Skin Necrosis After Deep Plane Facelift
Quick Answer
How common is skin necrosis after deep plane facelift and what causes it?
Skin necrosis — tissue death from insufficient blood supply — occurs in fewer than 1% of non-smoking facelift patients. Smoking is the dominant risk factor, raising incidence to 3–4%. The deep plane technique actually carries a lower necrosis risk than traditional facelifts because it preserves the subdermal blood supply rather than undermining it. Quitting smoking 4–6 weeks before surgery is the single most effective prevention step.
Source: DeepPlane.com · Reviewed
Skin necrosis risk zones after facelift: highest risk behind the ear and at skin flap edges, with smoking as the primary risk factor.
Skin flap necrosis
Major — operative or specialist management
- •Black or dusky-purple tissue at incision edge
- •Skin that does NOT blanch when pressed (loss of blood supply)
- •Cold to touch on one area (vs normal warm)
- •Foul odor from compromised tissue
- •Pain disproportionate to apparent injury
Conservative: serial debridement + wet-to-dry dressings to allow healthy tissue to reepithelialise. Adjuncts: hyperbaric oxygen therapy in select cases (5-10 sessions), nitroglycerin paste 2% for vasodilation, leech therapy in severe venous congestion. Scar revision waits 6-12 months until tissue stabilises.
- •Smoking / vaping / nicotine in any form (DOMINANT factor)
- •Diabetes with poor glycaemic control
- •Hematoma (compresses subdermal vessels)
- •Aggressive flap thinning
- •Excessive tension at closure
- •History of facial radiation therapy
Prevention: Strict 6-week pre-op + 6-week post-op nicotine cessation verified by urine cotinine test. Tension-free closure technique by surgeon. Drainless technique with fibrin sealant to reduce hematoma risk. Cotinine-positive patients: surgeons should defer elective surgery until verified abstinence.
During a facelift, the skin is elevated as a flap that temporarily loses its direct blood supply and must survive on small perforating vessels. Any additional reduction in blood flow — from smoking, haematoma pressure, or overly tight closure — can deprive a portion of the skin of oxygen long enough to cause irreversible tissue damage. The deep plane technique mitigates this risk by operating at a deeper layer, leaving the skin's primary blood supply intact.
- Occurs in <1% of non-smoking patients
- Smoking raises risk to 3–4%
- Deep plane technique is protective vs. traditional facelift
Skin necrosis is one of the most feared — yet actually rare — complications after facelift surgery[4]. What makes the deep plane facelift particularly relevant here is that its technique is specifically protective against necrosis compared to traditional approaches[1]. Understanding why this risk exists, and what factors elevate it, helps patients make informed decisions and take the right preventive steps during recovery. For context on how this compares to other complications, see our full overview. See also deep plane facelift safety profile.
Warning Signs of Skin Necrosis
Skin Darkening
Purple-black discoloration in a localised area, typically behind the ear or along the jawline incision.
Skin Blistering
Small fluid-filled blisters (bullae) along the incision line suggest full-thickness vascular compromise.
Skin Hardening
An area that becomes firm, leathery, and insensate (numb) rather than soft — indicates tissue no longer viable.
Manageable
Most cases are small, heal with wound care, and leave a scar that fades or can be revised.
Skin Necrosis After Facelift: Skin necrosis is the localised death of skin tissue caused by insufficient blood supply to the elevated skin flap during facelift surgery. It occurs most commonly behind the ear and along the jawline. Risk is below 1% in non-smokers and rises to 3–4% in active smokers. The deep plane technique preserves the subdermal vascular plexus, offering inherently lower necrosis risk than traditional skin-only undermining.
— DeepPlane.com Expert Panel
Skin Necrosis After Facelift: Quick Facts
- Incidence (Non-Smokers)
- <1% of patients
- Incidence (Smokers)
- Up to 3–4%
- Main Cause
- Compromised blood supply
- Biggest Risk Factor
- Active smoking
- Affected Areas
- Behind ear, jawline
- Prevention
- Quit smoking 4–6 weeks prior
Source: Clinical Studies & The Aesthetic Society
Why Deep Plane Facelift Has Lower Necrosis Risk
This is one of the most clinically important advantages of the deep plane technique — and it is often underappreciated. Here is why the risk differs:
Traditional SMAS facelift:
The skin is undermined over a large area as a thin flap, and the subdermal vascular plexus (the network of blood vessels just beneath the skin) is disrupted over the entire dissection zone. This leaves the skin dependent on fewer, smaller vessels.
Deep plane facelift:
Dissection occurs at the deep plane level, below the SMAS. The skin and superficial fat are lifted together with the SMAS as a composite flap, preserving the subdermal vascular plexus intact. The blood supply to the skin is therefore much more robust throughout the healing process.
