Hematoma is a known complication of rhytidectomy, and improved understanding of its incidence and the impact of adjunctive measures is essential to guide evidence-based practice.
Objective:
Compare hematoma rates among patients undergoing deep plane facelift in those where either tranexamic acid (TXA), hemostatic nets, or tissue sealants are used.
Methods:
A review was conducted in Ovid MEDLINE, EMBASE, PubMed MEDLINE, Cochrane, and SCOPUS to identify studies that employed deep plane facelifts and reported hematomas. The primary outcome was hematoma rates. Secondary endpoints included rate of revision surgeries and use of preventative measures (hemostatic nets, tissue sealant, and TXA). Meta-analyses were conducted to determine the probability of postoperative hematoma and the effectiveness of preventative measures.
Results:
Overall, 8,841 patients from 31 studies were included. Ages ranged from 31 to 84 years, and 85.2% (4,330/5,080) were women. Meta-analysis showed an overall hematoma rate of 2.7% (95% CI: 2.2–3.4%), with major hematomas at 0.97% (95% CI: 0.61–1.53%). Subgroup analysis showed major hematoma rates of 1.53% with TXA, 1.25% with sealants, and 1.23% with hemostatic nets.
Conclusions:
Evidence from this review suggests that deep plane facelifts have a 2.7% overall and 0.97% major hematoma rate, with no clearly superior adjunct among TXA, sealants, or hemostatic nets.
Get full access to this article
View all access options for this article.
References
1.
NahaiF, Bassiri-TehraniB, SantosaKB. Hematomas and the facelift surgeon: It’s time for us to break up for good. Aesthet Surg J., 2023; 43(10):1207–1209; doi: 10.1093/asj/sjad225
2.
GuptaV, WinocourJ, ShiH, et al.Preoperative risk factors and complication rates in facelift: Analysis of 11,300 patients. Aesthet Surg J., 2016; 36(1):1–13; doi: 10.1093/asj/sjv162
3.
TiourinE, BartonN, JanisJE. Methods for minimizing bleeding in facelift surgery: An evidence-based review. Plast Reconstr Surg Glob Open. 2021; 9(8):e3765; doi: 10.1097/GOX.0000000000003765
4.
AuersvaldA, AuersvaldLA. Hemostatic net in rhytidoplasty: An efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg. 2014; 38(1):1–9; doi: 10.1007/s00266-013-0202-5
JaconoAA, BryantLM, AhmedliNN. A novel extended deep plane facelift technique for jawline rejuvenation and volumization. Aesthet Surg J., 2019; 39(12):1265–1281; doi: 10.1093/asj/sjy292
7.
RoskiesM, BrayD, GordonNA, et al.Limited delamination modifications to the extended deep plane rhytidectomy: An anatomical basis for improved outcomes. Facial Plast Surg Aesthet Med. 2024; 26(6):657–664; doi: 10.1089/fpsam.2024.0018
8.
PageMJ, McKenzieJE, BossuytPM, et al.The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021; 372:n71; doi: 10.1136/bmj.n71
9.
StangA. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol., 2010; 25(9):603–605; doi: 10.1007/s10654-010-9491-z
10.
SterneJAC, SavovićJ, PageMJ, et al.RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366:l4898; doi: 10.1136/bmj.l4898
11.
JaconoAA, AlemiAS, RussellJL. A meta-analysis of complication rates among different SMAS facelift techniques. Aesthet Surg J., 2019; 39(9):927–942; doi: 10.1093/asj/sjz045
12.
BallanA, JabbourS, El RayessY, et al.Quilting sutures in rhytidectomy: A systematic review of the literature. Aesthet Surg J., 2020; 40(11):1157–1164; doi: 10.1093/asj/sjz353
13.
ChienWY, HuangYL, ChiuWK, et al.Tissue sealants for facial rhytidectomy: A systematic review and meta-analysis of randomized controlled trials. Facial Plast Surg Aesthet Med. 2023; 25(2):90–96; doi: 10.1089/fpsam.2022.0160
14.
AlenaziAS, ObeidAA, AlderaywshA, et al.Impact of tranexamic acid on bleeding outcomes and complication rates in facelift: A systematic review and meta-analysis. Aesthet Surg J., 2024; 44(11):NP749–NP761; doi: 10.1093/asj/sjae156
15.
BottiG, GentileP, PascaliM, et al.Comparison of commercial fibrin sealants in facelift surgery: A prospective study. Clin Cosmet Investig Dermatol. 2013; 6:273–280; doi: 10.2147/CCID.S45233
16.
BottiG, Contessi NegriniF, ScarabosioA, et al.Evaluating the effectiveness of the high-SMAS facelift technique: Objective clinical outcomes at 1 year. Aesthetic Plast Surg. 2024; 48(24):5257–5265; doi: 10.1007/s00266-024-04234-4
CastelloMF, LazzeriD, SilvestriA, et al.Modified superficial musculoaponeurotic system face-lift: A review of 327 consecutive procedures and a patient satisfaction assessment. Aesthetic Plast Surg. 2011; 35(2):147–155; doi: 10.1007/s00266-010-9567-x
19.
ChangKN. Analysis of the outcome of reoperative face lifts using sub-SMAS techniques. Plast Reconstr Surg. 2022; 150(1):47–56; doi: 10.1097/PRS.0000000000009199
20.
