Challenges and complications in secondary rhytidectomies, a systematic review

Abstract

Background

The demand for secondary rhytidectomies is increasing. These procedures are technically more demanding than primary surgery due to postsurgical anatomical changes, presenting unique challenges and risks. The objective of this systematic review is to define these challenges, describe common surgical principles, and summarize the reported outcomes and complications of secondary rhytidectomies.

Methods

A literature search was conducted on PubMed and Scopus using particular keywords. Inclusion criteria included randomized controlled trials, observational studies, comparative studies, case series and case reports that reported the surgical outcomes of secondary rhytidectomies.

Results

Fourteen articles were included in this systematic review, encompassing 737 patients. Presentation was approximately 9–12 years after primary surgery. The most consistent intraoperative finding was altered anatomy, including a thinner, more delicate superficial musculoaponeurotic system (SMAS), fibrosis, and scarred tissue planes. Reported complication rates in cohort studies ranged from 2.0 % to 21.1 %. The most common complications were hematoma and temporary facial nerve injury, with rates of the latter reaching as high as 11.9 % in some series. Other reported adverse events included seroma, minor skin slough, and delayed healing.

Conclusions

A secondary rhytidectomy presents distinct intraoperative challenges stemming from altered anatomy. Despite this increased complexity, the existing literature suggests that overall complication rates are comparable to those of primary facelifts.

Introduction

The demand for facial cosmetic surgery has grown significantly, partly driven by a cultural emphasis on maintaining a youthful appearance. This has led to an increasing number of patients seeking secondary facelifts.¹ The American Board of Plastic Surgery confirmed that the number of secondary rhytidectomies performed between 2015 and 2021 was four times higher than those performed between 2006 and 2014.² Although the terms “revision” and “secondary” are often used interchangeably to describe these procedures, a key distinction exists within the literature that this review will adhere to. A secondary rhytidectomy is a procedure that addresses the natural aging process occurring years after an initially successful and satisfactory primary facelift. The goal is to maintain a desirable outcome as age-related changes reappear.³ A revision rhytidectomy, in contrast, is performed to correct unsatisfactory results, complications, or deformities stemming from the primary surgery. The clinical significance of these procedures lies in their distinct goals. Revision facelifts are crucial for rectifying suboptimal outcomes, helping patients achieve their initially desired aesthetic, and restoring confidence. Secondary facelifts, on the other hand, allow patients to maintain their rejuvenated appearance as they continue to age naturally.

There are several factors contributing to this demand. The first is the growing elderly population that seeks to treat signs of old age such as fine lines, sagging skin, and decreased facial volume. There is also a parallel increase in awareness, interest and acceptance of facial rejuvenation procedures particularly at a younger age, making patients more prone to require further refinement of their initial facelifts.^1,4 Because of the continuous evolvement and advancement in surgical techniques, patients with poor previous surgical outcome, unbalanced facial harmony, or unnatural appearance seek another facelift to effectively treat and address these issues.5, 6, 7 Finally, the longevity of facial rejuvenation surgeries can be affected by several external factors such as patients’ lifestyle choices and habits as well as genetic and environmental factors.^3,8, 9, 10, 11

Compared to primary procedures, secondary rhytidectomies are associated with additional considerations and challenges. Primary manipulation of the facial skin and superficial musculoaponeurotic system (SMAS)/platysma muscle can lead to various secondary surgical complexities such as alterations in the skin’s soft tissue envelope, scar tissue formation, changes of facial nerve landmarks, and thinning or absence of the SMAS/platysma muscle.⁷ The literature highlights the critical role of deep tissue manipulation and volume restoration in secondary rhytidectomies, yet specific guidelines for reoperative procedures remain limited.12, 13, 14, 15, 16 Given the increased technical complexity of secondary rhytidectomies compared to primary facelift surgery, this systematic review aims to identify the associated complications and their risk factors to enhance surgical planning and improve outcomes in secondary procedures.

