Facelift Complications: Evaluating Surgical Outcomes with Facelift Before and After Photos

facelift gone wrong

What happen if facelift gone wrong? Although many people search best facelift doctors in South Korea, few have discerning eyes to judge the facelift results. This article aims to provide insights into the complications that can arise from facelift procedures and offers guidance on evaluating surgical outcomes using before and after photos. Key topics covered include common complications, preventive measures, assessment of scars and ear deformities, risks of skin necrosis and nerve damage, and tips for selecting a skilled facelift surgeon.


Q. What are the potential side effects of facelift surgery?

A: Possible complications of facelift surgery may include hematoma, skin necrosis, scarring along the incision line, changes in sideburn or ear shape, and facial nerve damage. It’s important to note that all surgeries carry some degree of risk, and the frequency of these risks can vary based on the surgical technique and the surgeon’s expertise.

Q. What causes scars and pixie ear deformity after a facelift procedure?

A: While there are several factors involved, the tension exerted on the skin closure site is the most significant factor contributing to the development of scars and pixie ear deformity.

Q. How common is facial nerve damage after facelift surgery, and how can it be prevented?

A: Based on a survey of plastic surgeons in the United States, the rate of permanent facial nerve damage is approximately 0.1%. To help prevent such damage during surgery, using a nerve stimulator are helpful.

Q. How can I minimize the occurrence of side effects from facelift surgery?

A: To reduce the likelihood of experiencing side effects from facelift surgery, it is recommended to thoroughly discuss the surgical technique with your surgeon. This includes understanding why they have chosen a specific method and exploring alternative methods along with their advantages and disadvantages. Additionally, following pre-operative instructions such as quitting smoking, discontinuing the use of aspirin, and avoiding skin shrinkage procedures is crucial. Keeping up with scheduled follow-up appointments to monitor the progress of healing is also important.

1. Facelift Hematoma: The most common facelift complications

Hematoma, characterized by the accumulation of blood after surgery, is a frequently observed complication in facelift procedures. Its occurrence ranges from 1.86% to 9% and is more prevalent in men, smokers, aspirin users, and individuals with high blood pressure (systolic 150mmHg or higher). Various preventive measures, such as avoiding epinephrine in anesthetic solutions or using low concentrations of epinephrine(1:1 million to 1:4 million), can help minimize the risk of hematoma. Some surgeons also employ hemostatic nets to prevent hematoma formation, although this method is not widely used among top facelift doctors in South Korea.

facelift hematoma prevention
Hemostatic net help to prevent hematoma after a face lift.
Hemostatic Net in Rhytidoplasty: An Efficient and Safe Method for Preventing Hematoma in 405 Consecutive Patients

2. Less Effective or Short-lived facelift results: Mini Facelift

Non-surgical facelift options (Ulthera, Thermage), thread lifts, and surgical procedures (mini-facelift, facelift) are the three main treatment options for facial wrinkles. Dissatisfaction with mini facelifts or less invasive methods often stems from the outcome not meeting the desired expectations. If the doctor lifts the face without cutting the retaining ligaments or pulls the skin in a direction that does not improve the sagging area, the outcome may result in minimal improvements. This dissatisfaction can also extend to classic facelifts involving SMAS (superficial musculoaponeurotic system).

3. Scar and hairline shifts: Incision line considerations

hairline receding after facelift
Hairline receding and scar problems after facelift
Aesthetic Rejuvenation of the Face and Neck

Proper incision placement plays a crucial role in avoiding scar and hairline shifts. Incisions made in front of the tragus may lead to disfiguration due to skin color mismatch. Improper incision placement can also result in the loss of sideburns and displacement of the hairline. Widened temple areas are considered signs of aging, as highlighted by renowned facelift surgeon Dr. Connell. 
Awareness of these issues is crucial, as even though patients may not recognize hairline shifts in facelift selfies discerning individuals can readily identify these changes.

facelift before and after selfies
A review was posted on a Korean RealSelf site, indicating that the patient is said to be satisfied. However, the disappearance of the sideburns is actually a severe side effect. Since many individuals lack the discerning eyes to accurately assess the outcomes of aesthetic procedures, they may mistakenly perceive these unfavorable results as good.
facelift scars behind ears pictures
The facelift scars behind the ears have healed well after 7 weeks. These scars are strategically placed along natural anatomic interfaces, effectively hiding any noticeable differences in color and texture that would be evident if a pre-tragal incision plan had been utilized. When visible, the scar in this area deceives the eye and appears as a reflected highlight.

