Facelift complications and how to prevent them

What complications can occur?

A facelift is surgery that lifts and secures sagging facial skin and the tissues beneath it. Rather than pulling only the skin, many methods also treat the superficial musculoaponeurotic system (SMAS), the layer where the facial muscles and their connective tissue (fascia) are joined. Because the surgery covers a large area, it carries risks, and the literature notes that while the complications are well known, many of them can be prevented ^[4].

Possible problems include hematoma, facial nerve injury, a collection of clear fluid (seroma), death of skin tissue (skin necrosis), and infection. In a large meta-analysis, the complications whose rates differed by surgical method were also temporary facial nerve injury, hematoma, seroma, necrosis, and infection ^[2]. Of these, hematoma is cited as the most common complication of a facelift ^[1].

Do complications differ by surgical method?

A 2019 meta-analysis pooled 183 studies and compared complications by method of handling the SMAS ^[2]. The methods compared were plication, in which the SMAS is folded and stitched; methods that remove part of the SMAS or overlap and secure it (SMASectomy, imbrication); the SMAS flap; the high lateral SMAS flap; the deep plane; and the composite lift ^[2].

Temporary nerve injury was highest with the high lateral SMAS flap (1.85%) and the composite lift (1.52%), and these were the only two methods that showed a statistically significant difference compared with plication (odds ratios of 2.71 and 2.22, respectively) ^[2]. The risk of permanent nerve injury did not differ between methods ^[2].

Major hematoma was increased with the deep plane (1.22%, odds ratio 1.67) and SMAS imbrication (1.92%, odds ratio 2.65), and skin necrosis was higher with the SMAS flap (1.57%, odds ratio 2.29) ^[2]. Even so, the authors concluded that the surgical method should be chosen based on the quality of the results, not the pattern of complications ^[2]. These figures are pooled results from many studies and were not analyzed separately for Korean patients, so your individual risk needs to be judged separately through an examination.

Hematoma is the most common: can it be reduced?

Because a variety of supplementary methods are used to prevent hematoma, a 2021 systematic review looked at which of these methods have strong evidence ^[1]. Of the 2391 articles found, 48 were ultimately included, and the methods were divided into tissue glues, medications used around the time of surgery such as anesthetics and blood pressure drugs, and measures taken during surgery such as blood-clotting (hemostatic) agents and drains ^[1].

Among the included studies, 9 were level of evidence II, 24 were level III, and the rest were level IV, so only some had relatively strong evidence ^[1]. While noting that many results were promising, the authors summarized that the current literature supports the senior author's experience that an approach combining several evidence-based methods is ideal ^[1]. In other words, they suggested combining several methods rather than relying on just one.

A meta-analysis that looked only at tissue glue (fibrin glue) pooled 7 controlled trials ^[3]. When glue was used, the likelihood of hematoma was about one quarter (relative risk 0.25), but seroma was not meaningfully reduced (relative risk 0.56), and drainage volume at 24 hours and bruising could not be assessed because of insufficient data ^[3]. Which measures and medications to use is decided by your surgeon, taking into account both the surgical method and your health.

Problems when the neck is treated as well

The neck is sometimes treated at the same time as a facelift. A review of neck surgery explained that cosmetic problems often result from treating the various components of the neck too much or too little ^[5]. With the platysma, the thin muscle of the neck, as the dividing line, the shallower structures that are easy to reach are prone to overtreatment, while the deeper structures that are hard to reach are prone to undertreatment and imbalance ^[5]. The review added that new complications have also appeared with the arrival of minimally invasive techniques ^[5].

Preparing to reduce complications

The literature explains that avoiding complications requires meticulous surgical technique, knowledge of anatomy, and an understanding of the risks before and after surgery ^[6]. A thorough medical history and examination before surgery, along with realistic expectations, are said to help both the surgeon and the patient understand in advance the possible complications and the care needed after surgery ^[4].

There are also things you can do as a patient. Telling your surgeon about any medical conditions, the medications and supplements you take, whether you smoke, and any previous surgery is the starting point of the medical history. After surgery, follow the care instructions you are given, and if you notice any unusual changes, such as sudden swelling on one side of the face or worsening pain, it is best to contact the clinic right away.

If a complication occurs, and what to check during your consultation

If a problem occurs, it is important for the surgeon to diagnose and resolve it quickly ^[6]. A review of common complications stated that most complications are temporary and that the overwhelming majority are managed without surgical treatment, but it stressed that complications can be difficult for both the patient and the surgeon, so a relationship of mutual trust is important ^[4].

The level of risk varies from person to person depending on your health, the condition of your skin, and the extent of surgery. Checking the following during your consultation can help.

• The planned surgical method and why it was chosen
• The measures taken before and after surgery to reduce hematoma
• How the risks change if the neck or forehead is operated on at the same time
• How to get in touch if you have unusual symptoms after surgery
• The plan for treatment and care if a complication occurs