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Original Article |

Hematoma Rates in Drainless Deep-Plane Face-lift Surgery With and Without the Use of Fibrin Glue FREE

Richard Zoumalan, MD; Samieh S. Rizk, MD
[+] Author Affiliations

Author Affiliations: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Lenox Hill–Manhattan Eye, Ear, and Throat Hospital (Drs Zoumalan and Rizk), and Department of Otolaryngology–Head and Neck Surgery, New York University School of Medicine (Dr Zoumalan), New York, New York.


Arch Facial Plast Surg. 2008;10(2):103-107. doi:10.1001/archfaci.10.2.103.
Text Size: A A A
Published online

Objective  To determine the rate of hematoma formation in drainless deep-plane rhytidectomy and compare it with the rate using the same technique with the use of fibrin glue.

Methods  This is a retrospective review of 605 patients (78 male and 527 female) who, over a 6-year period, underwent deep-plane face-lift surgery (n = 544) or lateral superficial musculoaponeurotic system (SMAS)ectomy (n = 61) by the senior author (S.S.R.) without the use of surgical drains. One hundred forty-six consecutive patients underwent rhytidectomy without fibrin tissue glue, and the following 459 consecutive patients were sprayed with fibrin glue under the flap prior to flap closure. Pressure dressings were used on all patients for 24 hours.

Results  None of the patients in either group had major or expanding hematomas requiring operative intervention. In the group of patients treated without fibrin glue (n = 146), there were 5 minor, nonexpanding hematomas, all managed by needle aspiration. This is a minor hematoma rate of 3.4%. In the fibrin glue group (n = 459), there were 2 hematomas, for a rate of 0.4%. Using a Fisher exact test, we found a statistically significant decrease in the hematoma rate from 3.4% to 0.4% (P = .01). Male patients had a higher hematoma rate than female patients, and only men had significantly fewer hematomas when fibrin glue was applied (P = .01). All 7 hematomas were recognized in the first 24 hours after surgery. Of the 7 patients with hematomas, 2 (29%) had emesis in the recovery room despite medication.

Conclusions  The use of fibrin glue demonstrates a significant decrease in the rate of hematoma formation. Fibrin glue may benefit male more than female patients. If meticulous hemostasis and pressure dressings are used, drains are not necessary. The prevention and prompt treatment of postoperative nausea may also help prevent hematoma formation.

Hematoma formation remains the most common major complication after face-lift surgery. Hematomas can lead to tissue ischemia, prolonged facial edema, hyperpigmentation, reoperation, and patient dissatisfaction. The incidence of hematoma ranges from 0.2% to 8.1%. Existing literature that documents the rate of hematoma formation after face-lift surgery includes the use of drains in the surgical site.129 Drains can malfunction, introduce infection into the wound, leak, become misplaced, and entail extra incision and scarring. They create tracts at the site of removal, necessitate painful extraction, and risk injury to vessels on removal. Increased nursing is required for drains. In the past, the use of drains was routinely advised. Surgeons have recently been omitting the use of drains in face-lift surgery.

The use of fibrin glue may help eliminate the necessity of surgical drains after face-lift procedures. By closing and sealing the dead space, fibrin glue has been shown to decrease postoperative drain output, hematoma rates, and ecchymosis. Marchac and Sandor27 had demonstrated a statistically significant decrease in the rate of major hematoma formation, ecchymosis, and edema when fibrin glue was used. The control group in their study had drains inserted. Kamer and Nguyen30 had decreased hematoma and seroma rates with the use of fibrin glue, but this did not reach statistical significance. In their study, the non–fibrin glue group also had drains inserted. The studies by Marchac and Sandor,27 Kamer and Nguyen,30 and Marchac and Greensmith31 demonstrated relative safety in the omission of drains if fibrin sealant is used. Oliver et al32 performed a prospective, randomized, double-blind trial to demonstrate a decrease in surgical drain output on the side of the face that was treated with fibrin glue. The sides of the face that were treated with fibrin glue had a median drainage of 10 mL, and the control side had a median output of 30 mL.32 Fezza et al33 had similar results with the use of fibrin glue.

