Open access peer-reviewed chapter

Complications in Esthetic Surgery

Written By

Seied Omid Keyhan, Mohammad Ali Asayesh, Arash Khojasteh and M. Hosein Amirzade Iranaq

Submitted: July 30th, 2015 Reviewed: March 29th, 2016 Published: August 31st, 2016

DOI: 10.5772/63371

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Facial plastic and reconstructive surgery is a remarkably diverse specialty, ranging from maxillofacial trauma and reconstruction to facial rejuvenation, rhinoplasty, cleft surgery, microvascular surgery, facial cosmetic procedures, and pain control. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an esthetic result.


  • complication
  • aesthetic
  • management
  • plastic surgery
  • facial surgery

1. Introduction

In this chapter, we address;

  • Complications in the periorbital area and midface

    • Table 1: periorbital and midface complication

  • Complications in cosmetic rhinoplasty

    • Table 2: summary of complications

    • Table 3: comparative incidence of complications with grafts implants

  • Complications in aesthetic blepharoplasty

  • Complications in rhytidectomy (facelift)

  • Complications in hair restoration surgery

  • Complications in otoplastic surgery

    • Table 4: complications in otoplastic surgery

  • Complications in forehead and brow lift surgery

  • Complications in skin resurfacing

    • Table 5: summary of common laser complications and their management

    • Table 6: the most common long-term complications specific to certain skin resurfacing modalities

  • Complications in facial suction lipectomy and fat transfer

    • Table 7: complication of fat grafting

    • Table 8: complications involving contour problems

  • Complications in filler injections in cosmetic facial surgery

    • Box 1-1: presentation and management of common filler complications

    • Box 1-2: vascular occlusive events: presentation, treatment, and prevention

  • Complications in botulinum toxin A (botax) injections

    • Table 9: complications of botox treatment

  • Complications in facial implants in cosmetic surgery


2. Periorbital area and midface

2.1. Periorbital area

The eyes play a central role in what we consider beautiful face. The goal of periorbital rejuvenation surgery is to restore youthful proportions and focus attention on the eyes. This is the reason made blepharoplasty as the third most common cosmetic procedure performed today, and for the foreseeable future. [1, 2, 3].

Patients with systemic diseases such as Sjogren syndrome, rheumatoid arthritis, Grave’s disease, or neuromuscular diseases should be evaluated appropriately and counseled regarding the increased risks (Table 1).

Keratoconjunctivitis sicca or dry eye syndrome (DES) is a common condition that has a wide range of etiologies. Symptoms of dry eyes (redness, soreness, mucoid discharge changes) must be asked from patients, because blepharoplasty can cause DES, or worsen the condition if present preoperatively [4].

Preoperative DES, transcutaneous approaches, preoperative skin laxity, simultaneous upper and lower blepharoplasty, hormone therapy, and male sex can also increase the incidence of both DES and chemosis. To reduce the risk of this complication, adjunctive lid-tightening procedures should be done in potential risky patients.

During the preoperative evaluation, it is important to identity patients with Grave’s disease. This condition is owing to autoimmune activity against thyroid-stimulating hormone receptors and is associated with orbital disease in 40% of patients [5]. It is characterized by glycosaminoglycan deposition, fibrosis of extraocular muscles, and adipogenesis in the orbit [6]. Although blepharoplasty is often required in the surgical management of this disease, there are often multiple stages and varying techniques to address the proptosis and lid retraction that are associated with this condition [5, 7].

Critical to maximizing outcomes after upper blepharoplasty is proper preoperative evaluation of the brow. Excessive contraction of the frontalis muscle occurs to compensate for significant upper lid dermatochalasia. If blepharoplasty is performed alone, relaxation of the brow will occur after surgery, which reduces the effectiveness of the operation [8]. Relaxed gaze is preferred to identify brow ptosis. Another method is to manually fixate the brow while assessing for excess skin.

Unusually high creases can be a sign of levator dehiscence that, if present, should be addressed at the time of surgery. Prolapse of lacrimal gland can be mistaken for excess fat, and injury to this structure can lead to postoperative complications such as DES (Figure 1). Proper evaluation of the lower lid helps to prevent complications from lower blepharoplasty such as ectropion/entropion, lid malposition, DES, and chemosis [9].

Excessive lid laxity should be addressed by either lid tightening or shortening techniques. Malposition of the lower lid should also be assessed by placing upward traction on the lower lid. A normal lid should elevate to at least the mid-pupillary level (Table 1).

Anterior lamellar shortening can be prevented by preoperative evaluation of excess skin in the lower eyelid. This is evaluated by having the patient open the mouth widely while pinching the lower eyelid skin. If there is no excess in this position, removal of skin will put the patient as risk for lower lid malposition and ectropion. A negative vector eyelid is described as a prominent globe with a recessed orbital rim/maxilla [10]. Blepharoplasty in these patients is associated with higher complication rates, particularly lid malposition [11].

For patients with significant exophthalmos, operative intervention should be modified by performing minimal fat excision or using spacer grafts to reduce the incidence of lid malposition. In addition, canthal-tightening procedures can exacerbate the malposition, as increased tension along the prominent globe will force the lid to retract further [13].

Cause Prevention Management
Dry eye
Missed preoperative,
exposure, irritation
Preoperative history/
examination, eye
Lubrication, lacrimal
puncta ducts
Chemosis Conjunctival irritation,
disruption of lymphatics
Temporary tarsorrhaphy Topical dexamethasone,
topical phefrylephrine,
lubricants, severe
Ptosis Missed preoperative,
mechanical factors,
levator injury
Limited deep cautery
in lateral fat pad,
muscle preservation
If persistent after 3
months, surgical ptosis
Scar tissue, muscle
Preoperative history/
Local steroid injections,
corrective strabismus
Lower lid
Missed brow ptosis,
under resection
Preoperative history/
examination, Chantal
tightening procedures
spacer graft, skin
brow lift
Corneal abrasion Muscle injury,
preoperative lid laxity,
overzealous skin
Corneal protector Lubrication, topical
Hemorrhage Corneal exposure
during surgery
Meticulous homeostasis Surgical exploration,
lateral canthotomy
Lacrimal gland
Anticoagulant use,
vascular injury
Proper identification
Infection. Improper diagnosis,
missed preoperative
Preoperative antibiotics Oral antibiotics, surgical
decompression for abscess
Overcorrection Surgical wound
contamination, unsterile
Thorough preoperative
assessment, conservative
fat removal
Postoperative fat
grafting, fillers
Under correction Inappropriate
Thorough preoperative
assessment, marking
Revision surgery
Sensory nerve
Surgical error Subperiosteal dissection Expectant management
Facial nerve
Cautery, wrong plane
of dissection
Subperiosteal dissection Expectant management
Infection Oral contamination Copious irrigation,
possibly avoiding
Antibiotics, surgical
drainage as indication
Asymmetry Suture fixation Revision surgery
Improper placement,
Tight subperiosteal pocket,
implant fixation
Revision surgery.

Table 1.

Periorbital and midface complications.

Figure 1.

(A) Prolapsed lacrimal gland causing temporal fullness in the left upper eyelid (black arrow). (B) On eversion of the upper eyelid, the prolapsed gland can be seen beneath the conjunctiva (yellow arrow) [12].

2.1.1. Intraoperative complications

Corneal abrasions are a potential perioperative complication. Oculotoxic sterilization chemicals, surgical instruments, gauze, or desiccation of the ocular surface predispose to inadvertent injury to corneal epithelium. By using corneal shields, which can be placed after applying tetracaine drops to the eye and a generous amount of oil-based lubricant, it is completely preventable. When corneal abrasions occur, patients often complain of pain, foreign body sensation, burning, tearing, and blurry vision. Evaluation with a fluorescein stain and a slit lamp seems to be necessary. Most can be managed with 48 h use of topical erythromycin or bacitracin [14]. The surface can also be protected with application of contact lens [15].

Thermal injuries have been reported after cosmetic blepharoplasty, and complications have resulted in postoperative astigmatism [16].

Topical antimicrobials followed by topical steroids to reduce scar tissue formation are mentioned for treatment. Hemorrhage is a potentially devastating complication with high risk of the potential blindness. Retrobulbar hematoma presents symptoms like rock hard proptosis, chemosis, severe pain, and visual changes. Ophthalmic consultation is requested early on in the course of therapy. Intraocular pressure is also elevated; however, surgical management is more dependent on the presence of visual changes. For patients with intact vision, conservative measures of cold compresses, intravenous osmotic agents, topicalb-blocker drops, and acetazolamide are initiated. For patients with visual loss, aggressive management is required beginning with a lateral canthotomy. Persistent visual should be evaluated with an orbital CT. If a posterior hematoma is present, bony decompression is warranted [17]. Postoperative complications

Postoperative DES is a common complication after blepharoplasty, as mentioned. Postoperative lagophthalmos, orbicularis injury, and lacrimal gland injury can have increasing effect on the risk of developing DES. Irritation, blurry vision, or foreign body sensation are some of the patient’s common complains. Diagnosis is confirmed with a positive Schirmer test [18].

The management generally entails usage of ocular lubricants such as artificial tears and a petroleum-based ointment. If symptoms persist, blockage of the lacrimal outflow via a punctal plug can be useful. Chemosis often accompanies DES after blepharoplasty and is defined as swelling of the conjunctiva. It can be incited by inflammatory factors such as allergy or infection, as well as traumatic causes. After blepharoplasty, chemosis has been attributed to disruption of the lymphatic channels [19] or canthal disruption [20].

Temporary tarsorrhaphy should be performed if significant chemosis is encountered intraoperatively, to limit propagation of the chemosis and protect the conjunctiva. Conservative measures include topical phenylephrine, dexamethasone, and lubrication. Severe cases are managed with a conjunctivotomy and patching to apply pressure to the eye. There are several causes for ptosis after upper blepharoplasty. The most common is likely failure to properly identify ptosis before surgery. Injection of anesthetic agents causes a temporary ptosis if the levator superioris innervation is affected. Ptosis in the immediate postoperative period is usually dependent on mechanical forces and increased weight of the lid from edema. This edema resolves by 1 week after surgery as it is resorbed.

The levator is more susceptible to injury at the inferior aspect of the lid where it attaches to the orbital septum and muscle to form the upper eyelid crease. To avoid injury, access to the orbital fat pads should be performed at the superior aspect of the lid through the orbital septum. The medial fat pad serves as an important landmark because it rests on top of the levator aponeurosis, preventing its injury. Correction of ptosis requires operative exploration of the wound through an anterior approach. If a tear in the aponeurosis is identified, direct repair is performed. If the aponeurosis is disarticulated from the tarsal plate, it must be reattached using interrupted sutures [21].

