Deep Plane Facelift Complications: What Can Go Wrong and How I Manage It

Every surgical procedure carries risk. The deep plane facelift is no exception. As a plastic surgeon who performs this operation regularly, I believe patients deserve a transparent, detailed account of what can go wrong — not a sanitised marketing version that minimises complications to make the sale. This article is my honest discussion of deep plane facelift complications, how I work to prevent them, and how I manage them when they occur.

— Dr. Umut Zereyak

What are the most common deep plane facelift complications?

In the published literature and in my own practice, the complications associated with deep plane facelift surgery fall into several categories. I always tell patients about each of these during consultation, because informed consent requires honesty — not reassurance.

Hematoma is the most common complication following any facelift procedure. Published rates range from 1 to 3 percent. A hematoma is a collection of blood beneath the skin flap that, if not addressed promptly, can compromise the blood supply to the overlying skin and lead to secondary problems including skin necrosis. Male patients have a higher incidence due to greater vascularity of facial skin.

Nerve injury is the complication patients fear most. In experienced hands, the rate of permanent facial nerve injury following deep plane facelift is less than 1 percent. Temporary weakness — known as neuropraxia — is more common, occurring in roughly 2 to 5 percent of cases, and typically resolves within weeks to months. The marginal mandibular branch and the temporal branch of the facial nerve are the two branches most at risk during deep plane dissection.

Infection following facelift surgery is uncommon, occurring in less than 1 percent of cases in published series. The face has an excellent blood supply, which contributes to both healing and infection resistance. When infection does occur, it is usually localised and responds to antibiotics, though rarely a more serious deep infection may require surgical drainage.

Unsatisfactory scarring can occur despite meticulous closure technique. Hypertrophic scars, widened scars, or visible scars behind the ear are all possible. Most scars mature and become virtually invisible by 12 to 18 months, but a small percentage of patients may require scar revision.

Asymmetry is inherent in all faces — no face is perfectly symmetrical before surgery, and no face will be perfectly symmetrical after surgery. However, significant asymmetry in the degree of lift or in contour can occasionally occur and may require revision if it does not settle with time.

Skin necrosis is rare in the deep plane technique because the skin flap retains its blood supply through the underlying SMAS layer during dissection. This is one of the genuine advantages of deep plane over SMAS plication or SMASectomy techniques, where skin flaps are elevated separately and are therefore more vulnerable. However, skin necrosis can still occur in smokers, patients with diabetes, or cases where excessive tension is placed on the skin closure.

How is hematoma prevented and treated?

Hematoma prevention begins before the patient enters the operating room. I require all patients to discontinue blood-thinning medications and supplements — including aspirin, ibuprofen, vitamin E, fish oil, and certain herbal supplements — at least two weeks before surgery. Blood pressure must be well controlled; uncontrolled hypertension is the single greatest risk factor for post-facelift hematoma.

During surgery, I maintain meticulous haemostasis throughout the dissection. In the deep plane approach, I release the retaining ligaments — the zygomatic ligaments, the masseteric ligaments, and the mandibular ligaments — under direct vision. Each ligament release point is a potential source of bleeding and is carefully cauterised or controlled before proceeding. At the conclusion of the procedure, I place closed suction drains beneath each skin flap to evacuate any fluid that accumulates during the first 24 hours.

A compressive dressing is applied in the operating room and maintained for the first 48 hours. This dressing serves two purposes: gentle compression to minimise dead space beneath the flap, and protection of the incision lines.

The critical window for hematoma detection is the first 24 hours after surgery. This is precisely why I keep all facelift patients overnight at the hospital. If a hematoma develops, the signs are unmistakable: rapid unilateral swelling, increasing pain, firmness beneath the skin flap, and sometimes visible discolouration. When caught early, a hematoma is treated by returning to the operating room, evacuating the collected blood, identifying and cauterising the bleeding source, and re-closing. The outcome after prompt evacuation is generally excellent with no long-term effect on the result.

This is one of the reasons I operate exclusively at a JCI-accredited hospital rather than a private clinic. A hospital has an operating room available at any hour. If a patient develops a hematoma at two in the morning, we are in the operating room within thirty minutes — not arranging an emergency transfer from a clinic to a hospital while the patient's skin flap is under threat.

What about facial nerve injury?

The facial nerve is the structure that controls the muscles of facial expression. It exits the skull at the stylomastoid foramen and divides into five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. During deep plane facelift surgery, the branches most at risk are the marginal mandibular branch (which controls the muscles of the lower lip) and the temporal branch (which controls the frontalis muscle responsible for raising the eyebrow).

There is a common misconception that the deep plane facelift is more dangerous to the facial nerve than more superficial techniques. In fact, the opposite is true, and understanding why requires some anatomical knowledge.

