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The modern facelift

A facelift once pulled the skin tight; today it lifts the layer under the skin, treats the neck with the face and closes the skin without tension. No named technique has been shown to last longer than the others, so the surgeon's plan for each face decides most of the result.

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

For most of the 20th century a facelift tightened skin. The surgeon lifted it, cut away the excess and closed it under tension, so the skin carried the whole lift and the result faded as it stretched (Barrett 2016). Today the lift happens one layer deeper. The surgeon moves the tissue under the skin, releases the ligaments that hold it down where the plan needs it, treats the neck with the face and closes the skin without pull (Schultz 2026, Minelli 2024, ligaments). For a patient the change shows in a face that moves normally after surgery, with no pulled corners at the mouth or eyes (Hamra 2000).

How a face ages

A face ages in two ways: the soft tissue loses volume, and it slides down (Schultz 2026). Rod Rohrich and Joel Pessa mapped the separate fat compartments of the face in 2007 (Rohrich 2007), and Bryan Mendelson's group showed that the bone recedes too, at the upper jaw, the eye socket rim and the chin in front of the jowl (Mendelson 2012). A lift corrects tissue that has slid down. Lost volume may need fat or filler as well (ASPS, Facelift).

From skin lifts to deep-layer lifts

The first facelifts, in the early 1900s, cut out skin (Barrett 2016). In the 1970s Tord Skoog lifted the deeper fascia together with the platysma, the neck muscle (Barrett 2016). In 1976 Vladimir Mitz and M. Peyronie described that layer over the parotid gland and cheek and named it the SMAS, the superficial musculoaponeurotic system (Mitz 1976). Facelift techniques since then differ mainly in how far the surgeon works under the SMAS and which ligaments are released (Schultz 2026).

In 1990 Sam Hamra described the deep-plane facelift. He released the SMAS from its attachments and lifted skin, cheek fat and platysma as one thick flap, to treat the fold between nose and mouth that earlier lifts left behind (Hamra 1990). He also named a problem the older lifts created. Pulled straight back toward the ear, the jaw tightened while the cheek above it kept sliding down, a look he called the lateral sweep. He turned his lift up and toward the center of the face (Hamra 1998).

In the 2020s Minelli, Mendelson and colleagues found in cadavers that the named ligaments of the face are reinforced points in a network of small retaining fibers. They concluded that once the ligaments are released, the tissue reattaches higher with its support intact, while a lift that leaves them in place puts the weight on the stitches (Minelli 2024, ligaments). Skin closed without tension leaves a smaller scar (Kim 2022). The papers behind each step are in The papers that changed the facelift.

Facelift techniques in use

Most named lifts fall into a few groups (Schultz 2026):

  • SMAS plication and SMASectomy. The surgeon folds the SMAS with stitches, or, in Daniel Baker's lateral SMASectomy, removes a strip of it beside the parotid gland and sews the edges together (Baker 2008). Plication is the method used most in American board case logs (Stein 2024). See SMAS techniques.
  • High SMAS. Timothy Marten and Dino Elyassnia raise the flap along the cheekbone arch, so midface, cheek and jawline rise as one piece (Marten 2022, high SMAS).
  • Deep plane. Hamra's lift, which Andrew Jacono carried into the jawline and the neck (Jacono 2019, jawline, Jacono 2022). Most facial plastic surgeons who answered a 2026 survey perform it (Pak 2026). See Deep plane facelift.
  • Short scar and MACS. Patrick Tonnard and Alexis Verpaele's MACS lift suspends the SMAS with stitches anchored at the temple, through a shorter incision (Tonnard 2002). The AAFPRS says mini lifts usually give less improvement than a full facelift, with a brief recovery that suits people in their 40s or early 50s (AAFPRS, facelift myths). See Short scar and MACS.
  • Subperiosteal and preservation. Jorge Psillakis and Paul Tessier lifted the face from the bone in the late 1980s (Psillakis 1988, Tessier 1989). Preservation lifts leave more tissue attached, and each group that publishes one describes a different operation (Sadati 2025, Quinodoz 2026). See Preservation and subperiosteal lifts.