Since 1915, fibrin sealant has been used in a variety of medical applications. Fibrin sealant is a nontoxic, physiologic hemostatic agent partially derived from human plasma. It consists of human fibrinogen, human thrombin, and bovine aprotinin. These ingredients stimulate the natural process of healing by simulating clot formation at the final phase of coagulation.34,35 This creates a fibrin matrix with structured strands that are more effectively cross-linked by factor XIIIa, which forms a stronger clot. After the clot is formed, the bovine apoprotinin component, which is an antifibrinolytic agent, reduces the rate of clot lysis by exogenous plasmin. The fibrin network is thought to reduce the amount of postoperative bleeding by sealing capillary vessels and adhering raw surfaces to each other. The glue is not indicated for stopping heavy arterial bleeding.36 With an improved purification method, it has also had an improved safety profile against viral and bacterial contamination.37,38

Previous studies included the use of surgical drains in the control group, which may have confounded the results. To our knowledge, this is the first study on deep-plane rhytidectomy that compares the drainless fibrin glue closure with a drainless control group.

This is an institutional review board–approved retrospective review of 605 patients who underwent deep-plane face-lift surgery or a lateral superficial musculoaponeurotic system (SMAS) ectomy by the senior author (S.S.R.) from January 2001 to January 2007. Group 1 comprised 146 consecutive patients who underwent face-lift surgery without fibrin tissue glue. The following group of patients, group 2, comprised the following 459 consecutive patients who were sprayed with fibrin glue under the flap prior to flap closure. All 605 face-lift procedures were performed without the use of drains. There were no exclusion criteria for the patients. Male and female patients were both included in the study. Smokers and patients who had received previous face-lift surgery were not excluded.

All the procedures were performed by the senior surgeon (S.S.R.). Patients in the review underwent either a formal deep-plane composite flap consisting of skin, SMAS, and malar fat pad undermining and elevation, or a lateral SMASectomy. For those undergoing a formal deep-plane composite flap, the deep plane was dissected anteriorly and inferiorly to the marionette lines and jowl areas. Superiorly, the dissection was made over the zygomatic muscles to the nasolabial folds. The deep-plane ledge was then pulled and attached in a posterior-superior direction. For patients undergoing lateral SMASectomy, subcutaneous elevation was performed toward a point midway between the zygomatic arch and nasolabial folds. A lateral strip of SMAS was removed from an imaginary line parallel to the nasolabial fold from the ear lobule superiorly toward the zygoma. The neck was addressed similarly in all patients by lifting the posterior border of the platysma and attaching it with horizontal mattress sutures to the mastoid periosteum. After multiple checks of hemostasis and skin tailoring, closure was performed. In group 2, before final closure of the incision, Tisseel Fibrin Glue (Baxter Healthcare Corp, Deerfield, Illinois) was sprayed on the raw dissected surfaces through the sideburn, preauricular, and postlobule incisions. After the Tisseel glue was sprayed, gentle external pressure was applied to the flaps with moist gauze for 3 minutes while avoiding shearing. Three layers of gauze were applied, and a surginet dressing was placed. Pressure dressings were maintained on all patients for 24 hours. For each patient, the purchase cost of Tisseel from Baxter Healthcare Corp was $210.

The patients' records were examined for major hematomas (an expanding collection containing ≥20 mL of blood) and minor hematomas (containing <20 mL of blood). Of those patients who had hematomas, the location of the hematoma was recorded. The medical charts were also examined for the timing of hematoma formation and any postoperative events such as emesis.

There were 78 male and 527 female patients in this review. The patient and surgical characteristics between the 2 groups are given in Table 1. Groups 1 and 2 had similar age ranges and mean ages and had a similar distribution of men and women. A total of 544 patients underwent deep-plane face-lift surgery, and the other 61 patients, lateral SMASectomy. Submentoplasty was performed in 145 patients (24%). There were 188 cases of revision face-lift procedures. There is a noticeable difference in the percentage of revision cases between the 2 groups owing to the gradually increased referrals of revision face-lift surgery to the senior surgeon during this period.