Methods

Literature search

A comprehensive literature search was run on PubMed and Scopus for all articles ever published until February 2024. The search strategy included the following terms: “secondary OR revisional OR reoperative OR multiple”, “rhytidectomy OR rhytidoplasty OR facelift”, and “complication”. A reference search was conducted to identify additional relevant studies.

Selection criteria

Randomized controlled trials, observational studies, comparative studies, case series and case reports written in the English language were included. Book chapters and articles in other languages were excluded. In addition, articles that do not mention complications of secondary facelift surgeries were excluded as well. Articles were cross referenced to include relevant works.

Data collection

Duplicates were removed and the remaining publications were imported into Rayyan.¹⁷ A first selection screening process was conducted based on title and abstract and a second one was conducted after reading all articles entirely. Two reviewers (C.S. and R.I.) conducted the selection procedures with a third reviewer (J.P.J.) resolving conflicts.

Outcomes

The primary outcome of this systematic review is determining the complications of secondary rhytidectomies and their risk factors. The secondary outcomes involve risk factors that lead to complications in secondary rhytidectomies.

Results

Study selection and characteristics

The initial literature search yielded 272 articles, of which 27 were selected for full-text review based on title and abstract screening. After applying the inclusion and exclusion criteria, a final selection of 14 articles was included in this systematic review.3, 4, 5, 6^,11,18, 19, 20, 21, 22, 23, 24, 25, 30 The selection process is detailed in the PRISMA flow diagram (Figure 1). These were comprised of primary research studies (retrospective cohorts, case series, and one prospective study) and represented a collective of 737 patients who underwent secondary or higher-order rhytidectomy. The characteristics of these primary studies are detailed in Table 1.

Figure 1.

Preferred reporting items for systematic review and meta-analysis protocols (PRISMA) flow diagram.

Table 1.

Study characteristics and patient timelines. This table provides an overview of the included studies’ design, patient cohorts, and key timelines.

First author & year	Study type	Sample	Avg. age at secondary surgery (years)	Avg. interval between procedures (years)	Level of evidence
Kamer, 1979	Retrospective Review	56 secondary (out of 258 total patients)	Not specified	Not specified (part of a “two-stage” concept)	IV
Cardoso de Castro, 1992	Retrospective Cohort	21 total (19 secondary, 2 tertiary)	56.4	9.8	IV
Ivy, 1996	Prospective Randomized Study	2 secondary (out of 21 total patients)	59 (mean for entire cohort)	Not specified	II
Guyuron, 1997	Retrospective Review with Questionnaires	55 secondary	59.9	8.5	IV
Ramirez, 1997	Case Series	23 total (19 secondary, 4 tertiary)	Not specified	Not specified	IV
Matarasso, 2002	Retrospective Comparative Review	101 total (97 secondary, 4 tertiary)	60 (mean for entire cohort)	Not specified	IV
Sundine, 2010	Retrospective Cohort	42 secondary	61.9	11.9	IV
Funk, 2011	Retrospective Comparative Review	21 total (18 secondary, 3 tertiary or higher)	62.6	9.5	IV
Basile, 2012	Retrospective Case Series	142 secondary (out of 626 total patients)	59.7 (mean for entire cohort)	Not specified	IV
Rawlani, 2012	Retrospective Cohort	47 secondary (out of 742 total)	Not specified	“Early” (within 2 years)	IV
Beale, 2013	Retrospective Case Series	60 secondary (10 tertiary)	60.5 (secondary), 65.3 (tertiary)	9.0 (primary to secondary), 7.5 (secondary to tertiary)	IV
Swanson, 2020	Retrospective Cohort	16 secondary (out of 225 total)	Not specified (secondary subgroup)	3.5 (for persistent jowls)	IV
Shauly, 2021	Retrospective Review	81 secondary (out of 241 total)	60.7 (mean for entire cohort)	Not specified	III
Chang, 2022	Retrospective Case Series	70 total (54 secondary, 12 tertiary, 4 quaternary)	64.1	9.6	IV

Patient demographics and timelines

The average age of patients undergoing a secondary rhytidectomy was consistently reported to be in the early 60s, ranging from 56.4 to 64.1 years. The interval between the primary and secondary procedure was also consistent across studies, with an average of approximately 9 to 12 years. In a large cohort of 42 patients who had both procedures performed by the same surgeon, the average interval was 11.9 years.³ One study analyzing reoperations for persistent jowls reported a shorter average interval of 3.5 years.²⁴ Another study specifically analyzed the reasons for early reoperation (within 5 years), attributing it primarily to a rapid loss of skin elasticity due to factors like sun damage or medical conditions.

