Facelift risks: haematoma, nerve injury and warning signs

The facelift guide says that haematoma is the most frequent complication. That is true, and it is not enough: someone making a decision wants to know how much, in whom, when and what to do if it happens to them.

This page answers that with the large series that exist. It also explains why online you find risk figures ranging from 1% to 5% for the same operation — and none of them is lying.

Why the figures you read do not match

This comes first, because almost all the confusion starts here.

The low figure: 1.8%. A 2016 paper analysed 11,300 facelifts within a prospective database of more than 129,000 cosmetic procedures. It counted major complications, strictly defined: those that led to attending A&E, admission or reoperation within 30 days. The answer was 1.8%, with haematoma in 1.1% and infection in 0.3%.

The high figure: 5.1%. A 2020 paper analysed 13,346 facelifts in a different database and counted any recorded adverse event. The answer was 5.1%, with haematomas and infections again at the top.

🔑 Both are correct and they measure different things. The first answers “what is the probability of this really going wrong?”. The second answers “what is the probability that something does not go as planned?”. A bruise that takes longer than it should counts in the second and not in the first.

It is worth holding on to both, because together they say something useful: it is a safe operation and, even so, it is not uncommon to have some setback that almost always resolves without consequences.

Haematoma: what it is, when it appears and in whom

A haematoma is a collection of blood under skin that has been undermined. In a facelift it matters because that mobilised skin depends on a tighter blood supply than usual, and the accumulated blood presses on it.

When. Almost always in the first few hours, and overwhelmingly in the first twenty-four. That is the real reason — not a formality — why the first reviews are the ones that matter most and why you are asked not to go far in the first few days.

How much. Around 1.1% in the strict series of 11,300 patients. And to gauge its relative weight: in a systematic review of 59 papers published between 2000 and 2024, haematoma accounted for 27% of all reported complications, ahead of unfavourable scarring (24%) and transient nerve weakness (22%).

In whom. This is where the data are clearest and least intuitive:

• ⚠️ Being male: relative risk 3.9. It is the strongest factor of all those studied. Male facial and neck skin has a far richer blood supply because it has to feed the beard follicle.
• Uncontrolled blood pressure, especially spikes in the first few hours.
• Anticoagulants and antiplatelet drugs, including those not thought of as medication: aspirin, some anti-inflammatories and several supplements. The intervals for stopping each one are further down, in their own section.
• Exertion, vomiting and coughing in the immediate postoperative period, because they all raise the venous pressure in the head abruptly.

What is done. A small haematoma reabsorbs on its own. A significant one is evacuated, and the sooner it is detected the simpler that is. Hence this page insisting so much on the sign.

The nerves: what gets disturbed and what recovers

It is the fear people put into words most and the one explained worst online. Two families have to be separated, because they are nothing alike.

The sensory nerves: the numb lobe

The great auricular nerve runs down the side of the neck and supplies sensation to the earlobe and the surrounding area. It is the nerve most often affected in facial rejuvenation surgery, and what it produces is numbness, not weakness: the ear feels “like cardboard”, an earring does not feel the same.

It usually improves over the following months. It does not change appearance or expression, and that is why it gets little coverage — but it is what most people notice.

The motor nerves: the brow and the lip

The facial nerve moves the face. In a facelift, two of its branches are particularly exposed:

• The frontal branch, which raises the eyebrow. If it is affected, that eyebrow does not rise and the forehead does not wrinkle.
• The marginal mandibular branch, which pulls the lower lip down. If it is affected, the smile is asymmetric.

🔑 And here is a point almost never made that changes the outlook. Many of those asymmetric lips after a facelift are not an injury to the marginal branch but to the cervical branch, which produces a pseudoparalysis: it looks like it, and it is not the same thing. In a series of 2,002 SMAS and platysma facelifts, it appeared in 1.7% of patients and recovered completely in 100%, within three weeks to six months.

There is even a clinical sign that separates them: if the patient can evert the lower lip — push it outwards — the mentalis muscle is working, and that indicates the cervical branch is affected and not the marginal one.

Overall, the systematic review comparing SMAS techniques with deep plane techniques, across 47 studies and 10,766 patients, concluded that nerve injury rates are similar between techniques, that most of the injuries reported were temporary and resolved with time, and that permanent injury was rare.