Lagophthalmos can occur owing to anterior lamellar deficiency (aggressive skin excision), incorporation of septal fibers into the skin during closure, or significant injury to the orbicularis muscle. Anterior lamellar shortening can often be treated with full-thickness skin grafts. Septal adhesions should be explored early and lysed. A new technique that is gaining popularity is the application of fillers to correct lagophthalmos [22, 23]. The technique mentioned has been used for patients with paralytic lagophthalmos [23] and for patients with superior sulcus syndrome [22] with excellent results.

Infections after blepharoplasty are extremely rare. Infections typically occur 5–7 days after surgery and present with increasing edema, erythema, and pain.

Orbital cellulitis involves the orbit and is associated with proptosis, restricted extraocular muscle movement, and visual changes. Organisms involved in periorbital infections include beta-hemolytic streptococcus and staphylococcus aureus and require more aggressive treatment [24].

Necrotizing fasciitis has been reported after blepharoplasty [25, 26].

Diplopia is thought to relate to direct trauma to the extraocular muscles during the procedure [25] or scar tissue formation, which limits extraocular muscle movement [27].

Strabismus in which superior oblique injury or inferior rectus injury is diagnosed can be treated successfully with systemic steroids and triamcinolone injections.

Diplopia has also been reported directly owing to lower lid fat repositioning [28].

Canthal webbing can occur both medially and laterally after blepharoplasty. The usual error is incision placement too medial or lateral, or too close to the lid margin. It can also occur from excessive anterior lamellar shortening. Managements ranging from gentle massage, steroid injections up to surgical correction with V–Y advancement, or multiple Z-plasties are performed.

Poor scarring is a potential complication anytime the skin is incised. Joshi and colleagues [29] looked at various closure techniques and found that a running 6-0 plain gut with several interrupted prolenes resulting in the lowest rates of standing cone deformities and milia formation. Running locking 6-0 prolene was associated with the highest rate of complications. For patients with track formation, subcuticular closure reduces the risk of recurrence. Fat repositioning can be performed in the subperiosteal or preperiosteal plane [30].

If hollowing does occur in the lower lid, this can be corrected with autologous fat grafting or placement of fillers. Owing to the delicate quality of the lower lid, softer hyaluronic acid fillers are preferred to prevent palpable or visible abnormalities. Hollowing in the upper lid is also a potential complication not only does it result in a cosmetic deformity, severe cases can result in lagophthalmos [22]. Recent techniques such as limited removal of the central fat pad and repositioning of the nasal fat into the orbitoglabeller groove are developed [30].

Lower eyelid retraction can be caused by inadequate vertical laxity from lamellar shortening in 1 or a combination of the 3 lamella. To diagnose which of the 3 has the deficiency, cheek skin is pushed up to artificially recreate the anterior lamella. If the deformity is corrected, then the issue is from anterior lamellar shortening. If the retraction persists, middle or posterior lamellar shortening is more likely. Vertical inadequacy results in ectropion with anterior lamellar shortening, entropion with posterior lamellar shortening, and lower lid retraction with middle lamellar shortening.

Ectropion most commonly occurs from excessive skin excision. A transcutaneous approach alone, without skin excisions leads to 2–3 mm of anterior lamellar shortening [31].

Correction of anterior lamellar shortening is usually done with full thickness skin grafts. The ideal skin donor is the upper eyelid skin owing to the thinness and color match. If patients have had recent upper eyelid surgery and this skin is not available, supraclavicular skin or postaurical skin is an option. Another option to correct lower lid malposition from anterior lamellar shortening is the midface lift. Repositioning of the suborbicularis oculi fat pad supports the lower lid, recruits skin and muscle, and rejuvenates the midface. Multiple approaches have been described, including a transconjunctival, temporal approach, and subcilliary with subperiosteal or preperiosteal dissections. Marshak et al. [40] described a lateral canthal incision that allows for release of scar tissue and adequate access to the subperiosteal plane of the midface. Middle and posterior lamellar shortening is managed with scar lysis and placement of spacer grafts. Various autogenous and allogenic materials have been used with varied results. Common autogenous grafts include palate grafts, conchal cartilage, septal cartilage, temporalis fascia, and fascia lata [32].

Allogenic grafts, such as acellular dermis, palate grafts [33] dermis fat grafting [34], have also been used with variable results. Another significant factor in lower eyelid malposition is horizontal lid laxity, which is assessed preoperatively with snap and distraction tests. If this laxity is present preoperatively, a prophylactic canthal tightening procedure can prevent lid malposition. Multiple techniques can be used to resuspend the canthus, including canthoplasty, tarsal strip removal, and canthal suspension.

2.2. Midface

Midface rejuvenation can be performed using a multitude of different techniques. Preventable complications include improper implant choice, migration, and improper placement. The proper size is one that is slightly smaller than the desired projection, because soft tissue over the implant increases the fullness [35].

Implant migration is a preventable complication. Creating a limited subperiosteal pocket to reduce mobility, placement of a temporary stay suture, or screw fixation of the implant can prevent this complication. There have been several reports of severe orbital complications from implant migration, including conjunctival extrusion, scleral erosion [36], and intraorbital erosion [37].

Nerve injury can occur, and the most common is the infraorbital nerve which occurred during malar augmentation with implants, owing to its close proximity of the dissection. These injuries are commonly transient [38] and resolve without intervention. Infection is also potential complication, as with any other surgical implants. These complications were reported in proplast implants and often occurred as a late sequela owing to maxillary sinus erosion [39].

The transtemporal approach has been shown to be an effective technique to rejuvenate the midface. Because the lateral canthus and other orbital structures are not manipulated in this approach, lower lid malposition is not encountered [40].

The incision in the temporal tuft of hair carries a risk of Alopecia, which can be limited by beveling the incisions to limit disruption of hair follicles. Bleeding and infection are not common complications. Abscess formation has been reported, which led to malar wasting requiring malar implants for correction [41].


3. Rhinoplasty

Rhinoplasty is one of the most difficult cosmetic operative procedures performed today. Surgeons must develop skills for a three-dimensional manipulation of various tissues, often performed with limited access. Like all other surgeries, occurrence of complications is inevitable but must be managed properly. Early complications in rhinoplasty can be avoided through very careful and precise techniques during or at the end of the operative procedure. Late complications may occur due to failure to understand the consequences of surgical manipulation of the underling tissues, or from the idiosyncrasies of the various anatomic tissues healing (Table 2).

Complication Cause  Avoidance Correction
Asymmetry of the
bony vault
Asymmetric osteotomies Meticulous attention
to osteotomies
Percutaneous osteotomies
Asymmetry of the
middle vault
Unmasked dorsal septal
deviation after dorsal
Recognition of septal
Crushed cartilage
camouflage grafts
Tip asymmetry Asymmetric tip sutures
unmasked caudal
septal deviation
Meticulous attention
to suture technique
Meticulous inspection
Revision Possible placement
of septal extension graft
Possible repositioning
of caudal septum with
swinging door, secure
to nasal spine with
Over resection
of nasal bones
Overaggressive resection Judicious bony
dorsal reduction
Placement of
dorsal onlay graft
Open roof
Bony dorsal
Judicious bony dorsal
reduction when no
osteotomies are planned,
but unavoidable when
narrowing of the
bony base is planned
Lateral osteotomies
to close open roof
Rocker deformity Continuation of
osteotomies into
frontal bone
Meticulous planning of o
steotomies and continuous
Percutaneous osteotomies
Stair step
Improper placement of
lateral osteotomy
anterior to the
ascending process
of the maxilla
Meticulous planning of
dorsal reduction,
both bony and
cartilaginous dorsum
Percutaneous osteotomies
Polly beak
Over resection of nasal
bones under resection
of dorsal septum (anterior
septal angle) Postoperative
soft tissue scar
Meticulous planning of
reduction both bony
and cartilaginous dorsum
Avoid overaggressive
dossal reduction in\
thick-skinned patients
Dorsal onlay camouflage
graft Appropriately match
cartilaginous dorsal
reduction to that of
bony dorsal reduction
May require revision
Kenalog injections
Inverted V
Upper lateral cartilages
drop inferior and posterior,
causing show of the
nasal bones and dorsal
septum This results
from failure to repair
the upper laterals to
the dorsal septum after
dorsal reduction
Repair upper lateral
cartilages to dorsal
septum after dorsal
reduction use of spreader
grafts or auto
spreader grafts
Revision with use
of spreader grafts
(if upper lateral
cartilage present),
possible onlay crushed
cartilage camouflage
grafts, consider osteotomies
to narrow the bony base
if this is a contributing
Saddle nose
(Figure 2)
Overaggressive dorsal
reduction with septoplasty,
resulting in a dorsal
strut that is inadequate
to support cartilaginous
Maintain 1.5-cm
dorsal strut
Revision with dorsal
onlay camouflage graft
(minor cosmetic deformity)
and rib cartilage graft
reconstruction (severe
Bossae Overaggressive cephalic
trim of lateral
Note predisposing
factors for bossae
formation (see below),
avoid over aggressive
Revision with structural
grafting of lateral crura
(strut grafts). crushed
cartilage, and/or temporal
is fascia camouflage
Visible grafts
(Figure 3)
Thin skin Note thin skin
preoperatively and
place temporalis fascia
overlay grafts to
Revision with possible
graft removal and/or
placement of temporal
is fascia for contour
smoothing and camouflage
Pinched tip
(Figure 4)
Over resection of
lateral crura during
cephalic trim malpositioning
of lateral crura Contracture
from wound healing
Spare 6- to 7-mm rim
strip Ensure appropriate
orientation and patient
about this risk and
document having done so
Lateral crural strut
grafts, possible crushed
cartilage grafts for
camouflage Removal/revision
of any offending tip
sutures, possible lateral
crural strut grafting,
possible repositioning of
lateral crura Revision
surgery with one or
more of the above
defined tip
Overaggressive tip
deprojection in
thick- skinned patient
Avoid overaggressive
Judicious superficial
nasalis aponeurotic system
(SNAS) excision intra
operatively, ken log
Altered caudal septum,
medial, intermediate, and
lateral crura dynamics
from intra-operative sture
technique or alteration
Meticulous attention to
symmetric placement of
sutures, such as tip
and tongue in groove
Revision, with correction
of underlying offending
Overly tight closure of
marginal incision Over
resection of lateral crura
during cephalic trim
Malpositioning of
the lateral crura
Overly tight lateral
crural spanning sutures
Contracture from wound
Remove/revise offending
sutures Lateral crural
strut grafts, possible
alar rim grafts (minor
cases), auricular composite
grafts (severe cases)
Repositioning of the lateral
crura, lateral crural
strut grafts, possible alar
rime Grafts (minor cases),
auricular composite grafts
(severe cases) Removal/
revision of any offending
tip sutures Revision
surgery with one or
more of the above
Over resection of the
caudal septum Excessive
setback of the medial
crura during tongue-
Avoid over resection
Avoid excessive setback
Caudal septal extension
graft, columellar strut
graft, columellar plumping
graft Revise tongue-
in-groove, consider
columellar plumping graft
Septocolumellar suture
can be used to help
prevent contracture
during wound healing
and alar
base scar
Wound healing Meticulous wound
Kenalog injections
with revision reserved
for severe cases
External nasal valve
collapse Internal nasal
valve collapse
Septal deviation
intranasal synechia
Recurvature of the
lateral crura
Maintain integrity and
appropriate position of
lateral crura, avoid
overaggressive narrowing
of the alar base
Avoid overaggressive
narrowing of the bony
base, use spreader grafts
or auto spreader grafts
to maintain patency
Appropriately address
any septal deviation
careful soft tissue
handling and fastidious
wound closure Recognize
contribution to the
patency of the nasal
Lateral crural strut
grafts, possible alar rim
grafts Spreader or
autospreader grafts
Septoplasty Lysis of
synechia Lateral crural
strut grafts
lacerations Septal
Meticulous elevation
of mucoperichondrial
flaps to prevent opposing
lacerations Placement
of septal whip
sutures and use of
removable soft silastic
intranasal splints,
prophylactic mucoperichondrial
flap incision to allow
drainage of any accumulated
Place fascia or
crushed cartilage
graft interposed
between lacerations
Incision and
and homograft)
Intrinsic property
of cartilage
Concentric carving Revision
after costal
cartilage harvest
Injury to the pleura Harvest cartilage in
subperichondrial plane
Close wound under water
with positive pressure