Table Graphic Jump LocationTable 1. Patient and Surgical Characteristics

The incidence of major and minor hematomas is given in Table 2. There were no major hematomas in any of the patients in either group. In group 1, 5 of the 146 patients experienced a unilateral minor hematoma (<20 mL, nonexpanding). In group 2, 2 of 459 patients experienced a unilateral minor hematoma. These were all managed by aspiration with a large-bore needle. Using a Fisher exact test, we found a significant decrease in the hematoma rate from 3.4% to 0.4% (P = .01). In group 1, 4 of 5 minor hematomas were in male patients. In group 2, 1 of 2 minor hematomas was in a male patient. Among the male patients, there was a statistically significant difference in hematoma rates between groups 1 and 2 (P = .01) (Table 2). Among female patients, there was no significant difference between hematoma rates (P = .43). There was an even distribution of the minor hematomas between the preauricular (group 1, n = 2; group 2, n = 1) and postauricular (group 1, n = 3; group 2, n = 1) regions. All hematoma cases occurred in patients without prior face-lift surgery. When nonrevision cases were evaluated independently, a statistically significant difference in hematoma rates was found between the 2 groups (P = .02).

Table Graphic Jump LocationTable 2. Incidence of Hematomas and Distribution of Hematomas Between Sexes

All 7 hematomas were recognized in the first 24 hours after surgery. Of the 7 patients with hematomas, 2 (29%) had emesis in the recovery room despite medication. One patient was in group 1, and the other was in group 2.

The use of fibrin glue demonstrates a significant decrease in the rate of minor hematoma formation. Hematoma rates of 3.4% (without fibrin glue) and 0.4% (with fibrin glue) in patients in whom surgical drains were not used fall within the major hematoma rate of 0.2% to 8.1% observed in patients in whom drains were used.129 In their study, Marchac and Sandor27 had a major hematoma rate of 9% in patients treated without fibrin glue and with the placement of surgical drains. They also had a 2% incidence of major hematomas in patients treated with fibrin glue and without the placement of surgical drains. Their incidence of minor hematomas was 8% to 9% in both groups, which did not achieve a statistically significant difference. The patients who received fibrin glue did not have pressure dressings applied, whereas all patients in our study did have pressure dressings.27 Major hematomas did not occur in our study, and the incidence of minor hematomas (3.4%) was not only less but also demonstrated a significantly decreased hematoma rate with the use of fibrin glue (0.4%). This suggests that fibrin glue can decrease the formation of minor hematomas. When combined with pressure dressings, fibrin glue traps and limits the spread of bleeding and creation of pockets. Previous studies have also shown a decrease in ecchymosis and edema.31,33 Fezza et al33 demonstrated that patients not only had a statistically significant decrease in bruising but also had a faster recovery and were able to return to normal functioning earlier than the control group. Tisseel glue is not significantly different from any other fibrin sealant. The different fibrin glue products vary in methods of production but rely on the same physiologic process.

As expected, there was a higher hematoma rate in male patients. The male patients who received fibrin glue had a significantly decreased hematoma rate. The female hematoma rate was not significantly changed. Fibrin glue may benefit male patients more than female patients. However, there may have not been enough hematomas in female patients to demonstrate a significant difference for women who received fibrin glue.

In previous studies, the groups that did not receive fibrin glue had drains.27,3033 To our knowledge, this is the first study that compares 2 groups in which fibrin glue was and was not used. A strength of the study is its isolation of fibrin glue as the major variable factor in the operation. This study also has a larger sample size when compared with previous studies. A weakness of the study is that the time when group 2 underwent surgery occurred after the time when group 1 underwent surgery. The learning curve of the senior surgeon may have been a confounding factor. However, the senior surgeon did not make any changes in instruments used, suture material, bipolar cautery settings, pressure dressings, nor the general approach to surgery. The only significant factor that changed was the addition of fibrin glue. This does not discount the fact that there were no major hematomas in group 1 and that there was a minor hematoma rate in the non–fibrin glue group, which fell to the rate seen for major hematomas.

