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Why facelifts are safer now

Facelift surgeons have lowered the old risks of bleeding, skin loss and a pulled look by lifting the deeper tissue, controlling blood pressure and nausea, and asking patients to stop nicotine. The risks that remain are known, and a patient lowers them by choosing an accredited facility, treating high blood pressure and stopping nicotine weeks ahead.

Dr. T. Gerald O'Daniel, whose work is cited here, is a featured surgeon and a client of the publisher; see the disclosure.

For a person who had a facelift in the 1960s and early 1970s, the major complications were bleeding under the skin, loss of skin and damage to the facial nerve (Leist 1977). Lifts of that era could also leave a pulled look and visible scars (Hamra 1998, Kridel 2003). Hematoma rates have fallen since (Baker 2005, Rees 1994), and the changes came in the lift itself, blood pressure control, anesthesia, nicotine rules and accredited operating rooms. For a patient today, a serious complication after a facelift is uncommon (Gupta 2016), and the risks that remain are known. What the surgery itself does now is told in The modern facelift.

Risks in earlier decades

The first facelifts cut away or undermined skin and closed it under tension. With nothing deeper lifted, the skin carried the whole lift, and the result faded as the skin stretched (Barrett 2016). Tension left marks: an earlobe pulled down onto the cheek, called the pixie ear (Coscia 2013), hairless cheek skin carried up into the sideburn (Barrera 1998), hair loss at the temple, conspicuous scars and a distorted tragus (Kridel 2003). Lifts pulled sideways tightened the jaw while the cheek above kept sliding down, the pulled look Sam Hamra named the lateral sweep (Hamra 1998).

Bleeding was common. Published rates of hematoma, blood collecting under the skin, ran to about 1 in 10 in men (Baker 2005). Nausea and vomiting after surgery went with hematoma (Thompson 1978). Smokers lost skin: in 1984 Thomas Rees and colleagues traced many skin losses after facelift to cigarettes (Rees 1984).

The lift moved to the deeper layer

In 1976 Vladimir Mitz and M. Peyronie described the SMAS, the layer of fascia and muscle under the facial fat, and surgeons since have lifted it so the deeper tissue carries the lift (Mitz 1976, Barrett 2016). Skin-only lifts are now a small share of the facelifts in American board case data (Stein 2024). Hamra moved the main pull up and toward the center of the face to prevent the lateral sweep (Hamra 2000).

The skin is now closed without pull. Setting the earlobe so its lower edge carries no tension prevented pixie ear in a consecutive series (Mowlavi 2005), and skin closed without tension heals with a smaller scar (Kim 2022). Injecting a large volume of dilute fluid before dissection, called tumescent infiltration, was followed by less skin loss, hair loss and thick scarring (Jones 2004).

Bleeding under the skin

A hematoma is the most common serious complication of a facelift. Most appear within 12 hours of surgery, often after office hours, and a large one left untreated can cut off blood flow to the skin (Niamtu 2005). See Hematoma and the hemostatic net.

Blood pressure control

High blood pressure after surgery was identified as a key cause of hematoma in 1976 (Baker 2005), and blood pressure control has the longest record against it. At Daniel Baker's hospital, hematomas needing surgery in men fell by about half after a strict regimen began (Baker 2005). Rod Rohrich's group kept hematoma under 1 in 100 with a protocol built around clonidine, a blood pressure drug (Ramanadham 2015), and a lower target after surgery cut the rate again in another practice (Bassiri-Tehrani 2023). Pressure during surgery matters too. One hospital credited a fall in its hematoma rate to avoiding low pressure under anesthesia (Rees 1994), and wide swings in pressure during surgery predicted hematoma in a later series (Abi-Rafeh 2024). One surgeon had no hematomas once pain, blood pressure, anti-nausea and calming medicines were given routinely at the end of surgery (Beer 2010).

Tranexamic acid

Tranexamic acid (TXA) slows the breakdown of blood clots and is given by vein or in the numbing fluid (Davison 2025). It reduces bruising (Cohen 2021, Klimczak 2025) and minor hematomas, with no clear drop in major ones (Alenazi 2024); applied locally, it lowered hematomas overall in a 2026 meta-analysis (Mokhtar 2026). Wound-healing problems were reported after local TXA (Yalamanchili 2023), and a larger matched comparison at a dilute dose found none (Darras 2025).