Table 2.

Summary of complications [42].

Figure 2.

A saddle deformity caused by excessive loss of the bony and cartilaginous dorsum [1].

Figure 3.

Erosion of a dorsal Gore-Tex implant through the skin of the nasal dorsum [2].

Figure 4.

A pinched tip due to over-resection of the tip cartilages and insufficient tip framework [43].

The focus of rhinoplasty is to achieve nasal balance and maintain harmony with the face while keeping the nasal airway functional. Understanding the use of autologous, homologous, and alloplast materials for grafting and implantation purposes has become a necessity (Table 3; Figures 5 and 6).

Resorption Warping Infection Extrusion Skin changes Support
Cartilages + + Low Good
Bone ++ + Low Rigid
Homograft +++ + +++ Good
Alloderm ++++ NA Low Low None
Silicone + +++ + Rigid
Medpor Low Rigid
Gore-Tex ++ Low + Mesh
Mersilene ++ Mesh
Prolene Low Mesh

Table 3.

Comparative incidence of complications with grafts and implants [44].

Figure 5.

Extruding silastic implant 14 years postoperatively [45].

Figure 6.

(A) Patient at surgery to remove an infected alloplastic dorsal graft that had been in place for 5 years. The patient was a heavy smoker. (B) No incision was made, as the graft had begun extruding through the columella. The material appeared to be porous, high-density polyethylene [46].


4. Midface lifting and blepharoplasty

4.1. Complications of midface lifting and the related surgical technique

Various complications may be encountered in the transeyelid approach, including temporary complaints of dry eyes, and lateral periorbital skin excess may occur in the early postoperative period, but these typically resolve with time. In the subciliary approach, a visible scar may remain. In the transconjunctival approach, conjunctival edema (chemosis) may be seen in up to 20% of patients [47].

In addition, there is a potential for middle lamellar scarring, leading to vertical shortening of the eyelid, which could present as a cicatricial ectropion or entropion or even permanent changes in the shape of the eyes. There could also be zygomatic branch injury, leading to forms of lagophthalmos (Figure 7).

Figure 7.

Patient referred with bilateral lagophthalmos resulting from overzealous skin excision during prior blepharoplasty [12].

4.2. Endoscopic temporal approach

Several complications may be encountered in this approach. Injury to the frontal branch of the facial nerve may occur. Injury may occur when approaching the zygomaticotemporal nerve and vein [48].

Injury to the vascular structures without adequate hemostasis results in hematoma formation. Aggressive medial dissection through the temporal incision may lead to lateral canthal distortion [41]. When beginning this temporal approach, if the plane is dissected too superficially, injury to hair follicles can lead to permanent hair loss. The use of the sublabial incision carries risks, given the potential exposure to oral flora. These patients may be at greater risk for developing malar subperiosteal abscesses [41]. Therefore, it is of the utmost importance for patients to receive postoperative antibiotics to cover oral flora for 7–10 days [48].

4.3. Preauricular deep plane approach

Complications include parotid duct fistulas if the parotid duct is invaded [49]. These complications are addressed by recannulizing the duct after locating the stensen duct intra-orally. If not a full cut, this complication could be addressed with warm compresses and aspiration. Another complication is earlobe deformity, including pixie ears. There could also be complications of the buccal branch or marginal branch nerve injury. There is also the risk for hematomas, leading to possible necrosis of the skin flap.

4.4. Complications of lower eyelid blepharoplasty and the related surgical technique

Lower eyelid blepharoplasty is generally performed through a transconjunctival or transcutaneous route. Both approaches can be complicated by lower eyelid retraction, DES, retrobulbar hemorrhage, diplopia, and volume depletion.

4.4.1. Lower eyelid retraction

The transconjunctival approach has a lower incidence of retraction, because it avoids the orbital septum [50].

Patients can present with an inferior scleral show chemosis, rounded lateral canthus, tearing, and a postsurgical look. A forced upward traction test can show tethering to the orbital rim or an overall tight feel. During the first 3 months, it is customary to encourage lower eyelid pushups and, if needed, injections of fluorouracil 50 mg/mL directly into the cicatrical region once per month. If, after 3 months, lower eyelid retraction remains, a surgical approach is planned. Depending on the severity of the lower eyelid retraction, a plan is formulated accordingly.

  • First, it must be established whether the problem is anterior or middle lamella. If there is vertical inadequacy of the anterior lamella, a full-thickness skin graft is generally the treatment of choice.

    • More commonly, a middle lamellar problem is encountered. In this case, because of cicatrical contraction of the middle lamella, a spacer graft is the treatment of choice.

      • A cantholysis is performed, a transconjunctival incision is made with tenotomy scissors, and the tether is released.

      • If needed, a SOOF lift can be performed, and the orbitomalar ligament disinserted at this point.

        • A spacer graft, whether hard palate graft or acellular human or animal product, is secured, essentially extending the lower eyelid retractors to the conjunctiva.

        • The canthus is closed with a standard tarsal strip procedure, and the lower eyelid is placed up on a frost lower eyelid suspension suture for 5–7 days.

4.4.2. Diplopia

If the medial and central fat pads are injured during a lower eyelid blepharoplasty, torsional diplopia can result. If injury results from scarring to the inferior rectus or its attachments, hypotropia can result.

4.4.3. Dry eye syndrome

Most eyelid surgery can result in temporary dry eye symptoms or can be subclinical, which is evident only in the tear film breakup time or consistency of the tear film itself. Artificial tears can be prescribed, and, if more significant symptoms present, punctual plugs can be used.

4.4.4. Volume depletion

Excessive fat removal during a lower eyelid blepharoplasty will present the patient with complaints of a sunken appearance or darkened lower eyelids from a shadow effect and looking more tired than before surgery. The orbital rim can be seen with increased definition, especially in patients with a less prominent orbicularis or thinner skin. A more prominent tear trough deformity can also be seen. This complication can be corrected with fat grafting to the newly hollowed area or a transeyelid midface lift. The best option is to avoid this complication by conservative fat reduction or performing a fat transposition.


5. Rhytidectomy (face lift)

A thorough preoperative evaluation will result in fewer complications after surgery. Patients are instructed to avoid the use of aspirin and nonsteroidal anti-inflammatory drugs for at least 2 weeks before surgery. Smoking must be stopped for at least 1 month before surgery. All other medications should also be avoided for 2 weeks prior to surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications, including arrhythmias [51].

Chemotherapeutic agents and oral steroid use can alter the wound. Facial nerve paresis or paralysis must be documented preoperatively. Complete documentations for possible submalar hollowing, microgenia, facial asymmetry, submandibular gland ptosis, low-riding hyoid, and platysmal bands need to be done and discussed with the patient. Patients must be aware that perioral rhytids, deep neck rhytids, and nasolabial folds are unaffected by this surgery so alternative treatment plans must be discussed. It is important to evaluate the patient’s position of the frontal and temporal hairline and look for evidence of alopecia. The present position of the temporal and mastoid hairlines needs to be respected in the design of any rhytidectomy incision. The temporal hairline must not be elevated or narrowed as the result of a poorly designed incision. The upper end of the rhytidectomy incision should be placed along and parallel to the lower end of the temporal hairline and should not extend above the upper edge of the pinna. If it does, the temporal hairline is raised and narrowed, compromising the final aesthetic result and making reconstruction of this valuable landmark difficult. Hairline incisions in the mastoid and post-auricular area should be avoided because they often result in hypopigmented and quite obvious scars that prevent the patient from wearing her hair up, which might expose them. If it is necessary to extend the incision behind the ear, then it is prudent to continue it into the hair-bearing scalp.

5.1. Intraoperative complications

5.1.1. Positioning and preparation

Careful patient positioning following anesthesia and before surgery improves patient visibility and outcome and reduces complications. Surgical lights should shone on the outer surface of the skin flaps and not directly into the surgical field for transillumination and to achieve the so-called peau d’orange effect in order to make necessary adjustments to avoid perforation of the SMAS and possibility of parotid fistula.

5.1.2. Parotid duct injury

It may occur along the anterior border of the masseter on a line from the external auditory canal to the upper lip. If it is injured, the distal end of the duct is cannulated with a small catheter and passed retrograde into the field and then passed into the proximal severed end. It is left in place for about 2 weeks.

5.1.3. Facial nerve branch injury

Too deep dissection might result in injury to branches of the facial nerve. If recognized during the surgery, the nerve must be repaired. The temporal branch is most vulnerable anterior to the temporal hairline so dissection here must be superficial with observation of the overlying hair follicles in the skin flap. Marginal mandibular and cervical branch injuries are possible if the dissection below the mandibular border extends beneath the platysma.

