Facial Feminization Surgery Complictions

General complications of any surgery.

Note: Numbers for risk estimation are based on current studies. Sometimes no data’s are available for a specific complication, it means unless stated otherwise a risk of less than 1%. This number is considered low.

Since most of our patients are from out of town I consider important that you read the following. I am available to discuss or respond to any questions you’d have.

- Thrombophlebitis and pulmonary embolism: with any prolonged anaesthesia and due to immobility, blood cans cloth into the deep veins of the calves. The calf becomes swollen and tender. This is a very rare complication (less than…..). In a very small percentage of those patients, the blood cloth may get dislodged and go into the blood stream all the way to the lung causing a pulmonary embolism. This later complication is very serious and can lead to death. The estimated chance of having the later is less than 1/100000.

- Infection: as with any surgery infection can occur. These is easily treated with antibiotics unless an implant is present and get infected, it might need more surgery to remove the implant. Infections if they occurs, is after 5 days. Estimated risk less than 1%

- Bleeding: as with any surgery the risk is less than 1%. It is easily recognize as the area becomes swollen and tender. Bleeding if it occurs is during the first 24hours after the surgery. Usually a prompt surgery is indicated to stop the bleeding and clean the blood.

- Bad scaring: most of the time the surgeon is credited as having made a nice or a bad scar. In fact if proper technique is used the quality of the scar depends mostly on the patient genetics. Scars are permanents and most of the time heals inconspiously. Bad scars can be hypertrophic or cheloid type. Face usually heals nicely compares to other areas of the body.

- Bruising and swelling: not considered a complication, bruising and swelling is almost universal after any surgery. It is a sign that the body is taking action to heal. Swelling rapidly takes place the first 48 hours after the surgery to peak for about 7 days before starting to resolve.

Forehead surgery

- Frontal branch nerve injury: this is a branch of the facial nerve. Its function is to raise the eyebrow. This nerve can be injured during a brow or forehead surgery. The eyebrow becomes fixed and fails to move on demand. The cosmetic effect of this injury is quiet obvious. Fortunately most of the time this palsy of the eyebrow is temporary but can also be permanent. Risk classified as very low.

Cosmetic aspect of frontal branch palsy.

- Supraorbital nerve injury: can lead to forehead permanent anaesthesia. There is not any cosmetic effect of this complication but the forehead feels numb and sometime painful if a neuroma develops. Risk classified as very low.

- Scalp itching: can occur behind the scar. In fact it is a sensation of itching that is perceived by the patient. It is caused by the fact that the nerve endings are severed when the incision is done. It recovers in the vast majority of cases. Some numbness behind the scar can persist.

- Alopecia: loss of hairs around the scar. Hairs may or may not grow back. A hair transplant is a solution for hairs that doesn’t grow back. Risk classified as very low.

- Implant infection: means infection of the implants that are used to recontour the forehead. Antibiotics are not usually efficient to treat infected implants. Implant removal becomes necessary and may lead to contour deformity after wise. Secondary procedures can be done for corrections at a later time. Risk of infection is usually less than 1%.

- Loss of scalp and forehead sensation: almost universal behind the scar of the bicoronal incision, the top of the head becomes numbed

- Hardware palpability or visibility: in some very thin skinned patients, and if screws or wires are used the material can be palpable through the skin. Usually it is not a problem and it doesn’t warrant surgery. Any material can be removed after the bone is healed but it is seldom necessary.

- Bony resorption: Like in any other bone surgery, when bone is cut and moved it can resorbe and lead to contour irregularities. This is another very rare situation.

Eyelid surgery

- Retrobulbar haematoma: it is a bleeding that occurs behind the eyeball. It can happen within 24 hours after surgery. If it happens it is very painful and warrant immediate surgery to avoid vision damage. This risk is extremely rare. The risk is probably less than a deep venous thrombosis.

- Lagophthalmos: means incapacity to close the upper eyelid. It can lead to chronic eye irritation. The main reason is excessive skin removal. This is why it is better to remove a little skin. Risk: very very rare

- Ectropion: is a lower eyelid retraction and eversion. The lower eyelid is too low, and doesn’t touch anymore the eyeball. If it happens the patient can experiment eye inflammation, tearing and a very obvious cosmetic deformity. Massages and tapping the eyelid can resolve the problem. If not a relative minor surgery to correct the problem becomes necessary. Ectropions can happen on very weak lower eyelid, if excessive skin is removed or if the patient heals too strongly. That is the reason why we sometime perform an eyelid tightening on weak eyelid, and we are very carefull on the amount of skin that is taken out. If those precations are taken the risk is very rare.

Aspect of an ectropion of the lower eyelid.

- Milia: is tiny white head in the scar. Removed by pinching them with tweaser.

Under correction: it is in my opinion that it is better to leave one or two extra millimiter of skin rather than trying to take out the maximum possible skin. The goal it to refresh the eyelids rather than making them too tight. This gives a more natural look and minimizes complications.

- Diplopia: could happen if a muscle of the eye is injured during fat removal. This should be extremely rare.

Prolonged swelling: most of patients do have swelling for a week to 10 days. Sometimes it takes more time but in any cases the swelling end up to resolve completely

- Chemosis: means swelling of the conjunctiva (the inner membrane of the eyelid). Chemosis looks like a bulge of water between the eyeball and the eyelid. It takes sometime but it resolves.

