Complications following surgical correction of age-related changes of the face and neck (causes of development and possible avenues for their prevention)

The dissertation is devoted to the study of complications arising during surgical correction of age-related changes of the face and neck and to the development of measures for their prevention. On the basis of the systematization of the author's own clinical observations and an analysis of published data, the structure and frequency of undesirable sequelae have been determined for operations on the upper, middle and lower zones of the face and on the neck. Modern techniques are considered, including frontotemporal lifting, correction of the middle zone of the face and interventions on the lower lateral regions of the face and neck, including those using endoscopic equipment and deep (subSMAS, subperiosteal) dissections. The influence of the choice of the scope of surgical intervention, the location and size of accesses on the frequency of complications is demonstrated. The results of the work are of significance for the optimization of surgical tactics and for reducing the risk of unsatisfactory outcomes in aesthetic surgery of the face and neck.

Relevance. At present, aesthetic surgery is one of the most sought-after specialties in medicine. It attracts considerable interest both from surgeons and from patients. The introduction of technologies into everyday clinical practice is one of the factors that attract physicians. One of the tasks of aesthetic surgery is the reduction or correction of the external manifestations of signs of age-related changes on the face and neck.

According to published data, references to local excision of skin excesses in various anatomical parts of the face date back to the mid-nineteenth century (McKenzie W., 1830). At the beginning of the twentieth century, the operation for the removal of facial wrinkles — rhytidectomy — was described by several prominent surgeons of the time (Passot R., 1919; Noël A., 1926). It consisted in excising small strips of skin in the region of the cheeks, forehead and neck without dissecting flaps. Dissection of the cutaneous-fatty flap began to be performed from the 1920s onward, initially locally and then increasingly aggressively, which was greatly facilitated by the accumulation of knowledge in the field of the topographic anatomy of the face (Mikhelson N. M., Kruchinsky G. V. et al., 1965). Further study of the pathophysiology of aging and of the topographic anatomy of the deep structures of the maxillofacial region made it possible to perform surgical correction of age-related changes of the face and neck on the basis of entirely different principles. Thus, in 1974 (Skoog T., 1974), he proposed a technique of surgical rejuvenation of the neck with intervention on the platysma. In 1976, W. Mitz and V. Peuronie (Mitz W. and Peuronie V., 1976) first described the structure of the superficial musculo-aponeurotic system (SMAS) of the face. The development in the 1970s–1980s by P. Tessier and his colleagues (Tessier P., Firmin F., Le Pesteur R. et al., 1974) of operations on the deep layers of the upper and middle thirds of the face (the deep musculo-aponeurotic system, abbreviated in English as DMAS) provided an impetus for the successful introduction of endoscopic techniques into clinical practice (Isse N., 1994; Ramirez O., 1994, 1994). The marked increase in the complexity of surgical approaches and the vagueness of indications for their use could not fail to lead to a greater number of unsatisfactory results and to a growing number of dissatisfied patients. At the same time, analysis of the efficacy and safety of a given technique proved to be not entirely objective, because in the course of clinical application the operative technique underwent substantial changes, and comparison of the results of the initial and final groups of operated patients became incorrect (Ramirez O., 1992; Ramirez O., 2000).

Having undertaken a comparative evaluation of the numerous operative modifications presented in the literature available to us, we arrived at the following conclusions: there are virtually no domestic clinical studies devoted to the topic under discussion. We have not encountered works by Russian authors devoted to analysis of the structure of complications arising during surgical correction of age-related changes of the face and neck of varying degrees of complexity, and, accordingly, to recommendations on the prevention of typical complications and their treatment. While analyzing the numerous foreign sources devoted to the question of interest to us, we drew attention to the following:

• Over the past 20 years, knowledge in the field of the topographic anatomy of the soft tissues of the face and neck has expanded considerably, which has made it possible to a significant degree to complicate previously employed methods in order to achieve more effective results.

• The concept of "assessment of efficacy" in aesthetic surgery of the face is sufficiently subjective and depends largely on the personal characteristics of both the particular surgeon and the person who ultimately assesses the result in a biased manner — the patient. Quite often an operation that is impeccably performed from the surgeon's point of view does not satisfy the patient at all, who imagined the final result differently and expected from the performed intervention certain expected changes in his or her life for the better — career advancement, remarriage, and so on.