5.1.4. Auricular nerve and jugular vein injury

The posterior neck flap dissection must be done superficially but without buttonholing the skin flap. Care is taken to avoid exposing the fascia overlying the sternocleidomastoid muscle and risking injury to the great auricular nerve and accompanying external jugular vein. If injured, direct repair of nerve and suture ligature of vein should be undertaken.

5.1.5. Spinal accessory nerve injury

More posteriorly, injury to the spinal accessory nerve can occur if the dissection becomes too deep. A good superficial landmark to keep in mind is Erb’s point (Figure 8).

Figure 8.

Erb’s point [51].

5.2. Postoperative complications

5.2.1. Hematoma

Hematoma formation the most common postoperative complication typically occurs within the first 24 h following surgery, ranging from 3 to 8% of cases according to multiple studies [5256]. Before discharge, the dressings are inspected and flaps viewed with a flashlight while lifting up the Kerlix wrap from each cheek. In the presence of significant pain or asymmetric swelling, flaps inspection is done. If a hematoma is discovered, the patient is returned to the operating room to prevent further complication to an already compromised flap. The incision is opened, clots evacuated, bleeding controlled, and the incisions closed over an active drain.

5.2.2. Infection

Infection is unusual following rhytidectomy but may occur as the result of a stitch abscess or, more rarely, a suture passed through the tragal cartilage. The offending suture(s) should be removed, and local wound care with an antimicrobial ointment often clears the problem. Significant erythema and tenderness to the auricular cartilage warrants oral antibiotics to cover Staphylococcus, Streptococcus, and Pseudomonas to prevent permanent cartilage damage.

5.2.3. Nerve injury

If noted during surgery, primary repair results in the best outcome. Mild facial paresis is usually temporary but may persist for 12 h after surgery, caused by the prolonged duration of local anesthetic agents or edema of the nerve. The great auricular nerve is the most frequently injured sensory nerve and results in numbness. If the nerve is repaired during surgery, return of sensation is common but may be delayed for 12–18 months and result in localized areas of persistent anesthesia. The temporal branch is the most frequently injured motor nerve and may resolve within 18–24 months of onset, but the resultant asymmetric brow can be improved with careful use of paralytic agents like Botox or Dysport on the nonparalyzed side. If the forehead paralysis is permanent, treatment is dictated by the extent of the subsequent deformity and disability. Mild asymmetry is best managed by the paralytic agents mentioned earlier, whereas significant brow ptosis may require a brow lift on the affected side.

Other nerve injuries may include marginal mandibular, zygomatic, buccal, or cervical branches of the facial nerve, and permanent damage was <1% in a large study [57].

5.2.4. Systemic complications

Major systemic complications are unusual in patients undergoing facelift surgery and may include deep vein thrombosis (DVT), pulmonary embolism, stroke, blood transfusions, major anesthetic complications, and death [58].

5.2.5. Skin slough

Skin slough is a rare occurrence following rhytidectomy (Figure 9). Vascular compromise is usually noted in the periauricular region and may appear as a distinct area of ecchymosis. Local application of nitropaste or DMSO 2–3 times daily may be beneficial to reduce the chance of full-thickness skin loss. Nevertheless, the area of concern is allowed to demarcate fully into an eschar before conservative debridement is done in the office. Excision of scars and closure are delayed until full maturation of the wound and scars has occurred to prevent further compromise of the flaps and ultimate aesthetic result.

Figure 9.

Preauricular skin slough. The preauricular and postauricular regions represent the most distal segments of the facelift skin flap. These sites are prone to skin loss in smokers and in other instances where flap vascularity is compromised [59].

5.2.6. Scarring

Hypertrophic scars are injected with a dilute concentration of Kenalog 2–5% every 6 weeks once noted, along with the use of silicone sheeting or gels. Persistent scars may respond to pulsed dye laser therapy if resistant to the aforementioned measures and usually require multiple treatments. Hypopigmented scars are most common along the posterior hairline when incisions have been placed along the hairline instead of behind it.

5.2.7. Alopecia

Alopecia occurs following damage to the hair follicles from electrocautery, excess traction of tension on the skin flaps, and inadvertent elevation or elimination of the temporal hair tuft and temporal hairline. Temporary loss may be shortened with the use of topical minoxidil. Permanent alopecia requires the insertion of single-hair follicular units into the areas of alopecia or the replacement or lowering of the temporal hairline.

5.2.8. Contour deformities

Contour deformities are common immediately after rhytidectomy. Most of these are temporary and related to postoperative edema and ecchymosis and occur in the preauricular and submental regions (Figure 10). As the swelling subsides, most of these resolve, and resolution may be hastened with gentle local digital massage. Persistent contour deformities may be seen for several months and require no further treatment. If localized areas of depression persist after 6–12 months, they can be improved by injections of dermal fillers or fat.

Figure 10.

Submental banding following overaggressive liposuction. Excessive fat removal or aggressive liposuction with scarification of the dermis may result in banding and an unnatural contour. This deformity is difficult to correct. Early in the postoperative period, massage and the judicious use of triamcinolone injections may help to minimize such irregularities. In the long run, the juxtaposition of soft tissue or fat grafting may diminish the appearance of banding. Avoidance of overaggressive lipocontouring is an important tenet [59].

Another problem with facelift skin adjustment is an unnatural-appearing earlobe. Although this seems like a straightforward part of the lift, failure to address the earlobe properly can lead to the most telltale sign of a poor technique, which is a “pixie” earlobe (Figure 11). The pixie or “elfin” earlobe is a result of lack of attention to the skin cutback to deliver the earlobe from under the excess pulled skin.

Figure 11.

The pixie ear lobe deformity can occur with improper technique in facelift surgery [60].


6. Hair restoration surgery

6.1. Donor site

6.1.1. Complications

Figure 12.

Donor-site necrosis resulting from a high-tension suture closure. Eschar is identified over the necrotic site in this 2-week postoperative photo. Early postoperative effluvium surrounds the devitalized incision site [61].

  • Poor wound healing/scarring (atrophic, widened, hypertrophic, hypopigmented)

  • Necrosis (Figure 12)

  • Chronic pain

    1. Cause: Improper donor harvesting (too wide a scar, too much tension, poor location, transection of hair follicles, transection of blood and nerve supply, improper undermining).

    2. Avoidance: Surgical complications can be avoided by paying attention to the depth and angle of one’s harvest (staying within the subcutaneous plane and above the galea), avoiding transection of the underlying blood supply, nerves, galea, and surrounding hairs. It should be ascertained that there is sufficient laxity (preoperative scalp relaxation exercises in a tense scalp), sufficient time between operative harvesting cases so that the scalp has had time to relax, and only 1 cm or less in width should be harvested when removing a donor strip. Use of tumescent solution to help straighten follicles and to limit injury to the underlying nerve and blood supply is critical. A careful two-layered closure is helpful to minimize scarring. Use of platelet-rich plasma (PRP) can help with good wound healing. If a wound is under tension, the wound should be closed in a delayed fashion rather than undermined or forcefully drawn close, both of which can lead to necrosis, unpredictable hair loss in the donor area, and additional scarring.

    3. Correction: Albeit tempting, surgical excision of a scar tends to lead to the reappearance of the same scar over time. Placing grafts into the scar can be helpful but sometimes the blood supply is poor and may not be entirely beneficial. Use of micropigmentation (tattooing) can also help cover the previous scarring. Chronic nerve pain (or conversely permanent anesthesia) that can arise from inadvertent transection of occipital nerves can be addressed with targeted botulinum-toxin injections into the specific area of discomfort. After 1–2 sessions of neurotoxin (2–5 units), the patient can be afforded lasting relief.

6.2. Recipient site

6.2.1. Complications

Figure 13.

Graft height error. Careless graft placement resulted in a combination of cobblestoning (too high) and pitting (too low) [61].

  • Pitting (Figure 13)

    1. Cause: The graft was placed too deep relative to the surrounding tissue.

    2. Avoidance: The graft should fit the site correctly, and test grafts should always be undertaken first to ensure that the graft-to-site fit is appropriate before major graft dissection is undertaken. The graft should fit so that it rests approximately 1 mm above the surrounding skin because when the edema resolves, the graft settles to be flush with the surrounding skin. If placed flush or lower than the surrounding skin, the site has a greater likelihood of eventual pitting.

    3. Correction: It is very hard to correct pitting. In sensitive areas like the hairline, if the hairline is at the appropriate position or too low, then the grafts can be removed through punch excision. Otherwise, additional grafts can be placed around the bad grafts to camouflage them in an approach known as “de-emphasis grafting.”

  • Cobblestoning (Figure 13)

    1. Cause: Cobblestoning is the opposite problem of pitting. When grafts are placed too high to the surrounding scalp, they can create a cobblestoned appearance (i.e., raised vis-a`-vis the surrounding scalp).

    2. Avoidance: Grafts must be placed that fit the site correctly. If the grafts are too large, they may not settle into the site correctly and thereby leave a cobblestoned appearance after wound healing.

    3. Correction: Cobblestoning is very hard to correct. The cobblestoned area can be transected flush to the scalp, or more grafts can be used to be placed around the existing bad grafts through “de-emphasis grafting.”

  • Compression

    1. Cause: Grafts with numerous hairs and that are too large for a particular site can be squeezed together to appear as a central tuft of hair, almost like a plug of yesteryear.

    2. Avoidance: Ensure that grafts fit the site appropriately.

    3. Correction: Similar to the correction stated above in “pitting.”

  • Kinky hair

    1. Cause: The hair shaft is overly manipulated or crushed during insertion by the grasping forceps leading to a wiry hair growth.

    2. Avoidance: The graft should be held only by the surrounding fat cuff and never on the hair shaft itself.

    3. Correction: Correction is similar to the correction stated above in “pitting.”

  • Poor growth

    1. Avoidance: Patients must understand that sometimes, despite a surgeon’s best efforts, growth can be underwhelming based on a patient’s growth characteristics. However, certain factors can predispose toward poor growth including not using recipient tumescent solution (0.01% lidocaine with 1:500,000 epinephrine) to protect the underlying neurovasculature, implanting grafts into too dense a distribution, and poor handling and manipulation of grafts (as mentioned above in pitting and kinky hair). Use of PRP during a procedure can improve a patient’s chance of success with hair growth in the author’s experience.

