What Lies Beneath: Navigating Carotid Artery Depth for Safe Hemostatic Net Use in Facelift Surgery

Highlight

• Hemostatic nets reduce hematoma risk in facelift surgery but raise concerns over carotid artery injury due to vessel proximity.
• A retrospective imaging study mapped common, internal, and external carotid artery depths at vertebral levels C2-C4 in 33 post-rhytidectomy patients.
• The internal carotid artery at the thyroid cartilage level (C4) is closest to skin, with mean depth as shallow as 20.5 mm.
• Needle size and surgical technique must be carefully chosen to maintain a safe margin from carotid vessels during hemostatic net placement.

Study Background

Facelift surgery (rhytidectomy) often carries the complication risk of postoperative hematoma, a potentially serious collection of blood beneath the skin flap that can compromise aesthetic outcomes and patient safety. The hemostatic net, a suture technique designed to provide uniform pressure and control oozing, has demonstrated efficacy in reducing hematoma rates but introduces questions about the safety margin relative to the underlying carotid artery and its branches. Injury to these vital vessels can lead to catastrophic bleeding or neurologic events. Despite widespread adoption of the hemostatic net, anatomical data delineating the depth of carotid arteries along the neck is sparse, leaving surgical guidelines largely empirical. This study addresses this knowledge gap by quantifying carotid artery depth to inform safe hemostatic net use in facelift patients.

Study Design

The investigators conducted a retrospective cohort analysis at a single academic aesthetic surgery center. Patients who underwent rhytidectomy and had available neck imaging (CT or MRI) within ten years postoperatively were included. The study evaluated 33 patients (81.9% female) with an average age of 64.2 years at the time of rhytidectomy and 69.1 years at imaging. Using axial and sagittal imaging views, measurements of the common, internal, and external carotid arteries were taken bilaterally at three anatomical landmarks corresponding to cervical vertebral levels: C2 (angle of mandible), C3 (hyoid bone), and C4 (thyroid cartilage). Two key metrics were recorded: (1) lateral distance between left and right carotid vessels and (2) vessel depth from the skin surface.

Key Findings

The analysis revealed carotid artery depths ranged between 20.5 and 32.9 mm across C2-C4 levels. Among these, the internal carotid artery at C4—the thyroid cartilage level—was the closest to the skin with a mean depth of 20.5 mm, making it the most relevant for surgical risk consideration. The common and external carotid arteries, positioned slightly deeper or more lateral, posed relatively less immediate risk. Distance between bilateral carotid arteries widened slightly at lower levels.

From a surgical instrumentation perspective, the study compared needle dimensions commonly used in hemostatic net placement. A ⅜ circle suture needle of 24 mm length (with 19 mm chord length) inherently provided a greater safety margin relative to the mean vessel depth at C4. Conversely, a larger 32 mm needle (chord length 25 mm) approached the vessel depth limit, necessitating meticulous control of bite depth and oblique needle entries to avoid vascular injury. These findings underline the importance of precision in surgical technique alongside anatomical knowledge to minimize inadvertent carotid puncture.

Expert Commentary

This investigation fills a critical gap in evidence-based facelift surgery by quantifying the spatial relationship between the carotid arteries and surgical plane in postrhytidectomy patients. Given the life-threatening potential of carotid injury, the demonstrated mean depth of approximately 20 mm at the thyroid cartilage level serves as a valuable reference for surgeons employing hemostatic nets. The study’s use of live patient imaging rather than cadaveric models enhances clinical relevance as postoperative tissue characteristics may differ from fresh specimens.

Limitations include the retrospective design, modest cohort size, and potential variability in neck anatomy not fully captured by imaging resolution or demographic diversity. Furthermore, the imaging did not account for dynamic changes in tissue thickness under surgical manipulation or edema. Future prospective studies with intraoperative ultrasonography could refine real-time safety parameters. Integration of this anatomical data with emerging needle technology or alternative hemostatic techniques might optimize outcomes.

Conclusion

The use of hemostatic nets in facelift surgery effectively mitigates hematoma incidence but requires careful consideration of carotid artery depth to avoid vascular complications. This study provides valuable anatomical benchmarks highlighting that the internal carotid artery at C4 is the most vulnerable vessel relative to skin surface. Surgical choices regarding needle size and insertion angle are pivotal to maintaining safe margins, particularly when using larger needles. Surgeons should incorporate these anatomical insights into operative planning and technique to enhance patient safety and procedural success. Further research may explore customized approaches based on individual vascular anatomy.

Funding and Clinical Trials

The original study did not report external funding sources or clinical trial registration.

References

1. Gupta S, O’Shea AW, Edalatpour A, Afifi AM. What Lies Beneath: Carotid Artery Depth and the Safe Use of Hemostatic Nets in Facelift Surgery. Aesthetic Surgery Journal. 2026 Jul 15;46(8):933-936. PMID: 41992563.
2. Rees TD, Rivkin A. Hematoma prevention in facelift surgery. Clinics in Plastic Surgery. 1995;22(2):423-32.
3. Klein JA. Safe use of local anesthetics in cosmetic facial procedures. Dermatologic Clinics. 2010;28(3):455–462.