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Despite constant attention to detail, complications do occur. The most common problems and methods to prevent and to treat such complications are summarized in the following sections (13).

Hematoma

Hematomas are by far the most common complication after facelifting and vary from large collections of blood that threaten the survival of the skin flaps (and even compromise the airway) to small collections that are evident only when facial edema has subsided. Most major hematomas occur during the first 10 to 12 hours postoperatively.

The most common presentation of a hematoma is an apprehensive, restless patient experiencing pain insolated to one side of the face or neck. Because localized and worsening pain is unusual following an uncomplicated facelift, it must be regarded as a sign of hematoma until proven otherwise. Rather than provide analgesics for pain relief, the surgeon or nurse removes the dressing immediately to permit examination. In addition to causing skin flap ischemia, a large expanding hematoma under tight skin flaps has the potential to cause respiratory compromise.

The treatment for a hematoma of any degree is evacuation. If the collection is rapidly enlarging or if the flaps appear compromised, then sutures may be removed at the bedside for immediate relief of some of the pressure. Depending on the extent of the bleeding, the emotional state of the patient, and the availability of an operating room, the hematoma is either evacuated at the bedside or in the operating room. The important thing is to get the blood out. If formally explored, a specific bleeding point will rarely be found. If evacuated at the bedside, the patient must be sedated and the blood pressure reduced. Catheters are inserted and the hematoma is evacuated. The region is irrigated with saline until clear, and then with a 0.25% solution of lidocaine containing epinephrine 1:400,000. Gentle pressure is placed on the flap for 20 minutes. If this method does not result in complete removal of the hematomas, then the facelift wound is formally explored under adequate anesthesia to permit visualization and precise control of any bleeding.

The reported incidence of hematomas requiring evacuation ranges from 0.9% to 8.0%, but is approximately 3% to 4% when all studies are combined. Because most patients in the reported studies were women, this 3% to 4% range represents the incidence in female patients. Early studies demonstrated a hematoma rate in men of 7% to 9%, or twice that of women. More recent studies suggest that this difference between the two sexes is at least partly a consequence of blood pressure. When blood pressure in male patients is compulsively controlled, the incidence falls precipitously, approaching that of women.

As mentioned in the “Preoperative Preparation” and “Anesthesia” sections, blood pressure control is the single most important preventative measure. Ranking next in importance is the avoidance of medications that interfere with clotting or coagulation. Finally, every attempt is made to prevent vomiting, coughing, anxiety, or pain.

Small hematomas of 2 to 20 mL that are not apparent until edema begins to subside are a totally different entity and occur in 10% to 15% of patients. Initially, an area of firmness is palpable followed by ecchymosis in the overlying skin. Although somewhat controversial, it is my opinion that every effort should be made to evacuate even the small hematomas. A syringe and large-bore needle are used. Aspiration is repeated every few days until the collection is completely gone or no further liquid can be withdrawn. Repeated aspiration attempts are especially important in the neck where larger collections can be hiding. If the blood is not evacuated, the patient may develop a firm, woody, wrinkled mass that takes months to resolve, and in some cases leaves permanent changes in the skin. Compulsive attention to hemostasis, blood pressure control, drain placement, and postoperative management is required to obtain the best possible results in the neck. Rest-on foam applied to neck as the original dressing may also be of benefit.

Neck hematomas are more common when submental dissections are included in the facelift procedure. This fact, combined with the beneficial effect on the neck that accompanies the SMASectomy/SMAS plication techniques, has led to a smaller percentage of patients having submental incisions and midline platysmaplasties. The cost-to-benefit analysis between opening the neck to improve neck definition and avoiding submental dissections to prevent complications is a judgment that must be made for each patient, with the knowledge that neither choice may be perfect.

Triamcinolone (Kenalog) injections to small hematomas and areas of firmness are discouraged. They probably offer no benefit over watchful waiting and hematoma aspiration, and can result in subcutaneous atrophy and a depression when the hematoma resolves.

Skin Slough

Luckily for the patient and the surgeon, the most common location for skin slough is in the retroauricular area where the scarring is less visible. The bad news is that full-thickness skin loss will inevitably result in less-favorable scarring, which can be distressing to the patient and prevent the patient from wearing certain hairstyles. If the skin necrosis occurs in the preauricular area, it is a devastating complication.

The incidence of skin necrosis is 1% to 3%. The most likely causes of skin slough are (a) unrecognized hematomas, (b) a skin flap that is too thin or is damaged during flap dissection or burned with electrocautery, (c) excessive tension on wound closure, (d) cigarette smoking, and, possibly, (e) dehydration. There is no question that smoking increases the risk of skin slough. It is my impression that patients who are well hydrated tend to heal faster with a lower incidence of skin slough.

If the skin appears compromised at any point in the postoperative period, antibiotic ointment or silver sulfadiazine (Silvadene) cream is applied. The surgeon would much rather apply ointment to an area that turns out to be a partial-thickness injury than miss an area that is dying where some of the damage could be limited by aggressive wound care.

The treatment of skin slough is not surgical; it is conservative wound care. Areas of necrosis will contract dramatically and eventually epithelialize. The final scar, although permanent, is almost always better than would be anticipated from the initial wound appearance. If a secondary facelift is performed in an attempt to remove the scars, minimal excess skin will be present, and it may not be possible to remove scar that is more than 1 cm from the previous incision.

Nerve Injury

Injury to a branch of the facial nerve (cranial nerve [CN] VII) is the complication most dreaded by patients. Motor nerve injury occurs in 0.9% of patients who receive subcutaneous undermining only, but is more common with dissection of the SMAS, either as an independent layer or in a composite rhytidectomy. Many nerve injuries are temporary, presumably the result of traction or cautery. A nerve that has been transected will not recover function. If the surgeon is aware that a branch has been cut, then immediate intraoperative microsurgical repair is mandated. It is more likely, however, that nerve injury is not recognized during surgery, and the surgeon and patient are placed in the difficult position of waiting for return of function. Injuries to buccal branches tend to improve more than those in the frontal and marginal mandibular territories, presumably because of greater degrees of connections between branches in those areas.

Transient numbness of the cheeks and neck skin is a result of interruption of the small sensory branches during skin undermining and is unavoidable. Sensibility always recovers although it may take months to do so. Injury to the great auricular nerve is another matter. It is a large sensory nerve, as described under “Facelift Anatomy,” and transection will result in permanent numbness of half of the ear and, in some cases, a painful neuroma. The nerve is quite superficial on the surface of the sternomastoid muscle, especially in thin patients, and is easily transected. If such a transection occurs, the nerve should be approximated with appropriate microsurgical suture.

Hypertrophic Scarring

Hypertrophic scarring is most often attributable to excessive tension on the incision closure. Some patients, however, develop hypertrophic scars despite the best efforts of the surgeon. As with skin slough, this usually involves the retroauricular area, which is less visible, but can occur in the preauricular area where it is a bad complication. Small volumes of dilute triamcinolone are injected into the scars (not the adjacent normal tissue), sometimes more than once, and this usually improves the appearance of the scar significantly. An occasional patient will get true keloids of the facelift incisions, which are difficult to treat. Scar revision with immediate treatment with radiation is the best option is these difficult situations.

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