In a traditional SMAS facelift, the surgeon elevates the skin flap first, then works on the SMAS layer separately. During the skin flap elevation — particularly near the parotid gland and along the mandibular border — the facial nerve branches can be at risk because they run within or just deep to the SMAS layer. The surgeon is approaching the nerve from above, and the nerve is not directly visible.

In the deep plane technique, the dissection enters the sub-SMAS plane early and proceeds beneath the SMAS in continuity with the skin. This means the facial nerve branches are running above the plane of dissection — they are on the superficial surface of the SMAS flap being elevated, not in the surgical field below. The surgeon is moving away from the nerve, not toward it. This is the anatomical basis for the paradoxically lower nerve injury rates reported in deep plane series compared to more superficial techniques.

That said, the nerve is still at risk in certain zones — particularly where the retaining ligaments are released. The zygomatic ligament release zone is near the zygomatic branch, and the mandibular ligament release zone is near the marginal mandibular branch. These areas require precise anatomical knowledge and careful technique.

When nerve injury does occur, it is most commonly neuropraxia — a temporary loss of function caused by stretching or compression of the nerve, without structural disruption. In my experience, the vast majority of cases of temporary nerve weakness resolve within two to six weeks. In rare cases, recovery may take three to six months. True permanent injury — where the nerve is transected — is exceedingly rare in the hands of an experienced deep plane surgeon, occurring in well under 1 percent of cases in published literature.

If I identify a nerve injury during the procedure itself, immediate microsurgical repair is performed. If weakness is noted postoperatively, the patient is monitored closely with serial examinations. Electromyography can be performed at three months to assess the status of nerve recovery. In the rare event of permanent paralysis, secondary procedures such as nerve grafting or muscle transfer are available, though I have not needed to perform these for my own facelift patients.

How does infection risk compare to other surgeries?

The infection rate following facelift surgery is among the lowest of any surgical procedure. The face is one of the most vascular regions of the body, and this rich blood supply delivers immune cells and antibiotics efficiently to the surgical site. Published infection rates in facelift surgery are consistently below 1 percent.

In my practice, infection prevention begins with the operating environment itself. I operate at a JCI-accredited hospital with laminar airflow operating theatres, rigorous sterilisation protocols, and an infection control team that audits compliance continuously. These are not marketing claims — JCI accreditation requires documented evidence of these systems, and the hospital is re-audited every three years.

My antibiotic protocol follows established guidelines: a single dose of intravenous prophylactic antibiotic administered within 60 minutes of the first incision, with one additional dose if the procedure exceeds four hours. I do not routinely prescribe extended postoperative oral antibiotics, as the evidence does not support their benefit and overuse contributes to antibiotic resistance. An exception is made for patients with specific risk factors such as diabetes or immunosuppression.

Wound care instructions are provided to every patient in both written and video format. Incision lines are kept clean and dry for the first 48 hours, after which gentle cleansing is initiated. Sutures behind the ear — where skin is thinner and more vulnerable to moisture — receive particular attention.

Early signs of infection include increasing redness, warmth, swelling, pain, and discharge from the incision line beyond the normal postoperative period. If a patient reports these symptoms — whether still in Istanbul or already at home — I review clinical photographs immediately and initiate targeted antibiotic therapy. In the rare event that a deep infection or abscess develops, surgical drainage under anaesthesia may be required.

What about unsatisfactory scarring?

Scar quality after facelift surgery depends on several factors: incision placement, closure technique, tension on the wound, the patient's individual healing biology, and postoperative care.

The deep plane facelift offers a significant advantage with regard to scarring. Because the deep tissue repositioning — the release of retaining ligaments and mobilisation of the SMAS and platysma as a composite flap — provides the actual lift, the skin is redraped without tension. A tension-free skin closure heals with a finer, less visible scar than a closure that relies on skin tension to maintain the result (as occurs in skin-only or SMAS plication techniques).

My incision design follows the natural contours of the ear. It begins in the temporal hairline, curves in front of the ear along the tragal border, wraps beneath the earlobe, and continues behind the ear into the occipital hairline. Each segment is designed to sit within a natural crease or at a junction between different skin textures, where a fine scar becomes virtually invisible once mature.

Scar maturation is a process that takes 12 to 18 months. In the early weeks, scars are pink and slightly raised. By three months, they begin to flatten and lighten. By six to twelve months, most facelift scars are thin, flat, and nearly invisible. Some patients — particularly those with a genetic predisposition to hypertrophic scarring — may develop thicker, more visible scars that benefit from silicone sheeting, steroid injection, or laser treatment.

If a scar remains unsatisfactory after full maturation, scar revision surgery is a straightforward procedure that can be performed under local anaesthesia. In my practice, the need for scar revision following deep plane facelift is uncommon, occurring in fewer than 2 percent of patients. The area most likely to require attention is the postauricular incision (behind the ear), where skin tension is greatest and moisture from hair washing can affect early healing.

