Facelift complications and outcomes

The risks in numbers

• Major complications: about 1 in 55 facelifts; hematoma about 1 in 90 and infection about 1 in 300. The rate was about 1 in 65 for a facelift alone and up to about 1 in 27 when other operations were added (PMID 26578747).
• Who is at higher risk: men had about four times the hematoma risk; overweight patients and combined procedures had more infections (PMID 26578747). Patients over 55, men and patients with high blood pressure or on aspirin had more hematomas in another large series (PMID 22446820).
• Facial nerve: any weakness of a facial muscle followed about 1 in 150 facelifts in pooled data, and permanent weakness about 1 in 2,000 (PMID 40456989).
• By technique: pooled deep-plane studies found any complication in about 1 in 15, temporary nerve weakness in about 1 in 80, hematoma in about 1 in 55, skin loss in about 1 in 1,000, and no permanent nerve injury (PMID 42576065). SMAS techniques had temporary nerve injury in about 1 in 120 (PMID 38283861). Short-incision facelifts had complications in about 1 in 30 (PMID 37950895).

Hematoma

• Bleeding under the skin flap is the most common serious complication (PMID 26578747). It followed about 1 in 25 facelifts in a large series from 2001 (PMID 11513508). In pooled deep-plane studies any hematoma occurred in about 1 in 37 and a major hematoma in about 1 in 100 (PMID 41203255).
• In 2014 Auersvald reported the hemostatic net, a running stitch that tacks the skin flap down: no netted patient had a hematoma in the first three days, against about 1 in 7 before he used it, with no rise in poor blood supply to the skin (PMID 23949130).
• Tranexamic acid, tissue sealants and nets each went with major hematoma rates of about 1 in 65 to 1 in 80 in pooled deep-plane studies (PMID 41203255).

Facial nerve injury

• In 1979 nerve injury followed under 1 in 100 facelifts, and more than 4 in 5 recovered within six months (PMID 515227). Pooled data from recent decades give similar rates (PMID 40456989).
• Most injuries are temporary: about 7 in 10 recover fully within six months without surgery, and about 1 in 10 keep some weakness (PMID 41273502).
• Surveyed facial plastic surgeons report temporary weakness in 1 to 5 of every 100 cases, most often the muscle that lowers the lower lip; it was more common with deep-plane lifts and frequent salivary gland reduction (PMID 41251721).
• Pooled data link temporary injury to deeper techniques (high lateral SMAS and composite lifts), with no difference in permanent injury by technique (PMID 30768122).
• Revision facelifts carry more risk: temporary nerve injury about 1 in 14, against about 1 in 45 in first facelifts (PMID 35511039).
• When paralysis persists, a referral center explored and repaired some nerves; about half of patients in both the surgical and non-surgical groups regained normal function (PMID 38015890).
• Rarely, complete paralysis of one side of the face follows a facelift; it is most often linked to Bell's palsy and is usually treated with steroids (PMID 37897668).

Skin loss and smoking

• Smokers have damage in the small blood vessels of the skin, and skin loss after facelift was linked to smoking after surgery (PMID 3952215).
• A facelift with limited skin lifting avoided skin loss in a series where about a third of patients smoked (PMID 3952216). Deep-plane lifts have been proposed as an alternative for smokers (PMID 21768564).
• Pooled data across elective plastic surgery did not show a significant rise in total facelift complications in smokers (PMID 29426809).

Infection

• Infection followed about 1 in 300 facelifts (PMID 26578747).
• A review sets out the evidence on antibiotics before surgery, clearing skin bacteria, keeping the patient warm, body weight and smoking (PMID 25539351).

