A stylish woman relaxing at home with tablet
Home / Guides / The papers that changed the facelift

The papers that changed the facelift

Today's facelift grew out of papers by surgeons who dissected faces in the anatomy lab or followed their own patients for years. Their work moved the lift into the deeper tissue, added fat for lost volume, reshaped the neck and made bleeding rarer, and surgeons still debate how far the deep work needs to go.

Dr. T. Gerald O'Daniel, whose work is cited here, is a featured surgeon and a client of the publisher; see the disclosure.

A facelift plan today names a layer to lift, ligaments to release, volume to restore, a neck to reshape and a way to prevent bleeding. Each of those steps goes back to a surgeon who looked closely at the anatomy or at results over time. No single technique is the standard, and surgeons still argue over which approach works best (Barrett 2016). What surgeons do with these ideas now is in The modern facelift, and the people behind them are in The surgeons behind the modern facelift.

Skoog and Mitz: the SMAS (1976)

Until the 1960s a facelift lifted skin, and skin tension held the result (Barrett 2016). Tord Skoog went one layer deeper. He raised the fascia of the cheek and the platysma muscle of the neck as one sheet, moved it up and back and fixed it there, and presented the method in Miami in 1973 (Kim 2015; Barrett 2016). In 1976 Vladimir Mitz and M. Peyronie dissected the cheek, X-rayed it and studied it under the microscope. They named the layer the superficial musculoaponeurotic system, or SMAS, and warned that working under it is safe over the parotid gland and dangerous in front of it (Mitz 1976).

What a patient gets. The deeper layer carries the lift in place of skin tension (Barrett 2016). Facelifts are now sorted by what the surgeon does with the SMAS: fold it, cut out a strip, raise it as a flap or release it widely, the deep plane (Jacono 2019, meta-analysis). See SMAS facelift techniques.

Still debated. In 1977 Thomas Rees and Sherrell Aston lifted the SMAS on one side of the face and only the skin on the other, and observers later saw no difference between the sides (Rees 1977). In 2024 Minelli, van der Lei and Mendelson concluded that no continuous layer joins the facial muscles, and that the "SMAS" is the compound flap the surgeon creates (Minelli 2024, SMAS).

Furnas: the cheek ligaments (1989)

David Furnas of the University of California, Irvine described the ligaments that anchor the skin of the cheek. The zygomatic ligaments under the cheekbone and the mandibular ligaments at the front of the jaw hold the skin against gravity, mark the front edge of the jowl and hold the skin back during a lift. Furnas wrote that both must be divided for the skin to move as far upward as possible (Furnas 1989).

What a patient gets. Releasing these ligaments lets the cheek and jowl move with the lift (Furnas 1989). Lifts are now classed by whether the dissection goes past the cheek ligaments (Schultz 2026).

Still debated. In a blinded photo review, Talei and Ziai found that fat grafted into the hollow in front of the jowl corrected jowls more than cutting the mandibular ligament (Talei 2024, mandibular ligament).

Hamra: the deep plane (1990)

Sam Hamra of Dallas saw that facelifts did little for the nasolabial fold, the crease from nose to mouth. In 1990 he carried Skoog's dissection under the SMAS up over the cheek muscles and past that fold, released every SMAS attachment, and lifted skin, cheek fat and platysma as one thick flap (Hamra 1990). In 1992 his composite lift added the muscle around the lower eyelid. His reasoning: these tissues age together, and a conventional lift separates the skin from them (Hamra 1992).

What a patient gets. The cheek moves with its fat still attached to the skin (Hamra 1990). "Deep plane" now names a family of lifts, and most facial plastic surgeons who answered a 2026 survey perform one (Pak 2026). See Deep-plane facelift.

Still debated. Hamra followed his own 1990 patients. The jawline result lasted, while the correction of the fold held for one to two years and then faded (Hamra 2002). A 2026 systematic review by Stuzin, Rohrich and colleagues found that lifts reaching past the cheek ligaments have not been shown to improve the midface or to last longer (Schultz 2026). In a 2026 randomized trial, deep plane, high SMAS and plication lifts made faces look younger by the same amount (Baptista 2026).

