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All surgical procedures carry some uncertainty and risk. Even in the best hands, complications do occur. Patients vary in their anatomy, physical reaction to surgery and anesthesia, and healing capabilities, so that the outcome is never completely predictable. That’s just the nature of surgery.


Surgeons know from experience that two operations in different patients, done almost exactly the same way, may have very different outcomes. Even operations on two sides of the same face or body can have different outcomes, particularly in terms of discomfort, bruising and swelling. Patients are often surprised at this. They think that both sides should heal at the same rate after surgery, but in reality one side always seems to take a little longer than the other, whether it’s the eyelids, face, breasts, or body.


It is best if patients anticipate having a complication, and if they don’t, that’s a bonus. There is a well-worn phrase in surgery: “The only way to avoid complications is by not operating.” Experienced surgeons (particularly toward the end of their careers) are often very candid and admit that they’ve seen just about every complication in their practice over the years. If you are seeing an experienced surgeon, you are seeing a surgeon who has seen plenty of complications, including his or her own complications, not just complications in patients treated elsewhere.


One of my colleagues says he divides complications into two groups—those he has seen in his own practice and those he has not seen yet. The reality of complications makes it vital for the patient and surgeon to have a mutual trusting relationship, so that complications may be appropriately managed when they develop. If patients are forewarned about possible risks, they are not surprised if a complication develops and are better prepared.


Patients should maintain a healthy degree of skepticism regarding complication rates quoted by surgeons. One well-known New York surgeon repeats at meetings, “Double any complication rate you see advertised, including mine.” Surgeons are human beings, after all. They don’t always remember all the complications they have encountered and few keep a real-time tally. A complication rate of 1% is commonly quoted. Such a rate seems small, only 1 in 100, and perhaps this is a rate that is comfortable from a psychological standpoint, an event that sometimes happens to other people. But such a low rate should not be too reassuring, even if it is correct. If patients encounter a complication, it’s 100% as far as they are concerned. They have to understand that it could happen to them. They should have the surgery only if they can tolerate this risk.




A hematoma is a collection of blood under the skin that is usually removed by the surgeon. This is a possible complication of all surgical procedures that involve elevation of skin flaps (“undermining”), creating a potential space for fluid accumulation. A hematoma does not typically occur after liposuction because there is no sharp dissection and no creation of large spaces for blood to accumulate. In cases where there is substantial tissue undermining, such as facelifts (and abdominoplasties), a drain is inserted at the time of surgery. The drain helps draw off blood and fluid that would otherwise pool under the skin. Drains are usually removed the morning after surgery.


A hematoma typically develops within 24 hours of surgery (the patient below was a little unusual in that the hematoma developed several days later). It can form in the recovery room, or is evident at the time of the postoperative visit the day after surgery. It is caused by bleeding from one or more blood vessels. A clot may dislodge from a vessel that has been cauterized, particularly a small artery that carries more pressure. Sometimes hematomas are precipitated by spikes in blood pressure after surgery. For example, nausea and vomiting in the recovery room can cause the blood pressure to go up, which is one reason we try to prevent nausea by avoiding anesthetic gases (using intravenous propofol instead) and routinely administering anti-nausea medications.


A short procedure is usually necessary to drain a hematoma. If it is not drained, the body will eventually absorb the blood, but this would take weeks and there would be prolonged bruising. Patients and their caretakers are told to report any significant neck swelling after surgery, usually on one side, and usually the size of a lemon or larger. A smaller amount of swelling is normal. If there is any question, it is best for the patient to call and come in right away to be assessed.


V.H., Age 47, Manager

Procedure: Facelift, submental lipectomy, upper blepharoplasties, chin implant, fat injection (30 cc), excision of skin lesion of right chin, rhinoplasty, and pulsed dye laser treatment of facial veins.


Comments: This patient developed a collection of blood under the skin after surgery—a hematoma. It was drained (“aspirated”) with a needle in the office. This treatment is not painful. The skin is still numb where the needle is introduced.


Facelift complication- hematoma

Before, 3 days after, and 8 weeks after




Infection is uncommon because of the excellent blood supply of the face. Frequent bathing (washing the face at least 3 times a day) and antibiotics are used to treat infections.


Persistent Numbness


Loss of feeling is normal, especially in front of the ears. This feeling gradually returns. However, sometimes a larger nerve that supplies feeling to the lower part of the ear, called the great auricular nerve, is injured during the neck dissection, causing ear numbness that improves gradually with time but may never return completely to normal. Experienced surgeons learn to avoid this nerve by performing “hydrodissection” of the subcutaneous plane with local anesthetic solution and staying in this plane when the neck skin flap is raised.


Delayed Wound Healing and Increased Scarring


Facelift scars are usually well-hidden within the hairline or in natural creases around the ear. They fade with time and are usually barely noticeable. However, some patients are prone to forming raised, “hypertrophic” scars, which may require revision or steroid injection.


