Complications of facelift surgery — Haematoma, flap compromise and nerve injury
The most frequent complication and its prevention, the distinction between flap compromise and necrosis with their respective treatments, the actual incidence of nerve injury and the postoperative schedule.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Haematoma is the most frequent complication and the only one that may require urgent reoperation. Its incidence is higher in men.
- Complete facial palsy is exceptional with correct technique. What is observed is paresis of an isolated branch, around 0.5 %, with spontaneous recovery within three months.
- Flap compromise recognises two factors, one of them modifiable: advanced age is not; closure of the skin under tension is.
- The distinction between compromise and established necrosis determines the treatment: the former is treated to preserve viable tissue; the latter, to direct healing.
- Cicatricial alopecia depends entirely on technique: bevel orientation, closure tension and choice of suture.
Major complications
Four complications concentrate the morbidity of this surgery, and they share one feature: their management depends more on early recognition than on the therapeutic manoeuvre, which in all of them is well established. The table below sets out the incidence, expected course and corresponding conduct for each.
Incidence, course and conduct
| Complication | Incidence and course | Conduct |
|---|---|---|
| Haematoma | Around 1 %, with higher incidence in men owing to the vascularity associated with the beard follicle and a greater tendency to postoperative hypertension | Most resorb under observation. An expanding haematoma constitutes an emergency: evacuation in theatre and haemostasis, without delay |
| Facial nerve injury | Paresis of one branch at around 0.5 %, with spontaneous resolution within 3 months. Complete palsy is exceptional | Explain the expected course and compensate the asymmetry with botulinum toxin on the contralateral side during recovery |
| Flap compromise | Altered colour and delayed capillary refill, without tissue loss. It appears in elderly patients or after closure under tension | 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, characteristically at the distal end of the retroauricular flap, the region furthest from peripheral vascular inflow | Oral antibiotic, daily washing with soap and water and silver sulfadiazine twice daily for two weeks. It heals by secondary intention; if the scar is conspicuous, resurfacing at 6 months |
Haematoma prevention precedes the incision
The measures that reduce the incidence of haematoma are applied before and during the operation, not afterwards. In consultation: identify and correct antiplatelet therapy, anticoagulation and haemostatic disorders, and advise on the effect of tobacco. In theatre: tumescent anaesthesia with vasoconstrictor, meticulous haemostasis before closure and tranexamic acid, whose local infiltration during rhytidectomy has been associated with less bleeding and greater surgical efficiency. At closure: drains, quilting stitches in the temporal and submandibular regions to obliterate dead space, and a dressing without compression on the first day, compression being added the following day after the drains are removed. And control of blood pressure in the immediate postoperative period, the interval in which expanding haematoma occurs.
The anatomical basis of the low incidence of palsy
The rarity of complete palsy after rhytidectomy has an anatomical explanation. The facial nerve divides into its terminal branches before reaching the dissection field, and the zygomatic and buccal branches present abundant anastomoses between them, so that division of an isolated ramus is usually compensated by the adjacent ones. The frontotemporal and marginal branches have few connections and are therefore those that leave a permanent deficit; they are also those that a correct dissection plane keeps out of reach, according to the principle developed in the note on nerves and vascular supply. The orbicularis oculi illustrates the same mechanism with particular clarity: it receives innervation from three distinct branches, and that redundancy explains why its paresis after periorbital resuspension manoeuvres is exceptional.
Minor complications and their treatment
| Finding | Treatment |
|---|---|
| Hypertrophic scarring | Intralesional corticosteroid injection. The full development is found in the note on facial scar revision |
| Hyperchromic lesions | Microneedling with hyaluronic acid and strict photoprotection throughout resolution |
| Hypochromic lesions | Prostaglandin analogues in ointment, once daily for two weeks, with or without associated CO₂ laser |
| Cicatricial alopecia | It has no effective treatment once established: the approach is preventive — incision bevel parallel to the follicles, wide scalp release and tension-free closure |
| Infection | Infrequent. When it occurs it does so characteristically in relation to suspension material, which constitutes an argument for fixation without permanent material |
Postoperative schedule
- Same dayCleansing of the auditory canals, antibiotic ointment on the incisions, one gauze per ear and a dressing without compression. Oral antibiotic, corticosteroid and analgesia
- Day 1Removal of drains, wound cleansing and application of a long-stretch compressive bandage
- Day 3Removal of the quilting stitches and start of patient-led hygiene: washing of the hair and incisions with pH-neutral soap and dressing changes every 12 hours
- Day 10Removal of sutures and dressing, verification of incision stability and start of a moisturiser with sunscreen for one month
- Weeks 2 and 3Manual lymphatic drainage from the second week. Light activity at two weeks and usual activity at three
- Six weeksReview for submental corticosteroid injection if indicated and botulinum toxin in the depressor anguli oris. If the scar is conspicuous, CO₂ laser from this point. Sensory recovery begins
- Three monthsControl photographic record, reproducing the position and lighting of the preoperative views
Adjuvant postoperative measures
- Hyperbaric oxygen therapy in the first week: five sessions, one daily, of 60 minutes at 2 atmospheres. It is indicated as an adjuvant and does not replace the treatment of established necrosis.
- Radiofrequency on skin quality once the inflammatory process has resolved.
- If resurfacing is combined in the same procedure — fractional laser or radiofrequency — add its specific care: gentle washing, local cold, oral corticosteroid and photoprotection from the third day.
Content of the preoperative information
Four elements must appear in the preoperative information, since the patient’s perception of them depends on whether they were anticipated. Haematoma: stating that it is the most frequent complication and may require reoperation places that eventuality within the expected course. Paresis: explaining that it may occur, resolves at around three months and is compensated meanwhile with botulinum toxin allows it to be managed as a scheduled review. Altered sensation: numbness of the operated territory is the rule and its recovery extends over months. And preexisting asymmetries, which persist after the operation and are for that reason demonstrated and documented 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