Facelift complications — Haematoma, flap and nerve, and what to do with each
The commonest complication and how to prevent it, the difference between flap suffering and necrosis with their treatment, the real risk of nerve injury, and the postoperative course ordered by the rule of 3.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Haematoma is the commonest complication and the only one that may demand an urgent return to theatre. It is commoner in men.
- Complete facial palsy is practically impossible with correct technique; what occurs is paresis of a branch, around 0.5 %, recovering spontaneously within three months.
- Flap suffering has two causes and only one is avoidable: advanced age is not, but closing the skin under tension rather than passively is.
- Distinguishing suffering from necrosis changes treatment entirely: one is treated to save tissue, the other so that it heals well.
- Cicatricial alopecia depends entirely on technique: incision bevel, closure tension and choice of suture.
The major complications
| Complication | Frequency and course | What to do |
|---|---|---|
| Haematoma | Around 1 %, and commoner in men because of beard vascularity and a greater tendency to postoperative hypertension | Most resorb with observation. An expanding haematoma is an emergency: theatre drainage, evacuation and haemostasis, without delay |
| Facial nerve injury | Paresis of a branch around 0.5 %, with spontaneous resolution within 3 months. Complete palsy is practically impossible | Explain the expected course and balance the asymmetry with toxin on the healthy side while it recovers |
| Flap suffering | Doubtful colour, slow capillary refill, no tissue loss yet. It appears at very advanced ages or after a tension closure | Oral antibiotic, topical nitroglycerin three times daily for two weeks and pentoxifylline 400 mg three times daily for two weeks |
| Flap necrosis | Established tissue loss, typically at the tip of the retroauricular flap, the area furthest from the blood supply | Oral antibiotic, daily soap-and-water cleansing and silver sulfadiazine twice daily for two weeks. It heals by secondary intention; if a scar remains, resurfacing at 6 months |
Haematoma is prevented before the incision
Almost everything that reduces haematoma is done before or during, not after. In clinic: detect and correct antiplatelets, anticoagulants and haemostatic disorders, and warn about smoking. In theatre: tumescent anaesthesia with vasoconstrictor, meticulous haemostasis before closing, and tranexamic acid, whose local use during facelift has been associated with less bleeding and greater operative efficiency. On closing: drains, transfixing sutures in the temporal and submandibular areas to eliminate dead space, and a dressing without compression on day one — compression is added the next day, after drain removal. And blood pressure control in the immediate postoperative period, which is when the expanding haematoma occurs.
Why complete palsy does not happen
It is not luck but anatomy. The facial nerve divides into five branches before entering the dissection field, and the zygomatic and buccal branches are richly anastomosed, so division of an isolated twig is usually compensated. The temporal and marginal branches have few connections and therefore leave deficits, but they are also the ones a correct plane keeps out of reach. And one example illustrates the principle: orbicularis oculi receives innervation from three different branches — temporal, zygomatic and buccal — so its paresis after periorbital resuspension manoeuvres is practically impossible. Redundancy protects.
Minor complications and their treatment
| Problem | Treatment |
|---|---|
| Hypertrophic scarring | Intralesional corticosteroid injection. It connects with the scar revision note: in surgery whose result depends on hidden scars, a tendency to hypertrophy should have been detected before operating |
| Hyperchromic lesions | Microneedling with hyaluronic acid, and strict photoprotection while they resolve |
| Hypochromic lesions | Prostaglandin analogue ointment once daily for two weeks, with or without associated CO₂ laser |
| Cicatricial alopecia | There is no good treatment: it is prevention. Incision bevel parallel to the follicles, wide scalp release and tension-free closure |
| Infection | Uncommon. When it appears, typically around suspension hardware: an argument for fixing without permanent foreign material |
The postoperative course, day by day
- Same dayEar canal irrigation, antibiotic ointment on the wounds, one gauze per ear and a dressing without compression. Oral antibiotic, corticosteroid and analgesia
- Day 1Remove drains, clean the wounds, and now apply a long-stretch compression bandage
- Day 3Remove the transfixing sutures. From here the patient starts hygiene: washing hair and wound with pH-neutral soap and dressing every 12 hours
- Day 10Remove sutures and dressing, check incision stability and start a moisturiser with sun protection for one month
- Weeks 2 and 3Lymphatic massage from week two. Light activity at two weeks and normal activity at three
- Six weeksReview for submental corticosteroid injection if needed and toxin in depressor anguli oris. If the scar shows, CO₂ laser from 6 weeks. Global sensation starts to return
- Three monthsFollow-up photography, with the same position and lighting as the preoperative images
The rule of 3
- At day three, hygiene starts and the transfixing sutures come out.
- At three weeks, normal activity.
- At three months, photographs. Before that, oedema still distorts and comparisons mislead.
- It is an easy scheme to remember and, above all, easy to explain to the patient, which is where it really helps.
Measures that improve the postoperative course
- Hyperbaric chamber in the first week: five sessions, one daily, 60 minutes at 2 atmospheres. It is an adjunct, not a rescue: it does not replace management of established necrosis.
- Radiofrequency as an adjunct for skin quality once the inflammatory process has settled.
- If resurfacing is combined in the same procedure — fractional laser or radiofrequency — add its own aftercare: gentle cleansing, local cold, oral corticosteroid and photoprotection from day three.
What must be said before, not after
Three things change in nature depending on when they are said. Haematoma: if the patient knows it is the commonest complication and may require a return to theatre, a reoperation is an anticipated setback; if not, it is a failure. Paresis: explaining that it can occur, that it recovers in about three months and that toxin compensates meanwhile turns an anxious phone call into a review. Sensation: numbness in the area is the norm and takes months to recover; almost no patient expects it unless told. And a fourth that gets forgotten: pre-existing asymmetries are still there, which is why they are pointed out and recorded at the first consultation.
References
- 1.Vaquero Martínez P. Cirugía de lifting. En: Manual de la Sociedad Española de Cirugía Oral y Maxilofacial y de Cabeza y Cuello. SECOM CyC; 2025.
- 2.Sinclair NR, Coombs DM, Kwiecien G, Zins JE. How to prevent and treat complications in facelift surgery, part 1: short-term complications. Aesthet Surg J Open Forum. 2021;3(1):ojab007.
- 3.Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg. 2001;54(6):481-486.
- 4.Coombs DM, Kwiecien GJ, Ortiz D, et al. Local infiltration of tranexamic acid during facelift improves operating room efficiency: a matched patient study. Aesthet Surg J. 2022;42(9):971-977.
- 5.Khoury S, Almubarak Z, Khan H, Boldt G. The deep plane versus SMAS facelift: a systematic review and meta-analysis. Aesthetic Plast Surg. 2025;49(21):5895-5903.
- 6.Davis RA, Anson BJ, Budinger JM, Kurth LE. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet. 1956;102(4):385-412.
Related specialty: Facial Lifting & Rejuvenation