Rhinoplasty

- Nasal obstruction: when we reduce the width and length of the nose, the airway is smaller and some degree of nasal obstruction can occur in some patient. You might experience difficulty breathing through the nose. Sometime if there is a septal deviation we can correct it and improve the breathing. In other circumstances cartilage grafts called spreader grafts are used to support the opening of the internal nasal valve if it is necessary. Those grafts are most often taken from extra cartilage that is removed and are placed inside the nose. They don’t show on the final appearance of the nose.

- Aesthetic outcome: can be compromised if any of the following complications occurs

- Necrosis of collumella: most our rhinoplasty are done buy an open approach. We make a little incision at the base of the nose, the rest of the incision are done inside. This allows us to have great visualisation and control on the shaping and tailoring of the nasal structures. It is a new trend since the past years to proceed that way. Although very rarely described the skin under the nose can lake blood supply and lead to skin damage and compromised aesthetic outcome.

- Septal perforation: Very rare occurrence that can lead to difficulty breathing thought the nose and collapse of the nose in sever cases. It is very rare and more frequently seen in cocaine users.

- Collapse of bony pyramid: Collapse of the bony pyramid may occur during removal of a bony hump with an osteotome, particularly when the patient has had previous nasal trauma or surgery.

- Infection: since a rhinoplasty is done in a relatively non sterile field infection (although very rare) specific to rhinoplasty should be discussed:

Wound infection: The wound infection rate following rhinoplasty is variously quoted as less than 2%. Localized cellulitis, abscesses, or granuloma may respond to antibiotics and drainage. Use of foreign material may promote an infective episode. No consistent association between routine antibiotic prophylaxis and wound infection has been reported. If implants are used and get infected they need to be removed.
Septicemia: Awareness of the possibility of this complication is essential. This severe infection may lead acute circulatory failure and multiple organ dysfunctions. It is extremely rare.
Toxic shock syndrome: Postoperative fever, vomiting, diarrhea, hypotension without obvious blood loss, and erythematous sunburn like rash characterize this syndrome. In severe cases, septicemia may manifest. A few days later, desquamation of the skin of the palms and soles may occur. Toxic shock syndrome follows nasal surgery in 0.016% of cases.
Subacute bacterial endocarditis: Every patient with a cardiac murmur is at risk. Ensuring good dental health and antibiotic prophylaxis is essential.
Intracranial infections: Proximity of the cranium and provision of a traumatic pathway during an operation influences the likelihood of meningitis, subdural empyema, cerebral abscess, or cavernous sinus thrombosis, although hematogenous spread also may occur. Headache, drowsiness, fever, meningism, epilepsy, focal hemisphere, and cranial nerve signs should provoke suspicion, relevant investigation, and referral.
Acute and/or chronic sinusitis: These conditions may follow rhinoplasty surgery. The patient may require functional endoscopic sinus surgery following failure to respond to adequate medical treatment

Cheek implants

- Implants infection: means infection of the implants that are used. Antibiotics are not usually efficient to treat infected implants. Implant removal becomes necessary until the infection resolves. It may lead to contour deformity after wise. Secondary procedures can be done for corrections at a later time. Risk of infection is usually less than 1%.

- Implant visibility or palpability: care is taken to place the implant properly but in some very thin skinned patients the edges of the implants may be visible or palpable.

- Infraorbital nerve injury: this nerve exits the bone and course to the tissues of the upper lip. It is a quiet big nerve that is seen and protected during the surgery. Although very unlikely to occur an injury is possible and can lead to permanent upper lip numbness.

Area of numbness in an infraorbital nerve injury.

- Asymmetry: A great care is taken to shape and place the implants in a symmetric fashion to minimize the risk of asymmetry.

- Implants dislodgment: Implants are properly placed and fixed in place to ensure stability. It will be very rare that they dislodge. In this event it will be noticeable and will need replacement.

Mandibular surgery

- Mandibular nerve injury: This nerve course in the bone. It is susceptible to injury with any mandibular surgery. It can lead to partial or total numbness in the lower lip. It is a very rare occurrence.

Area of numbness in the event of mandibular nerve injury.

- Asymmetry: as with any surgery that needs to be carried on both sides risk of differences are a potential problem. Normal or slight differences are considered normal since the whole body is not perfectly symmetric to begin with.

- Bone infection: also called osteomylitis is possible but very rare. Treatment includes surgery to clean the bone and many weeks of intravenous antibiotics. Very rare.

- Prolonged swelling: It may take a few weeks or month before you can see the final shape of the surgery.

- Uncontrolled fracture: unexpected fracture during bony surgery. Can occur in an area of weakness in the bone. In this event it might be necessary to repair it or to wire the jaw for a period of tree to four weeks to prevent misalignment of the teeth. Very rare.

- Sulcus contracture: It means excess scaring around the intra-oral incision. It may lead to difficulty wearing or fitting dentures.

- Wound dehiscence: It means wound opening or delayed healing. It is best treated with month wash and time. It happens more frequently in smokers. It can be a problem in the presence of an implant because the implant might get infected. It is still very rare.

Bichat fat pad

- Overressection: can lead to hollow cheeks. Conservative resection is usually done.

- Asymmetry: Even if great care is taken to remove the same quantity of fat in both sides, asymmetry can still occur. It is still a very rare occurrence.

- Buccal branch injury: Can cause some kind of weakness of the muscle responsible for the smile. It is very rare.