CohenJC, GlasgoldRA, AllojuLM, et al.Effects of intravenous tranexamic acid during rhytidectomy: A randomized, controlled, double-blind pilot study. Aesthet Surg J., 2021; 41(2):155–160; doi: 10.1093/asj/sjaa072
21.
CohenSR, HewettS, BarafP, et al.Facelift with power-assisted dissection: A preliminary report. Aesthet Surg J., 2021; 41(6):641–651; doi: 10.1093/asj/sjaa213
22.
De La PeñaJA, Soto-MirandaMA, López-SalgueroJF. Ultrasonically assisted face-lift. Aesthet Plast Surg. 2012; 36(4):780–787; doi: 10.1007/s00266-012-9880-7
23.
HesterTR, ShireJR, NguyenDB, et al.Randomized, controlled, phase 3 study to evaluate the safety and efficacy of fibrin sealant VH S/D 4 s-apr (Artiss) to improve tissue adherence in subjects undergoing rhytidectomy. Aesthet Surg J., 2013; 33(4):487–496; doi: 10.1177/1090820X13479969
IsmailM, GhorabaS. Hemostatic net versus surgical drain after deep plane facelift surgery: A prospective randomized controlled trial. Aesthetic Plast Surg. 2025; 49(16):4572–4578; doi: 10.1007/s00266-025-04745-8
26.
JaconoAA, ParikhSS. The minimal access deep plane extended vertical facelift. Aesthet Surg J., 2011; 31(8):874–890; doi: 10.1177/1090820X11424146
27.
JaconoAA, AlemiAS, HarmonJJ, et al.The effect of a novel platysma hammock flap during extended deep plane facelift on the signs of aging in the neck. Aesthet Surg J., 2022; 42(8):845–857; doi: 10.1093/asj/sjac086
28.
KamerFM, NguyenDB. Experience with fibrin glue in rhytidectomy. Plast Reconstr Surg., 2007; 120(4):1045–1051; doi: 10.1097/01.prs.0000278092.28351.c9
29.
KamerFM, SongAU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast Surg. 2000; 2(4):240–242; doi: 10.1001/archfaci.2.4.240
30.
ManiM. Endoscopic, “scarless” composite flap face and neck lift. Facial Plast Surg., 2025; 41(1):43–53; doi: 10.1055/a-2204-8798
31.
MaricevichMA, AdairMJ, MaricevichRL, et al.Facelift complications related to median and peak blood pressure evaluation. Aesthetic Plast Surg. 2014; 38(4):641–647; doi: 10.1007/s00266-014-0353-z
32.
MenkesA. A short-incision deep plane face-lift technique with a composite cheek flap performed with tumescent local anesthesia by a dermasurgeon. Cosmet Dermatol. 2007; 20(1):55–59.
33.
Graça NetoL, GraçaACM, RibeiroSP. From surface to depth: Learning curve in extended deep facelift—My first 100 cases. RBCP. 2024; 39(1); doi: 10.5935/2177-1235.2023RBCP0823-EN
34.
PouJD, MatabeleMN, RobertsonKM. Subcutaneous and topical tranexamic acid use during rhytidectomy. Laryngoscope., 2025; 135(5):1685–1690; doi: 10.1002/lary.31937
35.
RammosCK, MohanAT, MaricevichMA, et al.Is the SMAS flap facelift safe? A comparison of complications between the sub-SMAS approach versus the subcutaneous approach with or without SMAS plication in aesthetic rhytidectomy at an academic institution. Aesthetic Plast Surg. 2015; 39(6):870–876; doi: 10.1007/s00266-015-0558-9
36.
RistowB. Preoperative use of alpha tocopherol does not increase the risk of hematoma in the face lift patient: A preliminary report. Plast Reconstr Surg., 2009; 124(5):1696–1699; doi: 10.1097/PRS.0b013e3181b98a3a
37.
Conejero RoosJA, Macchiavello MachoRA, Hurtado DíazMJ, et al.The deep plane facelift: Technique and results. Rev Cir. 2023; 75(6); doi: 10.35687/s2452-454920230061848
38.
SchroederRJ, LangsdonPR. Effect of local tranexamic acid on hemostasis in rhytidectomy. Facial Plast Surg Aesthet Med. 2020; 22(3):195–199; doi: 10.1089/fpsam.2020.0061
39.
SwansonE. Clinical evaluation of 225 sub-SMAS facelifts with no temporal incision. Plast Reconstr Surg Glob Open. 2020; 8(2):e2640; doi: 10.1097/GOX.0000000000002640
40.
SwansonE. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg., 2011; 127(2):823–834; doi: 10.1097/PRS.0b013e3181fed81f
41.
TaghizadehF, LeibowitzA, EllisonT, et al.Short flap rhytidectomy and fractional CO2 laser rejuvenation of the aging face. J Cosmet Dermatol., 2013; 12(1):49–56; doi: 10.1111/jocd.12018
42.
WongCH, HsiehMKH, MendelsonB. Asian face lift with the composite face lift technique. Plast Reconstr Surg. 2022; 149(1):59–69; doi: 10.1097/PRS.0000000000008686
43.
ZhaoM, WuL, WangQ, et al.Design and clinical application of X-shaped cross-dressing method in rhytidectomy. Adv Oral Maxillofac Surg., 2023; 10:100404; doi: 10.1016/j.adoms.2023.100404
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