Sometimes, healing of the skin is impaired due to compromised blood supply, seen most commonly in smokers. If the skin does not receive an adequate blood supply, it does not survive. Remarkably, the skin can tolerate up to 90% interruption of its blood supply from dissection. But add the effects of smoking, and this can tip the balance. The skin may appear red and blistered, then turns black and forms an unsightly scab that surgeons call a crust or eschar. With time, the wound heals as new skin cells are created along the wound margins, which contract inward, shrinking the wound. The final scar is typically much smaller than the original wound, although it will be thicker than it would otherwise have been without the delayed healing. Fortunately, areas of delayed healing and increased scarring are usually tucked behind the ears where they are inconspicuous.


Facelift complication-infection

This 55-year-old smoker had a facelift. She developed an area of skin breakdown behind her ear. This gradually healed in with additional scar tissue. Fortunately, the scar remains relatively hidden behind the ear. If the scar is noticeable later, it may be revised. This complication is rarely seen in nonsmokers.


Facial Nerve Weakness


The facial nerve is responsible for making the facial muscles work. It branches out as it runs from a point just behind the ear to the facial muscles. It has 5 branches that may be stretched when a deep-plane facelift is performed. Experienced surgeons take every precaution to avoid cutting the nerves, although some branches are likely to be stretched. These nerve branches are like tiny insulated electrical leads going to the muscles they supply. Stretching them temporarily interferes with their transmission. They do have the capability of self-repair, if not completely divided, but this takes time. Patients may experience an asymmetrical smile, drooping of a corner of the mouth, or weakness on one side of the forehead.


Risk of injury to the facial nerve may be reduced by confining the dissection to a more superficial plane, as done in a skin-only lift, or a lift that relies on sutures and minimal, if any, SMAS mobilization (including all mini-lifts). However, the limitations of a superficial mini-lift are significant.


Limitations of a Superficial Mini-lift


• The skin is notorious for stretching, and lifts that rely on skin tightening are unlikely to provide good long-term results.


• It may produce a drawn-tight or artificial look.


• It does not allow for an effective cheek lift.


• It is not effective for correction of jowls.


• More skin undermining is needed, jeopardizing skin circulation.


• The dissection is in the same plane as fat injection, possibly compromising fat take.


To achieve better results with SMAS elevation, patients need to accept the risk of facial nerve stretching that is associated with a deep-plane facelift.


D.N., Age 51

Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, erbium laser resurfacing, and pulsed dye laser treatment of face and neck.


Comments: This patient demonstrates weakness of her left frontal nerve branch supplying the forehead. Four months after surgery she is still unable to elevate her left eyebrow. Fortunately this temporary weakness is usually not very obvious to others. She is seen 10 months after surgery with full return of frontal nerve function. Her before-and-after photos are included in the Patient Photographs section.


Facelift complication-nerve weakness



Corneal Dryness


Corneal protection from dryness is essential. Normally, at night the cornea is protected by the closed eyelids. After surgery, however, the eyelids may not close completely, due to swelling or weakness of the orbicularis muscle. Incomplete eyelid closure places the cornea at risk of drying out from evaporation of the tear film. Patients are instructed to use lubricating ointment at night and eye drops during the day.


Pixie Ear


The pixie ear is an unnaturally tethered ear. The earlobe is pulled down by the facelift scar. Usually this results from too much skin removal around the ear, creating tension on the skin closure (See photo). Experienced plastic surgeons avoid any skin tension around the earlobe to prevent such a stigma of surgery.


Facelift complication-pixie ear deformity

This patient had a facelift performed elsewhere 2 years previously. He was unhappy with the appearance of his earlobe afterward. This deformity was corrected by revising the facelift. His other before-and-after photographs are available in the Patient Photographs section—Male Facelift.



Neck Pleating


In fair-skinned, older patients, the skin may be sun-damaged and leathery. This may be more severe on the left side of the neck because of sun exposure while driving. Removal of excess loose skin of the neck can produce vertical skin folds, like pleats in a drape. Sun-damaged inelastic skin simply does not redrape well. Usually the pleats eventually smooth out, but occasionally a revision is needed.


Lateral Sweep


A lateral sweep is an unnatural, operated-on appearance that can happen after facelifts that draw back on the skin of the lateral face, while leaving the vertical descent of the cheek and jowl uncorrected. In severe cases, the skin form may form horizontal folds, like clotheslines running from the ear to the corner of the mouth (“joker’s lines”). It is not a harmonious or pleasing appearance and is best avoided by using a vertical vector to elevate the facial tissues.


Tragal Deformity


Flattening of the tragus (the small bump just in front of the ear canal) may be avoided by using a pre-tragal incision, which is my preference. The tragus is a unique structure that is very difficult to re-create. I reserve a post-tragal incision for patients who had this approach at the time of a previous facelift.






Facelift complication- hematoma

Facelift complication-infection

Facelift complication-nerve weakness

Facelift complication-pixie ear deformity