Facelift in skin of color and Asian patients

What it is

A facelift in skin of color is the same operation adapted to each patient's anatomy. Aging in every group combines loss of bone support, loss of volume and loss of skin elasticity, in proportions that vary from person to person, so the plan has to address the skeleton, lift the soft tissue and close the incisions without tension (PMID 25049130).

Aging often shows later in darker skin. Black women reported the least facial aging and Caucasian women the most, with Asian and Hispanic women in between, and women with the darkest skin types reported less aging than those with lighter types (PMID 31702594). Caucasian men reported signs of aging 10 to 20 years earlier than Asian, Hispanic and Black men (PMID 29064988). Darker skin shows more aging from within and lighter skin more sun damage (PMID 21585594), although in Chinese women every facial aging sign was affected by sun exposure and predicted how old a woman looked better than her real age did (PMID 25709490).

The anatomy that changes the operation:

• Asian faces often have thick skin, a wide and short face, prominent cheekbones and prominent jaw angles (PMID 34172678). In Chinese patients, the drop of the outer brow and of the cheek fat pad needs more attention (PMID 33651016).
• South American faces are often wider, with thicker, heavier and less elastic skin; with age the nasolabial folds and jowls deepen and the neck skin hangs loose and heavy (PMID 32866979).
• A heavy neck in many patients of color comes from deep structures (fat under the muscle, the digastric muscles, the glands) and a chin set back, while the skin stays elastic (PMID 42086192). In East Asian necks, limited bone support makes a prominent submandibular gland more visible (PMID 42695798).
• The African-American face ages differently from the traditional models of facial aging, which changes both surgical and nonsurgical planning (PMID 20446209).
• Darker skin carries a higher risk of pigment change after injury, peels and lasers (PMID 21585594).

Where it came from

In 1983 Onizuka described a facelift designed for Japanese faces, with key stitches from the ear cartilage to the cheek skin to prevent wide scars and incisions shaped to keep the earlobe from being pulled down (PMID 6354059). In 1999 Lee reported that the prominent cheekbone and jaw angle of many Asian faces, once thought to get in the way of a subperiosteal lift, held the lift in place (PMID 10597702).

In the 2010s, Brissett described how the African-American face ages differently from the traditional models (PMID 20446209), Sykes set out bone support, volume and tension-free incisions as the principles for non-Caucasian faces (PMID 25049130), and Nagai mapped a danger zone for a cheek branch of the facial nerve in Asian faces (PMID 22361958).

Recent work on Asian faces includes matching the SMAS technique to face shape (PMID 38984658), a deep-plane protocol for Asian faces (PMID 40183553) and deep neck surgery on the glands (PMID 42695798). A 2024 review called for departing from a single aesthetic standard measured against White faces and found little published on Black and Hispanic patients (PMID 38408032). A 2026 review states that the plan should follow the individual anatomy, whatever the patient's ancestry (PMID 42086192).

Who it suits

• Heavy neck with firm skin. Deep neck contouring through a small incision under the chin, joined to an extended facelift, treats the deep cause (PMID 42086192).
• Wide face with prominent cheekbones or jaw angles. Bone contouring or cheekbone reduction can be done with the facelift (PMID 34172678, PMID 26207549).
• Thick, heavy skin with a sagging midface. An extended SMAS or deep-plane lift, a subperiosteal midface lift for the heaviest skin, and almost always a neck lift (PMID 32866979).
• Full lower face. Laser-assisted liposuction of the lower face during a deep-plane lift raised satisfaction with the jawline (PMID 36731512).
• Darker skin types (Fitzpatrick III to V). Hematoma prevention that avoids needle marks on the skin (PMID 41181304).