Stuzin: layers and nerves (1992)

Deeper lifts put the facial nerve at more risk (Baker 1979). James Stuzin, Thomas Baker and Howard Gordon of the University of Miami checked cadaver dissections against what they saw in surgery. They described the face as concentric layers, from skin and fat down through the SMAS and the facial muscles to a deep fascia, and found that in the cheek the facial nerve branches lie under that deep fascia (Stuzin 1992).

What a patient gets. Surgeons could work under the SMAS knowing that the deep fascia lay between the dissection and the nerves (Stuzin 1992). Permanent weakness of a facial muscle after a facelift is now about 1 in 2,000 (Gandra 2025). How the other risks fell is in Why facelifts are safer now.

Coleman: fat grafting (1995)

Sydney Coleman began a controlled test in 1987. He filled one facial crease with the patient's own fat, left a nearby crease untreated, and photographed both for six years. The treated crease stayed filled; the other stayed the same or deepened (Coleman 1995). His method, lipostructure, places the fat in small parcels through many tunnels so each parcel lies close to a blood supply (Coleman 1997).

What a patient gets. Lost volume replaced with the patient's own fat during the lift. Fat grafting has become a more common part of the facelift (Stein 2024). See Fat grafting and volume with facelift.

Still debated. Some patients keep losing volume after the lift; O'Daniel replaces it with injections of poly-L-lactic acid (O'Daniel 2022). Fat injected into an artery can block it, and a 2023 review collected reports of vision loss, stroke and death after facial fat grafting (Moellhoff 2023).

Baker: lateral SMASectomy (1997)

Daniel Baker of New York University kept the deep work small. His lateral SMASectomy removes a strip of SMAS where the fixed SMAS over the parotid meets the mobile SMAS in front of it, and sews the edges together (Baker 1997; Kim 2015).

The case for a smaller lift came from a test on the same faces. In 1996 Ivy, Lorenc and Aston at Manhattan Eye, Ear and Throat Hospital gave each patient a smaller SMAS lift, lateral SMASectomy among them, on one side and an extended or composite lift on the other. On the operating table the extended side looked better. Once swelling set in the difference was gone, and at a year surgeons could not tell the sides apart. The authors concluded that the added risk and recovery of the extended lifts did not seem warranted for the average patient (Ivy 1996).

What a patient gets. A deep-layer lift with little dissection under the SMAS, which lowers the risk to the facial nerve (Kim 2015). Plastic surgeons still use SMASectomy widely, along with plication and flaps (Stein 2024).

Tonnard and Verpaele: MACS lift (2002)

Patrick Tonnard and Alexis Verpaele of Ghent, Belgium wrote that most of their patients wanted improvement without long disfigurement or a high risk of complications. Their minimal access cranial suspension (MACS) lift, a modified S-lift, uses a short incision in front of the ear, limited skin undermining and permanent purse-string sutures woven into the SMAS and anchored above the ear. Tying them lifts the jowls and upper neck vertically, under local anesthesia (Tonnard 2002).

What a patient gets. A shorter scar and a smaller operation (Tonnard 2002). The vertical pull spread into other lifts, including a deep plane hybrid (Jacono 2011). See Short-scar facelift and MACS lift.

Still debated. Compared with lateral SMASectomy, the MACS lift looked the same at two years, and by then more than half of the patients needed a tuck for jowls or loose skin (Prado 2006).

Mendelson: the facial spaces (2002)

Bryan Mendelson's team found a space over the cheekbone, bounded by ligaments, that the facial nerve branches do not cross: the prezygomatic space (Mendelson 2002). In 2008 Mendelson described the premasseter space over the lower part of the masseter, the chewing muscle. With age its borders weaken, the space expands, and the jowl forms (Mendelson 2008).

What a patient gets. Tissue released in planes the nerves do not cross. Mendelson advised placing the SMAS incision over the premasseter space, where dissection is bloodless and the nerve branches lie outside it (Mendelson 2008).

Rohrich and Pessa: fat compartments (2007)

Rod Rohrich of the University of Texas Southwestern and Joel Pessa injected blue dye into cadaver faces and dissected under magnification. The fat under the skin divided into separate compartments with their own borders, and some structures called ligaments turned out to be lines where compartments meet. They concluded that the face does not age as one mass (Rohrich 2007).