Why I operate exclusively at a JCI-accredited hospital

The deep plane facelift is a significant surgical procedure performed under general anaesthesia, typically lasting three to five hours. It involves dissection in proximity to major nerves and blood vessels, and it carries the same anaesthetic risks as any procedure of comparable duration and complexity.

I have chosen to perform all of my facelift procedures at a JCI-accredited hospital for specific, practical reasons — not as a marketing distinction.

Emergency response capability. If a patient develops a hematoma, an adverse anaesthetic reaction, or any other acute complication, the hospital has an operating room, an intensive care unit, blood bank, and a full resuscitation team available at all times. A private clinic — no matter how well equipped for elective surgery — cannot match this infrastructure.

Anaesthesiology team. My patients are anaesthetised by board-certified anaesthesiologists who are full-time hospital staff, not freelance providers. They have immediate access to advanced monitoring, difficult airway equipment, and a crash cart. For a three-to-five-hour procedure under general anaesthesia, this is not an optional luxury.

Standardised safety protocols. JCI accreditation mandates specific protocols for surgical safety — the WHO surgical safety checklist, medication reconciliation, patient identification, infection control, and adverse event reporting. These systems are audited externally and enforced through institutional policy. They exist to catch errors before they become complications.

Overnight monitoring. Every facelift patient spends at least one night in the hospital under nursing observation. Vital signs are monitored at regular intervals. The surgical site is checked according to a standardised protocol. If anything deviates from normal — swelling, blood pressure spike, asymmetric drainage — I am contacted immediately.

I am aware that many surgeons — including excellent ones — perform deep plane facelifts in private clinics and surgery centres. I am not suggesting their results are inferior. I am saying that when a complication occurs — and complications do occur, regardless of surgeon skill — the response time and resource availability at a hospital are meaningfully different from what a clinic can provide. For my patients, particularly those travelling from abroad, I consider this margin of safety non-negotiable.

How I discuss complications with my patients

Informed consent is not a form to be signed — it is a conversation. In my practice, this conversation happens during the initial video consultation, and it is repeated in person before surgery. I discuss every complication listed in this article, including the approximate incidence rates, the symptoms to watch for, and the management plan for each scenario.

I always tell patients: "If you leave this consultation feeling that deep plane facelift has no risks, I have failed in my communication. Every surgery has risks. What matters is that you understand what those risks are, that you are comfortable with the probability, and that you trust the system in place to manage them."

For international patients, one complication scenario requires specific planning: what happens if a problem develops after you have returned home?

My protocol for remote complication management is as follows:

• Every patient receives my direct contact information — not a receptionist, not a coordinator. If a concern arises at any hour, they reach me or my clinical team directly.
• For issues that can be assessed remotely — minor wound concerns, questions about swelling, potential early infection — I review clinical photographs and video calls within hours. If local treatment is needed (for example, an antibiotic prescription), I coordinate with the patient's local physician.
• For issues that require in-person assessment or intervention — suspected hematoma, significant nerve weakness, wound dehiscence — I arrange the patient's return to Istanbul. My team assists with flight rebooking, hospital admission, and logistics. If surgical intervention is needed, it is performed at no additional surgical fee.
• Every patient is scheduled for virtual follow-up appointments at one week, two weeks, one month, three months, six months, and one year. These are not optional check-ins — they are part of the treatment protocol.

I do not pretend that managing complications from a distance is ideal. It is not. This is one of the real trade-offs of medical tourism, and I am honest about it. But with a structured protocol, direct access to the surgeon, and a willingness to have the patient return when necessary, the vast majority of complications can be managed effectively regardless of geography.

Transparency about complications is not a weakness in a surgeon's practice — it is the foundation of trust. The patients who choose to proceed after a thorough discussion of risks are better prepared, more compliant with postoperative instructions, and ultimately more satisfied with their experience — even if minor complications do occur.

References

1. Jacono AA, Parikh SS, Glosgow LA. "Rate of Nerve Injury with the Deep-Plane Technique of Rhytidectomy: A Review of 1,142 Cases." Aesthetic Surgery Journal, 2023;43(6):617-624.
2. Baker DC. "Complications of Cervicofacial Rhytidectomy." Clinics in Plastic Surgery, 1983;10(3):543-562.
3. Grover R, Jones BM, Waterhouse N. "The Prevention of Haematoma Following Rhytidectomy: A Review of 1078 Consecutive Facelifts." British Journal of Plastic Surgery, 2001;54(6):481-486.
4. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. "Current Concepts in Facelift: Complications and Management." Plastic and Reconstructive Surgery, 2004;114(6):16e-30e.

Further reading

• Deep Plane Facelift in Turkey — Procedure Overview
• Recovery After Deep Plane Facelift
• Is Facelift Safe in Turkey?
• About Dr. Umut Zereyak