Surgical techniques and intraoperative findings

All primary research studies that detailed surgical technique described some form of SMAS manipulation during the secondary procedure, with SMAS flaps, SMASectomy, or plication being the most common approaches (Table 2). The consistent intraoperative finding reported by multiple authors was that the anatomy was altered from the primary surgery. Specifically, the SMAS layer was frequently found to be thinner and more delicate in secondary cases.²⁰ Chang et al., in a detailed analysis of 70 reoperative cases, found anatomical changes in the SMAS-platysma complex in 82.9 % of patients, including increased fibrosis, altered thickness (both thinner and thicker), and sub-SMAS adhesion.¹⁹ Multiple authors also noted that the amount of skin resected during a secondary rhytidectomy is significantly less than in a primary procedure.^20,21

Table 2.

Surgical techniques & intraoperative findings in primary research studies.

First author & year	Secondary surgical technique(s) used	Key intraoperative anatomical findings
Cardoso de Castro, 1992	SMAS treatment (47.3 %), platysma treatment (68.4 %)	Skin undermining was “less bloody” and the retroauricular skin was thinner.
Guyuron, 1997	SMAS elevation (20 %), platysmorrhaphy (33 %)	The amount of excess skin removed is significantly less.
Ramirez, 1997	Endoscopic periosteal midface dissection in an unoperated plane	Subperiosteal plane is unviolated by prior surgery
Sundine, 2010	SMAS flap elevated (90.5 %), SMAS plication (7.1 %)	A secondary SMAS flap was able to be elevated in the vast majority of cases.
Funk, 2011	Primarily deep-plane rhytidectomy (90.5 %)	The SMAS was found to be significantly thinner and more delicate.
Basile, 2012	Triple-anchoring sub-SMAS face-lift with tunnel dissection	Not specified
Rawlani, 2012	Full undermining in the same sub-SMAS plane as the primary procedure.	Not specified
Beale, 2013	“The Five Rs”: Resect, Release, Refill, Reshape, Redrape.	Amount of skin resected is less.
Swanson, 2020	Re-elevation of sub-SMAS flap with corset platysmaplasty.	Not specified
Shauly, 2021a	Primarily SMASectomy (78.4 % of total cohort).	Not specified for secondary subgroup.
Chang, 2022	Sub-SMAS techniques (lamellar and composite)	Anatomical changes in the SMAS-platysma were found in 82.9 % of cases.

^aData for the total cohort of 241 patients, of which 81 were secondary facelifts; technique-specific findings were not stratified for the secondary facelift subgroup.

Complications and outcomes

The overall complication rates reported in the primary research studies varied, ranging from 2.0 % to 21.1 % (Table 3). The most frequently reported complications were temporary facial nerve injury and hematoma. The rate of temporary neuropraxia ranged from 0 % to 11.9 %. Hematoma rates ranged from 0 % to 12.7 %. Other less common complications included minor skin slough, necrosis, seroma, and infection. The rate of subsequent revision or re-operation to improve the outcome of the secondary facelift ranged from 0 % to 21.4 %.^3,20 Patient satisfaction, when reported, was generally higher for a secondary facelift (4.49/5) than for their primary procedure (3.97/5).²¹

Table 3.

Complications and revisions. This table provides a detailed breakdown of the adverse events and reoperation rates reported in the studies.