How it is done

Matching the technique to the face

In one large Asian practice, the SMAS technique was chosen by face shape: a full SMAS dissection for a square face with heavy jowls and marionette lines, a SMAS fold (plication) for milder jowls with prominent cheekbones and a hollow side profile, and removal of a strip of SMAS for a full (convex) side profile or a thin SMAS (PMID 38984658). Extended lifts that fully release the retaining ligaments work across ethnic groups (PMID 39492204, PMID 42086192).

Lift direction

A vertical lift of an extended SMAS flap sharpened the jawline and did not widen the midface (PMID 36173963). The deep-plane protocol for Asian faces sets release endpoints, places each fixation stitch at a named landmark and closes the skin without tension (PMID 40183553). Maximal and minimal pull on the flap gave the same results and satisfaction at one year (PMID 42371719).

Shorter and hidden incisions

Some surgeons use shorter or hidden incisions: a short-scar lift for the nasolabial folds (PMID 34432684), a midface lift through a temple incision (PMID 39650682) and endoscopic lifts through hidden incisions, chosen to avoid raised scars (PMID 36396261).

Neck

Deep neck structures are treated under direct view through an incision under the chin (PMID 39492204): fat under the platysma, the digastric muscles and the submandibular glands, with a platysma tightening (PMID 42086192). In East Asian patients, part of a prominent gland is removed lobule by lobule, and fibrin sealant and botulinum toxin are applied to the remaining gland (PMID 42695798).

Cheek volume and jaw width

The goal in many Asian faces is an oval shape (PMID 34172678). Part of the deep-plane flap can be rotated up onto the cheekbone to add volume while the jaw angle is reduced (PMID 38394266), and fat over the jaw muscle can be reduced by laser liposuction during the lift (PMID 36731512).

Nerve safety

In Asian cadavers, cheek branches of the facial nerve sometimes ran through the fibers at the front edge of the jaw muscle, outside the space surgeons open there, so that edge is treated as a danger zone (PMID 22361958).

Results and how long they last

Patients in one large Asian practice felt they looked about 11 years younger a year after surgery, rated their cheeks, jawline and neck highly, and had very few complications (PMID 38984658). Nearly all Asian deep-plane patients were satisfied or highly satisfied at an average of a year and a half (PMID 40183553).

How much younger a face looks depends on who judges. Chinese women at one year looked about 4.5 years younger to outside observers (PMID 39085528). The women themselves felt about 7 years younger (PMID 39085528).

Blinded graders saw less sagging and shallower nasolabial folds after a SMAS lift with cheek fat repositioning designed for Asian women (PMID 31592914). Patients who had cheekbone reduction or bone contouring with the lift were satisfied with their face shape (PMID 26207549, PMID 34172678), and adding flap rotation or lower-face liposuction gave higher satisfaction than the lift alone (PMID 38394266, PMID 36731512).

Risks and how surgeons lower them

• Raised scars and keloids. After a deep-plane lift with a tension-free skin closure, a raised scar formed in about 1 in 60 Asian patients (PMID 40183553). A zigzag closure with botulinum toxin around the incision gave better scars at one year (PMID 35697816). In darkly pigmented skin, the earlobe and face are common keloid sites, and injury such as ear piercing was the leading cause (PMID 36057975).
• Pixie ear. Rotating part of the earlobe during the lift gave better ear results in Asian patients (PMID 41810509).
• Darker patches of skin. Peels and lasers carry a higher risk of uneven pigment in darker skin (PMID 21585594). When laser resurfacing is done during a facelift, lasting pigment change occurs in 0.35%, and it is more likely when lifted skin is lasered with several techniques at once (PMID 41063540).
• Hematoma and the stitch marks that prevent it. A hemostatic net of stitches through the skin prevents bleeding under the skin but can leave pigmented needle marks in darker skin (PMID 41181304). In Thai patients the net left no lasting pigmentation (PMID 39623234). In Indian and Middle Eastern patients, stitches placed under the skin instead (internal quilting) prevented hematoma and seroma without puncturing the skin (PMID 41181304).
• Nerve injury. Temporary nerve weakness occurred in about 1 in 60 Asian deep-plane patients (PMID 40183553), and high-SMAS lifts in Chinese patients had no permanent nerve injury (PMID 40356621).
• Deep neck surgery. Gland reduction carried a hematoma risk of about 1 in 100 (PMID 42695798). Temporary lower-lip weakness affected about 2 in 100, and no nerve injury was permanent (PMID 42695798, PMID 42137253).

