Anesthesia and recovery in facelift surgery

Where and how facelifts are done

• ABPS tracer data, 3,400 facelifts 2006-2021: 76% in an accredited office facility, 18% in hospital (PMID 38302713).
• CosmetAssure, 11,300 facelifts: type of facility was an independent predictor of hematoma (relative risk 2.6) (PMID 26578747).

Total intravenous anesthesia (TIVA) and dexmedetomidine

• O'Daniel 2006, 50 nonintubated extended SMAS facelifts: dexmedetomidine infusion 0.2-0.7 mcg/kg/h held systolic pressure at 120 mmHg or less in all but 8 patients; no antiemetics needed; 1 hematoma at 72 hours (PMID 19338881).
• Moore, O'Daniel 2022, 791 facelifts under propofol TIVA with dexmedetomidine: blood pressure lowered and held from induction to discharge; nausea/vomiting 0.8%; no admissions; conversion to general endotracheal anesthesia 5.3% (PMID 35512645).
• Conversion risk factors in that series: higher BMI, ASA class II or higher, preoperative hypertension, multiple procedures (PMID 35512645).
• Randomized trial, 30 patients: propofol-ketamine with bispectral index monitoring vs inhalational anesthesia; faster emergence (29.8 vs 46.0 min) and discharge (51.4 vs 66.1 min); nausea and vomiting differences not significant (PMID 25906190).
• 1,089-facelift protocol: anxiolysis, antiemetics, antihypertensives and controlled emergence; 10 hematomas (PMID 25415274).
• Prophylactic analgesic, antihypertensive, antiemetic and sedative given before extubation: hematoma 0% against 7% with on-request dosing (PMID 20333520).

Local anesthesia and awake facelift

• 174 facelifts under local anesthesia and oral sedation: hematoma 13.2% (21 of 23 aspirated, 2 evacuated in office); no thromboembolism or hospitalization (PMID 30107493).
• Scoping review 2026, 21 studies, 7,115 facelifts under local anesthesia: hematoma 2.35%; fewer thromboembolic events and more hemodynamic stability than general anesthesia (PMID 42034464).
• Deep-plane facelift with extended deep neck work under tumescent local anesthesia, 200 patients: complications 8.5%, hematoma 2.0%, no lidocaine toxicity (PMID 41800201).
• SMAS plication and platysmaplasty under tumescent local anesthesia, 80 patients: no toxicity, no conversion to general anesthesia, hematoma 2.5% (PMID 42380310).
• Limited incision facelifts: 84% of 4,451 patients under local or conscious sedation (PMID 37950895).
• Conscious sedation in 300 plastic surgery patients: nausea/vomiting caused 11 of 15 unintended admissions (PMID 10513915).
• Office-based anesthesia review for facial plastic procedures (PMID 37780676).

Venous thromboembolism (VTE)

• 630 facelifts: 2 DVTs, both in combined procedures; DVT risk rose with operating time over 5 hours (PMID 22446820).
• Multicenter survey of local-anesthesia facelifts: 1 VTE per 5,844 operations (PMID 23708241).
• 136 facelifts without chemoprophylaxis, mean Caprini score 5.6: no VTE (PMID 35601235).
• Low-molecular-weight heparin: postoperative bleeding 16.2% with vs 1.1% without (PMID 16874225).

ERAS (enhanced recovery after surgery)

• O'Daniel's group describes dexmedetomidine TIVA as a route to "enhanced recovery" in facial aesthetic surgery (PMID 35512645).
• Systematic review of plastic surgery ERAS studies 2020-2023: 50 studies, 5 aesthetic; mean reporting quality 22.6 of 40 (PMID 39729950).

Recovery timeline: measured data points

• Randomized steroid trial in 30 facelifts: no difference in facial swelling (PMID 8657760).
• The only facelift trial in the Cochrane review found no steroid effect on edema (PMID 24887069).
• FACE-Q Early Life Impact scale measures the first weeks after treatment (PMID 25626785).

Glossary

• TIVA: total intravenous anesthesia, usually propofol-based (PMID 35512645).
• Dexmedetomidine: alpha-2 agonist sedative that lowers blood pressure without respiratory depression (PMID 19338881).
• Bispectral index (BIS): EEG-derived depth-of-anesthesia monitor (PMID 25906190).
• Tumescent local anesthesia: dilute lidocaine with epinephrine infiltrated in volume (PMID 42380310).
• PONV: postoperative nausea and vomiting (PMID 35512645).
• Caprini score: VTE risk score (PMID 35601235).
• ERAS: enhanced recovery after surgery protocols (PMID 39729950).
• Hilotherapy: cooling mask with circulating cold water (PMID 21570371).

Papers

Open questions / controversies

• Local vs general anesthesia: lower VTE and more stable hemodynamics reported for local (PMID 42034464), but one local/oral sedation series had 13.2% hematoma (PMID 30107493).
• ERAS evidence in plastic surgery has low reporting quality, and aesthetic studies were 5 of 50 (PMID 39729950); the facelift ERAS claim rests on one retrospective series (PMID 35512645).
• Chemoprophylaxis: Caprini scores recommend it for most facelift patients, while LMWH raised bleeding in one series (PMID 35601235, PMID 16874225).
• Steroids: no facelift benefit in 2 randomized trials (PMID 8657760, PMID 7480274).