A "vertical" lift names a direction of pull, and the best direction differs by patient and by side of the face (Talei 2024, vectors).

How the techniques compare

When surgeons have tested their methods on the same faces, the named techniques have been hard to tell apart. In 1977 Thomas Rees and Sherrell Aston lifted the SMAS on one side of each face and only the skin on the other, and observers later saw no difference between the sides (Rees 1977). In 1996 Ivy, Lorenc and Aston compared a standard SMAS lift on one side with an extended or composite lift on the other. The extended side looked better on the operating table; once swelling set in the difference was gone, and independent surgeons could not tell the sides apart at one year (Ivy 1996).

Recent studies agree. Deep plane, high SMAS and plication made women look younger by the same amount in a 2026 randomized trial (Baptista 2026), and a prospective comparison of deep plane and plication found no difference in satisfaction, recovery or complications (Neel 2026). The Neel group concluded that results depend largely on the surgeon's expertise and the choice of patient (Neel 2026).

Incision length shows in the neck. In identical twins given a full or a short incision, results matched at one year and the full incision scored better in the neck at five (Antell 2016).

Surgeons still disagree about the deep plane. Pooled deep-plane series report no permanent facial nerve injury (Koroma 2026). A 2026 review by James Stuzin, Rohrich and colleagues found that dissecting past the ligaments has not been shown to improve the midface or make results last longer (Schultz 2026). The reviews on both sides come from surgeons who use the method they review (Jacono 2019, meta-analysis, Schultz 2026). In one surgeon's randomized trial, blinded raters scored the extended deep plane better than the standard version for jowls and neck in the first year (Golparvaran 2026); long-term comparisons are still missing (Koroma 2026).

How long a facelift lasts

The face keeps aging after a lift (ASPS, Facelift). Bruce Connell's patients who came back for a second lift did so about 12 years after the first, on average, and those who returned early most often had poor skin elasticity (Sundine 2010). In John Owsley's practice, about two in three patients still rated their result very good more than ten years later (Friel 2010).

Fuller necks relapse more often, and stitching the midline neck bands together lowered recurrence (Rohrich 2016). No named technique has been shown to last longer than the others (Pak 2026, Schultz 2026).

The neck

Patients judge a facelift largely by the neck (Marten 2022, neck). Neck bands come from the muscle's own movement: Patrick Trévidic found that patients with one-sided facial paralysis had bands only on the side that still moved (Trévidic 2017). A cadaver study by Minelli, with T. Gerald O'Daniel and Mendelson among the authors, found the platysma supplied by nerves in segments, which explains why bands can return after the muscle is cut and why the lower lip can weaken after a neck lift (Minelli 2023). See Platysma bands.

Tightening skin and muscle leaves what lies under the platysma in place: deep fat, large submandibular glands and bulky digastric muscles (Marten 2022, neck). O'Daniel measured what he removed in deep neck lifts, and most of it came from under the muscle (O'Daniel 2021).

The deeper work adds risk. Deep neck lifts carry more nerve weakness than traditional neck lifts (Chinta 2025), and gland reduction can bleed deep in the neck and press on the airway (Mendelson 2015). Weakness of the lower lip is the most common problem after gland reduction, in about 1 in 10 patients across published series (Shauly 2026). See Deep neck lift.

Fat and volume

Sydney Coleman standardized how fat is taken, refined and placed (Egro 2022). Adding fat to a facelift improves facial volume (Molina-Burbano 2021). Deep-plane surgeons report needing less fat, because lifting the cheek fat restores some of the midface (Jacono 2015). The rare serious risk is fat entering an artery, with reported cases of blindness, stroke and death (Moellhoff 2023). ASPS lists stem cell facelifts as of unproven benefit (ASPS, Facelift). See Fat grafting and volume.

Skin and scars

A facelift leaves fine wrinkles and uneven color as they were; lasers and peels treat them (Atiyeh 2021, AAFPRS, facelift myths). Laser and facelift can be done together with rare skin loss, and skin loss rose when the lifted skin got the same laser energy as the rest of the face (Wen 2026). See Resurfacing with a facelift.

