Facial Aesthetic Procedures after Radiation

Goals/Purpose: If radiotherapy caused skin ischemia, then facial aesthetic and reconstructive procedures such as facelifts and facial advancements involving irradiated tissue should lead to disastrous skin loss. A frequently cited theory regarding tissue healing in irradiated patients is that radiotherapy for cancer treatment causes gradual microvascular occlusion and ischemia, which cause poor healing after surgical treatment. Radiation-induced tissue damage is generally divided into three phases: a) acute (0-6 months), during which there is release of reactive oxygen species and free radicals into the exposed cells, with fibroblast, endothelial cells and epidermal cells affected; b) latent period, which begins around 6 months after treatment; c) late reactions occur next and can progress up to 20 years after initial exposure, with continued release of cytokines and growth factors, with proliferation of fibroblasts and extracellular matrix deposition. All of this may lead to stiff, poorly compliant skin. However, significant evidence suggests that irradiated skin is not ischemic and that poor healing is attributable to irradiated fibroblasts and fibroblast stem cells. Normal oxygenation in irradiated tissue should thus allow surgical healing, as long as skin tension is avoided. We report three successful cases of facial procedures performed within heavily irradiated tissues, with normal healing.

Methods/Technique: A retrospective review was performed identifying patients who underwent aesthetic or reconstructive facial procedures after undergoing radiation. Patients operated on by the senior author (S.A.W.) were reviewed. Aesthetic outcomes and postoperative complications such as tissue loss or necrosis were evaluated.

Results/Complications: A total of 3 patients were identified who underwent aesthetic or reconstructive facial procedures after significant radiation.

Patient 1: A 56-year-old female with squamous cell carcinoma of floor of mouth, underwent radiation therapy, with resultant accelerated facial aging. She underwent a subcutaneous SMAS plication facelift for improvement of the lower neck and mandibular contour. Following this, for skin resurfacing, she underwent phenol-croton oil peel with a significant improvement in skin texture and fine rhytides; there was no hyper- or hypopigmentation nor skin loss. After 23 months, due to moderate residual unilateral jowling, she underwent another unilateral facelift with tightening of the jowl area; again, recovery was uneventful, with no increase in downtime compared to other patients.

Patient 2: A 63-year-old male had received 6000-cGy cobalt irradiation for treatment of a T3N2M0 squamous cell carcinoma of the left floor of the mouth, tonsil, lateral pharyngeal wall, and neck 13 years earlier, with no long-term skin sequelae. A right carotid artery endarterectomy had been performed. A face lift, submental lipectomy, and genioplasty were performed, using the prior right neck scar. Healing was uneventful, with no skin necrosis.

Patient 3: A 14-year-old male with rhabdomyosarcoma of the maxillary sinus, underwent radical excision and radiation therapy at age 3 years, with subsequent significant hypoplasia of his midface, loss of almost all teeth. He then underwent multiple reconstructive procedures, including bilateral serratus anterior free muscle flaps, a LeFort III osteotomy with external distraction, iliac bone grafting to the orbit, and a tip rhinoplasty. There were no complications with these procedures, with good skin viability and no prolonged wound healing issues. He also additionally went fat grafting two years after finishing distraction, with good maintenance of grafted volume and a good overall clinical aesthetic result.

Conclusion: In all three patients, the irradiated skin healed normally, with no ischemia, necrosis or increase in down-time compared to other patients. Radiation itself can cause tissue damage, fibrosis, scarring and radionecrosis. Irradiated tissues are associated with increased rates of surgical complications, which have been extensively studied in the breast, with increased infection, capsular contracture, implant exposure and overall reconstructive failure, which has led some surgeons to avoid offering contralateral symmetry or other cosmetic interventions to this patient population. Our results lend support that patients undergoing facial aesthetic procedures following radiation can have an acceptable aesthetic result without complications. These cases provide support for the theory that irradiated tissues have normal perfusion and oxygenation. The thin face lift flaps likely would not have survived if irradiated tissue was truly ischemic. Patients who have suffered through malignancy and radiotherapy need not be deprived of aesthetic procedures. However, the quality of the skin should be evaluated before operating in previously irradiated patients; indocyanin green angiography or infrared imaging methods may prove to be of benefit and require further investigation.