Why Did This Happen After my SMAS Facelift? (photo)

Doctor Answers 10

Bilateral Skin flap necrosis.

The most appropriate quote here imo is from Oscar Wilde's Importance of being Earnest

Lady Bracknell: To lose one parent, Mr. Worthing, may be regarded as a misfortune; to lose both looks like carelessness.

Sadly in this case I woulds substitute the word parent for Skin flap.

I am so sorry for your rare complication on both sides, one which I have never seen photos of before.

I agree with all other expert comments posted.


London Facial Plastic Surgeon
4.9 out of 5 stars 172 reviews

Facelift with vascular comprise.

There are many reasons for this rare occurrence. Not having been there I cannot honestly say what caused this.  For more than 35 years of facelifting fortunately I have never had this complication. 

The blood supply to the dark areas of skin is less than what is needed for the skin. Frequent follow up with your surgeon is needed. Polysporin ointment over the dark areas and no surgery for at least a year. This will look worse before it gets better and then will get much better 

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 34 reviews

Flap Compromise after Facelift

    Flap compromise after facelift happens very infrequently.  If the patient is a nonsmoker and there is no hematoma, this may never happen.  If a hematoma is present, it should be drained expeditiously.  If tension on the flap is suspected the sutures should be released.  If everything has been managed and there are no signs of infection, conservative management is the best option.  The flaps should be allowed to heal.  Scar revision may be necessary in the future.

Kenneth B. Hughes, MD
Los Angeles Plastic Surgeon
4.9 out of 5 stars 496 reviews

Etiology and treatment of skin flap necrosis after rhytidectomy

As others have mentioned, the blood supply to your skin (subdermal plexus) was compromised by any of a number of possible factors.  If you smoke or have a history of smoking, then the delicate microcirculation that supplies blood to your skin could have been impaired.  Raising a skin flap in a plane that is too thin, aggressively dissecting too large a flap, excess tension on the wound, excessive compression from dressings, untreated hematoma, etc. can all lead to vascular compromise and skin flap necrosis.  

Some treatment options to consider with your surgeon:  hyperbaric oxygen, Trental (medication to improve bloodflow), and Santyl ointment (to help the necrotic areas heal more quickly).  

Donald B. Yoo, MD
Beverly Hills Facial Plastic Surgeon
4.9 out of 5 stars 58 reviews

Post Op Bleed??

So sorry about your untoward event & unfavorable outcome. From your photographs it appears you had a significant bleeding episode in the peri-operative period with vascular compromise to the facial skin. This can occur from many factors such as medications that affect coagulation like Aspirin, NSAID’s, Vitamin Supplements, etc. Vascular compromise can occur in the presence of an unaddressed blood clot under a patients skin (Hematoma), decreased oxygen delivery (smokers), loss of blood delivery (excessive undermining of the skin), etc. Continue with local wound care and be sure to watch carefully for signs of infection (fever, purulent drainage, excessive pain, etc.) as this can result in worse scaring.  Best,


Gary R Culbertson. MD, FACS

Gary R. Culbertson, MD
Columbia Plastic Surgeon
4.9 out of 5 stars 9 reviews

Poor blood flow after face lift

Thank you for your question and photographs.  I am sorry that your are having complications after your facelift.  It appears that you are suffering from poor blood flow to the skin flaps in front of your ears.  This is the skin that has been elevated and moved forward.  

There are several reasons that this could be happening:  1) smoking, 2) skin flaps that are too thin, 3) bleeding under the flaps (hematoma), 4) excessive skin removal, 5) or skin closure under too much tension (tightness).  

If there is a hematoma under the skin flaps, this should be addressed quickly.  Topical nitroglycerin may be an option to help minimize the area of tissue that undergoes necrosis (death of skin tissue).  I would not recommend removal of the dead tissue until the full extent is known.  Topical antibiotic ointment can be used to help encourage the dead skin cells to slough off. You may need a skin graft if you have a large open wound or the body may heal itself with scar tissue.  This scar can be revised at a later time to improve the appearance.  Frequent follow up with your board certified plastic surgeon is essential to help maximize the aesthetic outcome. 

Matthew H. Steele, MD
Sioux City Plastic Surgeon
5.0 out of 5 stars 85 reviews

Skin Loss after Facelift

I am sorry for your unfortunate result.  It appears that you at least had a hematoma that may have contributed to skin loss (dark area).  There are many more reasons for skin loss including smoking, Skin that is sewn too tight, and skin too thin would be some examples.  The best treatment now would be to allow the area to heal and debride any unhealthy skin.  The area can be revised or grafted if needed.


Dr. ES

Facelift, skin necrosis

I wonder if the facelift was done by a Board Certified Plastic Surgeon(American Board of Plastic Surgery)?

This is a major vascular compromize that will end in some areas with scars.

These issues are seen mostly in smokers.including second hand smoke.

Otherwise this results from elevating the skin very thin in the wrong plane, and the subdermal vessels are injured.

On top of that It looks that you had a hematoma, and that made things worse.

When recognized early treatment is to remove the sutures to relief any tension. Use vasodialators on the skin, May be a hyperbaric oxygen treatment. It is too late now and you need to make sure all hematoma is removed, skin should be treated as a wound to prevent infection and make things worse.

Follow up with the surgeon every other day. Skin evantually will form an eschar which will peel, and sometimes need to be debrided by the surgeon  very conservatively. with time raw surface will heal by scarring. Must wait a long time before attempting to do anything to deal with the results.

Samir Shureih, MD
Baltimore Plastic Surgeon
4.2 out of 5 stars 7 reviews

Skin after a facelift

Local wound care, hyperbaric oxygen, and time will help you get through this process. Scar treatments afterwards can help improve skin texture.


Dr. Karamanoukian

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 94 reviews


It looks like you may have had a hematoma underneath the skin on the affected side which probably contributed to some vascular compromise of the tissues.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

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