Recovery

• Lower face and neck measurements fell most in the first month, rose slightly at three months and fell again through the first year, so the result keeps changing for a year (PMID 39143305).
• Hemostatic net marks faded within a month in 9 of 10 patients (PMID 39623234).
• Skin dimpling after internal quilting stitches settled without further surgery (PMID 41181304).
• Scar symptoms eased with time in both Asian and White patients; Asian patients rated their facial scars more harshly, so scar follow-up and counseling matter (PMID 41263428).

With a facelift

• Deep neck contouring is joined to the facelift or neck lift when the skin is loose (PMID 42695798, PMID 42086192).
• In South American patients a neck lift is almost always part of lower-face rejuvenation (PMID 32866979).
• Bone contouring and cheekbone reduction can be done in the same operation (PMID 34172678, PMID 26207549).
• A lift of the brow tail through the scalp can be added to a high-SMAS face and neck lift (PMID 40356621).
• Laser resurfacing at the same time needs settings chosen for skin type and for skin that has been lifted (PMID 41063540, PMID 21585594).

Questions to ask a surgeon

• How will you plan my lift around my own skin thickness, cheekbones, jaw and neck? (PMID 42086192)
• Which direction will you lift my face, and will it make my face look wider? (PMID 36173963)
• How do you close the skin to lower my risk of a raised scar? (PMID 40183553)
• I have had a keloid, including after ear piercing: how does that change your plan? (PMID 36057975)
• How will you prevent a hematoma, and will any stitches leave marks on my skin? (PMID 41181304)
• Does my neck need deep work under the muscle, such as gland reduction? (PMID 42695798)
• Should laser resurfacing be done at the same time, given my skin type? (PMID 21585594)
• Can I see results at a year or more in patients with skin and features like mine? (PMID 38408032)

Open questions

• The evidence is thin outside East Asian patients: little has been published on Black and Hispanic facelift patients (PMID 38408032).
• Whether ancestry adds anything once anatomy is measured: the 2026 review says planning should follow anatomy alone (PMID 42086192).
• Why Asian patients judge facial scars more harshly than White patients, and how to change that (PMID 41263428).
• External hemostatic net or internal quilting stitches for darker skin: no direct comparison yet (PMID 39623234, PMID 41181304).
• Most series are single-surgeon and retrospective (PMID 38408032, PMID 38984658).

Terms

• Fitzpatrick skin type: scale I to VI of skin color and tanning response; III to VI are darker types (PMID 41181304).
• Skin of color: darker skin types, with a higher risk of pigment change after peels and lasers (PMID 21585594).
• Dyspigmentation / hyperpigmentation: darker or uneven skin color after injury (PMID 41063540).
• Keloid: scar that grows beyond the wound edge (PMID 36057975).
• Hemostatic net: stitches placed through the skin at the end of a facelift to prevent blood collecting under it (PMID 39623234).
• Internal quilting sutures: absorbable stitches between skin and deeper tissue that close dead space without skin punctures (PMID 41181304).
• Vertical vector: lifting the cheek and jaw tissue upward instead of backward (PMID 36173963).
• Reduction malarplasty: surgery that narrows a prominent cheekbone (PMID 26207549).
• Gonion: the angle of the lower jaw (PMID 38394266).
• Premasseter space: a tissue plane over the jaw muscle opened in some SMAS lifts (PMID 22361958).
• SCAR-Q: patient questionnaire on scar appearance, symptoms and psychosocial effect (PMID 41263428).

Papers