The hemostatic net

André and Luiz Auersvald described the hemostatic net, a running stitch through the skin and the tissue beneath it that closes the space where blood collects. Their first series with the net had no early hematomas (Auersvald 2014), and pooled data put hematoma with the net below 1 in 100 (Ribeiro 2026, Gonçalves 2026). Most of those comparisons use earlier patients as controls. The one randomized trial found the net equal to drains (Ismail 2025), and a 2026 meta-analysis rated the evidence that the net beats standard surgery as very low certainty (Gonçalves 2026). The stitches leave red marks in some patients that fade within a few months (Ribeiro 2026).

Drains and tissue glue

Drains did not prevent hematoma in a randomized split-face trial, and the drained side bruised less (Jones 2007). Tissue glue lowered hematoma in pooled trials and made no difference in a national database (Chien 2023, Eberly 2025). In deep-plane lifts, no measure among TXA, glue and the net was clearly better than the others (Azzi 2026).

Anesthesia and nausea

Modern facelift anesthesia aims at steady blood pressure and little nausea. Total intravenous anesthesia gives the anesthetic by vein instead of as a gas; in a randomized trial, women given it woke and were ready to go home sooner (Jones 2015). Dexmedetomidine is a sedative that lowers blood pressure and spares breathing (Taghinia 2008). T. Gerald O'Daniel reported it in facial rejuvenation surgery in 2006: it held blood pressure low in most of his patients, and none needed medicine for nausea (O'Daniel 2006). A later series using it by vein with propofol had little nausea and no hospital admissions (Moore 2022).

Nausea and vomiting can contribute to hematoma. In a randomized trial of plastic surgery patients under sedation, the anti-nausea drug ondansetron cut vomiting by more than half (Marcus 2002). Some surgeons operate under local anesthesia with light sedation, which brought steadier blood pressure and fewer clots than general anesthesia in a 2026 review (Beaufigeau 2026). See Anesthesia and recovery.

Blood clots

Clots in the leg veins and lungs are rare after face surgery: about 1 in 10,000 after face procedures in a US cosmetic surgery registry, and higher when face and body procedures were combined (Winocour 2017). In one facelift practice both clots followed combined procedures, and risk rose with operations longer than five hours (Abboushi 2012). The American Society of Plastic Surgeons (ASPS) recommends scoring each patient's clot risk with the Caprini model and matching prevention to the score (Murphy 2012).

Blood thinners raise bleeding in a facelift. In one series the bleeding rate rose sharply with low-molecular-weight heparin, while compression stockings and walking on the day of surgery were followed by no symptomatic clots (Durnig 2006).

Smoking and nicotine

Smokers have about 13 times the risk of skin loss after a facelift (Knobloch 2008), and among smokers, skin loss was tied to smoking after surgery (Riefkohl 1986). Stopping for at least 4 weeks before surgery lowers the risk (Rinker 2013, Knobloch 2008), and a cotinine test shows smoking in the previous few days (Knobloch 2008).

Nicotine patches and gum did not appear to raise surgical risk in a 2022 review, and e-cigarettes deliver nicotine much like cigarettes. The review advised stopping all nicotine before and after surgery (Guérif 2022).

Facial nerve safety

The facial nerve moves the muscles of expression. In 1979 Daniel Baker and Conley warned that newer, deeper dissections would raise the risk of injuring it (Baker 1979). Early lifts from the bone did injure it more often, and Oscar Ramirez moved his dissection at the temple deeper and reported no nerve injuries after the change (Ramirez 1991).

In 1992 Stuzin, Baker and Gordon described the face as a series of layers, with the nerve branches of the cheek lying under the deep fascia (Stuzin 1992). Where a branch sits varies from person to person, but its depth relative to the layers is nearly constant (Roostaeian 2015). Surgeons use that to keep their dissection in planes away from the branches and to mark the danger zones where a branch runs close (Stuzin 2020).

Today permanent weakness of a facial muscle after a facelift is about 1 in 2,000 (Gandra 2025). Most temporary weakness recovers within six months (Arianpour 2025). Pooled data show no difference in permanent injury between SMAS techniques (Jacono 2019) and no permanent injury in deep-plane series (Koroma 2026). The nerve injured most often is the great auricular nerve, which gives feeling to the ear (Lefkowitz 2013).

