Which of the following is the most common complication of rhytidectomy?

(A) Facial nerve injury
(B) Hair loss
(C) Hematoma
(D) Infection
(E) Skin slough

The correct response is Option C.

The risk for development of hematoma following rhytidectomy has been reported in various studies to range from 0.3% to 8.1%; however, it is generally reported to occur in approximately 4% of rhytidectomy patients. Male gender and a previous history of hypertension are risk factors. Facial nerve injury is less common, occurring in approximately 1% of patients; hair loss occurs in 1.2% of those undergoing rhytidectomy. Infection is exceedingly rare (0.18% of patients) and is almost always caused by Staphylococcus organisms. Skin slough occurs in approximately 2% of rhytidectomy patients and is more common in those who smoke cigarettes.

References
1. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:543-562.
2. Le Roy JL Jr, Rees TD, Nolan WB III. Infections requiring hospital readmission following face lift surgery: incidence, treatment, and sequelae. Plast Reconstr Surg. 1994;93:533.

Ten years after undergoing primary rhytidectomy, a 65-year-old woman is scheduled for a secondary rhytidectomy procedure. Which of the following complications is more likely to occur with this procedure than with the primary procedure?

(A) Distortion of the hairline
(B) Hematoma
(C) Hypertrophic scarring
(D) Skin laxity
(E) Skin slough

The correct response is Option A.

The most likely complication associated with secondary rhytidectomy is distortion of the hairline. Hairline shifts, especially in the temporal region, can result in difficulties with incision placement. Redraping of the facial skin superiorly can result in recession of the temporal hairline with elevation of the sideburn above the helical attachment. When planning a secondary rhytidectomy procedure, the anatomy of the hairline, ear lobes, and tragus should be analyzed.

The risk for hematoma is lower following a secondary procedure than following the initial surgery, as flap dissection and undermining are easier and associated with less blood loss. Because the facial skin is delayed following primary rhytidectomy, the vascular supply to the cervicofacial skin is usually healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal. Secondary skin flaps are also able to endure greater tension. Most of the contouring performed during secondary rhytidectomy involves tightening of the lax superficial fascia and not the already tightened facial skin. Therefore, the amount of excess skin removed during the repeat procedure will be less, and skin laxity will not be seen.

References
1. Guyuron B, Bokhari F, Thomas T. Secondary rhytidectomy. Plast Reconstr Surg. 1997;100:1281-1284.
2. Stuzin JM, Baker TJ, Gordon HL. Reoperative rhytidectomy. In: Grotting JC, ed. Reoperative Aesthetics and Reconstructive Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995:205.

Pseudoherniation of the buccal fat pad results from weakening of which of the following structures?

(A) Buccinator muscle
(B) Buccopharyngeal membrane
(C) Levator labii superioris
(D) Parotid fascia
(E) Zygomaticus major muscle

The correct response is Option B.

Pseudoherniation of the buccal fat pad results from a weakening of the buccopharyngeal membrane in which the fat pad is encased. The fat pad, which aids in suckling during infancy and has metabolic characteristics that differentiate it from subcutaneous fat, typically becomes less prominent with facial growth. However, in patients who develop pseudoherniation, there is a visible outpocketing of the fat. Affected patients have a well-demarcated walnut-sized mass in the lower cheek that can be manually reduced into the buccal space. Numerous factors including previous facial surgery, diabetes mellitus, or administration of corticosteroids can lead to a loss of strength of the buccopharyngeal membrane. In patients who have these findings, salivary gland tumors, hemangiomas, abscesses, and lymphadenopathy should first be ruled out. Once this is accomplished, intraoral excision should be performed.
The buccinator muscle lies deep to the fat pad and is unaffected. The levator labii superioris and zygomatic muscles are not weakened in patients with pseudoherniation of the buccal fat pad. The parotid fascia lies posterior and superior to the fat pad and also demonstrates normal strength.

References
1. Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg. 1999;103:2061.
2. Matarasso A. Buccal fat pad excision: aesthetic improvement of the midface. Ann Plast Surg. 1991;26:413.
3. Matarasso A. Pseudoherniation of the buccal fat pad: a new clinical syndrome. Plast Reconstr Surg. 1997;100:723-730.