    2. Correction: A second hair transplant may need to be performed with better technique.

  • Unnatural hairline

    1. Cause: An unnatural hairline can arise from a host of problems that involve a badly positioned hairline (too low, too high, improper slope, too wide, too narrow, and does not match a natural Norwood pattern of hair loss), too straight or harsh [use of grafts that are too large in the frontal hairline, not angling the grafts correctly (see Figure 4), not creating a natural micro-undulating hairline, not putting “sentinel” one-hair grafts to soften the hairline], or having any of the problems like pitting, kinky hair, and so on, mentioned above.

    2. Avoidance: The macro-hairline (the line drawn on the head) should be undertaken only after a surgeon understands the natural Norwood patterns and can construct a hairline based on accepted principles that mimic nature. The micro-hairline (the actual recipient sites and grafts placed) must be constructed with utmost care so that the angles are low and straightforward and appear to look like a cragged coastline (i.e., without appearing too straight and harsh). The assistants who place grafts must adhere to careful attention to avoid previously enumerated problems, including pitting, kinky hair, placement of inappropriate graft sizes for a particular location, poor growth, and similar problems.

    3. Correction: If the hairline is too high, the hairline can be redrawn lower and a better designed and constructed hairline can be placed in front of the bad grafts to camouflage them (“de-emphasis grafting”). If the hairline is too low to be acceptable or natural in appearance, then grafts can be punched out that reside in front of the proposed new hairline (Figure 13). Alternatively, a strip of grafts can be excised from the hairline to raise the hairline upward, after which time when the wound is well healed, a new hairline can be constructed according to the meticulous principles of good hairline design and execution.

  • Necrosis/poor scalp healing. Poor scalp healing can manifest as a hypopigmented scalp, a chronically discolored scalp, or frank necrosis.

    1. Cause: Besides a patient’s predisposing factors, such as smoking, chronic sun damage, and diabetes, a surgeon can inflict this outcome when the underlying vasculature is carelessly transected during recipient-site creation.

    2. Avoidance: Use of proper recipient-tumescent fluid is important to increase the distance between the recipient-site creating instrument (e.g., needle, blade) and the underlying neurovasculature. Also, avoiding overdense packing (>50 sites per cm2) may help to minimize this problem. For signs of venous congestion or incipient necrosis, using nitropaste can be an immeasurably important rescue tactic. As mentioned earlier, use of PRP injected into the scalp an hour or so before site creation can help improve wound-healing capacity and minimize this risk. In patients who are very bald and have signs of poor vascularization, use of topical minoxidil for several months may anecdotally improve blood supply to the target recipient area but no conclusive studies have been undertaken to demonstrate that benefit.

    3. Correction: If the scalp looks discolored or hypopigmented in some way, additional grafts (placed in a more careful manner explained above and only undertaken a year or more later to allow for wound healing) may camouflage the scalp appearance. However, clearly the concern is compromising the blood supply further from additional transplantation. Use of minoxidil postoperatively may also help revitalize the scalp. In cases of frank necrosis, the eschar should be left in place (not debrided for fear that the tenuous blood supply is further compromised) and kept moistened with an antibiotic solution. When the eschar sloughs, the surgeon can consider excision of the necrosis or grafting into the area preferably many months to a year later. As an alternative, micropigmentation of the scalp can be performed to camouflage the area of baldness.


7. Otoplastic surgery

Complication Importance Cause Treatment Note
Early complications Hematoma Can lead to
infectious chondritis
and necrosis
Lead to cauliflower
ear deformity
Improper plane
of dissection
Inadequate hemostasis
before closure
Poor auricle
with dressing
Release sutures
and milk out
clotted blood
Passive closure
over a passive
Penrose drain
Apply fresh
dressing Prescribe
Pay attention
to extreme or
asymmetric pain
Bent ear and
pressure necrosis
can cause
Infection Chonritis Non aseptic
operative technique
Ischemia Pressure
necrosis Untreated
Irrigate with antibiotics
before closure Incision
and drainage Wound
irrigation with
clindamycin or
and antipseudomonas
Uncommon Associated
with pain and
focal erythema
Purulence may
be seen
Skin and
cartilage necrosis
Cartilage necrosis Technical error
Violation of subdermal
plexus during
dissection Excessive
cautery use An
overly compressive
dressing causing
compartment syndrome,
and placement
over a bent ear
Similar to that
of infection
Possible skin
grafting or flap
advancement to
cover exposed
Rare Necrotic
tissue must be
debrided before
Late complications Patient
Technical error
Unrealistic expectation
of patient and family
Revision Preoperative discussion
with the patient and
family must establish
realistic expectations
Slight overcorrection
is likely to be more
accepted than slight
Surface irregularities
Erosion of the sutures
through the skin
Contour irregularities
of the ear Narrowing
of the external
Auditory meatus
Granuloma formation
Monofilament nonabsorbable
sutures, such as
nylon or polypropylene,
can erode through
the thin postauricular
skin causing suture
fistulae or granuloma
formation Polyfilament
nonabsorbable sutures,
such as silk or
polyester, may cause
less erosion through
the skin, but tend
to have a higher
infection risk placing
sutures under tension
across a gap
spanning an area
with little to no
subcutaneous tissue
No treatment
Suture removal using
4–0 mersilene
suture for the
mustarde technique
Postauricular skin
incision is closed
with 4–0 plain
gut suture
Sutures can safely
be removed after 6
months without
fear of relapse
Loss of
Elastic recoil of
the auricular cartilage
Technical error such
as improper suture
location or placement
Too few sutures,
resulting in excess
tension and subsequent
pull-through of the
sutures Inadequate
weakening of the
cartilage with
adjunctive techniques
Proper placement of
the suture through
the anterior perichondrium
Slight overcorrection
is advisable to account
for the expected loss
of correction
Pathologic scarring Patients at risk
are younger
or darkly
pigmented or
those with
either a
personal or
Pathologic scarring
occurs almost
exclusively in
Asians, Africans,
and Scandinavians
Particularly following
postauricular incision
Careful surveillance
for infection
Particularly following
postauricular incision
Hypesthesia Technical error Resolves spontaneously
over several months
During the winter
months patients
must cover their
ears when outside
for prolonged periods to
help avoid frostbite
Quite rare
Patients may be at
increased risk of
frostbite following
otoplasty because of
disruption in blood
supply and/or
transient sensory
Esthetic complications Telephone ear
Protruding superior
and inferior poles
Overcorrection in
the mid-third, such
as overzealous conchal
setback or excessive
skin removal in
the mid-portion
of the auricle under
correction of the
superior and inferior
Careful preoperative
planning and proper
intraoperative technique
Positioning the
patient during surgery
to be able
to evaluate the
ear from the frontal
telephone ear deformity
Protruding middle
Prominence in the mid-
third persists, and the
superior and inferior
poles are relatively
overcorrected under
correction of the
middle third occur in
the absence of conchal
setback sutures
when indicated
overutilization of
Mustarde-type sutures
Careful preoperative
planning and proper
intraoperative technique
Positioning the patient
during surgery to
be able to evaluate
the ear from the
frontal view
Vertical post-deformity Shows
Mustarde-type sutures
placed in a vertical,
rather than oblique,
Placement of sutures
along the natural
arc of the antihelix
Overcorrection and
hidden helix deformity
“stuck down” appearance
of the auricle
Excessive reduction of
cartilage in the concha
bowl is performed
excess flattening
if overcorrection
of the antihelix
is applied Helix that
sits medial to (and
hidden by) the antihelix
on frontal view
Can be circumvented
by initial placement
of conchal setback
sutures to avoid over
tightening the
antihelical sutures
creasing and puckering
Mustarde sutures that
are too closely
placed will cause
notches or creases
to form within the
antihelix, rather
than the desired gentle
curvature overly large
bites of more than
6 mm may cause puckering
within the scapha
Careful preoperative
planning and proper
When a considerable
degree of conchal
setback is attempted
without adequate
excision of postauricular
soft tissue
Careful preoperative
planning and proper
intraoperative technique
techniques tend to
destabilize the
auricular cartilage
Cutting techniques
should be confined to
finely feathered abrasions
or scoring of the
anterior antihelical
Interaural asymmetry Technical error Precise replication of
both the sites
for suture placement
Frequent reevaluation
and comparisons of
both ears throughout
the procedure
When prominauris
is present only
unilaterally, the
patient should be
advised of the
possibility of
achieving greater
balance if both ears
are operated on
despite the
relative normalcy
of the uninvolved

Table 4.

Complications in otoplastic surgery [62].


8. Forehead and brow lift

Although the nonendoscopic approaches (coronal or trichophytic) have been the standard, there has been a trend toward, and wider acceptance of, the endoscopic brow lift as a preferred method for surgical rejuvenation of the brow.

8.1. Trichophytic forehead and brow lift

8.1.1. Bleeding

Bleeding complications may occur with any approach. Avoidance of injury to the superficial temporal or zygomaticotemporal arteries, supraorbital or supratrochlear vascular bundles, and sentinel vein improves outcomes.

8.1.2. Nerve injury

The supratrochlear and supraorbital neurovascular bundles should be identified and preserved to minimize additional forehead hypoesthesia medially up to the vertex. Direct injury is uncommon; however, traction neuropraxia may occur secondary to suspension [63].

Temporally, dissection in a plane superficial to the superficial layer of the deep temporal fascia minimizes injury to the zygomaticotemporal and auriculotemporal branches of the second division of the trigeminal nerve and avoids temporal and lateral frontal paresthesias [64].

Additionally, in the temporal region, great care must be taken to avoid injury to the temporal branch of the facial nerve because this results in paralysis and asymmetry of the forehead.

8.1.3. Scarring and alopecia

This complication may be minimized in open approaches by making an irregular incision with an extreme bevel 4–5 mm posterior to the hairline in an area of consistent follicular density to avoid dermal appendages and allow for postoperative hair follicle growth through and around the forming scar [65].

8.1.4. Asymmetry

Brow asymmetry and over/under elevation: Postoperative brow asymmetries may cause poor patient satisfaction. Asymmetries must be documented preoperatively and discussed with patients. Postoperative asymmetry may be caused by unrecognized preoperative asymmetries or blepharoptosis with failure [66].

Overelevation or underelevation of the brow may occur with any approach to forehead rejuvenation [66].

Overresection of skin in any variation of the coronal lift or excessive suspension with any technique may result in overelevation of brow with possible lagophthalmos. This may resolve with time or uncommonly may be permanent and difficult to manage. Concomitant upper blepharoplasty can increase the risk. The forehead lift should always be done before eyelid surgery and overexcision of eyelid skin must be avoided. Lagophthalmos with symptoms of dryness or irritation should be treated with lubricating eye drops and ointments. Limiting postoperative lagophthalmos to <2 mm is advised to decrease the risk of DES [4].

