Reasons for secondary facial aesthetic surgery

There are many clinical scenarios that call for either revision surgery or a planned second procedure. It is helpful to examine the motivations of the patient, as they will guide your clinical management. If the patient is unhappy with the initial surgery, regardless of whether you or anyone else feels that the results were good, the operation was not successful14. That doesn’t mean that anything was done incorrectly or that in your opinion, anything more could have been done to correct the problem. If, in fact that is the case, you need to explain your assessment to the patient, while being sympathetic to their concerns. However, if there is room for improvement it is often a good idea to address the issue in a forthright, non-evasive manner.

If the secondary procedure is intended to correct a problem created by previous surgery performed either by you or another surgeon, emotional support and an understanding and non-judgmental attitude are essential. As with all soft tissue procedures, time will often allow the problem to ‘fix’ itself. However, with time, some problems can be exacerbated owing to scar contracture, abnormal scar deposition, or scar widening. If conservative measures such as serial steroid injections and massage fail to address the issue, and the patient is concerned, revision surgery is indicated. It is generally recommended that any revision procedure be delayed for at least 1 year from surgery.

When patients present with aesthetic issues that either were not addressed initially or developed over time as they continued to age, there is no urgency or emotional overtones to the discussion. This makes communication much more comfortable for both parties. However, if the procedure(s) were successful but did not ‘last’ as long as they had been told or expected, some additional time and discussion may be necessary so that realistic expectations for the next procedure can be established.

Aesthetic interventions

Skin is the material with which the surgeon works and it must look its best to make the patient look his/her best. Therefore, sun related skin changes such as rhytides, hyperpigmentation and spider veins are treated with either ablative or non-ablative skin therapies. Pre-operative botulinum toxin is helpful as a biological dressing, keeping the skin resting while it is healing after ablative treatment for facial rhytidosis in areas such as the forehead, glabella, crow’s feet and white lip. Ongoing botulinum toxin therapy may be indicated to prolong the effects of resurfacing.

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Additionally, to optimise results and maintain improvement, topical daily skin care is recommended and should include exfoliation, hydration, collagen stimulation, colour correction and broad-spectrum sun protection. Gravitational changes (i.e. skin and muscle laxity) must be addressed with surgical soft tissue repositioning and skin resection. Volumetric loss, deficiency or redistribution, particularly in the mid-face, tear trough, and cheek highlight areas, may be corrected with surgical repositioning of deep tissues (e.g. a mid-face subperiosteal lift), implants, and/or the use of injectable fillers, collagen stimulants, or fat injections.

If the patient is receptive, lip architecture should be re-established. When altering the lips, unless the patient specifically requests a fuller look, your goal should be to re-establish the anatomy of their youth, not necessarily to create an idealised lip aesthetic. When volumising the lip area, a number of points can be made. Proportionate lip volume with the lower lip being about one third fuller than the upper lip, particularly in the central third, looks most attractive. If lacking, the vermillion border and philtral columns should be strengthened. An excessively full white upper lip, which can occur as a result of overzealous filling of vertical lip rhytides, should be avoided, as it can lend a simian appearance to the face. Additionally, the marionette lines should be volumised and the corners of the lip made to curl upward slightly.

Another important consideration is to reestablish a pleasing neck contour. When patients present for secondary cervicofacial rhytidectomy, recrudescence of neck skin laxity and platysmal bands or cervical irregularities following previous surgery are frequent complaints. This often necessitates a secondary facelift with wide cervical skin undermining, and muscle plication to correct skin and muscle issues. To address contour irregularities, fat sculpting, repositioning or grafting may be indicated.

Older patients requesting secondary facial rejuvenation often have skin that has lost a substantial amount of elasticity, which has both favourable and unfavourable consequences. Less elasticity often leads to very thin and aesthetically acceptable scars, as there is less intrinsic tension on the closure. However, inelastic skin that has undergone previous facelift surgery has a propensity to reveal misdirection of the lateral cheek skin rhytides, which should follow the relaxed skin tension lines. This gives an upward sweep appearance to the cheek, which is very unnatural. Thus, in revision rhytidectomy surgery, to avoid this problem, a less vertical, more posterior redirection of the cheek skin or composite flap is indicated.

[pull_quote align=”left” ]The greater auricular nerve is the most common nerve injury during rhytidectomy and may be at increased risk with revision surgery.[/pull_quote]

The surgeon must also decide whether incision placement from previous surgery is appropriate, and may be used again or, if it needs to be modified. To assess this, one must consider personal preferences, the current hairline, ear lobule position, tragal architecture, how well the scars healed previously, and the degree of cervical skin laxity, which will dictate the length of the posterior cervical scars. Under most circumstances, it is preferred in men and women, for both primary and secondary rhytidectomy procedures, to use a retro-tragal incision design. For most men, it is even more important to maintain surgical anonymity than it is for women and in most cases, after presenting both pre-tragal and post-tragal options to male patients, men prefer to shave the tragus or get laser hair removal rather than have a visible scar in front of their ear. Even if the incision curves inward just above the tragus and follows a natural crease, a pre-tragal incision can always be seen. It is important to remind your patients that they are trading skin laxity for a scar.