⚠️ Rare is not impossible. It is a possibility that forms part of the consent and that has to be accepted before surgery, not afterwards.

The skin and smoking

The skin mobilised in a facelift lives on a tighter blood supply. When that supply fails, the skin suffers: from an area that is slow to close to, in the worst case, necrosis of the edge of the flap.

Smoking is the avoidable factor that weighs most, and the standard recommendation is to stop at least four weeks beforehand. It is not general health advice slipped in along the way: it is the only factor on this list that depends entirely on the patient and that changes the risk a great deal.

In the series of 13,346 patients, being a current smoker featured among the factors associated with more adverse events, along with obesity, male sex, the length of the operation and combined procedures.

The scar is a complication too

It gets forgotten when talking about risks because it is not dangerous, but it is the second most reported complication in the recent literature: 24% of all those recorded between 2000 and 2024, a percentage that has doubled compared with the previous period.

Exactly where they sit, how they change and what makes them worse has a page of its own: facelift scars. And their care, which is common to all surgery, is in the post-surgical scar protocol.

🚨 Warning signs: when to ring without waiting

What follows is not to be memorised, but to be recognised if it appears.

Call the same day if you notice:

• 🚨 Pain that increases on one side only, especially in the first twenty-four hours, with a feeling of growing tightness or pressure. It is the sign of a haematoma, and it is the most important one on this page.
• 🚨 Clearly asymmetric swelling that grows over a matter of hours.
• 🚨 Active bleeding from an incision that does not stop with gentle pressure.
• 🚨 Difficulty breathing or swallowing if the neck has been operated on.
• 🚨 Fever, or redness and warmth that increase from the third or fourth day.
• 🚨 An eye that does not close fully, or an area of skin that changes colour towards grey or dark purple.

Get in touch without urgency if you notice an eyebrow that does not rise, an asymmetric smile, a numb lobe or an area of skin with no sensation. They are reasons to be seen and followed up; they are not reasons for a night-time call, and the vast majority resolve on their own.

⚠️ If you had surgery at another clinic, the person who has to see you is the person who operated on you. Outside their hours, the route is hospital A&E. Our clinic is available for anything that is not urgent.

What is done to lower the risk

The 2000-2024 systematic review identified which preventive measures are the most studied in facelift surgery. In order of how much they have been analysed:

1. Fibrin sealants, applied to the tissue bed before closing.
2. Tranexamic acid, which reduces bleeding.
3. Quilting sutures, which fix the skin to the deep plane and remove the space where blood could collect.
4. Strict blood pressure control around the operation.

🔑 Of that list, two are used here: intraoperative tranexamic acid and strict haemostasis.

Tranexamic acid is an antifibrinolytic that reduces bleeding, and it is the best-supported measure of the four after the sealants. Strict haemostasis sounds like nothing because it has no brand name, and it is probably what weighs most: checking and sealing every bleeding point before closing, taking as long as it takes. Haematoma is prevented above all inside the operating theatre.

And there is one contextual figure that helps place why this matters: research over the past twenty years has concentrated precisely on haematoma, and seroma — which was reported twice as often fifteen years ago — has halved, probably thanks to measures of this kind.

⚠️ After theatre, the part that falls to you is blood pressure. Nothing that raises it suddenly during the first few weeks: no exertion, no bending down to pick something up off the floor. It is on the recovery page.

Medication: the intervals the guidelines use, and who decides yours

Almost every page on this subject gives a bare figure — “stop aspirin ten days beforehand”. Here are the real intervals and where they come from, which is a different matter.

The reference in Spain is the 2025 consensus document on antithrombotic treatment around surgery, coordinated by the Spanish Society of Cardiology and endorsed by twenty-seven other scientific societies — among them SEDAR, the anaesthesiology society, and SECPRE, the plastic surgery one. It is what your anaesthetist will apply.

Antiplatelet drugs: how far in advance each one is stopped

Clopidogrel	5 days before
Ticagrelor	5 days before (3 for some procedures)
Prasugrel	7 days before
Triflusal	3-5 days before
Cilostazol, dipyridamole	48 hours before

🔑 And aspirin, which almost everyone takes for granted, has the least intuitive answer of all: you may not have to stop it. The consensus sets no fixed interval for it: it considers stopping it in patients at low thrombotic risk — above all if the procedure carries a moderate or high bleeding risk — and, when it is continued, recommends doses below 200 mg a day. If you take 100 mg and you are on primary prevention, what the guideline says is that stopping it is probably unnecessary, not that you should stop it four days beforehand.

