Aesth Plast Surg (2011) 35:9699
DOI 10.1007/s00266-010-9569-8
ORIGINAL PAPER
A Comparison of Primary and Secondary Rhytidectomy Results
Etai Funk Peter A. Adamson
Received: 10 May 2010 / Accepted: 6 August 2010 / Published online: 4 September 2010
Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010
Abstract
Background This study aimed to evaluate the authors
surgical experience with secondary rhytidectomy and to
compare these results with those for primary rhytidectomy
patients.
Methods A retrospective review of patients who had
undergone secondary rhytidectomy was performed. In
addition, an equivalent number of primary rhytidectomy
patients were selected randomly. Data were collected
evaluating patient age, time elapsed between rhytidecto-
mies, type of procedure performed, superficial musculo-
aponeurotic system (SMAS) thickness, amount of skin
resected, complications, adjunctive procedures, and patient
satisfaction.
Results This study enrolled 21 secondary rhytidectomy
patients. The average time elapsed between their previous
and last rhytidectomy was 9.95 years. Using a grading
scale of -4 to 4, the average SMAS thickness was 2.2 for
the primary and 0.67 for the secondary rhytidectomy
patients. The average skin resection was 26.6 mm for the
primary and 17.6 mm for the secondary rhytidectomy
patients. The complications for secondary rhytidectomy
included one hematoma and one hypertrophic postauricular
scar. The follow-up period ranged from 6 months to
7 years. All secondary rhytidectomy patients expressed
satisfaction with their overall aesthetic result.
E. Funk
P. A. Adamson
Department of OtolaryngologyHead and Neck Surgery,
University of Toronto, Toronto, ON, Canada
E. Funk (&)
6624 Fannin Suite 2550, Houston, TX 77030, USA
e-mail: etaifunk@yahoo.com
123
Conclusions Secondary rhytidectomy is a safe and
effective procedure for the aging face. The SMAS of older
patients appears to be thinner and more delicate and
therefore must be handled with care. Additionally, skin
resection is significantly reduced compared with that for
primary rhytidectomy patients.
Keywords Facelift
Rhytidectomy
Secondary
rhytidectomy
SMAS
The increased desirability for a youthful facial appearance
is apparent throughout our society, likely perpetuated by
the media and entertainment industries. Physical charac-
teristics attributed to aging such as laxity, rhytids, and
jowling are considered unattractive. The demand for facial
cosmetic surgery has increased significantly over recent
years, and more aesthetic procedures are being performed
for a younger population [1]. This observation in addition
to patients increased longevity and improved health likely
will lead to an increased demand for secondary procedures
in aesthetic surgery.
Special attention should be given to the secondary
rhytidectomy patient during examination because the
intricacy of the procedure may depend on what was done
during the primary rhytidectomy. Primary incision place-
ment, scarring, tragal definition, earlobe position, skin
thickness, and temporal tuft position should be analyzed
closely because these areas may be of greatest concern to
the secondary rhytidectomy patient.
One study noted that the superficial musculoaponeu-
rotic system (SMAS) is considerably thinner in the sec-
ondary rhytidectomy patient [2]. The same study
observed that the amount of skin resected was consid-
erably less than for primary rhytidectomy patients [2].
Aesth Plast Surg (2011) 35:9699
However, a review of the literature does not demonstrate
a quantitative study that examines these differences from
a statistical perspective. This study aimed to compare
secondary and primary rhytidectomy patients with regard
to SMAS thickness, amount of skin resected, and
complications.
Methods
A retrospective chart review was performed for all patients
who had undergone secondary rhytidectomy by the senior
author (P.A.A.) from 1 February 2001 to 30 July 2007.
Next, the same number of patients who had undergone
primary rhytidectomy were randomly selected during the
same time period. Data were collected documenting patient
age, duration of time since last rhytidectomy, number of
rhytidectomies in the past, type of secondary rhytidectomy
performed, SMAS thickness, amount of skin resected, and
complications.
The SMAS thickness was graded on a scale developed
by the senior author (P.A.A.) that ranged from -4
(thinnest) to 4 (thickest). The amount of skin resected
was measured intraoperatively by calculating the skin
excess without tension along the vector of pull overlying
the mandibular line as measured from the cut skin edge
to the intertragal notch following the SMAS aspect of
the lift (Fig. 1) [3]. To simplify measurements and
analysis, the amount of skin excess was averaged from
both sides of the face as they typically were fairly
similar.
Statistical analysis was performed using general linear
models to assess the effect of both patient age and patient
group (primary vs secondary rhytidectomy) on the two
outcome variables: SMAS thickness and average length of
the skin excised.