The lack of major hematomas and low rate of minor hematomas is aided by meticulous hemostasis and careful placement of pressure dressings. Fibrin glue is not a replacement for meticulous hemostasis. The results of this study support the literature demonstrating that surgical drains are not necessary. In a previous review of the use of tissue glue without drains, the authors experienced small fluid collections requiring aspiration but no major hematomas.39,40 Perkins et al41 did not find a significant difference in hematoma rates in 222 patients who underwent face-lift surgery with or without the placement of drains. Another retrospective study also found that drainage alone does not reduce the incidence of postoperative hematomas.42 A recent prospective randomized controlled trial found no difference in postoperative hematoma rates when drains were omitted but did find increased bruising in the group treated without drains.43 This difference in ecchymosis was contrary to 2 previous studies.31,33 Drain placement is undesirable for both the surgeon and the patient. For the patient, it is unsightly and may necessitate an extra incision and cause more pain. Drains often malfunction by plugging, leaking, and slipping out. Drains are also a known source of infection. However, many surgeons are uncomfortable with the omission of drains. They seek an extra source of protection against hematoma formation. Fibrin glue can give this added protection.

Pressure dressings remained on the patients for 24 hours. This may have helped prevent the formation of major hematomas and decrease the rate of minor hematomas. All hematomas developed in the first 24 hours, which indicates that this is the time of greatest risk. Pressure dressings were eliminated in previous studies that included the use of fibrin glue, which had higher rates of both minor and major hematomas.27,31 Pressure dressings may be uncomfortable for the patient, but this is an added level of security against hematoma formation.

While fibrin glue is used in a variety of medical procedures, face-lift surgery is an elective procedure, and use of a material derived from blood products has theoretical risks. These include the transmission of human immunodeficiency virus, hepatitis B and C virus, and human T-cell leukemia/lymphoma virus. However, a large study on infection of recipients of 20 000 U of blood revealed zero disease transmissions.44 Autologous fibrin glue can be used, but it is expensive and its production requires time and trained personnel. Cost- and time-effective methods of preparing fibrin glue material from autologous blood are being developed.

Postoperative emesis occurred in 2 of the 7 patients with minor hematoma formation. Whether the emesis led to the formation of these hematomas is unclear, but increased venous pressure is a factor in the development of hematomas. Adequate prevention and treatment of postoperative nausea should be a significant consideration in all operations, especially in those that can compromise a flap.

In conclusion, the use of fibrin glue demonstrates a significant decrease in the rate of hematoma formation. The use of fibrin glue may be more advantageous for male than for female patients. Surgical drains are not necessary for the prevention of hematomas. The prevention and prompt treatment of postoperative nausea may also help reduce the risk of hematoma formation. Hematomas after face-lift surgery can have devastating consequences. If meticulous hemostasis is achieved and the appropriate amount of pressure dressings are placed, the risk of major and minor hematomas can be decreased. Fibrin glue gives an added advantage to help prevent hematomas.

Correspondence: Samieh S. Rizk, MD, 1040 Park Ave, New York, NY 10028 (drsamrizk@aol.com).

Accepted for Publication: November 7, 2007.

Author Contributions: Drs Zoumalan and Rizk had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Zoumalan and Rizk. Acquisition of data: Zoumalan. Analysis and interpretation of data: Zoumalan and Rizk. Drafting of the manuscript: Zoumalan. Critical revision of the manuscript for important intellectual content: Rizk. Statistical analysis: Zoumalan. Administrative, technical, and material support: Rizk. Study supervision: Rizk.

Financial Disclosure: None reported.

Previous Presentation: This study was presented at the 2007 Annual American Academy of Facial Plastic and Reconstructive Surgery Meeting; September 19, 2007; Washington, DC.