Result: Experienced deep plane surgeons consistently report necrosis rates below 0.5% in non-smokers — lower than published rates for traditional facelift techniques[5].
Where Necrosis Happens — Watershed Zones
Risk Factors for Skin Necrosis After Facelift
Factors that compromise blood supply to the elevated skin flap
Active Smoking
Nicotine Replacement Products
Untreated Hematoma
Poorly Controlled Hypertension
Prior Facelift (Revision Surgery)
Prior Radiation to the Area
Diabetes (Poorly Controlled)
Collagen Vascular Disease
Quit smoking at least 4 weeks before surgery — 6 weeks preferred. This is the single most effective risk reduction step
Treatment Protocol for Skin Necrosis
Immediate: Identify and Optimise
Your surgeon will evaluate the area. If a haematoma is compressing blood supply, urgent drainage is performed. Smokers must stop immediately. Hyperbaric oxygen therapy is used in some centres to maximise tissue salvage in the early stages.
Weeks 1–4: Conservative Wound Care
Dead tissue (eschar) is gently debrided. Moist wound dressings (hydrocolloid, petrolatum gauze, or silver-based dressings if infection is suspected) keep the wound bed clean and promote granulation. Do not pull or scrub eschar.
Weeks 4–8: Secondary Healing
The wound fills in from the edges and base. Most small areas (under 1 cm) heal fully with conservative management. Larger areas may need split-thickness skin grafting — rare in experienced hands.
Months 12–18: Scar Revision if Needed
Once healing is complete and the scar is fully mature, surgical scar revision, laser treatment, or steroid injections can address any residual cosmetic concern. Many scars in the post-auricular area are naturally concealed.
When to Contact Your Surgeon Immediately
Any of the following in the first 2 weeks after surgery warrant an urgent call:
- A localised area of skin turning purple, grey, or black around the incision
- Blistering along the wound edges that is not simple friction
- An area of skin that becomes hard, leathery, and numb
- Foul odour from the wound — suggests secondary infection of necrotic tissue
- Any sign of rapidly spreading redness beyond the wound (may indicate concurrent infection)
Your Questions Answered
Medical References
- 01Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1):53-61(opens in new tab)(Journal Article)Accessed: 2026-03-21DOI: 10.1097/00006534-199001000-00006
- 02Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg. 1983;10(3):543-562(opens in new tab)(Journal Article)Accessed: 2026-03-21
- 03Matarasso A, et al. Hematoma prevention in rhytidectomy: current techniques. Aesthet Surg J. 2013;33(3S):100S-108S(opens in new tab)(Research Study)Accessed: 2026-03-21DOI: 10.1177/1090820X13497660
- 04Marchac D, et al. Skin slough after face-lifting. Plast Reconstr Surg. 1999;103(2):554-560(opens in new tab)(Journal Article)Accessed: 2026-04-13DOI: 10.1097/00006534-199902000-00017
- 05Niamtu J. Near-fatal airway obstruction after routine facelift surgery. Dermatol Surg. 2005;31(3):346-350(opens in new tab)(Journal Article)Accessed: 2026-04-13DOI: 10.1111/j.1524-4725.2005.31046.x
- 06FDA - Cosmetic Surgery Safety Information and Consumer Updates(opens in new tab)(Government Source)Accessed: 2026-04-06
Key Facts
Common Misconceptions
Myth: Skin necrosis is common after facelift
Fact: In non-smoking patients undergoing deep plane facelift with an experienced surgeon, skin necrosis rates are below 0.5%. It is one of the rarest serious complications in this technique.
Myth: I can smoke after surgery as long as I quit before
Fact: Smoking must be avoided for at least 4 weeks AFTER surgery as well. The skin flap remains vulnerable until vessels regenerate — typically 3–4 weeks post-operatively. Resuming smoking too soon carries the same necrosis risk as smoking before surgery.
Myth: If skin necrosis occurs, the whole facelift result is lost
Fact: Skin necrosis is a localised wound healing problem that does not affect the deep structural result of the facelift. The SMAS repositioning and deep plane work remain intact. Most patients achieve their expected aesthetic outcome after the wound heals, with any residual scar addressable at a later date.
Essential Considerations
Quit smoking — and all nicotine products — at least 4 weeks before and after surgery
Choose a surgeon experienced in deep plane technique for the lowest necrosis risk
Contact your surgeon immediately if any skin darkens, blisters, or becomes leathery
Conservative wound care resolves most small necrotic areas without revision surgery
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Dr. Yakup Duman
Plastic, Reconstructive & Aesthetic Surgery Specialist
Board-certified Plastic & Aesthetic Surgery specialist with 13+ years of experience. Specializes in deep plane facelift at Merkez Prime Hospital, Istanbul. Medical Reviewer for DeepPlane.com.
Turkish Plastic Reconstructive and Aesthetic Surgery Association