What a patient gets. A plan that names the areas to be lifted and the areas to be filled. The lift-and-fill facelift of 2014 grafts fat into named compartments during the lift (Rohrich 2014).

Lambros: aging photographs (2007)

Val Lambros of Newport Beach, California collected old photographs of his patients' friends and relatives, matched each to a recent picture, and made animations that fade one into the other. The border between lid and cheek skin, and moles and wrinkles on the upper cheek, stayed in place for decades. He concluded that vertical descent is not necessarily a major part of aging in that part of the face (Lambros 2007).

What a patient gets. A surgeon looks for lost volume as well as sagging, and a plan may fill as well as lift (Schultz 2026).

Still debated. A CT study of cadaver heads found that the midface fat compartments move downward with age (Gierloff 2012), and a 2026 review describes aging as both deflation and descent (Schultz 2026).

Jacono: the extended deep plane (2011)

Andrew Jacono of New York joined deep plane release of the cheek ligaments to the vertical pull of the MACS lift. A cut in the side of the platysma let the neck be pulled in its own direction (Jacono 2011). In 2019 he extended the lift with a flap rotated along the jaw, and 3D photographs showed added volume over the angle of the jaw and a longer jawline (Jacono 2019, extended deep plane).

What a patient gets. The jaw angle and the neck move in the same flap as the cheek (Jacono 2019, extended deep plane). In a 2026 randomized study by one surgeon, the extended lift corrected marionette lines, jowls and neck laxity more than the standard deep plane lift (Golparvaran 2026).

Auersvald: the hemostatic net (2014)

A collection of blood under the skin, a hematoma, is the most common complication after a facelift (Auersvald 2014). André and Luiz Auersvald of Curitiba, Brazil borrowed the quilting stitch of the tummy tuck: a running suture through the skin and the SMAS-platysma that closes the space left by the lift. Their earlier patients, without the net, had hematomas in the first three days; their patients with the net had none (Auersvald 2014).

What a patient gets. A lower chance of a hematoma. The net spread to other surgeons and to brow and neck lifts, and a 2026 meta-analysis found hematoma rare with it; some patients had red marks on the skin that cleared within a few months (Ribeiro 2026). See Hemostatic net and hematoma prevention.

The deep neck (1980 to 2023)

In 1980 Richard Ellenbogen and J. V. Karlin set out what a youthful neck looks like: tighten the platysma at the front more than from behind, and in a heavy neck remove the fat under the muscle (Ellenbogen 1980). Joel Feldman's corset platysmaplasty of 1990 joins the platysma edges with one continuous suture down and up the neck, leaving no free edges to show later as bands (Feldman 1990).

T. Gerald O'Daniel of Louisville, Kentucky measured what came out during his deep neck lifts: most of the volume came from under the platysma, from deep fat, the submandibular glands and the digastric muscles (O'Daniel 2021). In 2023 Minelli, O'Daniel, Mendelson and colleagues showed that the platysma receives its nerves in segments, which explains lower lip weakness after some neck lifts and the return of bands (Minelli 2023, platysma).

What a patient gets. When fat, glands or muscle under the platysma cause a full neck, reducing them sharpens the angle under the jaw (O'Daniel 2021). See Deep neck lift.

Still debated. Injury to the marginal mandibular nerve, the nerve to the lower lip, is the most common complication of gland reduction (Shauly 2026). See Submandibular gland reduction.

Open questions

The newest work on these questions is in The future of the facelift.

Sources

PubMed (records checked 2026-10-06; Barrett 2016 and Kim 2015 read in full text)