Fig. 1 a The intertragal incisural notch is marked with a 27-g needle. b Skin is measured from the cut skin edge to the intertragal notch
following the superficial musculoaponeurotic system (SMAS) aspect of the lift
97
Results
The 42 patients evaluated in this study included 21 sec-
ondary and 21 primary rhytidectomy patients. The average
age was 56.1 years for the primary patients and 62.6 years
for secondary rhytidectomy patients. The average number
of years elapsed after secondary rhytidectomy patients last
procedure was 9.5 years. Of the 21 patients, 18 were sec-
ondary rhytidectomy patients, whereas 3 had undergone
tertiary or higher rhytidectomy. The previous rhytidectomy
for 6 of the 21 secondary rhytidectomy patients had been
performed by the senior author (P.A.A.). Deep-plane
rhytidectomy was performed for 19 of the 21 patients in the
secondary rhytidectomy group. For one of the two
remaining patients, the SMAS was too thin to raise an
intact deep plane SMAS flap adequately. The other patient
elected to undergo only a sub-SMAS lift.
The average length of the excised skin was much greater
for the primary rhytidectomy patients (mean, 26.6
3.0 mm) than for the secondary rhytidectomy patients
(mean, 17.8 6.4 mm), as seen in Table 1. The results of
the general linear model analysis demonstrated that these
differences between the two groups are highly significant
statistically (p \ 0.0001) but that patient age is not a sig-
nificant predictor of skin excision length (p = 0.39).
The average SMAS score for primary rhytidectomy
patients was 2.19 (range, 1 to 4), whereas the average
Table 1 Average length of skin excised for primary versus second-
ary rhytidectomy
Group n Mean (mm) SD (mm) SEM
Primary rhytidectomy 21 26.6190 2.98708 0.65183
Secondary rhytidectomy 21 17.7619 6.45294 1.40815
SD standard deviation, SEM standard error of the mean
123
98
Table 2 Average superficial musculoaponeurotic system (SMAS)
thickness score for primary versus secondary rhytidectomy. SMAS
thickness
Group n Minimum Maximum Mean SD
Primary 21 1.00 4.00 2.1905 0.92839
Secondary 21 -4.00 2.00 1.0381 1.50515
SD standard deviation
SMAS score for the secondary rhytidectomy patients was
1.03 (range, -4 to 2) (Table 2). The results of the general
linear model analysis demonstrated that these differences
between the two groups are statistically significant
(p = 0.002) but that patient age is not a significant pre-
dictor of SMAS thickness (p = 0.22).
One patient in the primary rhytidectomy group experi-
enced hypertrophic postauricular scars. Complications
from secondary rhytidectomy included one hematoma as
well as hypertrophic postauricular scars experienced by
one patient. All the patients ultimately reported overall
satisfaction with their aesthetic result.
Discussion
The 2007 report on trends in facial plastic surgery pub-
lished by the American Academy of Facial Plastic Surgery
demonstrates an increasing percentage of younger patients
undergoing rhytidectomy compared with the 2005 per-
centage [1]. Our health care industry currently is more
focused on implementing health preventive measures,
increasing public awareness, and promoting avoidance of
risk factors. This in turn means not only substantial
increases in our longevity, but also improved overall health
as we progress in age. Consequently, we likely will observe
a rise in secondary procedures including rhytidectomy as
patients continue to age.
It is important to note that when a repeat rhytidectomy is
described, it is termed a secondary rhytidectomy and not
a revision rhytidectomy. In the case of the former, the
outcome is desirable for both the patient and the surgeon,
but after several years, the patient begins to show signs of
facial aging once again. This is understandable and
expected. No surgical result is completely permanent
unless we are able to stop the aging process altogether. As
patients continue to age, secondary procedures are inevi-
table with rejuvenation surgery.
Subtle details must be addressed when a patient is
evaluated for secondary rhytidectomy. Injection of local
anesthetic should be precisely in the correct superficial
subcutaneous plane. The thin SMAS of secondary rhyti-
dectomy patients can be easily punctured, and injection in
the area of the facial nerve can occur. Although the paresis
123
Aesth Plast Surg (2011) 35:9699
will be temporary, if a long-acting local anesthetic is used,
this can be a distressing several hours for both the patient
and the surgeon.
The scar from the previous rhytidectomy must be ana-
lyzed closely. We typically excise the previous scar by
including it in the skin to be resected once the SMAS lift is
complete. If a preauricular incision was made, we typically
use this same incision because there may not be sufficient
skin to redrape the tragus. Guyuron [4] describes a tech-
nique in which a small triangular portion of the redraped
skin is rotated inferiorly to cover the tragus.