8.2. Endoscopic brow lift

Despite noticeable advantages over coronal approach, like short incisions which limit scarring, direct endoscopic visualization, that enables a safer and more complete dissection in endoscopic brow lifting, there remain complications inherent to endoscopic brow lifting such as asymmetry, irregular facial expressions, lagaophthalmos, visible scars, alopecia, infection/abscess, bleeding and hematoma, temporary hypesthesia of forehead, permanent anesthesia of forehead, brow paresis, wound dehiscence, skin sloughs or perforations, eyelid ptosis, corneal abrasions, DES, relapse and contour irregularities.

When bleeding occurs, the superficial temporal and/or zygomaticotemporal vessels are often the source. A head wrap with Kerlix, placed for the first 24 h, helps eliminate dead space within the optical pockets. The risk of bleeding or infection is similar for all techniques (endoscopic, trichophytic or coronal approach).

Lagophthalmos must be considered a risk of brow lifting. Once complete release of the arcus marginalis has been achieved, considerable elevation of the upper eyelid will occur with brow elevation. Patients who have undergone a previous upper blepharoplasty are most at risk. The authors attempt to limit this risk by performing the brow lift procedure before performing the upper blepharoplasty.

The risk of alopecia is significantly less with the endoscopic technique than in the coronal approach brow lifting. However, hair follicle damage can occur at any of the 5 incision sites, resulting in transient or permanent alopecia. The risk of alopecia with trichophytic technique is extremely lower in comparison with other techniques.

There is inherent risk of temporary hypesthesia or even permanent anesthesia of the forehead. The authors think that the temporary hypesthesia commonly seen after an endoscopic brow lift is secondary to a traction neuropraxia of the supratrochlear and supraorbital neurovascular bundles that occurs during elevation and release of the arcus marginalis. Lastly, injury to the temporal branch should not occur during endoscopic brow lifting to avoid brow paresis. If paresis is noted in the immediate postoperative period, one must consider the possible temporary effect of local anesthetic. Sensation typically returns over the course of months, with improvements in sensation starting near the brow and extending toward the vertex, typically with full return of sensation by 12 months. Rarely, but occasionally, a patient may have some dysesthesia along the incision line or in the caudad scalp after sensation returns. It can be successfully treated with complete resolution through injection of the incision or with the use of supraorbital nerve blocks consisting of 0.5% marcaine with 1:200,000 epinephrines.

Postoperative brow asymmetry can result from failure to elevate either brow adequately by inadequate release of the orbital rim tissues.

We routinely place our patients in a standard facelift dressing for the first 2 postoperative days. The forehead component places pressure on the operative field, whereas the portion going around the head prevents displacement of the forehead dressing. The patient is instructed to keep the incision sites dry until sutures are removed on postoperative day 7.


9. Complications in skin resurfacing

Complication Risk factors Prevention and management
Erythema Sensitive and thin skin
Excessive sun damage
Icing, rigorous sun precautions
Masking with makeup
Treat with topical biafine (Valeant, Montreal, QC) and 590-nm LED photomodulation
Consider a mild topical corticosteroid
if condition persists
Blistering and burns High-energy/penetration lasers
Improper pulse stacking or
high-density passes
Insufficient cooling of the dermis
Loss of pain feedback with heavy
sedation or general anesthesia
Implement standard device safety and review of laser settings
Allow the dermis to cool between passes and after treatment
Burn care for severe thermal injuries
Infection (Figure 14) and herpetic
Closed facial dressing left >48 h
Insufficient facial hygiene/care
History of herpetic rash
Adherent to posttreatment facial care with topical disinfectant with hypochlorous acid 0.01% (NeutroPhase, NovaBay, Emeryville, CA) or acetic acid 0.25–0.0125% (vinegar solution)
Prophylactic antibiotic (cephalosporin), and a 1–2 weeks anti viral course (valacyclovir) started 24–48 h before treatment
Acne and milia Closed facial dressings
Oil-based creams
Daily facial rinses and noncomedogenic
moisturizer Course of oral tetracycline
for persistent acne Milia can benefit
from topical tretinoin, gentle
epidermabrasion, or extraction
Fitzpatrick skin type III–VI
Recent sun exposure/tanning
History of hyperpigmented
Careful skin type selection with
appropriate laser type setting
Sun precaution 2–4 weeks before
treatment and continued for 2–4 months
Prophylactic or therapeutic 2–4% hydroquinone,
2–4% kojic acid or Kligman formula
(5% hydroquinone, 0.1% tretinoin, and 0.1%
dexamethasone). This should be
started 2–4 weeks before treatment
and continued for 2–4 months
Scarring and hypertrophic healing Secondary to infections or burns
Poor healing capacity
History of keloid formation
The periorbital region, the neck,
and off-face areas
Scar-prone areas require lower fluence
and density Apply silicon gel dressing
to healing scars and hypertrophic bands
Intralesion corticosteroid or 5-fluorouracil

Table 5.

Summary of common laser complications and their management [67].

Resurfacing modality Complications
Phenol based peels Cardiac arrhythmias
Laryngeal edema and stridor
Baker-Gordon solution Prolonged erythema
Permanent hypopigmentation
Cardiac arrhythmias
Laryngeal edema and stridor
Medium-depth peels Scarring and permanent hypopigmentation (rare)
CO 2 lasers Scarring, permanent hypopigmentation (higher incidence in older lasers)
Infrared lasers Dermal blisters, heals with depressed scars
Microdermabrasion Streaks of hyperpigmentation
Visible light lasers and
broadband light sources
Epidermal blisters; may heal with scarring and permanent hypopigmentation
Monopolar capacitive radiofrequency Skin blisters
Permanent fat atrophy when delivered in very high energy
Plasma skin regeneration Burns, scarring
Fractional resurfacing Scarring
Recalcitrant hyperpigmentation
Photodynamic therapy Intra- and postoperative pain, burning sensation, edema

Table 6.

Resurfacing modality and complications.

Figure 14.

The crusting of a bacterial infection that developed after resurfacing [68].


10. Facial suction lipectomy and fat transfer

Complication How occurs How avoid How treat Note
Other complications Embolization:
blindness, stroke and skin/tissue necrosis
Permanent blindness
usually results by
tiny amount of the
filler slipping into
the retinal artery
which can precipitate
a central retinal
artery blockage It
is also possible to
force the column
back into the internal
carotid a rtery
and embolize into
any area supplied
by the internal
carotid area, and
this may result in
a stroke
-Do not use
Additionally, one
should limit
bolus size, limit
syringe size (only
1 mL syringe
to the face), and
avoid using
ratcheting guns
-The volume placed
with each pass of
the cannula should
also be limited.
Infiltration of
less than 0.1 mL
with each pass of
the cannula is
recommended in the
Use only 1 ml Luer-Lok
syringes for subcutaneous
infiltration into the face
Fat necrosis:
calcifications and oil cysts
Dead adipocytes
become oil droplets
and are first
surrounded by
infiltrated M1-
type (inflammatory)
for phagocytosis
At a later stage,
stratified layers
of M2-type (anti-
macrophages surround
the M1 macrophages
and form a fibrous
cyst wall
-Fat particles
with a more than
2–3 mm diameter
cannot been
grafted at 100%.
- Use smaller
injection syringes
such as 1 mL
syringe for the
face and 3 mL
syringe for the
not easy totreat
without surgical
resection. Another
option is to
partially cut the
cystic wall with
an 14–18G needle
and squeeze it,
leading to leakage
and phagocytosis
of oil or necrotic
assessment at
1 month after
lipoinjection is
Infection As the grafted fat is
not vascularized, it
can be a focus of
infection once
severely contaminated
by bacteria
Sterile technique
should be observedat
all times. Intraoperative
antibiotics are
recommended to use,
but perioperative
use of antibioticsis
not recommended
unless there is
a specific indication
In cases of delayed
infection, a high index of
suspicion should be
maintained for mycobacterialor
other unusual infections
Damage to underlying structures Even a blunt cannula,
when inserted for
removal and placement
of fat, can damage
underlying structures
Permanent injuries are extremely rare
Pneumonia Induced by damaging
the pleura with
an injection
Great care should be
taken to avoid when
introducing fat
into the bottom
layer close to the
It can be treated by
a conservative
treatment such as
waiting with careful
monitor of X-ray
and symptoms
Aesthetic problems and complications The presence of
irregularities, which
can be caused by the
intrinsic nature of
the patient’s body,
from the technique
used for placement,
and from migration
after placement, is
also noted
Irregularities after fat
grafting diminish
significantly as the
surgeon gains experience
with the technique
Swelling and downtime The placement of fatty
tissue may create
remarkable swelling
in the recipient
Elevation, cold therapy,
and external pressure
with elastic tape or
Tegaderm (3 M,
Maplewood, MN, USA)
help prevent swelling.
Certain medications
(Arnica montana and
bromelain) may also
speed recovery. The
patient is asked
to avoid heavy
pressure on the
grafted areas for
7–10 days to
avoid migration of
the grafted fat
A slight staining
of the skin,
possibly hemosiderin
deposits or
other pigment
changes, can
remain for
months in
some patients after
minimal fat
grafting to
the lower
Donor site problems Some patients simply
do not have adequate
donor sites, especially
if they have
previously undergone
Complications of the
donor sites are rare,
but irregularity of
the surface could
occur, particularly
when an excessive
volume liposuction is
performed in verythin

Table 7.

Complications of fat grafting.