Anticoagulants: here the interval is set not by the calendar but by a blood test

• Sintrom (acenocoumarol): 3 days beforehand. Warfarin: 5 days beforehand. With one condition that changes everything: only if the INR seven days before is between 2 and 3. If it is higher, the interval lengthens; if it is lower, it shortens by a day. And on the day of the operation it has to be measured again, aiming for an INR below 1.2.
• Direct-acting oral anticoagulants — apixaban, rivaroxaban, edoxaban, dabigatran: the interval comes from the drug’s half-life, from the bleeding risk of the procedure and from your kidney function. With dabigatran the adjustment is finer because it is cleared mainly by the kidney.
• ⚠️ And one that avoids a frequent error: with direct-acting agents no heparin “bridging” is used. With Sintrom, only in selected patients at high thrombotic risk.

🔑 Look at those two lists together and you will see why this page began by saying there is no single number. There are seven drugs with seven intervals, one that depends on a blood test, another that depends on your kidneys, and one — aspirin — where the question is not even when, but whether.

🚨 So what still stands is the same: do not stop an anticoagulant or an antiplatelet drug on your own. Stopping it carries its own risk, and anyone taking it is taking it for a reason. Bring the box to the pre-anaesthetic consultation and get the instructions in writing.

Supplements come into the same conversation, and they are the blind spot. Several of the most commonly used ones can interfere with clotting, and almost nobody declares them at the consultation because they are not perceived as medication: they do not come on prescription.

🔑 What you are asked is not to stop them: it is to mention them. Bring them to the consultation — name and dose, or simply the packet — and have them assessed along with the rest of your medication. The same applies to anti-inflammatories taken without thinking and to herbal remedies.

What nobody controls

Part of the risk does not depend on technique or on aftercare. How each person’s skin heals, the individual anatomy of the nerve branches — which varies more than an atlas suggests — each person’s own inflammatory response. Medicine is an obligation of means, not of result, and an honest page about risks has to say so plainly.

What can be demanded is that the risk is explained beforehand, that it is assessed individually and that there is a clear route for dealing with it if it appears.

✅ And that route, here, is this: the patient has their surgeon’s direct contact. There is no switchboard in the way and no clinic hours to wait for. If your surgeon cannot be reached at that moment, the team is six plastic surgeons and there is always someone available to deal with an emergency.

🔑 It is exactly what is worth asking at any clinic before surgery, and almost nobody publishes it: who answers on a Sunday night.

Frequently asked questions

What is my real chance of a serious complication?

In the strictest series available, 11,300 patients, 1.8% had a complication that led to attending A&E, admission or reoperation within the following 30 days. Haematoma (1.1%) and infection (0.3%) were the only ones of any weight. Your particular risk depends on your anatomy, your history and your habits, and it is assessed in clinic.

Is it true that men are at greater risk?

Of haematoma, yes, and clearly so: the relative risk is 3.9. The reason is anatomical — male facial and neck skin has a richer blood supply because it feeds the beard follicle — not a matter of resilience or of aftercare.

If my ear goes numb, does it stay that way?

Numbness of the lobe from involvement of the great auricular nerve is the most frequent sensory change after a facelift and it usually improves over the following months. It does not affect appearance or expression.

Could my face be left crooked for ever?

It is possible and it is rare. In the review of 47 studies and 10,766 patients, most of the nerve injuries reported were temporary and resolved with time; permanent injury was rare. In a series of 2,002 facelifts, weakness of the lower lip appeared in 1.7% and recovered in 100% of cases between three weeks and six months.

When do I have to ring without waiting for my review?

If pain grows on one side only with a feeling of pressure, if the swelling is clearly asymmetric and worsening over hours, if there is bleeding that does not stop, fever, an eye that does not close or difficulty breathing or swallowing. The rest — an eyebrow that does not rise, a numb lobe — should be reported, but is not urgent.

Is it riskier if I have several things operated on at once?

Yes. In the series of 11,300 patients, a facelift on its own had a 1.5% complication rate and one combined with another procedure up to 3.7%. Combining has real advantages — one anaesthetic, one recovery — and it also has this cost, which is why it is decided case by case.

