Editorial
Aesthetic Surgery Journal
Hematomas and the Facelift Surgeon: It’s
Time for Us to Break Up for Good
Foad Nahai, MD, FACS; Brian Bassiri-Tehrani, MD ;
and Katherine B. Santosa, MD, MS
Editorial Decision date: July 7, 2023; online publish-ahead-of-print July 12, 2023.
Hematoma after face- or necklift is a significant complica-
tion 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 stud-
ies 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; postop-
erative blood pressure;4,5 and ingestion of medications
that affect coagulation and platelet function. We firmly be-
lieve 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 report-
ed on the relationship between elevated systolic pressure
and hematoma.1,2,7,8 Controlling postoperative blood pres-
sure with antihypertensive agents such as clonidine, beta-
blockers, and calcium-channel blockers has been shown to
effectively reduce hematoma rates.9-12 Additionally, post-
operative anxiety, a full bladder, and nausea/vomiting
also contribute to blood pressure elevation.13 Beyond
blood pressure control, tissue glues, compression dress-
ings, and cooling devices have been advocated for hema-
toma 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 achiev-
ing hemostasis in oropharyngeal vascular malformations,20
2023, Vol 00(0) 1–3
© The Author(s) 2023. Published by
Oxford University Press on behalf of The
Aesthetic Society.
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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 reduc-
tion 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 proce-
dures, such as tip rhinoplasty,21 gliding brow lift,22 and lip
lift.23
In this issue, Janssen et al report on their 5-year experi-
ence with the hemostatic net.24 Compared to their histori-
cal 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.
Dr Nahai is a professor of plastic surgery, Department of Surgery,
Emory University School of Medicine, Atlanta, GA, USA and is the
editor-in-chief of Aesthetic Surgery Journal. Dr Bassiri-Tehrani is an
aesthetic plastic surgery fellow in private practice, Atlanta, GA, USA. Dr
Santosa is a plastic surgeon in private practice in Atlanta, GA, USA and
is a next-generation editor for Aesthetic Surgery Journal.
Corresponding Author:
Dr Foad Nahai, 875 Johnson Ferry Rd NE, Atlanta, GA 30304, USA.
E-mail: journal@theaestheticsociety.org; Twitter: @nahaidr
2 Aesthetic Surgery Journal
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 sig-
nificant. 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 pa-
tients and assuming a 0% hematoma rate results in costs of
US$600 per patient (from the additional 30 minutes of an-
esthesia 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 hemato-
mas 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 aes-
thetic surgery studies.
The senior author’s data suggest that strict blood pres-
sure management (systolic <120 mmHg) reduces hemato-
ma rates to 0.5% without the use of a hemostatic net.27
Before the implementation of this strict blood pressure con-
trol, hematoma rates among patients undergoing face- and
necklifts in the senior author’s practice was 3.7% when sys-
tolic blood pressure was maintained at systolic <140
mmHg.
We applaud Auersvald and his colleagues for introduc-
ing this novel technique, and for thoroughly evaluating
his data and outcomes. Similarly, we welcome the addition-
al confirmation of the effectiveness of the net by
Waterhouse and colleagues in this issue.24 With the inno-
vative hemostatic net and strict control of systolic pres-
sures 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.
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