Accredited facilities

ASPS requires its members to operate in an accredited, Medicare-certified or state-licensed facility for anything beyond local anesthesia with mild oral sedation (ASPS, Accredited facilities). The Aesthetic Society requires the same of its members and states that most office-based surgical facilities are not accredited (The Aesthetic Society, Facility accreditation). In the ASPS outcomes database, office-based surgery and general anesthesia were both linked to more adverse events after facelift (Chopan 2020).

Complication rates today

Rates depend on what is counted. CosmetAssure, a complication insurance program for members of ASPS and The Aesthetic Society (CosmetAssure), counts problems that need an emergency visit, a hospital stay or another operation within 30 days. In its data about 2 in 100 facelift patients had one, fewer after a facelift alone and more when other procedures were added (Gupta 2016). Records that count every adverse event, or every return to a hospital or surgery center, report higher rates, most often for hematoma (Chopan 2020, Lee 2018).

Patients over 65

Age alone did not raise complications. Patients 65 and older had major complication rates close to those of younger patients (Martén 2011), and a 2026 update of that series found no link between age and complications, including over 75 (Vishwanath 2026a). Patients 75 and older did as well as younger patients matched for overall health, and the authors advised judging health status rather than age (Becker 2004). One earlier series did find more complications after 55 (Abboushi 2012). See Facelift by age.

Men

Men bleed more after a facelift. In 1977 Baker and colleagues found large hematomas more often in men than in women (Baker 1977), and in the CosmetAssure data male sex raised hematoma risk almost four times (Gupta 2016). Proposed reasons include thicker skin with more blood vessels, higher blood pressure, and more alcohol and tobacco use (Vishwanath 2026b). Strict blood pressure control narrowed the gap (Baker 2005), and in a 2026 matched comparison under standard hematoma prevention, no man had a hematoma (Vishwanath 2026b). See Male facelift.

Risks that remain

Hematoma remains the most common serious complication (Gupta 2016). Risk is higher in these situations:

  • Other procedures added to the facelift, which raise major complications (Gupta 2016) and clot risk (Winocour 2017).
  • Long anesthesia, obesity and high blood pressure, which predicted unplanned hospital admission after outpatient facelift at one center, where dexmedetomidine was also linked to admission (Alnemri 2026).
  • A second facelift, which carries more risk of temporary nerve injury than a first (Chang 2022).
  • Reduction of the submandibular glands in the neck, followed by weakness of the lower lip in about 1 in 10 patients (Shauly 2026). See Deep neck lift.

The surgeon controls the venue, the number of added procedures, the length of the operation and the type of anesthetic (Chopan 2020).

Recovery then and now

Under sedation, nausea and vomiting once caused most unplanned hospital admissions after plastic surgery (Marcus 1999); in a 2022 facelift series under intravenous anesthesia, no patient was admitted (Moore 2022). Deep-plane lifts were described as having a longer recovery (Barrett 2016), and a 2026 comparison found recovery similar after deep-plane and plication lifts (Neel 2026). Patients returned to social life in about a week in one series (Firmin 2009) and to work at about two weeks after a short-scar lift (Mast 2014). TXA and drains reduce bruising (Klimczak 2025, Jones 2007). See Recovery week by week.

Steps a patient can take

  • Stop all nicotine, including vaping, at least 4 weeks before surgery, and stay off it while healing (Rinker 2013, Guérif 2022, Riefkohl 1986).
  • Have high blood pressure treated before surgery. High pressure before surgery was an independent hematoma risk (Maricevich 2014).
  • List every medicine and supplement. Aspirin and anti-inflammatory drugs raised hematoma risk (Grover 2001), some herbal supplements raise bleeding risk around surgery (Wong 2012), and ASPS asks patients to stop medicines that raise bleeding risk as the surgeon directs (ASPS, Your health and safety).
  • Choose a board-certified surgeon. Members of ASPS and of the AAFPRS are board certified (ASPS, Member qualifications, AAFPRS).
  • Confirm the facility's accreditation directly with AAAASF, AAAHC or The Joint Commission (ASPS, Accredited facilities).
  • Ask how long the operation will take, what else is planned with it, and how blood pressure and nausea will be controlled (Gupta 2016, Abboushi 2012, Beer 2010).
  • Plan for the first night. Most hematomas appear within 12 hours, often after office hours (Niamtu 2005).

See also The papers that changed the facelift and The future of the facelift.

Sources

PubMed (records checked 2026-10-06)

Society and program pages (fetched 2026-10-06)