In 1985 Franco listed the marks of an operated face: a raised temple hairline, heavy scars in front of the ear, a distorted tragus and a stepped hairline behind the ear (Franco 1985). Later work addressed each one. Bahman Guyuron's temple incision keeps the sideburn and hides the scar in hair (Guyuron 2005). An incision along the back edge of the tragus scored higher with blinded surgeons than one in front of it (Becker 1994). Tension at the earlobe causes the pixie ear, a lobe pulled down onto the cheek (Mowlavi 2005). Scar problems are uncommon with every modern incision design (Liu 2025). See Incisions and scars.

Safety

In a US insurance registry, about 2 in 100 facelift patients had a complication that needed an emergency visit, a hospital stay or another operation. The most common was a hematoma, blood collecting under the skin, and men carried a higher risk (Gupta 2016). Permanent facial nerve weakness is rare, about 1 in 2,000 (Gandra 2025).

Strict blood pressure control has the longest record against hematoma (Baker 2005, Ramanadham 2015). The hemostatic net, a row of temporary stitches described by André and Luiz Auersvald, closes the space where blood collects (Auersvald 2014). In trials and pooled data, no single measure has proved better than the others (Ismail 2025, Azzi 2026). The full story is in Why facelifts are safer now; see also Hematoma and the hemostatic net.

Recovery time

ASPS says most people are presentable in 10 to 14 days, and the face takes 2 to 3 months to feel normal again (ASPS, Facelift results). See Recovery week by week.

Signs of a good result

  • The face moves and smiles normally, with no pulled corners at the mouth or eyes (Hamra 2000).
  • Cheek and jaw rise together, with no fold of cheek over a tight jawline (Hamra 1998).
  • The jawline is clean and the neck matches the face (Gordon 2019).
  • Sideburn, tragus and earlobe keep their shape and place (Guyuron 2005, Becker 1994, Mowlavi 2005).
  • Scars are thin and match the skin color (Kumar 2023).

Repeat lifts can stay hidden: most of Daniel Marchac's patients with several facelifts were judged not to look operated on (Marchac 2008). See Signs of a bad facelift.

Treatments sold as facelift substitutes

Thread lifts fade. In one series the improvement was gone at one year (Bertossi 2019), and a systematic review found only two positive studies, both sponsored by thread makers (Gülbitti 2018). In a blinded comparison, one radiofrequency treatment gave about a third of the tightening of a surgical facelift (Alexiades-Armenakas 2010). The FDA warned in 2022 against using the Renuvion/J-Plasma device to tighten skin, then cleared specific handpieces for limited uses (FDA, Renuvion/J-Plasma update).

These treatments can make a later facelift harder. Yordanov found scar tissue and fused layers in faces with prior threads (Yordanov 2025), and O'Daniel found scar tissue, lost tissue planes and contour irregularities in necks treated before with fat-dissolving injections, fat freezing, radiofrequency or threads (O'Daniel 2026, nonsurgical). ASPS states that "minimally invasive rejuvenation treatments cannot achieve the same results" as a facelift (ASPS, Facelift). See Neck lift after nonsurgical treatments.

Newer work under study

  • Endoscopic deep-plane lifts through incisions hidden in the temple and scalp, so far in single-surgeon series without a control group (Kao 2024, Firat 2025).
  • Cutting the nerve branch to the platysma to stop neck bands, reported in small series (Trévidic 2019, Criollo-Lamilla 2026).
  • AI age estimators that measure how much younger a face looks; the gain they measured was larger at three months than at one year (Elliott 2023).

Where this work may lead is in The future of the facelift.

Questions for the surgeon

  • Ask which layer will be lifted, which ligaments released, and why for your face (Schultz 2026).
  • Ask what sits under the platysma in your neck, whether it will be treated, and the risks of treating it (Marten 2022, neck).
  • Ask where the incision runs at the temple and the tragus (Becker 1994, Guyuron 2005).
  • Ask how blood pressure is controlled before, during and after surgery (Ramanadham 2015).
  • Ask to see results at one year and later, in profile, on faces like yours, and about board certification and facility accreditation (ASPS, questions).
  • Tell the surgeon about any threads, fat-dissolving injections, fat freezing or energy treatments (O'Daniel 2026, nonsurgical).

Sources

PubMed

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