4. Ear Deformities: Pixie Ear and Chopped-off tragus

The incision around the ear should be carefully planned to follow the natural anatomic interfaces, in order to blend the color and texture transitions commonly observed between the ear and cheek. Incorrect execution of this step can result in ear deformities, which are well-known complications associated with facelift procedures, particularly affecting the earlobe and tragus. These side effects often occur simultaneously rather than independently, and can be categorized into two parts.

1) Deformities of the Earlobe

An ideal earlobe should be slightly turned backward at an angle of approximately 15 degrees from the ear’s longitudinal axis. 

Dr. Loeb angle of dangle
Dr. Loeb’s angle of dangle
Aesthetic Rejuvenation of the Face and Neck

Additionally, as depicted in the diagram below, it appears more natural when the point (S) below the ear is positioned lower than the attachment point (O) on the cheek.

Intertragal notch (I), otobasion inferius (O), and subaurale (S). Earlobe height parameters are defined with respect to the attached cephalic segment and the free caudal segment.
The “Pixie” Ear Deformity following Face Lift Surgery Revisited

However, not everyone naturally has this ideal earlobe shape, and some individuals are born with an earlobe attached to the cheek (as shown on the right side of the diagram below). 

Stuzin discusses his surgical skills on how to make a pendulous earlobe in this article.
Morphometry of the Adult Human Earlobe: A Study of 547 Subjects and Clinical Application

During a facelift, it is possible to reshape a ‘grandfatherly’ earlobe into a more natural and youthful appearance.

earlobe reduction
Earlobe reduction during facelift procedures. The attached aged-looking earlobe has been corrected.

However, if the earlobe is not properly shaped during the procedure, it can result in the following side effects.

a) Pixie ear deformity

Pixie ear deformity refers to a condition where the earlobe is pulled downward toward the lower face. While some people are born with this deformity, it is commonly caused by excessive skin tension after a facelift. 

Left: Case of Retro-tragal incision. Excessive tension results in pixie ear, an attached earlobe, retracted tragus, and shortened sideburn are seen.
Right: Case of Pre-tragus incision. Scar in front of the ear, mismatch of cheek and ear skin color, pixie ear, and an attached earlobe deformity.
Aesthetic Rejuvenation of the Face and Neck

The solution involves releasing the tension and revising the scars. Slight looseness of the skin and the superficial musculoaponeurotic system (SMAS) are essential for correcting these problems. However, if too much skin was removed during a previous operation, correcting the deformity may be challenging.

b) Attached ear deformity

Ideally, earlobes should hang from the cheek, as mentioned earlier. Therefore, when designing the incision, the final shape of the earlobe should be taken into consideration. Attached ear deformity is caused by skin tension, similar to pixie ear deformity.

2) Deformity of the Tragus

The tragus is a square-shaped cartilage located in front of the ear. Unlike earlobe deformities, tragus deformities are less recognized but can still result in an unnatural appearance.

a) Chopped-off tragus: 

his deformity occurs when the lower margin of the tragus becomes indistinct. It is caused by damage to the inter-tragic notch, which supports the inferior tragal margin. Proper design of the incision line and attention to skin tension are important to prevent this side effect.

안면거상 부작용
An example of a chopped-off tragus and incisional scar after facelift ten years ago(unknown surgeon).

b) Retracted tragus: 

If a chopped-off tragus is a deformity limited to the lower part, a retracted tragus occurs when tension is applied to the entire tragus area, causing the tragus to flip forward. It can occur due to excessive skin tension or excessive repositioning of the tragus in an attempt to hide the scar.

5. Facial Widening: Considerations for Asian facelift

Patients often complain of increased prominence in the cheek and malar area after undergoing facelift surgery. The direction of the SMAS pull or the design of the SMAS flap may be the contributing factors, and careful planning is crucial, especially for Asians who tend to avoid facial widening.

