Achieving success in face lift surgery requires a thorough understanding of facial anatomy and the ability to select from myriad techniques the most appropriate procedure for achieving the desired results and a high degree of patient satisfaction.

Numerous well-recognized complications of rhytidectomy have been described. Early local complications include hemorrhage,hematoma, seroma, motor or sensory nerve injury, skin flap necrosis, wound infection, edema, and ecchymosis. Late complications, developing more than 5 days after surgery, include hemorrhage, hematoma, neuroma, hair loss, salivary cyst or fistula, chronic burning facial pain, and hypertrophic scars.

Goldwyn reported 5 cases of late bleeding after rhytidectomy resulting from injury to the superficial temporal vessels and precipitated by physical exertion or salicylate ingestion. Owsley described a case of life-threatening hemorrhage from a dehisced scalp incision after a face lift procedure, which was managed with transfusions and emergency ligation of the injured branch of the superficial temporal artery.

There have been reports of traumatic pseudoaneurysm formation after cosmetic surgery, though not for rhytidectomy, including punch hair grafting and hair transplantation,and 16. REA Nordstrom and SM Totterman, Iatrogenic false aneurysms following punch hair grafting. Plast Reconstr Surg 64 (1979), pp. 563–565. View Record in Scopus | Cited By in Scopus rhinoplasty, augmentation mentoplasty, and orthognathic surgery.

To our knowledge, we report the first known case of a superficial temporal artery pseudoaneurysm ostensibly developing 3 months after a face lift.

Case report

A 51-year-old woman with a medical history significant for mild hypertension underwent a short-scar face lift with superficial musculoaponeurotic system tightening, submentalplasty, and secondary upper-lid blepharoplasty. She was taking no medications, had no history of excessive or prolonged bleeding, and had no family history of bleeding diatheses. Preoperative evaluation included complete blood cell count and coagulation studies, the findings of which were all normal. She reported having enlarged, dilated vessels, often prominent and palpable, located over her entire body, particularly in the temporal regions. The procedures were performed in a routine, previously reported manner without complications.No excessive bleeding was noticed during the operation. The patient had an uneventful first postoperative visit before departing to return home abroad.

On her return 4 months later, during her second follow-up visit, the patient identified a nontender, pulsatile mass in the right preauricular region, just below the junction of the preauricular and sideburn incisions. She had first noticed this mass approximately 3 months after the procedure and had noted no significant changes since then. On examination, the patient was found to have a 0.5-by-0.5-cm soft, compressible, pulsatile mass over the region of the right superficial temporal artery that corresponded to cardiac systole (Figure 1). A thrill was palpated, but no bruit was auscultated. The overlying skin was intact. Additionally, multiple dilated superficial veins were found over the patient’s entire body. A presumptive diagnosis of traumatic aneurysm versus a “kink” in the superficial temporal artery was made. The patient was started on oral nonsteroidal antiinflammatory medication as a presumptive maneuver to manage a kink, and magnetic resonance angiography (MRA) was performed ( Figure 2). The findings of the MRA were consistent with a 0.5-cm false aneurysm of the right superficial temporal artery.

Preoperative lateral view of the face showing the external appearance of the right superficial temporal artery pseudoaneurysm (arrow).

Selective external carotid artery angiogram showing the right superficial temporal artery pseudoaneurysm (arrow).

The patient returned to the operating room 4 months after the initial face lift procedure for exploration and possible excision of the pseudoaneurysm. With the patient under sedation anesthesia, the right short-scar face lift incision was opened along the transverse sideburn and preauricular incision, and skin flaps were elevated. The site of the mass was exposed and noted to be located in a plane deeper than the face lift dissection plane. Consequently, the fascial plane overlying the aneurysm was dissected to expose the proximal and distal ends of the pseudoaneurysm (Figure 3). The ends were dissected and controlled with microvascular clips, as well as 3-0 silk suture ties, and the aneurysm was excised ( Figure 4). The fascial plane was repaired with 4-0 Vicryl sutures (Ethicon, Somerville, NJ), and the face lift flap was elevated, advanced, trimmed to further tighten that side at the patient’s request, and closed with 5-0 nylon sutures. A standard face lift helmet dressing was applied, and the patient was discharged.

Intraoperative view of the pseudoaneurysm and its relationship to fascial planes.

View of excised superficial temporal artery pseudoaneurysm.

The gross specimen was sent for pathology examination, and the results were consistent with a pseudoaneurysm: an artery measuring 0.7 by 0.5 by 0.3 cm with an area of nodular fibrosis attached to the vessel wall (Figure 5). Sectioning of the specimen revealed a slitlike opening 0.3 cm long, surrounded by many layers of fibrous tissue without elastic fibers or muscle tissue in the tunica media and disruption of the internal elastic membrane. Loss of normal arterial architecture and aneurysmal dilation were also noted ( Figure 5).

Microscopic view of the pseudoaneurysm showing loss of normal arterial architecture and aneurysmal dilation surrounded by many layers of fibrous tissue.

The patient’s postoperative course was unremarkable. Follow-up revealed a well-healed incision with no recurrence of the swelling; no mass was appreciated.

Discussion

An aneurysm is an abnormal focal dilation of an artery. Aneurysms are subdivided into 2 classes: true and false. The pathogenesis of traumatic false aneurysm, also known as pseudoaneurysm or pulsating hematoma,has been well described.. A pseudoaneurysm forms when an artery is only partially transected, resulting in extravasation of arterial blood into the surrounding tissues. When the pressure between the hematoma and artery is in equilibrium, flow is restored to the artery. The hematoma subsequently liquefies and cavitates as a result of leukocyte infiltration, resulting in secondary hemorrhage, which may result in an increase in associated soft tissue deformity, asymmetry,31 neurologic defects and release of an embolic thrombus. The fibrous pseudocapsule of the hematoma may expand because of a deficiency in elastic fibers or assume pulsatile characteristics. In contrast, true aneurysms are caused by weakening of the vessel wall and comprise all 3 components: intima, media, and adventitia.