What are the immediate and long‑term side effects and complications of a facelift (rhytidectomy) in adults aged 40‑70, including those with risk factors such as smoking, uncontrolled diabetes, hypertension, cardiovascular disease, bleeding disorders, or anticoagulant use?

Facelift (Rhytidectomy) Side Effects and Complications

Immediate Complications

Hematoma is the most common major complication of facelift surgery, occurring in approximately 1.1–6.5% of cases, with male gender and uncontrolled hypertension being the strongest risk factors. 1, 2, 3

Hematoma

• Represents approximately 27–33% of all facelift complications and remains the most challenging immediate complication 1, 2
• Male patients have a 3.9-fold increased risk of hematoma compared to females 2
• Preoperative systolic blood pressure >160 mmHg independently predicts hematoma formation 3
• Operating room peak systolic blood pressure >165 mmHg significantly increases hematoma risk 3
• Recovery room peak systolic blood pressure >150 mmHg is associated with hematoma development 3

Infection

• Occurs in approximately 0.3% of cases 2
• BMI ≥25 increases infection risk 2.8-fold 2
• Combined procedures (facelift plus additional cosmetic surgery) increase infection risk 3.5-fold 2

Nerve Injury (Neurapraxia)

• Accounts for approximately 22% of all complications 1
• Reports of neurapraxia have doubled from 2000–2012 compared to 2013–2024, likely due to more aggressive deep-plane techniques 1, 4
• Facial nerve landmarks may be altered in revision cases, amplifying risk 4

Seroma

• Represents approximately 7% of complications 1
• Seroma rates have decreased by half in recent years, attributed to increased use of tissue sealants and quilting sutures 1

Long-Term Complications and Aesthetic Issues

Unfavorable Scarring

• Accounts for approximately 24% of all complications and represents the most common long-term issue 1
• Reports have doubled in recent studies (2013–2024), possibly reflecting increased patient expectations and reporting 1

Deformities Requiring Revision

• Cobra neck deformity can occur from over-aggressive platysma manipulation 4
• Pixie ear deformity results from excessive tension on the earlobe during closure 4
• Synkinesis (abnormal involuntary facial movements) adds complexity to revision surgery 4

Overall Safety Profile

The overall major complication rate for facelift surgery is 1.8%, comparable to other cosmetic procedures (2%), when performed by board-certified plastic surgeons. 2

• Major complications are defined as those requiring emergency room visit, hospital admission, or reoperation within 30 days 2
• Age alone (even ≥75 years) does not increase complication risk when patients are matched for ASA physical class <3 5

High-Risk Patient Populations

Cardiovascular Risk Factors

Patients with uncontrolled hypertension (systolic BP ≥140/90 mmHg or diastolic BP ≥110 mmHg) should have surgery deferred until blood pressure is optimally controlled to <130/80 mmHg. 6

• History of hypertension is an independent predictor of hematoma on multivariate analysis 3
• Perioperative blood pressure control is critical; peak systolic values should be maintained below 165 mmHg intraoperatively and below 150 mmHg in recovery 3

Anticoagulation and Bleeding Disorders

Patients on anticoagulant therapy or with bleeding disorders have substantially increased bleeding risk and are not ideal candidates for elective facelift. 6

• Aspirin use has been associated with increased hematoma risk 3
• Patients with aspirin allergy, bleeding tendency, or existing anticoagulant therapy require careful risk-benefit assessment 6

Smoking

Cigarette smoking is a modifiable risk factor that increases vascular complications; all patients should be counseled to quit and referred to formal cessation programs. 6

• Smoking has been associated with increased hematoma risk 3
• Nicotine replacement therapy or bupropion should be considered for smoking cessation 6

Diabetes

Uncontrolled diabetes increases infection risk and impairs wound healing; glycemic control with HbA1c as close to 6–7% as possible should be achieved before elective surgery. 6

• Patients with diabetes aged >40 years have additional cardiovascular risk factors that compound surgical risk 6

Male Gender

Male patients have a 3.9-fold increased risk of hematoma independent of other factors. 2

• This represents the strongest independent predictor of hematoma on multivariate analysis 2

Obesity

BMI ≥25 increases infection risk 2.8-fold and should prompt enhanced perioperative monitoring. 2

• Obesity is present in 38.5% of facelift patients 2

Combined Procedures

Performing facelift in combination with other cosmetic procedures increases complication rates from 1.5% to 3.7%. 2

• Combined procedures increase infection risk 3.5-fold 2

Risk Stratification Algorithm

1. Assess cardiovascular status:

   • If systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg → defer surgery until controlled to <130/80 mmHg 6, 3
   • If on ACE inhibitors or ARBs → consider stopping 24 hours before surgery 6
   • If on beta blockers or clonidine → continue perioperatively to avoid withdrawal syndrome 6

2. Evaluate bleeding risk:

   • If on anticoagulation or has bleeding disorder → not an ideal candidate 6
   • If taking aspirin → assess risk-benefit; consider discontinuation 3

3. Optimize metabolic factors:

   • If diabetic → achieve HbA1c 6–7% before surgery 6
   • If BMI ≥25 → counsel on increased infection risk 2

4. Address modifiable factors:

   • If smoking → mandatory cessation with formal program and pharmacotherapy 6

5. Consider patient-specific risk:

   • If male → counsel on 3.9-fold increased hematoma risk 2
   • If age ≥75 years with ASA class ≥3 → defer elective surgery 5

Critical Perioperative Management

Meticulous blood pressure control is mandatory: maintain systolic BP <165 mmHg intraoperatively and <150 mmHg in recovery to minimize hematoma risk. 3

• Continuous blood pressure monitoring should be performed throughout the perioperative period 3
• If unable to take oral antihypertensives, intravenous medications should be used 6