Pitanguy  IPinto  RAGarcia  CLLessa  SF Ritidoplastia em homens. Rev Bras Cir 1973;63209
Baker  DCAston  SJGuy  CLRees  TD The male rhytidectomy. Plast Reconstr Surg 1977;60 (4) 514- 522
PubMed Link to Article
Lawson  WNaidu  RK The male face-lift: an analysis of 115 cases. Arch Otolaryngol Head Neck Surg 1993;119 (5) 535
PubMed Link to Article
Grover  RJones  BMWaterhouse  N The prevention of haematoma following rhytidectomy: a review of 1078 consecutive face-lifts. Br J Plast Surg 2001;54 (6) 481- 486
PubMed Link to Article
Berner  REMorain  WDNoe  JM Postoperative hypertension as an etiological factor in hematoma after rhytidectomy: prevention with chlorpromazine. Plast Reconstr Surg 1976;57 (3) 314- 319
PubMed Link to Article
American Society of Plastic Surgeons, National plastic surgery statistics: cosmetic and reconstructive procedure trends. http://www.plasticsurgery.org. Accessed June 15, 2004
Sersonneto  D Rhytdoplasties: study of 170 consecutive cases. J Int Coll Surg 1964;42208- 216
PubMed
Conway  H The surgical face lift—rhytidectomy. Plast Reconstr Surg 1970;45 (2) 124- 130
PubMed Link to Article
McGregor  MWGreenberg  RL Rhytidectomy. Goldwyn  RMThe Unfavorable Result in Plastic Surgery. Boston, MA Little Brown Co1972;
McDowell  AJ Effective practical steps to avoid complications in face lifting. Plast Reconstr Surg 1972;50 (6) 563- 572
PubMed Link to Article
Gallozzi  EBlancato  LSStark  RB Deliberate hypotension for blepharoplasty and rhytidectomy. Plast Reconstr Surg 1965;35285- 290
PubMed Link to Article
Webster  GV The ischemic face lift. Plast Reconstr Surg 1972;50 (6) 560- 562
PubMed Link to Article
Pitanguy  IRamos  HGarcia  LC Filosofia, tecnica e complicacoes das ritidectomias atraves de observacão e analise de 2600 casos pessoais consecutivos. Rev Bras Cir 1972;62277
Rees  TDLee  YCCoburn  RJ Expanding hematoma after rhytidectomy: a retrospective study. Plast Reconstr Surg 1973;51 (2) 149- 153
PubMed Link to Article
Barker  DE Prevention of bleeding following a rhytidectomy. Plast Reconstr Surg 1974;54 (6) 651- 653
PubMed Link to Article
Stark  RB A rhytidectomy series. Plast Reconstr Surg 1977;59 (3) 373- 378
PubMed Link to Article
Leist  FDMasson  JKErich  JB A review of 324 rhytidectomies emphasizing complications and patient dissatisfaction. Plast Reconstr Surg 1977;59 (4) 525- 529
PubMed Link to Article
Baker  TJGordon  HKMosienko  P Rhytidectomy. Plast Reconstr Surg 1977;59 (1) 24- 30
PubMed Link to Article
Straith  RERaju  RHipps  CJ The study of hematomas in 500 consecutive face lifts. Plast Reconstr Surg 1977;59 (5) 694- 698
PubMed Link to Article
Thompson  DPAshley  FL Face-lift complications: a study of 922 cases performed in a 6 year period. Plast Reconstr Surg 1978;61 (1) 40- 49
PubMed Link to Article
Baker  DC Complications of cervicofacial rhytidectomy. Clin Plast Surg 1983;10 (3) 543- 562
PubMed
Cohen  SRWebster  RC Primary rhytidectomy: complications of the procedure and anesthetic. Laryngoscope 1983;93 (5) 654- 656
PubMed
Matsunaga  RS Rhytidectomy employing a two-layered closure: improved results with hidden scars. Otolaryngol Head Neck Surg 1981;89 (3, pt 1) 496- 503
PubMed
Shirakabe  Y The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in face-lifting. Aesthetic Plast Surg 1988;12 (1) 25- 32
PubMed Link to Article
Owsley  JQ  Jr SMAS-platysma face-lift. Plast Reconstr Surg 1983;71 (4) 573- 576
PubMed Link to Article
Rees  TDBarone  CMValauri  FAGinsberg  GD Hematomas requiring surgical evacuation following face lift surgery. Plast Reconstr Surg 1994;93 (6) 1185- 1190
PubMed Link to Article
