Hematomas and the Facelift Surgeon: It's Time for Us to Break Up for Good

Hematoma after face- or necklift is a significant complication with the potential for devastating consequences such as airway obstruction and skin necrosis. Reported incidence rates range from 0.6% to 14.2%.^1-6 Previous studies have identified a number of predisposing patient-level factors as contributors to hematoma formation, including male sex and pre-existing hypertension;^1-3 procedure-specific factors such as intraoperative blood loss; postoperative blood pressure;^4,5 and ingestion of medications that affect coagulation and platelet function. We firmly believe that postoperative blood pressure elevation is the most common and prime etiological factor. In 1976, Berner et al first recognized the link between hypertension and hematoma following facelifts.⁶ That landmark study connected blood pressure elevation with postoperative bleeding and suggested controlling blood pressure with chlorpromazine.⁶ Since then, multiple studies have reported on the relationship between elevated systolic pressure and hematoma.^1,2,7,8 Controlling postoperative blood pressure with antihypertensive agents such as clonidine, beta-blockers, and calcium-channel blockers has been shown to effectively reduce hematoma rates.^9-12 Additionally, postoperative anxiety, a full bladder, and nausea/vomiting also contribute to blood pressure elevation.¹³ Beyond blood pressure control, tissue glues, compression dressings, and cooling devices have been advocated for hematoma reduction.^14-19

Auersvald and colleagues introduced a surgical solution to prevent hematoma through the use of a hemostatic net.³ Drawing inspiration from Popescu's 1985 work on achieving hemostasis in oropharyngeal vascular malformations,²⁰ Auersvald has extrapolated this concept to quilt the skin flap elevated during a facelift to eliminate the dead space in the subcutaneous plane, resulting in a remarkable reduction in hematoma rates from 14.2% to 0%.³ The “A-net,” which was initially described in face- and necklifts, has been implemented in various other facial aesthetic procedures, such as tip rhinoplasty,²¹ gliding brow lift,²² and lip lift.²³

In this issue, Janssen et al report on their 5-year experience with the hemostatic net.²⁴ Compared to their historical control, which in which they found a 3.6% rate of hematoma, they improved their incidence to 0.6% among patients who had a hemostatic net.²⁴ The accompanying commentary by the Auersvald brothers points to the safety of the net, in particular concerning flap viability.²⁵ Notably, Neto et al have found similar improvements with the use of the hemostatic net in facelift surgery.²⁶ The hemostatic net is also an effective method to redrape excess skin, and may be one of the most significant technical improvements in reducing hematoma after facelifts.

Auersvald and colleagues estimate that application of the net takes about 30 minutes. On the surface, 30 minutes of additional anesthesia and facility time may not seem significant. At our current facility in the southeastern United States, this amount of time incurs an additional cost of US$600. Based on a very rudimentary analysis of costs for 100 patients, if we assume a 1% hematoma rate without the use of the net, we estimate that taking that 1 patient back to the operating room in our setting costs about US$5000. Implementing the hemostatic net for 100 facelift patients and assuming a 0% hematoma rate results in costs of US$600 per patient (from the additional 30 minutes of anesthesia and facility fees) × 100 patients, yielding total costs of US$60,000. However, assuming a 14% hematoma rate without the use of the net (as was the case with Auersvald and Auersvald's original 2014 paper on hemostatic nets),⁷ 14 (of 100) patients × US$5000 (for taking patients back to the operating room) totals US$70,000, arguing for the use of hemostatic nets. With that being said, the analysis of costs is highly dependent on each surgeon's incidence of hematomas without the use of the net. Additionally, it is imperative to note that many other factors other than costs should be considered when evaluating the potential benefit of the net (eg, physical implications to the patient, psychosocial distress to the patient, distress to the surgeon, patient-reported outcomes [PROs]). More robust cost-effectiveness studies along with other data points are warranted. Finally, in addition to evaluating complication rates such as hematoma, future studies on hemostatic nets should incorporate PRO data. Although the impact of hemostatic nets on short- or long-term PROs remains unclear, it is crucial to explore and emphasize the significance of these data in future aesthetic surgery studies.

The senior author's data suggest that strict blood pressure management (systolic <120 mmHg) reduces hematoma rates to 0.5% without the use of a hemostatic net.²⁷ Before the implementation of this strict blood pressure control, hematoma rates among patients undergoing face- and necklifts in the senior author's practice was 3.7% when systolic blood pressure was maintained at systolic <140 mmHg.

We applaud Auersvald and his colleagues for introducing this novel technique, and for thoroughly evaluating his data and outcomes. Similarly, we welcome the additional confirmation of the effectiveness of the net by Waterhouse and colleagues in this issue.²⁴ With the innovative hemostatic net and strict control of systolic pressures below 120 mmHg, we hope that we can finally break up with hematomas after facelifts for good.

Disclosures

Dr Nahai receives a stipend from The Aesthetic Society for his role as editor-in-chief of Aesthetic Surgery Journal. The other authors declared no other potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.