• Given the economic attractiveness of aesthetic surgery, correction of age-related changes of the face and neck is being performed increasingly often on an outpatient basis, which does not allow for operations of adequate scope. A tendency toward maximum simplification of the intervention is observed, replacing necessary lifting techniques with various peelings, injections of "Botox" preparations, fillers, etc. At the same time, a result that is absolutely unsatisfactory from the standpoint of a competent plastic surgeon may be regarded as excellent both by the surgeon and by the patient, who trusts his or her doctor and is, naturally, not informed by the latter about other treatment options.

• There are few works with more or less detailed references to postoperative complications in the foreign literature available to us — about 180 sources. Despite the fact that the types of typical complications in any given type of intervention are similar, the statistics cited may differ considerably (see below).

• We have not encountered specific recommendations for the use of one or another scope of surgical intervention depending on the structural features and severity of age-related changes of the face. The available data (Rees T., 1980; Hamra S., 1993) are of a general recommendatory nature and do not take into account the existing diversity of fundamentally different approaches to performing lifts in various anatomical regions of the face or neck.

These arguments served as the basis for undertaking the present study.

Aim of the study: on the basis of analysis of the structure of complications and the conditions of their occurrence, to identify probable causes, as well as possible avenues for the prevention of undesirable consequences of surgical correction of age-related changes of the face and neck.

Objectives of the study:

1. To study the structure and causes of complications arising during surgical correction of age-related changes of the upper, middle and lower thirds of the face and neck.

2. To study the frequency of occurrence of complications in the groups under discussion and to compare it with previously published data.

3. To determine possible avenues for the prevention of the development of complications during operations for the correction of age-related changes in various anatomical zones of the face and neck.

Scientific novelty.

On the basis of systematization and analysis of the data obtained, for the first time the structure and frequency of development of complications after various types of surgical interventions for the correction of age-related changes of the face and neck have been determined. The interrelations between the occurrence of particular undesirable postoperative sequelae and the operative techniques have been studied. Possible avenues for the prevention of the development of undesirable consequences in the correction of age-related changes of the face and neck have been determined.

Practical significance. Introduction of the results of the study into clinical practice makes it possible to reduce the frequency of complications and shorten the rehabilitation time.

Main propositions submitted for defense.

1. The choice of the scope of surgical intervention for the correction of age-related changes of the face and neck should be based on a comprehensive assessment of the severity of all gravitational changes of the face and neck present in the patient.

2. The location, number and size of surgical accesses depend on the state of the soft-tissue structures of those anatomical zones where the intervention is planned.

3. Expansion of the scope and increased complexity of operative techniques in patients with widespread gravitational changes of the tissues of the face and neck do not lead to an increase in the number or a change in the structure of postoperative complications.

4. The use of endoscopic equipment makes it possible to reduce the risk of postoperative complications when performing operations for the correction of the upper and middle zones of the face.

5. The use of "deep" — subSMAS, subperiosteal dissections during interventions in the upper, middle and lower zones of the face and neck does not lead to an increase in the number of complications but makes it possible to avoid some of them.

Approbation of the work. The main propositions of the dissertation were presented at the X Scientific and Practical Conference of the Tajik Institute of Postgraduate Training of Medical Personnel on the topic "Structure of complications in surgical correction of age-related changes of the face and neck" (2004), and at the section of plastic surgery of the Saint Petersburg Scientific Society named after N. I. Pirogov on the topic "Analysis of complications after surgical correction of age-related changes of the face and neck" (2005). Three articles and one thesis have been published on the topic of the dissertation.

Implementation of the study results.

The results of the work carried out have been implemented in the practice of the Department and Clinic of Plastic and Aesthetic Surgery of the Saint Petersburg Medical Academy of Postgraduate Education (SPb MAPE) and of the Saint Petersburg Multidisciplinary Clinic named after N. I. Pirogov.

The materials of the present study are used in the educational process of the Department of Plastic and Aesthetic Surgery of SPb MAPE.

Structure and scope of the dissertation.

The dissertation is presented in one volume and consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations and a list of references. The work is set out on 145 pages of text, illustrated with 31 figures and 25 tables. The bibliographic index contains 213 entries, including 25 domestic and 188 foreign sources.