6. Unnatural Look: Aesthetic Perspectives

Unlike the aforementioned side effects, the perception of a facelifted look can vary depending on cultural preferences and aesthetic perceptions. The desired outcome of a successful facelift should not result in a windblown or overly pulled appearance. The goal is to restore a natural, youthful appearance for the patient. However, excessive dissection of the peri-oral skin can lead to awkward appearances. Pre-operative evaluation should be cautious of depressions around the mouth that may indicate the risk of joker line deformity.

안면거상과 조커라인 부작용
Patients with two times of facelifts previously. Shadows and depressions seen in the mouth corner in the direction to the ear are signs of a joker line.
The cross-cheek depression: surgical cause and effect in the development of the “joker line” and its treatment

7. Skin necrosis

Skin necrosis can occur when adequate blood circulation is not provided to the skin. Causes of insufficient circulation include:

1) Past medical history:

The doctor should be fully informed about the patient’s history of smoking, past diseases, and previous aesthetic facial procedures. Smoking and skin shrinking therapies (such as Ultherapy or Thermage) should be discontinued for at least 4 weeks and 1 year, respectively, as thin skin flap dissection can compromise blood circulation. This is crucial in preventing skin necrosis or delayed healing problems.

Skin necrosis can occur in the following situations:

  • a) When the skin flap is raised too thin
  • b) Due to inappropriate skin incision design

The design of the skin flap’s base should ensure sufficient blood flow, following basic principles of plastic surgery. In some cases, the sideburns may need to be shortened to prevent skin necrosis, and it is advisable to discuss this issue with the patient before surgery.

안면거상 구레나룻 소실
The length of the intact sideburn depends on the height of the ear helix.
  • c) When excessive tension is applied

That’s why it is important to visit the hospital during the facelift recovery period. If there is a suspicion of skin necrosis, a few stitches should be released during this visit.

skin necrosis after facelift
A case of skin necrosis after facelift. Facelift scars behind ears pictures show a large skin defects. Review posted on a Korean RealSelf site.

8. Nerve damage

Patients often express concerns about facial nerve damage after a facelift. The risk of facial motor nerve injury during facelift surgery depends on the surgeon’s technique and anatomical knowledge. Even experienced doctors can still encounter nerve damage when raising the SMAS flap. Nerve branches are less likely to be completely severed in this situation, and temporary facial paralysis typically recovers within 3 to 6 months. The use of a nerve stimulator during surgery can help determine the proximity of the nerve, ensuring a safer creation of the SMAS flap.

9. Tips for choosing a facelift surgeon: understanding successful results

Many people search for the best plastic surgeon, but surprisingly, they often lack a clear understanding of what a youthful appearance should look like. It is crucial to develop the ability to judge whether the results are good or bad. To do this, consider the following:

a) eye training

Train your eyes to assess the entire face in a balanced way.

b) catching differences in target areas

Facelift usually treats nasolabial folds, marionette lines, jowls, jawline, and neck contour. It’s important to note that the degree of improvement may vary based on each individual’s facial structure. Before the surgery, discuss with the doctor the limitations of the procedure and how to address them.

c) naturalness

Assess the naturalness of the postoperative appearance

d) longevity

Consider the duration of the surgical effects as an important factor.

It is important to understand that facelifts do not result in dramatic changes for everyone. Each individual’s wrinkles and sagging are unique, and the amount of tissue that can be lifted varies. Instead of striving for perfection, it is typically better to focus on changes. Having realistic expectations and understanding the limitations of the surgery are also important.

10. Conclusion

This article has examined the potential complications associated with facelift procedures. No doctor wants their patients to experience side effects, and even the best facelift surgeons cannot guarantee 100% satisfaction. However, it is crucial for doctors to comprehend the causes of these side effects and establish a surgical strategy to minimize them. If side effects do occur, the doctor should make every effort to treat the patient. Patients should trust their chosen doctor and follow their recommended treatment plan.
Interestingly, many side effects related to facelifts manifest around the ears. This may be related to the fact that the master of facelifts tends to be more obsessed with their results in ears.

Invisible scars in front of the ear are the hallmark of how well a surgeon can perform a facelift.”

Timothy Marten

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