Deep plane facelift - What determines the need for haemostatic suturing vs. drains?

Drains and hemostatic sutures have different functions. Drains help eliminate the fluid that is produced when elevating the facial flap and thus the drains help prevent the formation of seromas. Hemostatic sutures reduce the dead space between the skin flap and the underlying tissue by applying pressure to the tissue and acting as a hemostatic barrier (compression hemostasis). They are two different procedures with very different objectives, and I use both techniques on my patients. There can be a risk of flap necrosis. This depends more on the surgeon's skills to perform the dissection (detachment or, elevation of the flap) in the appropriate anatomical plane to preserve subdermal blood flow, which is responsible for maintaining vital circulation to the skin. Flap necrosis can slow the healing process and leave more visible scars. Flap necrosis depends not only on the surgeon but also on the patient's risk factors and lifestyle, such as whether they are smokers or were smokers , have high blood pressure, are diabetic, obese, or have another medical conditions. For this reason, the ideal "Healthy" candidate for this procedure should be carefully chosen.

This is truly a question regarding Surgeon preference. Some Surgeons like hemostatic sutures and some do not: I fall in the latter category. Neither dressings, sutures, nor drains will prevent a hematoma any better than appropriate instruction adherence and blood pressure management. Situations where necrosis occur are invariably related to some form of nicotine use, excessive dressing pressure or other negative incisional factor. Although less than optimal, appropriate wound care in the setting of small areas of necrosis often lead to very acceptable incisions/ scars. In the setting of an objectionable scar, this can almost always be addressed in the 6-12 month window with scar revision techniques. As in most scenarios, a ounce of prevention is the best approach. Hence my practice has an extremely thorough preoperative counseling session and attention to detail is necessary in blood pressure management.

Thanks for your question. I know some talented surgeons who recommend and use hemostatic net suturing after a facelift. This essentially is to prevent or minimize the risk of hematoma, which in our practice is already very low. I worry about permanent marks after these sutures, as well as perhaps increased risk for bleeding with dozens of extra punctures of the deep tissue after the skin closure. For this reason, I don't think these are necessary or helpful in our practice, and I do not use them.

Each surgeon will develop routines that he or she is comfortable with, and they should be able to discuss them with you. For example, I never use hemostatic suturing because I'm trying to place less holes in a patient's face, not more. We often use drains and remove them the next day. If a patient is bleeding minimally throughout the case, we may not use any drains. With proper surgical technique and patient selection, necrosis of the skin should be a very rare complication. For example, if a patient smokes, the risk is higher. Ultimately, if necrosis occurs, it will heal with whitish skin most of the time. That's why it's important to find a plastic surgeon who specializes in facial procedures for your facelift.

1. In a deep plane facelift, the choice between hemostatic suturing and drains depends on the surgeon’s technique, extent of dissection, and the patient’s bleeding risk. Hemostatic suturing helps seal vessels and reduce dead space, often minimizing the need for drains. However, drains may still be used in cases with higher risk of fluid accumulation. Both methods are effective, but careful suturing may offer fewer complications and more comfort post-op.
2. Skin necrosis after a deep plane facelift is rare when performed by an experienced surgeon, but risk increases with smoking, poor vascular supply, or excessive tension. Necrosis can negatively affect scar quality and healing, potentially leading to wider or more noticeable scars. Prompt management reduces long-term impact.
Erman AK, Dr. MD, Plastic Reconstructive & Aesthetic Surgeon