And if I hardly smoke?

The recommendation is to stop at least four weeks beforehand, with no qualification about quantity. Smoking compromises the blood supply of the mobilised skin, which is exactly the tissue at risk in this operation.

Sources

• Gupta V, et al. Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients. Aesthetic Surgery Journal, 2016. PMID 26578747. — Multicentre prospective cohort (CosmetAssure) of 11,300 facelifts within 129,007 cosmetic procedures: 1.8% major complications at 30 days, haematoma 1.1%, infection 0.3%; 1.5% for a facelift alone against up to 3.7% when combined; male sex as an independent predictor of haematoma with a relative risk of 3.9.
• Chopan M, Samant S, Mast BA. Contemporary Analysis of Rhytidectomy Using the Tracking Operations and Outcomes for Plastic Surgeons Database with 13,346 Patients. Plastic and Reconstructive Surgery, 2020. PMID 32459769. — Adverse event rate of 5.1%, with haematomas and infections the most frequent; male sex, obesity, current smoking, length of the operation, combined procedures, general anaesthesia and an office-based operating theatre associated with more adverse events.
• Fang AH, de la Torre J. A Systematic Review of Rhytidectomy Complications and Prevention Methods: Evaluating the Trends. Annals of Plastic Surgery, 2025. PMID 40459450. — Review of 59 papers published between 2000 and 2024: haematoma 27% of reported complications, unfavourable scarring 24%, neurapraxia 22%, seroma 7%; scarring and neurapraxia reported twice as often in the recent period and seroma half as often; fibrin sealant, tranexamic acid, quilting sutures and blood pressure control as the most analysed interventions.
• Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in patients undergoing face lift. Plastic and Reconstructive Surgery, 2003. PMID 12794490. — Pseudoparalysis of the marginal branch caused by cervical branch injury in 34 of 2,002 SMAS and platysma facelifts (1.7%), with complete recovery in 100% of cases between three weeks and six months; the distinguishing sign is that the patient retains eversion of the lower lip.
• Vayalapra S, et al. Comparing the Safety and Efficacy of Superficial Musculoaponeurotic System and Deep Plane Facelift Techniques: A Systematic Review and Meta-analysis. Annals of Plastic Surgery, 2025. PMID 40600822. — 47 studies and 10,766 patients: similar nerve injury rates between techniques, most injuries temporary and resolving over time, and permanent injury rare.
• Vivas D, Roldán I, Ferrandis R, et al. Abordaje del tratamiento antitrombótico durante el perioperatorio y el periprocedimiento: documento de consenso 2025 de SEC, SEDAR, SEACV, SECCE, AEC, SECOM CYC, SECPRE, SEPD, SEGG, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEN, S.E.N., SENEC, SEPAR, SEO, SEORL-CCC, SEPA, SERVEI, SECOT y AEU. Revista Española de Cardiología, 2026;79:68-79. Full text. — Preoperative stopping intervals: clopidogrel 5 days, ticagrelor 5 days (3 for certain procedures), prasugrel 7 days, triflusal 3-5 days, cilostazol and dipyridamole 48 hours; acetylsalicylic acid with no fixed interval — stopping it is considered at low thrombotic risk, above all with moderate-to-high bleeding risk, and if it is continued, at doses below 200 mg/day; acenocoumarol 3 days and warfarin 5 days provided the INR seven days beforehand is between 2 and 3, aiming for an INR < 1.2 before the procedure and with no preoperative vitamin K in elective surgery; direct-acting oral anticoagulants according to half-life, bleeding risk of the procedure and creatinine clearance, with no heparin bridging; heparin bridging for vitamin K antagonists only in selected patients at high thromboembolic risk.
• Cervicofacial Rhytidectomy. StatPearls, NCBI Bookshelf. NBK564338. — Haematoma as the most frequent complication and its higher incidence in men, with uncontrolled hypertension and with anticoagulants; frontal and marginal mandibular branches as the most exposed, with involvement usually transient; recommendation to stop smoking at least four weeks beforehand.

Book your consultation

If you are considering a facelift and want to know what your risk is — not that of a series of eleven thousand patients — the route is an assessment consultation in Valencia. There your blood pressure, medication, habits and anatomy are reviewed, and what each risk means in your particular case is explained before anything is decided.

Clinical confirmation by the surgeon

Last reviewed: 6 September 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.