Marchac  DSandor  G Face lifts and sprayed fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg 1994;47 (5) 306- 309
PubMed Link to Article
Heinrichs  HLKaidi  AA Subperiosteal face lift: a 200-case, 4 year review. Plast Reconstr Surg 1998;102 (3) 843- 855
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Kamer  FMSong  AU Hematoma formation in deep plane rhytidectomy. Arch Facial Plast Surg 2000;2 (4) 240- 242
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Kamer  FMNguyen  DB Experience with fibrin glue in rhytidectomy. Plast Reconstr Surg 2007;120 (4) 1045- 1051
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Marchac  DGreensmith  AL Early postoperative efficacy of fibrin glue in face lifts: a prospective randomized trial. Plast Reconstr Surg 2005;115 (3) 911- 918
PubMed Link to Article
Oliver  DWHamilton  SAFigle  AAWood  SHLamberty  BG A prospective, randomized, double-blind trial of the use of fibrin sealant for face lifts. Plast Reconstr Surg 2001;108 (7) 2101- 2107
PubMed Link to Article
Fezza  JPCartwright  MMack  WFlaharty  P The use of aerosolized fibrin glue in face-lift surgery. Plast Reconstr Surg 2002;110 (2) 658- 666
PubMed Link to Article
Nowotny  RChalupka  ANowotny  C  et al.  Mechanical properties of fibrinogen adhesive material. Winter  GDGibbons  DFPlenk  H  JrBiomaterials. New York, NY John Wiley & Sons1982;
Redl  HSchlag  G Properties of different tissue sealants with special emphasis on fibrinogen-based preparations. Schlag  Gredl  HFibrin Sealant in Operative Medicine, General Surgery, and Abdominal Surgery. Vol 6. Berlin, Germany Springer-Verlag1986;
Man  DPlosker  HWinland-Brown  JE The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 2001;107 (1) 229- 239
PubMed Link to Article
Dorner  F Validation of virus removal and inactivation in the course of the manufacture of sealer protein concentrate (human) vapor heated, deficient in factor VIII, using HIV-1, HAV, and model viruses: a pre-clinical study.  Deerfield, IL Baxter Health Care Corp August22 1996;Internal study PR099403
Mannucci  PMSchimpf  KAbe  T  et al. International Investigator Group, Low risk of viral infection after administration of vapor-heated factor VIII concentrate. Transfusion 1992;32 (2) 134- 138
PubMed Link to Article
Matarasso  ARizk  SSMarkowitz  J Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005;23 (3) 495- 504
PubMed Link to Article
Matarasso  ARizk  SS Use of fibrin sealant in short scar face-lift. Saltz  RToriumi  DMTissue Glues in Cosmetic Surgery. St Louis, MO Quality Medical Publishing2004;134- 147
Perkins  SWWilliams  JDMacdonald  KRobinson  EB Prevention of seromas and hematomas after face-lift surgery with the use of postoperative vacuum drains. Arch Otolaryngol Head Neck Surg 1997;123 (7) 743- 745
PubMed Link to Article
Jones  BMGrover  R Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest reviewing 910 patients. Plast Reconstr Surg 2004;113 (1) 381- 387
PubMed Link to Article
Jones  BMGrover  RHamilton  S The efficacy of surgical drainage in cervicofacial rhytidectomy: a prospective, randomized controlled trial. Plast Reconstr Surg 2007;120 (1) 263- 270
PubMed Link to Article
Regan  FAHewitt  PBarbara  JAContreras  MTTI Study Group, Prospective investigation of transfusion transmitted infection in recipients of over 20 000 units of blood [published correction appears in BMJ. 2000;321(7256):266]. BMJ 2000;320 (7232) 403- 406
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Patient and Surgical Characteristics
Table Graphic Jump LocationTable 2. Incidence of Hematomas and Distribution of Hematomas Between Sexes