The incision into the temporal hair tuft is extended only
slightly into the hairline and parallel to the follicles to
ensure that the tuft is not further elevated. In the case of a
preexisting elevated hairline, the incision must be made
just at the hairline or a few follicles behind it, again in
parallel fashion.
Patients who desire earlobe reduction or release of a
preexisting attached earlobe should be adequately assessed
preoperatively. The location of the piercing should be
noted in addition to any slot ear abnormality. The incision
around the earlobes should be performed before the
remaining rhytidectomy incisions are made. Close attention
to symmetry and location of the piercing is critical. A small
amount of fibrofatty earlobe tissue is gently resected, and
the earlobe skin is closed using 6-0 nylon suture.
The neck should be addressed much the same as in a
primary rhytidectomy. We routinely use the same sub-
mental incision followed by platysmal plication with
interrupted 3-0 Vicryl suture [5]. Fat picking or open
liposuction rarely is needed in secondary rhytidectomy
patients if it was performed primarily.
Elevation of the rhytidectomy flaps should be meticu-
lous, and close adherence to the superficial subcutaneous
plane must be maintained. The elevation may be more
difficult secondary to scarring and fibrosis from the pre-
existing rhytidectomy [6] Patience, prudence, and close
attention to detail are essential for adequate flap elevation.
In light of the results by Mitz and Peyronie [7]
describing the anatomy of the SMAS, deeper dissections
have been adopted. Almost any face-lift techniques per-
formed judiciously will result in an improvement. The
question is how long this improvement will last. Kamer and
Frankel [8] demonstrated that the tuck rate or revision rate
for a deep-plane rhytidectomy was significantly less sta-
tistically than for an SMAS lift. It also has been demon-
strated that the deep-plane face-lift provides a vector of lift
for the midface, improving this region in addition to the
jawline and neck [9, 10].
The senior author (P.A.A.) has demonstrated that the
deep-plane rhytidectomy provides a better lift with double
the amount of skin excision than the SMAS plication [3, 9].
Depending on the type of primary rhytidectomy, the
Aesth Plast Surg (2011) 35:9699
secondary face-lift patient may have significant subcuta-
neous scarring and fibrosis that may thwart a substantial lift
and skin redrapage. We therefore recommend a deep-plane
rhytidectomy for these patients to obtain the maximum lift
possible. However, this is not without its limitations. We
have demonstrated that the SMAS is significantly thinner
statistically in these secondary patients. Lifting a deep-
plane SMAS flap that is extremely thin and delicate may
lead to buttonholing of the SMAS and a technically more
difficult lift. The integrity of the SMAS must be assessed
before elevation to determine whether a sub-SMAS lift or
SMAS imbrication would be in the patients best interest.
Conclusions
Secondary cosmetic procedures for the aging face likely
will become more commonplace as our societys longevity
and health continue to improve. Adequate analysis and
knowledge of secondary procedures are essential in main-
taining our rigid commitment to excellence and patient
satisfaction.
In this study, examination of the secondary rhytidec-
tomy patient demonstrated significant differences in SMAS
thickness and skin excess between primary and secondary
rhytidectomy patients. Interestingly, these variables were
not related to patient age. Careful preoperative assessment,
meticulous surgical technique, and proper patient selection
99
are critical to achieving a successful outcome and a pleased
aesthetic patient.
References
1. Retrieved January 2006 from http://www.aafprs.org/media/stats_
polls/aafprsMedia2006.pdf
2. Guyuron B, Bokhari F, Thomas T (1997) Secondary rhytidec-
tomy. Plast Reconstr Surg 100:12811284
3. Litner JA, Adamson PA (2006) Limited vs extended face-lift
techniques: objective analysis of intraoperative results. Arch
Facial Plast Surg 8:186190
4. Guyuron B (2004) Secondary rhytidectomy. Plast Reconstr Surg
114:797800
5. Adamson PA, Litner JA (2005) Surgical management of the
aging neck. Facial Plast Surg 21:1120
6. Morales P (2000) Repeating rhytidoplasty with SMAS malar fat
pad and labiomandibular fold treatment: the NO primary proce-
dure. Aesth Plast Surg 24(5):364
7. Mitz V, Peyronie M (1976) The superficial musculo-aponeurotic
system in the parotid and cheek area. Plast Reconstr Surg
58:8081
8. Kamer FM, Frankel AS (1998) SMAS rhytidectomy vs deep-
plane rhytidectomy: an objective comparison. Plast Reconstr
Surg 102:878
9. Adamson PA, Dahiya R, Litner J (2007) Midface effects of the
deep-plane vs the superficial musculoaponeurotic system plica-
tion face-lift. Arch Facial Plast Surg 9:911
10. Kamer FM (1996) One-hundred consecutive deep-plane face-
lifts. Arch Oto Head Neck Surg 122:17
123