First author & year	Total complication rate (%)	Hematoma (%)	Nerve injury (%)	Skin complications (%)	Other (%)	Re-operation/Revision rate (%)
Cardoso de Castro, 1992	21.1 % (4/19)	10.5 % (1 major, 1 minor)	5.3 % (1 case)	0 %	5.3 % (1 seroma)	Not specified
Ivy, 1996a	9.5 % (total cohort)	0 %	9.5 % (2 temporary buccal)	9.5 % (2 necrosis)	4.8 % (1 edema)	4.8 % (1 patient)
Guyuron, 1997	18.2 % (10/55)	12.7 % (7 cases)	Not specified	Not specified	Not specified	Not specified
Ramirez, 1997	Not specified	Not specified	4.3% (1 buccal branch)	Not specified	4.3% (1 port site infection)	Not specified
Matarasso, 2002	2.0 % (2/101)	1.0 % (1 case)	1.0 % (1 temporary motor)	0 %	1.0 % (1 DVT/PE)	Not specified
Sundine, 2010	11.9 % (5/42)	0 %	11.9 % (5 temporary)	0 %	0 %	21.4 % (9 patients)
Funk, 2011	9.5 % (2/21)	4.8 % (1 case)	0 %	4.8 % (1 hypertrophic scar)	0 %	0 %
Basile, 2012b	3.4 % (total cohort)	1.3 % (8 cases)	1.4 % (9 temporary)	0.3 % (2 necrosis)	0.3 % (2 infections)	Not specified
Rawlani, 2012	0 %	0 %	0 %	0 %	0 %	0 %
Beale, 2013	5.0 % (3/60)	0 %	1.7 % (1 temp. marginal)	1.7 % (1 skin slough)	1.7 % (1 seroma)	5.0 % (3 patients)
Swanson, 2020c	7.6 % (total cohort)	Not specified	7.6 % (all temporary, usually frontal)	Not specified	0.9 % DVT	7.1 % (16 patients)
Shauly, 2021c	13.0 % (total cohort)	5.80 %	0 %	Not specified	1.7 % seroma, 2.5 % infection	15.80 %
Chang, 2022	9.9 % (7/70)	0 %	7.1 % (5 temporary)	1.4 % (1 delayed healing)	1.4 % (1 seroma)	11.4 % (8 patients)

^aData for the total cohort of 21 patients, of which only 2 were secondary facelifts.

^bData for the total cohort of 626 patients, of which 142 were secondary facelifts; complication rates were not stratified.

^cData for the total cohort of 241 patients, of which 81 were secondary facelifts; complication outcomes were not stratified for the secondary facelift subgroup.

Discussion

This systematic review provides a comprehensive overview of the secondary rhytidectomy, confirming it is a safe and effective procedure. The findings reveal a predictable timeline for reoperation, significant anatomical challenges that have driven an evolution in surgical technique, and a safety profile comparable to primary surgery.

A key finding of this review is the consistent timeline for reoperation. Across multiple studies, a successful primary SMAS facelift appears to have a durable result, with patients returning for a secondary procedure after an average of 9 to 12 years to address the natural, ongoing aging process.^3,4,6,19,21 This suggests a predictable longevity rather than a failure of the initial operation. This planned secondary procedure must be contrasted with the concept of “early relapse” which is relatively an ill-defined and under-reported adverse outcome occurring within a couple years of surgery. A meta-analysis found a 2.4 % rate of early relapse-related outcomes,²⁶ highlighting that the low reoperative rates reported in our findings may not fully capture the incidence of all suboptimal early results.

