Certainly, there is no replacement for meticulous surgical technique and adequate intraoperative hemostasis in reducing the risk of postoperative hematoma after rhytidectomy. Interestingly, the series by Jones et al. found a higher hematoma rate in patients infiltrated with a tumescent solution containing epinephrine, presumably due to temporary vasoconstriction of small bleeding vessels that could not be identified at the time of surgery. Independent of their conclusions, if proper hemostasis is not achieved prior to closure, there is no drain or dressing that can reliably prevent postoperative complications from occurring.
The most commonly used adjunctive measures for minimizing the risk of hematoma formation in the postoperative setting are drain placement, application of tissue sealant, and use of compression dressings. In terms of drain use after facelift surgery, the majority of studies have failed to demonstrate a significant clinical benefit and do not support their routine use. The highest quality investigation, a prospective trial from 2007, did show a reduction in bruising with drain placement that the authors surmise may lead to more rapid return to regular activities and therefore greater patient satisfaction. When contemplating drain placement following rhytidectomy, this may be a factor to be considered against the potential downsides of this practice.
The literature for tissue sealant use is somewhat more controversial. As mentioned, a recent meta-analysis including three prospective randomized studies did not show a significant reduction in hematoma rate with tissue sealant use, although there was a trend toward improved outcomes. Another large series without drains did find a significant decrease in hematoma formation with application of tissue sealant; however, the study design was retrospective in nature. Until larger prospective studies are conducted, the routine use of tissue sealants during rhytidectomy is not clearly justified.