Signs of an operated face

• Pixie ear: the earlobe pulled down and forward onto the cheek by tension on the skin flap; it appeared in about 1 in 20 earlobe repairs in a review (PMID 39013675).
• Lateral sweep: a pulled look toward the ear. Hamra traced it to lifts that pull only sideways while the cheek and lower lid tissue keep falling, often with hollow eyes after lower lid fat is removed (PMID 9774028, PMID 11802570). A vertical sweep deformity has also been described (PMID 28006056).
• Joker line: a groove running from the mouth corner toward the ear. Most patients who develop it show a version before surgery, and it is treated by adding volume (PMID 18971739).
• Hamra proposed lifting the cheek and the muscle around the eye upward and inward, and keeping lower lid fat, to prevent and correct the "face-lifted" look (PMID 9774028, PMID 11802570).

How long results last

• A second facelift came an average of 9 to 12 years after the first in a review of secondary lifts (PMID 42382704). After SMAS flap facelifts the interval averaged about 12 years, and about 1 in 5 patients returned within five years (PMID 20224461).
• Nearly all patients rated their result very good or better at one year; about two in three did so at about 12 years, as aging continued (PMID 20224460).
• Patients under 50 rated their improvement as lasting longer (PMID 22186515).
• Fuller necks relapsed more over 25 years of one surgeon's practice, and opening the midline neck muscle reduced the return of neck bands (PMID 27348643).
• In identical twins, a full incision gave a better neck at five years than a short-scar lift (PMID 26890507).
• No randomized study has measured how long a facelift lasts; the figures come from revision intervals and surveys (PMID 20224461, PMID 20224460).

How much younger patients look

• Patients felt about six to seven years younger after a facelift (PMID 25909302, PMID 30488241). Satisfaction with the decision was high, and the neck and the area under the chin scored lowest (PMID 25909302).
• Blinded observers judged patients about five years younger (PMID 29040425).
• Face-age software read patients as about 3.5 years younger at three months and 1.7 years younger at 12 months, with no technique ahead of another (PMID 36706713). Software and observers consistently estimate a smaller change than patients do (PMID 34181603, PMID 39085528).
• Adding procedures such as fat grafting raised satisfaction after high-SMAS facelifts (PMID 28002252).

Revision and second facelifts

• Second facelifts make up a growing share of facelifts by board-certified plastic surgeons (PMID 38302713).
• They are harder: the SMAS is thinner and the planes are scarred, complication rates vary widely, and temporary nerve injury reaches about 1 in 8 in some series (PMID 42382704).
• Patients were at least as satisfied with a second facelift as with the first, and more extra procedures were added (PMID 9326793).

Questions to ask a surgeon

• How often do your patients have a hematoma, and what do you do to prevent it? (PMID 26578747)
• How often do your patients have facial weakness, and how long does it last? (PMID 40456989)
• Should I stop smoking, and for how long? (PMID 3952215)
• How do you avoid a pulled look or a pixie ear? (PMID 11802570)
• How long do your results usually last? (PMID 20224461)
• What would a second facelift involve for me? (PMID 42382704)

Open questions

• Nerve injury rates range from under 1 in 100 in pooled data (PMID 40456989) to 1 to 5 in 100 in a surgeon survey (PMID 41251721), depending on definition and reporting.
• Durability has no randomized evidence; figures come from revision intervals and surveys (PMID 20224461, PMID 20224460).
• Software age estimates run below patients' own (PMID 34181603, PMID 39085528).
• Smoking: strong evidence of vessel damage (PMID 3952215) but no significant facelift effect in pooled data (PMID 29426809).
• Neck results by technique: open platysmaplasty with liposuction and closed techniques scored differently in selected patients (PMID 42500364).

Terms

• Major complication (CosmetAssure): a complication needing an emergency visit, admission or reoperation within 30 days (PMID 26578747).
• Neuropraxia: a temporary nerve conduction block that recovers (PMID 41273502).
• Skin slough / necrosis: death of part of the skin flap (PMID 3952215).
• Pixie ear: an earlobe pulled down and forward onto the cheek (PMID 39013675).
• FACE-Q: a validated patient questionnaire for facial aesthetic procedures (PMID 24105086, PMID 25626785).
• Apparent age: the age observers assign from photographs (PMID 29040425).
• Secondary facelift: a second facelift after a prior one (PMID 42382704).

Papers