References

Pitanguy  IPinto  RAGarcia  CLLessa  SF Ritidoplastia em homens. Rev Bras Cir 1973;63209
Baker  DCAston  SJGuy  CLRees  TD The male rhytidectomy. Plast Reconstr Surg 1977;60 (4) 514- 522
PubMed Link to Article
Lawson  WNaidu  RK The male face-lift: an analysis of 115 cases. Arch Otolaryngol Head Neck Surg 1993;119 (5) 535
PubMed Link to Article
Grover  RJones  BMWaterhouse  N The prevention of haematoma following rhytidectomy: a review of 1078 consecutive face-lifts. Br J Plast Surg 2001;54 (6) 481- 486
PubMed Link to Article
Berner  REMorain  WDNoe  JM Postoperative hypertension as an etiological factor in hematoma after rhytidectomy: prevention with chlorpromazine. Plast Reconstr Surg 1976;57 (3) 314- 319
PubMed Link to Article
American Society of Plastic Surgeons, National plastic surgery statistics: cosmetic and reconstructive procedure trends. http://www.plasticsurgery.org. Accessed June 15, 2004
Sersonneto  D Rhytdoplasties: study of 170 consecutive cases. J Int Coll Surg 1964;42208- 216
PubMed
Conway  H The surgical face lift—rhytidectomy. Plast Reconstr Surg 1970;45 (2) 124- 130
PubMed Link to Article
McGregor  MWGreenberg  RL Rhytidectomy. Goldwyn  RMThe Unfavorable Result in Plastic Surgery. Boston, MA Little Brown Co1972;
McDowell  AJ Effective practical steps to avoid complications in face lifting. Plast Reconstr Surg 1972;50 (6) 563- 572
PubMed Link to Article
Gallozzi  EBlancato  LSStark  RB Deliberate hypotension for blepharoplasty and rhytidectomy. Plast Reconstr Surg 1965;35285- 290
PubMed Link to Article
Webster  GV The ischemic face lift. Plast Reconstr Surg 1972;50 (6) 560- 562
PubMed Link to Article
Pitanguy  IRamos  HGarcia  LC Filosofia, tecnica e complicacoes das ritidectomias atraves de observacão e analise de 2600 casos pessoais consecutivos. Rev Bras Cir 1972;62277
Rees  TDLee  YCCoburn  RJ Expanding hematoma after rhytidectomy: a retrospective study. Plast Reconstr Surg 1973;51 (2) 149- 153
PubMed Link to Article
Barker  DE Prevention of bleeding following a rhytidectomy. Plast Reconstr Surg 1974;54 (6) 651- 653
PubMed Link to Article
Stark  RB A rhytidectomy series. Plast Reconstr Surg 1977;59 (3) 373- 378
PubMed Link to Article
Leist  FDMasson  JKErich  JB A review of 324 rhytidectomies emphasizing complications and patient dissatisfaction. Plast Reconstr Surg 1977;59 (4) 525- 529
PubMed Link to Article
Baker  TJGordon  HKMosienko  P Rhytidectomy. Plast Reconstr Surg 1977;59 (1) 24- 30
PubMed Link to Article
Straith  RERaju  RHipps  CJ The study of hematomas in 500 consecutive face lifts. Plast Reconstr Surg 1977;59 (5) 694- 698
PubMed Link to Article
Thompson  DPAshley  FL Face-lift complications: a study of 922 cases performed in a 6 year period. Plast Reconstr Surg 1978;61 (1) 40- 49
PubMed Link to Article
Baker  DC Complications of cervicofacial rhytidectomy. Clin Plast Surg 1983;10 (3) 543- 562
PubMed
Cohen  SRWebster  RC Primary rhytidectomy: complications of the procedure and anesthetic. Laryngoscope 1983;93 (5) 654- 656
PubMed
Matsunaga  RS Rhytidectomy employing a two-layered closure: improved results with hidden scars. Otolaryngol Head Neck Surg 1981;89 (3, pt 1) 496- 503
PubMed
Shirakabe  Y The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in face-lifting. Aesthetic Plast Surg 1988;12 (1) 25- 32
PubMed Link to Article
Owsley  JQ  Jr SMAS-platysma face-lift. Plast Reconstr Surg 1983;71 (4) 573- 576
PubMed Link to Article
Rees  TDBarone  CMValauri  FAGinsberg  GD Hematomas requiring surgical evacuation following face lift surgery. Plast Reconstr Surg 1994;93 (6) 1185- 1190
PubMed Link to Article
Marchac  DSandor  G Face lifts and sprayed fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg 1994;47 (5) 306- 309
PubMed Link to Article
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