Complication Cause Treatment Caution
Lumps (Figure 15) -May arise if too
large a bolus
of fat is placed
in a sensitive
region like the
lower eyelid.
-The fat may
have been placed
too superficially
so that it becomes
visible as a
contour deformity
Steroid injections
may be a reasonable
first step, these
lumps may need
to be excised to
achieve complete
If excision is
required in the
lower lid region,
the most discreet
placement for an
incision is in
the tear trough
at the junction
of the thin lower
lid skin and thicker
sebaceous cheek
Bulges -Arise from imprecise
placement of fat
along the
inferior orbital
rim, usually
from a lateral
entry point.
-Arise in the lateral
aspect of the malar
region and may
be caused by
-May develop when
the patient gains
excessive weight
-Readily responds to
injectable agents
that can reduce
the element of
scarring, such as
and dilute triamcinalone
acetonide. -Focused
to reduce the
bulk of fat
A bulge may develop
when the patient
gains excessive
weight. The best
way to mitigate
this problem is
through weight
Persistent malar mound edema (Figure 16) Generally occurs
only in patients
who have a visibly
defined malar mound
especially if
they have a history
of cyclical malar
mound edema
The condition may
resolve independently
over time, if it
persists, dilute
steroid (kenalog)
injections repeated
every 4–6
weeks as necessary
may hasten this
The most important
step in avoiding this
complication is to
identify the presence
of a malar mound
preoperatively and
determine whether
the patient has
a history of
cyclical swelling
Overcorrection Waiting a minimum
of 6 months before
intervention is
advisable to allow
for resolution of
edema or resorption
of fat over time.
If this fails,
then microliposuction
of the overcorrected
area may be required
Overcorrection is
best avoided through
a conservative fat
transfer. “Hitting
doubles” should
underscore every
fat-grafting endeavor
Undercorrection Pre-operative counsel
and description on
the likely chance
that a second fat
transfer procedure
will be needed to
obtain the ideal
The need for secondary
fat transfer is seen
more frequently in
patients requiring
large volume
augmentation, those
who smoke, and
those who are
extreme exercisers

Table 8.

Complications involving contour problems.

Figure 15.

(A) Patient before fat transfer to the inferior orbital rim and cheek. (B) At 6 months postoperatively, patient had a lump in the central inferior orbital rim and was also unhappy with the residual lateral fat pad. (C) Intraoperative photograph showing removal of the lump of transplanted fat that was causing the contour irregularity. This incision, at the junction of the lower lid and cheek skin, allowed for removal of redundant lower-lid skin. At the same setting, the lateral fat pad was reduced through a transconjunctival approach. (D) Postoperative photograph, after correction of the contour irregularity [69].

Figure 16.

The malar mound is a triangular-shaped elevation (large arrow), anatomically delineated by the orbital septal–periosteal adhesion superiorly and the malar septum inferiorly (small arrow) [70].

11. Filler injections

Although HA fillers have been touted to be safer and thus more widespread than the other filler types, all have been associated with adverse outcomes. These complications range from localized bruising, erythema, edema, migration, allergic response, the formation of small bumps underneath the skin, to more serious sequelae, such as permanent visual loss and nerve paralysis (Tables 58).

The importance of hyaluronidase is due to its value in treating a variety of the complications of facial fillers. Hyaluronidase has the ability to dissolve HA. Approximately 30 U of hyaluronidase are needed to dissolve 0.1 mL of HA. Restylane may resolve the fastest and Belotero the slowest relative to more cross-linking in the latter [71].

Chronic prolonged edema can also be related to a type 4 hypersensitivity reaction. If it is unresponsive to antihistamines, it may need to be dissolved with hyaluronidase (Figure 17). Angioedema is an immediate allergic response that can last for several weeks. It may respond to antihistamines or prednisone [72].

Bruising is a complication of any procedure that involves the use of a needle or cannula. There is debate as to whether or not one should stop anticoagulants for patients receiving fillers [74].

For patients at low risk for cardiac disease or cerebrovascular disease, discontinuation of aspirin, nonsteroidal anti-inflammatory drugs, or herbal supplements, such as vitamin E, fish oil, ginseng, and ginkgo, is generally suggested. If a patient is at risk of thrombotic disease, the anticoagulants may be continued and the patient must be made aware of the increased risk of bruising [72]. Some physicians believe that cannulas are safer and have less chance of causing bruising than needles [75].

Figure 17.

This patient was injected with hyaluronic acid filler for tear trough correction and the filler was injected too superficially (top image). The same patient is shown 24 h later (lower image) after injecting 70 units of hyaluronidase (diluted with local anesthetic) in each lower lid in the area of the filler excess [73].

Arnica montanais a herbal supplement that inhibits transcription factor nuclear factor-kB2 has been promoted for its ability to minimize bruising. Some dermatologists fear contact dermatitis from the topical form. Oral Arnica demonstrated no improvement with blepharoplasty and hand surgery [76, 77]; however, it did improve postoperative bruising associated with facelift procedures [78].

Patients can also suffer from vasovagal responses or seizures because of the stress of the injection procedure. Close supervision of the patient at all times is recommended. Asymmetry is always a consideration in filler injections (Figure 18).

Figure 18.

This patient exhibited asymmetry from under treatment of her left side. The marked area indicates where the touch up filler was needed [73].

11.1. Infection: biofilms

Proper topical preparation of the skin is inherently critical for prevention of infection. Topical alcohol 70% is inexpensive, readily available, and has quick onset. Topical chlorhexidine, available by swab or surgical scrub, is gaining popularity because it demonstrates a longer frame of action and tends to be nonirritating [79].

Immediate bacterial infections are thought to be caused by introduction of bacteria from the surface of the skin though the injection portal sites. Such infections can often be treated with broad-spectrum oral antibiotics, such as clarithromycin, because of its activity against atypical mycobacteria [80].

Makeup application should be delayed until 4 h after injection. Reactivation of a herpetic infection is also possible and can be treated with oral valcyclovir, 2–3 g/day.

Delayed infections caused by biofilms can be more difficult to treat. An inflamed nodule with a delayed presentation of 2 or more weeks can be caused by a biofilm.

They can contain bacteria, protozoa, or fungi in a low-grade infection that chronically seeds the local area and can even trigger a systemic infection [81]. Biofilms can be associated with foreign body granulomas (discussed in next section). Antibiotics should be started before any attempts to remove the granuloma with hyaluronidase (for HA); steroid, 40 mg/mL or fluorouracil (5-FU), 50 mg/mL injections; laser lysis; or surgical excision [72].

11.2. Granulomas

Granulomatous reactions are rare and can present months to years after an injection. Intralesional steroids and 5-FU are the therapeutic mainstay to inhibit fibroblast activity. If the nodules are associated with an abscess, the infectious component is often sterile. Granulomas may occur more commonly with long-lasting or permanent fillers, such as silicone, polyacrylamide, poly-(L)-lactic acid (PLLA), and Poly(methyl methacrylate) (PMMA) [72].

Granuloma can be localized or present as a global systemic response (Box 1). All can be treated with use of hyaluronidase and oral or intravenous steroids.

(Box 1) Presentation and management of common filler complications.

Nodules (early presentation)

  • HA: extrusion, hyaluronidase

  • Non-HA: intraregional steroids with lidocaine and or 5-FU, micro-focused ultrasound or fractional lasers, surgical excision

Inflammatory nodules

  • Biofilm: antibiotics (biaxin, ciprofloxacin, or clarithromycin) for 4–6 weeks.

  • 5-FU 50 me/mL, 0.1- to 0.5-mL injections

  • Consider biopsy and infectious consultation for atypical mycobacterium of fungus.

Foreign body granulomas

  • Localized; hyaluronidase if HA and intraregional steroids and/or 5-FU injections, then excision

  • Global: hyaluronidase if HA, test spot on arm, biopsy, intralesional, or intravenous systemic steroids

11.3. Vascular occlusion

It is one of the most devastating complications arising from facial filler injections. Arterial embolization is more commonly direct anterograde with occlusion of an artery causing ischemia distal to the injection point. This direct form of occlusion usually occurs with injections to the glabellar region [82].

Clinically, patients manifest with significant pain and ischemic pallor, eventually leading to necrosis and atrophic changes. Hot compresses, massage, hyaluronidase, aspirin, and possibly oral steroids should be immediately considered. A venous occlusion is also possible during cosmetic injections. Instead of immediate pain and blanching, this presents with venous mottling termed livido. Livido from venous occlusion should be distinguished from bruising. Patient can be treated with heat, massage, hyaluronidase, and prednisone (Box 2).

(Box 2) Vascular occlusive events: presentation, treatment, and prevention.


  • Presentation: livido, lack of significant pain

  • Treatment: heat, massage, oral prednisone, hyaluronidase if HA

  • Prevention: awareness of anatomy danger zones, consider injection with cannulas, aspiration before injection, slow retrograde injections, avoid bolus injections >0.1 mL



  • Presentation: Pain, blanching distal to site of injection

  • Treatment: heat, massage, aspirin, hyaluronidase, dase, oxyent infusion cream, hyperbaric oxygen

  • Prevention; awareness of anatomy danger zones, consider injection with cannulas, aspiration before injection, slow retrograde injections, avoid bolus injections >0.1 mL

Retrograde followed by anterograde

  • Presentation: dizziness, blindness, cerebrovascular accident, pain

  • Treatment: heat, massage, acetylsalicylic acid (aspirin), hyaluronidase, hyperbaric oxygen

  • Prevention: awareness of anatomy danger zones, consider injection with cannulas, aspiration before injection, slow retrograde injections, avoid bolus injections >0.1 mL

The literature has described devastating permanent visual loss from injections of steroids in the head and neck region for various benign lesions (i.e., chalazion, capillary hemangioma) [83, 84].

The substance must be injected against the systemic arterial pressure to fill the entire vessel retrograde past the bifurcation before it flows anterograde into the central retinal artery or its distal tributaries. Egbert and colleagues [85] approximated as little as 0.01 mL as the minimum required volume to cause vascular occlusion in the setting of intralesional corticosteroid injections to eyelid lesions. Numerous case reports describe this retrograde occlusive event clinically arising from filler injections in the nasal dorsum, nasolabial folds, and lips [8689].

When such a vascular event occurs, patients can immediately experience significant pain, skin blanching, loss of vision, and decreased extraocular motility. Rapid recognition of these symptoms can allow the injector to promptly manage the evolving vaso-occlusion with the following measures: applying pressure to the injection site in an effort to dislodge the embolus, injecting hyaluronidase (if an HA filler was used) to dissolve the filler particles, and applying nitroglycerin paste and topical oxygen therapy to allow for vasodilatation and spontaneous release of the occlusive bolus. Some sources, however, indicate that nitroglycerin paste may worsen the impending ischemia by propagating the filler substance into other portions of the arterial tree [90].

Additionally, fat is more likely to cause an embolus, whereas HA filler attracts water, which may prevent further particle migration. The method of injection also contributes to the overall result. Slower injection of smaller volumes generally <0.1 mL in any given location allows for more controlled filling. Injection by blunt cannula may minimize the risk of perforating a vessel and facilitates remodeling of facial ligaments with gentle manipulation of the cannula tip.