  • Auersvald 2014. Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg.
  • Baker 1979. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg.
  • Baker 1997. Baker DC. Lateral SMASectomy. Plast Reconstr Surg.
  • Baptista 2026. Baptista VS et al. Perceived age reduction after rhytidoplasty: a randomized clinical trial comparing three surgical techniques using human and AI assessment. Facial Plast Surg.
  • Barrett 2016. Barrett DM et al. Evolution of the rhytidectomy. World J Otorhinolaryngol Head Neck Surg. Full text: https://www.ebi.ac.uk/europepmc/webservices/rest/PMC5698509/fullTextXML
  • Coleman 1995. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg.
  • Coleman 1997. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg.
  • Ellenbogen 1980. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg.
  • Feldman 1990. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg.
  • Furnas 1989. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg.
  • Gandra 2025. Gandra G et al. Facelift surgery and nerve injury: a systematic review and meta-analysis. Aesthetic Plast Surg.
  • Gierloff 2012. Gierloff M et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg.
  • Golparvaran 2026. Golparvaran S et al. Comparative effectiveness of deep plane and extended deep plane facelifts in lower facial rejuvenation. Aesthet Surg J.
  • Hamra 1990. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg.
  • Hamra 1992. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
  • Hamra 2002. Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure. Plast Reconstr Surg.
  • Hornick 2026. Hornick MM et al. Assessing rigor in facelift research: a scoping review of 20 years of reported outcomes in the United States. Aesthet Surg J.
  • Ivy 1996. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg.
  • Jacono 2011. Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthet Surg J.
  • Jacono 2019, extended deep plane. Jacono AA, Bryant LM, Ahmedli NN. A novel extended deep plane facelift technique for jawline rejuvenation and volumization. Aesthet Surg J.
  • Jacono 2019, meta-analysis. Jacono AA, Alemi AS, Russell JL. A meta-analysis of complication rates among different SMAS facelift techniques. Aesthet Surg J.
  • Kim 2015. Kim BJ et al. Development of facial rejuvenation procedures: thirty years of clinical experience with face lifts. Arch Plast Surg. Full text: https://www.ebi.ac.uk/europepmc/webservices/rest/PMC4579162/fullTextXML
  • Lambros 2007. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg.
  • Mendelson 2002. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg.
  • Mendelson 2008. Mendelson BC et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg.
  • Minelli 2023, platysma. Minelli L et al. The functional anatomy and innervation of the platysma is segmental. Aesthet Surg J.
  • Minelli 2024, SMAS. Minelli L, van der Lei B, Mendelson BC. The superficial musculoaponeurotic system: does it really exist as an anatomical entity? Plast Reconstr Surg.
  • Mitz 1976. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg.
  • Moellhoff 2023. Moellhoff N et al. Arterial embolism after facial fat grafting: a systematic literature review. Aesthetic Plast Surg.
  • O'Daniel 2021. O'Daniel TG. Optimizing outcomes in neck lift surgery. Aesthet Surg J.
  • O'Daniel 2022. O'Daniel TG, Kachare MD. The utilization of poly-l-lactic acid as a safe and reliable method for volume maintenance after facelift surgery with fat grafting. Aesthet Surg J Open Forum.
  • Pak 2026. Pak KY, Salehi PP, Azizzadeh B. Evaluating facelift outcomes and technique trends in the United States. J Craniofac Surg.
  • Prado 2006. Prado A et al. A clinical retrospective study comparing two short-scar face lifts: minimal access cranial suspension versus lateral SMASectomy. Plast Reconstr Surg.
  • Rees 1977. Rees TD, Aston SJ. A clinical evaluation of the results of submusculo-aponeurotic dissection and fixation in face lifts. Plast Reconstr Surg.
  • Ribeiro 2026. Ribeiro LF et al. Efficacy and safety of hemostatic net in facelift and rejuvenation surgeries (browlift and necklift): a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg.
  • Rohrich 2007. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg.
  • Rohrich 2014. Rohrich RJ et al. Lift-and-fill face lift: integrating the fat compartments. Plast Reconstr Surg.
  • Schultz 2026. Schultz KP, Sherif R, Ganesh Kumar N, Stuzin JM, Rohrich RJ. Demystifying deep layer face-lift techniques: a systematic review of superficial musculoaponeurotic system techniques. Plast Reconstr Surg.
  • Shauly 2026. Shauly O, Dhawan R, Gould DJ. Submandibular gland reduction in the modern necklift surgery: a systematic literature review. Aesthet Surg J.
  • Stein 2024. Stein MJ et al. Clinical practice patterns in facelift surgery: a 15-year review of continuous certification tracer data from the American Board of Plastic Surgery. Aesthetic Plast Surg.
  • Stuzin 1992. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg.
  • Talei 2024, mandibular ligament. Talei B, Ziai H. Mandibular ligament and the prejowl sulcus explained. Aesthet Surg J.
  • Tonnard 2002. Tonnard P et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg.