Anesthesia and recovery in facelift surgery

The three choices

• General anesthesia: the patient is fully asleep with a breathing tube, and the anesthetist controls waking so that it is calm and blood pressure stays low (PMID 25415274).
• Total intravenous anesthesia (TIVA): propofol given by drip, often with dexmedetomidine, a sedative that lowers blood pressure without slowing breathing; most patients need no breathing tube (PMID 35512645, PMID 19338881).
• Local anesthesia ("awake" facelift): dilute lidocaine with adrenaline injected into the face, with or without a sedative pill or light sedation (PMID 42034464, PMID 42380310).
• Where facelifts are done depends on the data source. In American Board of Plastic Surgery case data, about three in four were done in an accredited office facility (PMID 38302713). In the American Society of Plastic Surgeons outcomes database (TOPS), about half were office-based and about six in ten were under general anesthesia (PMID 32459769).
• In that outcomes database, adverse events followed about 1 in 20 facelifts; general anesthesia, office-based surgery, longer operations, combined procedures, male sex, obesity and smoking were each linked to more of them (PMID 32459769).

How anesthesia made facelifts safer

• Bleeding under the skin flap (hematoma) has long been the most common serious problem after a facelift, and high blood pressure and male sex are its main risk factors (PMID 20333520).
• A surgeon who worked in two clinics compared two routines after surgery. When pain, blood pressure, anti-nausea and calming medicines were given before the patient woke, no patient had a hematoma; when they were given only on request, about 1 in 14 did (PMID 20333520).
• Rohrich's group used one anesthetic protocol from 1990 to 2013, with calming medicine beforehand, controlled waking, and treatment of nausea, pain and high blood pressure; about 1 in 100 patients had a hematoma (PMID 25415274).
• In 2006 O'Daniel reported dexmedetomidine as the main sedative for extended SMAS facelifts without a breathing tube. Blood pressure stayed controlled in most patients, breathing stayed normal, and no patient needed medicine for nausea (PMID 19338881).
• In 2022 O'Daniel's group reported a large series of facelifts under propofol TIVA with dexmedetomidine: blood pressure was lowered from the start of anesthesia to discharge, nausea or vomiting affected under 1 in 100 patients, and no one was admitted to hospital (PMID 35512645).
• About 1 in 20 of those patients needed conversion to general anesthesia with a breathing tube; it was more likely with a higher body weight, other health conditions, high blood pressure before surgery and several procedures at once (PMID 35512645).
• In a randomized trial, patients given intravenous anesthesia woke and were ready for discharge sooner than patients given inhaled anesthesia (PMID 25906190).

Local anesthesia

• Across studies of facelifts under local anesthesia, complications were low, with hematoma in about 1 in 40, fewer blood clots and steadier blood pressure than under general anesthesia (PMID 42034464).
• Deep-plane facelifts with deep neck work have been done under local anesthesia: hematoma and wound infection each occurred in about 1 in 50 patients, there was no lidocaine toxicity, and every complication settled without further surgery (PMID 41800201).
• SMAS plication with neck tightening under local anesthesia needed no conversion to general anesthesia, and hematoma occurred in about 1 in 40 (PMID 42380310).
• One office series under local anesthesia with a sedative pill had more hematomas, about 1 in 8; most were small and drained with a needle, and there were no blood clots or hospital stays (PMID 30107493).
• Most short-scar facelifts are done awake or under light sedation (PMID 37950895).
• After sedation, nausea and vomiting are the main reason a patient planned for same-day discharge stays overnight (PMID 10513915).

Blood clots

• Blood clots in the legs or lungs are rare after facelift: about 1 in 5,800 operations under local anesthesia in a multicenter survey (PMID 23708241).
• Clot risk rises when the operation runs longer than five hours, and both clots in one large series followed a facelift combined with another procedure (PMID 22446820).
• Blood thinner injections carry a cost: in one series bleeding after surgery occurred in about 1 in 6 patients given heparin against about 1 in 90 without it (PMID 16874225).
• In a series of facelift patients with high clot-risk scores who received no blood thinners, no one had a clot (PMID 35601235).

Recovery

• Most patients go home the same day (PMID 35512645).
• Major complications after facelift occur in about 1 in 55 patients, most often hematoma at about 1 in 90, and the rate is higher when other operations are combined (PMID 26578747).
• Drains reduce bruising and do not change the hematoma rate (PMID 17572574).
• Tranexamic acid added to the local anesthetic reduced bruising at one week on the treated side (PMID 39574336).
• Steroids did not reduce facelift swelling in randomized trials (PMID 8657760, PMID 7480274, PMID 24887069).
• A cooling mask increased reported swelling at days 6 to 8 and did not reduce bruising or pain (PMID 21570371).
• Arnica tablets gave a smaller bruise area on days 1 and 7 only, with no difference patients or staff could see (PMID 16415448).
• Marks from a hemostatic net suture fade within a month in most patients (PMID 39623234).
• Return to work averaged about two weeks after a short-scar (MACS) lift (PMID 24691336). Recovery took a median of about four weeks after both deep-plane and SMAS plication facelifts (PMID 42384060).
• At three months patients rated themselves about six years younger, and the result held at six and twelve months (PMID 30488241).

Questions to ask a surgeon

• Who gives the anesthetic, and which kind will I have? (PMID 35512645)
• Is the operating room accredited? (PMID 38302713)
• How will my blood pressure be kept down during and after surgery? (PMID 25415274)
• What will I be given to prevent nausea and vomiting? (PMID 20333520)
• Will I get a blood thinner, and why or why not? (PMID 16874225)
• How long will the operation take, and what else is being combined? (PMID 22446820)

Open questions

• Local or general anesthesia: local is linked to fewer blood clots and steadier blood pressure (PMID 42034464), while one local-with-pill series had a high hematoma rate (PMID 30107493).
• Enhanced recovery protocols: plastic surgery studies of them are reported unevenly and few cover aesthetic surgery (PMID 39729950); the facelift case rests on one retrospective series (PMID 35512645).
• Blood thinners: risk scores recommend them for most facelift patients, while heparin raised bleeding in one series (PMID 35601235, PMID 16874225).

Terms

• TIVA: total intravenous anesthesia, usually propofol-based (PMID 35512645).
• Dexmedetomidine: a sedative that lowers blood pressure without slowing breathing (PMID 19338881).
• Bispectral index (BIS): a brain-wave monitor of anesthetic depth (PMID 25906190).
• Tumescent local anesthesia: dilute lidocaine with adrenaline injected in volume (PMID 42380310).
• PONV: postoperative nausea and vomiting (PMID 35512645).
• Caprini score: a blood-clot risk score (PMID 35601235).
• ERAS: enhanced recovery after surgery protocols (PMID 39729950).
• Hilotherapy: a cooling mask with circulating cold water (PMID 21570371).
• FACE-Q Early Life Impact scale: a patient questionnaire for the first weeks after treatment (PMID 25626785).

Papers