Microfat globules should be deposited in various planes and in multiple tunnels. One should endeavour to deliver each droplet size of average 0.01 ml at any one point. Larger globules of fat are likely to lead to ischemia and fat necrosis. Nodularity is due to fat necrosis and fibrosis. Firm massage or ultrasound will dissolve the nodularity.

Firm support post-operatively controls the swelling and limits the oedema. Gentle massage can be started 10 days post-operatively to even out the swelling and fullness.

Damage to important vessels, nerves and other structures can be avoided by using blunt tipped cannulas and using the knowledge of local anatomy before pushing the cannula.

A frequent complication after autologous fat grafting is either overfills or underfill. It is better to have the later complication than the former. If excess resorption happens, one can refill, however if the excess is left behind, then to take the excess out, one has to liposuction, which is difficult as it lacks control and precision. A few steps in preventing an overfill appearance is by injecting in the right areas first and then filling up to a desired aesthetic goal on table. If injected in the wrong areas, even a slight amount of fat will make it look unpleasant and give a chubby face look [Figure 11]. Anticipating a 30-50% resorption, a 10-20% overfill can be done.
Figure 11: Chubby face look due to over filling

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 » Conclusion Top

It is not difficult to give good results in facial rejuvenation surgery if the procedure is well thought out beforehand. Careful planning, meticulous execution, fore-knowledge of potential areas where things could go wrong and awareness of how to avoid those is the secret to having favourable results in Facial rejuvenation surgery.

 » References Top

1.Codner MA, Hanna MK. Upper and lower blepharoplasty. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. 1 st ed. St. Louis: Quality Medical Publishing, Inc.; 2005. p. 680-717.  Back to cited text no. 1
2.Oestreicher J, Mehta S. Complications of blepharoplasty: Prevention and management. Plast Surg Int 2012;2012:252-368.  Back to cited text no. 2
3.McCord CD Jr. Avoidance and treatment of complications of aesthetic eyelid surgery. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. 1 st ed. St. Louis: Quality Medical Publishing, Inc.; 2005. p. 776-823.  Back to cited text no. 3
4.Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: Incidence, management, and preventive measures. Aesthet Surg J 2011;31:21-9.  Back to cited text no. 4
5.Bloom JD, Immerman SB, Rosenberg DB. Face-lift complications. Facial Plast Surg 2012;28:260-72.  Back to cited text no. 5
6.Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin Plast Surg 2001;28:621-38.  Back to cited text no. 6
7.Marten T. Lamellar high SMAS face and midface lift. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. 1 st ed. St. Louis: Quality Medical Publishing; 2005.  Back to cited text no. 7
8.Marten TJ. High SMAS facelift: Combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg 2008;35:569-603.  Back to cited text no. 8
9.Nahai F. Avoiding complications in facial aesthetic surgery. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. 1 st ed. St. Louis: Quality Medical Publishing Inc.; 2005. p. 1328-57.  Back to cited text no. 9
10.Hamra ST. Prevention and correction of the "face-lifted" appearance. Facial Plast Surg 2000;16:215-29.  Back to cited text no. 10
11.Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: A 30-year review of 985 cases. Plast Reconstr Surg 2005;116:1973-85.  Back to cited text no. 11
12.Pu LL, Coleman SR, Cui X, Ferguson RE Jr, Vasconez HC. Autologous fat grafts harvested and refined by the Coleman technique: A comparative study. Plast Reconstr Surg 2008;122:932-7.  Back to cited text no. 12
13.Xing L, Almeida DR, Belliveau MJ, Hollands H, Devenyi RG, Berger A, et al. Ophthalmic artery occlusion secondary to fat emboli after cosmetic nasal injection of autologous fat. Retina 2012;32:2175-6.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

This article has been cited by
1 Ocular adverse effects after facial cosmetic procedures: a review of case reports
Lucas H. Ricci,Samia V. Navajas,Paula R. Carneiro,Stephanie A. Söderberg,Caroline A. Ferraz
Journal of Cosmetic Dermatology. 2015; : n/a
[Pubmed] | [DOI]


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