What the research shows
The face has five layers: skin, a fat layer, the SMAS (the fibrous and muscle layer a facelift lifts), a deep fat layer, and the bone lining or deep fascia (Cotofana 2019). The fat is divided into separate compartments by fibrous walls that run from the deeper fascia up to the skin. Each compartment changes in position and volume on its own, so the face ages in three dimensions (Rohrich 2008).
Retaining ligaments tie the skin to the bone at fixed points. The zygomatic ligaments under the cheekbone and the mandibular ligaments at the front of the jaw mark the edge of the jowl, and the skin cannot be moved fully upward until they are released (Furnas 1989). The ligaments also sit next to branches of the facial nerve, so surgeons use them as landmarks to stay clear of the nerve (Alghoul 2013).
Anatomy explains the signs of aging. The jowl forms when a natural space over the jaw muscle loosens and stretches with age (Mendelson 2008). The deep fat of the cheek shrinks with age and in very thin people while the surface fat holds its weight, so the authors put restoring deep volume first (Mertens 2016). The buccal fat pad, deep in the cheek, drops with age and bulges beside the mouth; left untreated during a facelift, it can leave patients unhappy with the result (Bellity 2026).
Anatomy also explains why some lifts last longer. Lifting tissue without releasing the ligaments drags the supporting fibers out of position and leaves all the weight on the stitches; after full release the surgeon can reattach the tissue higher with its support intact (Minelli 2024). In the usual midcheek lift, the pull past the stitch runs through the skin, which relaxes after surgery, so the fold beside the nose tends to return early (Minelli 2023).
Blood supply sets limits on how the skin is lifted. The side of the facelift flap is fed mainly by one artery branch, and keeping skin and SMAS together as one flap kept blood flow to the skin in front of the ear better than lifting the skin alone (Schaverien 2009).
Where surgeons disagree
- Whether the SMAS is one layer. One cadaver study found a single continuous network across the face (Ghassemi 2003). Another found a true SMAS only over the parotid gland, thin and broken in the cheek and absent in the neck (Gardetto 2003). CT matched to cadavers later showed it as a distinct layer in every person scanned (Okuda 2021).
- Rebuild the ligaments or fill the hollow. Reconstructing the ligaments under the SMAS after release cut early relapse from about 1 in 17 to about 1 in 200, with temporary facial nerve weakness in about 1 in 12 (Bitik 2022). Another group traced the hollow in front of the jowl to thinning of the tissue under the skin and found fat grafting with little release corrected the jowl better and with fewer side effects (Talei 2024).
- What to call each structure. Authors use different names and classifications for the same ligaments, which makes papers hard to compare (Alghoul 2013, Huettner 2015).
What is new
- The jaw branch of the facial nerve runs below a fibrous wall at the jaw angle and goes deeper at the front edge of the jaw muscle, where it is most at risk during a lift (Yalçın 2026).
- A 3D map of the artery branch that feeds the side of the face gives surgeons its usual position and depth, for safer flap design, fillers and threads (Lee 2026).
- A 2026 review offers a plan for handling the buccal fat during a facelift, through the facelift incision or inside the mouth (Bellity 2026).
What is still unknown
- Whether full ligament release makes a lift last longer in patients. The argument rests on cadaver work (Minelli 2024).
- How best to treat the midcheek and nasolabial fold so they do not return early (Minelli 2023).
Key papers
- Furnas 1989: described the retaining ligaments of the cheek and why they must be released for the skin to move.
- Ghassemi 2003: defined the SMAS as one fibrous network with two forms on either side of the nasolabial fold.
- Rohrich 2008: showed that facial fat sits in walled compartments that age separately.
- Mendelson 2008: traced the jowl to a loosening space over the jaw muscle and offered it as a safe plane for the lower facelift.
- Schaverien 2009: mapped the blood supply of the facelift flap.
- Alghoul 2013: review of the retaining ligaments as release points and nerve landmarks.
- Cotofana 2019: set out the five-layer model of the face.
- Bitik 2022: rebuilt ligaments held the lift better at the cost of more temporary nerve weakness.
- Minelli 2024: explained why lifts without release may not last.