Correcting Bad Results in Facial Plastic Surgery Aesthetic procedures of the face and neck are increasing in popularity with emergence of innovative techniques and a shift in the social stigma of plastic surgery. With this rise, we are seeing an onslaught of patients with poor results or significant complications following cosmetic operations. Although knowledge of potential risks in aesthetic surgery is abundant, comprehensive information on management of these complications is lacking.

Common Complications in Rhytidectomy Complications of rhytidectomy are well known, yet often preventable. A thorough preoperative history and physical along with realistic patient expectations provide the surgeon and patient with insight into potential complications and postoperative management. Understanding of surgical pitfalls and avoidance are crucial in beginning to manage facelift complications. Possible complications of facelift techniques should not discourage surgeons from pursuing a particular technique as the majority of complications are temporary. Though, a strong patient-physician relationship is critical when complications occur. Complications may be frustrating for both the patient and surgeon, yet are overwhelmingly temporary and manageable without surgical intervention.

Postsurgical Alar Retraction The cephalic trim technique is a popular maneuver that often leads to tip deformities, most notably postsurgical alar retraction (PSAR). We advocate using the external rhinoplasty approach to correct PSAR by (1) releasing and repositioning the retracted alar margin, (2) strengthening and immobilizing the central tip complex using a septal extension graft, (3) suspending and longitudinally tightening the mobilized lateral crural remnant by adjusting crural length to match the sidewall span, and (4) providing direct skeletal support to the repositioned alar margin using articulated alar rim grafts. Using this structural treatment paradigm, we have corrected severe PSAR in the preponderance of secondary rhinoplasty cases.

Correction of Nasal Pinching The pinched nasal tip deformity often results as sequelae of prior nasal surgery. Conventional tip surgery techniques that overemphasize tip narrowing often deform the lateral crura and weaken support for the alar margin. The pinched nasal tip is characterized by the demarcation between the nasal tip and the alar lobule, isolating the tip from the surrounding nasal subunits. Lateral crural strut grafts with or without repositioning offer the surgeon a powerful maneuver that can help correct this functional and aesthetic deformity and restore a natural appearance to the nasal tip.

Management of Postblepharoplasty Lower Eyelid Retraction Postblepharoplasty lower eyelid retraction is challenging and multifactorial and may occur after transcutaneous lower eyelid surgery. Surgical correction is difficult and unpredictable. Patient psyche is often negatively affected. This combination of events can limit patient satisfaction, so significant preoperative counseling to educate patients and modulate expectations is critical. The combination of midface lifting, implantation of a posterior lamellar spacer graft, and canthal suspension (standard surgery) has led to variable degrees of functional and aesthetic improvement. This article reviews the typical presentation, outlines the steps of standard surgery, and touches on other modalities of treatment that may improve patient satisfaction.

Correction of the Over-resected Nose Overzealous reduction during rhinoplasty may result in manifold functional as well as aesthetic injuries to the nose and is a prevailing antecedent of revision rhinoplasty. Although challenges for the revision rhinoplasty surgeon abound, careful assessment of the anatomic deficiencies of the nose, accurate evaluation and management of a patient’s expectations, and precise planning and execution of surgical technique serve to facilitate a successful result. Contemporary techniques for correction of the over-resected nose are discussed, with special attention directed toward costal cartilage grafting and diced cartilage fascia techniques.

Approach to Correction of Septal Perforation Iatrogenic septal perforation is a complication of nasal surgery. Small or posterior perforations cause few symptoms, and need only conservative treatment. Larger and anterior perforations contribute to nasal airflow disturbances and external nasal deformities. When considering surgical candidacy, one should consider the severity of symptoms, location and size of the perforation, and need for revsional rhinoplasty. We repair perforations using intranasal mucosal advancement flaps augmented by an interposition connective tissue graft. Septal perforation repairs are tedious and technically challenging. We review key points to minimize unintended perforation formation following nasal surgery.

Complications Associated with Fat Grafting to the Lower Eyelid Fat grafting is effectively used in the lower eyelid and periorbital area for rejuvenation of the aging face. Several complications may occur with fat grafting, including volume undercorrection or overcorrection, contour irregularities, prolonged bruising and swelling, infection, granulomas and inflammation, and vascular embolization with visual loss or stroke. In many cases, complications can be effectively treated, although permanent and serious injury can occur. Appropriate surgical techniques help to prevent most of these complications. An understanding of how and why complications of fat grafting of the lower eyelid occur aids in the avoidance and treatment of these complications.

Forthcoming Issues Update of Today's Facial Skin Rejuvenation Technology

Contents J. Regan Thomas