Patients presenting for a secondary facelift introduce a distinct set of challenges. They are, on average, older and medically more complex, with a higher prevalence of comorbidities and medication use.^1,3, 4, 5^,21,27 Interestingly, while comorbid conditions increase with age, complications did not directly correlate with age itself.^5,20 The timing of reoperation is also of significant value. A study was unable to draw a definitive conclusion on whether younger age at the initial surgery was protective, but they anecdotally noted that procedures performed before age 50 tended to last longer, hypothesizing this was due to better initial skin and SMAS quality.⁴ Extrinsic factors significantly influence this timeline; poor skin elasticity from sun damage or genetics can necessitate an earlier revision, while lifestyle choices, particularly smoking, pose a major risk.^2,3,28

Surgically, the reoperative patient presents with altered anatomy. The most frequently reported intraoperative finding is a change in the quality of the SMAS, which is often described as significantly thinner and more delicate.²⁰ Chang et al. (2022) found anatomical changes in the SMAS-platysma complex in 82.9 % of reoperative cases, including increased fibrosis and sub-SMAS adhesions.¹⁹ These changes make dissection more difficult and increase the theoretical risk to the facial nerve, although some surgeons report an easier dissection due to the “delay phenomenon” improving flap vascularity.¹

In response to these challenges, surgical techniques have evolved significantly. There is a clear consensus that secondary facelifts are not simply skin-tightening procedures; significantly less skin is resected compared to primary cases.^20,21 The modern approach focuses on the deep foundational structures to correct specific deformities such as lateral sweeps, pixie ears, and cobra neck deformities.¹ The centrality of the SMAS is undisputed, forming the foundation of the lift. A significant paradigm shift has been the increased focus on volume enhancement to correct soft tissue deflation with techniques such as autologous fat grafting enhancing facial contour, reducing reliance on skin excision.12, 13, 14, 15, 16

Despite the increased technical complexity, this review finds that secondary rhytidectomy can be performed with a high degree of safety, as multiple studies conclude that overall complication rates are not significantly different from those of primary procedures.3, 4, 5 The most frequently encountered surgical complication is hematoma, with rates for major hematomas requiring surgical intervention ranging from 3.6 % to 10.5 %.^6,21 The most significant functional complication is facial nerve injury, mostly a marginal mandibular nerve branch paresis. While a major concern for surgeons due to altered landmarks,⁷ the rates of permanent nerve injury are exceedingly low. The rates of temporary nerve injury in this review ranged widely from 0 % to 11.9 % across studies, with no consistent pattern to suggest a definitively higher risk than in primary surgery.^3,4,11,27 Other complications include surgical site infections, seromas, delayed healing, skin slough, edema, and transient alopecia.^{4,6,19,25,29,30}

Limitations

This systematic review is constrained by several limitations inherent to the available literature and study design. First, the included studies are predominantly retrospective case series (Level IV evidence), which are susceptible to selection bias, incomplete reporting, and variability in surgical techniques and outcome definitions. The absence of prospective or multicenter studies limits the generalizability of complication rates and hinders robust comparisons with primary rhytidectomies. Second, key outcomes, such as early relapse, are under-reported, with only 4.4 % of facelift studies addressing this phenomenon.²⁶ The lack of a standardized definition for “early relapse” further complicates cross-study comparisons and may underestimate its incidence in secondary procedures. Finally, variability in surgeon expertise, patient demographics, and follow-up durations across studies may confound complication rates and risk factor analyses. These limitations underscore the need for prospective, standardized studies to enhance the evidence base for secondary and revisional rhytidectomies.

In conclusion, secondary facelift procedures are increasingly popular and can be performed safely and effectively, with complication rates comparable to primary surgery. The procedure is technically demanding due to the altered anatomy from the primary operation, particularly a thinner SMAS. Success hinges on a surgeon’s ability to navigate this complex anatomy with a modern, individualized approach that prioritizes stable deep tissue support through SMAS manipulation and restores a youthful contour through volumetric reshaping.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

None of the authors received any funds or has any financial interests to disclose for the research, authorship, and publication of this article.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Presentation

This article has not been presented in a national or international meeting.

The contributions of all authors

Conceptualization: C.S.; Data curation: C.S. & R.I.; Formal Analysis: R.I., J.P.J. & I.H.; Funding acquisition: None; Investigation: all authors; Methodology: C.S.; Project administration: all authors; Supervision: N.E.; Validation: all authors; Visualization: all authors; Writing – original draft: all authors; Writing – review & editing: all authors.