12. Botulinum toxin A (Botox) injections

Complications Cause Treatment Note
of Botox
Under treatment A past subclinical
botulinum infection
from food poisoning
that did not require
could cause an
immunity to botulinum
toxin type A.
Secondary to that,
some patients simply
do not respond to
any amount of the
Use of botulinum
toxin type B
It is important for
patients to realize
that some patients
are sensitive to Botox
and some are resistant
or immune
Overtreatment If the frontalis is
heavily treated (especially
the lateral areas) the
main brow elevator
is deactivated. When
this happens, patients
who usually lift
their lids no longer
can, making the brow
and lid feel heavy
and, because the
brow is not elevated,
the excess upper
lid skin is more
treat the lateral
frontalis conservatively
in older patients who
have dermatochalasis
and protect with
informed consent and
preinjection consultation
True eyelid
Eyelid opening is
controlled by the
levator palpebrae
superioris muscle,
which in turn
inserts into the
levator aponeurosis
of the upper eyelid.
If Botox is injected
(or more commonly
diffuses) into this
muscle, the eyelid
does not open
This complication can
be avoided by keeping
all injections at
least 1 cm above
the bony orbital
It’s recommended that
inject just beneath the
brow. This is acceptable
if patients have normal
positioned brows,
but in patients who
have ptotic brows, the
injection may be close
to the levator muscle
Asymmetry Injector placement
or patient anatomic
This is easily
corrected by placing
some additional Botox
at the active area
One of the most
common asymmetries
is the Spock eyebrow.
This is a demonic
curvature of the
lateral brow that
occurs when the
central frontalis is
deactivated but the
lateral frontalis is
active and only
lifts the brow
Bruising This occurs when
a vessel is disrupted
by the injection
Using a 32-gauge
needle and paying close
attention to the
superficial vasculature
can limit this
Screening patients
for aspirin or other
drugs that affect
platelet aggregation
also is important
in preventing
Perioral droop Can cause or contribute
to dysfunctional
animation of the
perioral region
Lower facial Botox
treatment should be
reserved for advanced
injectors and
conservative treatment
should be a
A patient who
presents to a
cosmetic office
to look better
but is left
drooling, lisping,
or with the
inability to
pucker will
not be happy
Unrealistic patient expectations Although not a
complication, an
unhappy patient
is a problem
discussion and
informed consent
should cover this

Table 9.

Complications of Botox treatment.

13. Facial implants in cosmetic surgery

13.1. Improper selection or placement

Generally speaking, improper placement of the implant is the most common complication followed by improper implant selection. The implant should be slightly smaller than the desired increase in fullness to take the contribution of the soft tissue into account. Appropriate implant selection is also important [38] (Table 9).

13.2. Neuropraxia

The malar neuropraxias had a slightly higher ratio of motor nerve injuries than sensory. Neuropraxia can be incurred from impingement by the implant because a size selection that is too large, migration, improper placement, a traction injury, a thermal injury, or a direct traumatic injury from dissection. Most patients regain sensation and function within 3 weeks. Anesthesia postimplant placement probably indicates the implant is resting on the nerve. Dissection for malar implants can also involve instrumentation around the facial nerve branches. Weakness of the zygomaticus, orbicularis oculi, or the frontalis muscles can be induced by the disturbance of the temporofrontal branch of the facial nerve while dissecting posteriorly over the middle third of the zygomatic arch.

During dissection of the chin for genial alloplast placement, it is important to avoid the mental nerve. The marginal mandibular branch of the facial nerve, which supplies muscles of the lower lip and chin, is above the periosteum over the inferior border of the mandible and is difficult to injure unless there is a severe traction injury or perforation of the periosteum.

13.3. Edema and ecchymosis

Typically the majority of postoperative edema and ecchymosis resolves in 2 weeks, but edema can persist for 6 months and even up to a year [91].

Implant fixation is important because excessive continuing movement can cause tissue injury, chronic inflammation, and suboptimal soft tissue acceptance with prolonged edema. This could also be due to a nonspecific immune reaction to the implant material.

13.4. Hematoma and seroma

Smaller hematomas (<5 cc) resolve without treatment in 10–14 days. Large hematomas need to be recognized and evacuated with the implant removed as necessary. Seromas usually present around 2 weeks after surgery. The presence of liquefied hematomas or seromas 2–4 weeks postoperatively may be drained percutaneously. Hematomas and seromas are best prevented with control of blood pressure during the procedure with general anesthesia and adequate local anesthesia, postoperatively with antihypertensive prophylaxis, and gentle handling of the tissues, maintaining a subperiosteal plane, and consideration for a drain in secondary procedures [92].

13.5. Infection

There are many different factors that determine whether an infection will be propagated after an implant is contaminated. Some of these factors include the bacterial load of contamination, host factors such as immune function, the method of contamination and age of the implant, and the perioperative prophylactic interventions by the surgeon to prevent infection. Implants can be contaminated by hematogenous, contiguous spread, or direct inoculation.

Implants decrease the amount of bacterial innoculum required to produce an infection. Foreign bodies have been shown to reduce the number of bacteria required to produce an infection by 104–106 power [93].

Zimerli found that decreased overall bactericidal activity was seen, including opsonization, bacterial ingestion, and intracellular killing of bacteria in neutrophils exposed to a foreign body [94].

Scalfani and colleagues studied the infection susceptibility of implants with different pore sizes. They found that the PTFE with an average pore size of 22 microns became infected at lower innoculum counts and sooner than polyethylene with a pore size of 150 microns. Most infections in the early postoperative time phase are more likely to occur with porous implants because of increased surface area, irregularity, and surface energy, which facilitates glycolax formation and bacterial adherence. Late infections are less likely to occur with porous implants because of incorporation of host tissue and improved immune response. Late infection associated with malar implants has been associated with dental injections as reported by Cohen and Kawamoto [23]. In Wilkinson’s retrospective review of 35 malar implant found that infections were associated with an old hematoma and subsequently cultured Staphylococcus aureaus [95].

Some authors hypothesize that exposure to saliva confers enough risk for development of infection that the intra-oral route should be avoided. In a study by Deva and colleagues, 422 patients had silastic nasal augmentation consisting of primarily columellar struts using an intraoral approach without prophylactic antibiotics and no postoperative infections occurred. Karras and Wolford [96] reported on 18 patients who had hard tissue replacement polymer (HTR) chin implants placed intra-orally with perioperative and postoperative antibiotics and reported no incidence of infection. These studies support the idea that patients with an intact immune system and healthy wound bed do not need additional antibiotics.

If salvage is selected in the setting of a purulent infection, the implant should be removed and scrubbed and/or sterilized to remove the biofilm. In addition, debridement and copious irrigation of the implant pocket, and finally, a prolonged postoperative antibiotic course are advocated. If rapid improvement does not occur and the implant needs to be removed, it should not be replaced for 6–8 weeks to allow for resolution of the infection and inflammation [97].

13.6. Migration and contour changes

There is a hypothesis that this is highly influenced by implant shape and method of fixation. Migration is usually the result of overdissection, selection of the wrong-sized implant, and lack of fixation. Supraperiosteal placement can also predispose the implant to mobility especially without adequate fixation (Figure 19).

13.7. Extrusion

Factors which are critical to preventing extrusion include adequate soft tissue bulk with quality tissue for coverage and insertion in the correct plane without tension. Decreased tissue perfusion decreases the potential for successful wound healing. Factors such as prior surgery and history of radiation will decrease the local vascular supply and result in fibrosis and stiffening of the tissues [98].

Excessive tension is usually the result of using too large an implant for too small a dissection. In addition to tensionless closure, subperiosteal placement helps to prevent exposure.

Some biomaterials can be treated symptomatically if exposure occurs without the need for removal. Frodel and Lee report secondary healing over polyethylene implant exposure and believe that if there is adequate vascularity, the implant will do well [98].

Other authors report intra-oral exposure of silastic implants that go on to cover secondarily with local wound care. Typically, however, if extrusion occurs, the implant must be removed and the site allowed to heal for multiple weeks before replacement.

Figure 19.

The top figure demonstrations a superiorly displaced chin implant corrected by repositioning and placement of a larger anatomic implant with screw fixation. The lower figure shows on inferiorly displaced chin implant beneath the jaw requiring removal and replacement using screw fixation [99].

13.8. Palpability

Even the most perfect augmentation will be a failure if the patient can feel the implant and does not like it. This can be the result of improper size selection or contour, improper positioning, improperly placed fixation, or capsular contracture. It is important to make sure the implants are intimately adapted before fixation. Patient factors such as a thin amount of overlying tissue also predispose to palpability. In malar augmentation, Whitaker recommends limiting the thickness of the implant to no >4–5 mm and tapering the ends thinly to avoid palpability [100].

13.9. Lip dysfunction

Altered lip function is primarily associated with malar implants. This problem occurs because dissection can interfere with the muscles responsible for smiling mimetics, more so than for mandibular augmentation. Other factors could include edema, interposition of a solid implant which stretches the muscles of the midface, or interference with the facial nerve during dissection over the zygomatic arch. The edema can cause dysfunction in the muscles of the upper lip resembling facial nerve dysfunction. When dysfunction is due to muscle displacement, it usually takes 1–3 months for the muscles to reattach and the capsule to become soft and distensible. In malar augmentation, upper lip weakness can be minimized by a small, vertical mucosal incision, and dissection parallel to and in between the zygomaticus major and minor.

13.10. Bone resorption

Bone erosion under alloplastic implants have occurred to a significant extent with early implants (Figure 20) [101].

The bone resorption was often attributed to foreign body giant cell reaction between the implant and the bone or to pressure from the mentalis muscle against the implant. Other factors that were considered were improper implant positioning, pressure due to an oversized implant, subperiosteal placement, and hardness of the implant. Significant resorption poses not only an obvious problem associated with the creation of a bony defect and potential damage to underlying structures like tooth roots, but it also leads to loss of chin projection. Bony erosion probably occurs less with anatomic extended implants because of greater distribution of the pressure forces over a broader anatomic area [102].

Figure 20.

Erosion of cheek implant into the maxillary sinus. Fortunately, this is a rare occurrence and most often a result of inadvertent entry during placement over a thin bony sinus wall [99].

13.11. Postoperative asymmetry

Asymmetry has many causes, but it is usually caused by initial malposition or by creation of asymmetric bilaterally dissected spaces. It can also be the result of unrecognized preoperative skeletal or soft tissue deficiencies. Although major asymmetries require a second surgery, minor asymmetries have a natural tendency to adjust and correct themselves over a 6-month postoperative period as healing progresses and the tissue around the implant relaxes and softens.


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Written By

Seied Omid Keyhan, Mohammad Ali Asayesh, Arash Khojasteh and M. Hosein Amirzade Iranaq

Submitted: July 30th, 2015 Reviewed: March 29th, 2016 Published: August 31st, 2016