Resurfacing with a facelift

What it treats

• A facelift lifts the mobile parts of the face and has little effect on the skin itself or on the zones around the mouth, the eyes and the forehead (PMID 38828090).
• Fine wrinkles and uneven pigment from sun damage are the problems resurfacing treats (PMID 34183633).
• Vertical lip lines and a lengthened upper lip respond to resurfacing around the mouth, which the facelift cannot reach (PMID 24165626, PMID 41433344).
• Surgeons now add resurfacing to facelifts more often than they did twenty years ago (PMID 35383689), and an evidence review found reasonable support for laser resurfacing as a facelift add-on in selected patients (PMID 30593078).

Where it came from

• 1962: Thomas Baker described combining a chemical face peel with a facelift (PMID 13864170). Peels around the mouth on the day of the lift followed (PMID 6824486), and in 1994 a TCA peel was applied over a deep plane facelift (PMID 8278488).
• The CO2 laser of the 1990s raised a new question. The skin lifted in a facelift is separated from the tissue beneath it (undermined) and has less blood supply. In 1998 Bahman Guyuron lasered undermined flaps in pigs and found healing delayed by about a week, and saw delayed healing in most of his patients treated the same way; he advised avoiding the combination or using great caution (PMID 9500404).
• Surgeons answered with three changes: less undermining, so more skin keeps its blood supply (PMID 11129194, PMID 11084693); deeper lifts that keep the skin attached to thicker tissue (PMID 9111888); and lower laser settings over the lifted skin (PMID 25028109, PMID 25839172).
• 2001: a pig study showed the timing rule: laser on the day the flap was raised caused slough and scarring, and laser a week or more later healed normally (PMID 11743457).
• 2002: a review of the published combined cases found the complication rate no different from a facelift alone (PMID 12437427).
• 2014 and 2015: fractional CO2 lasers, which leave columns of untreated skin, were used directly over widely undermined flaps without flap loss (PMID 25028109, PMID 26144639).
• 2022 to 2026: plasma resurfacing and deeper hybrid fractional lasers were added to facelifts (PMID 36046720, PMID 41218171, PMID 41200268), and a meta-analysis pooled the evidence (PMID 41063540).

Who it suits

• People having a facelift who also have fine wrinkles, sun damage, lip lines or uneven pigment (PMID 34183633).
• People who want one recovery instead of two (PMID 10742461).
• Smokers are poorer candidates for same-day resurfacing: the skin losses in an erbium series and the one full-thickness loss in an early pooled review were in smokers (PMID 11214079, PMID 12437427).

How it is done

The rule that runs through every method: treat the skin that was lifted more gently than the skin that was not (PMID 41063540).

• Fractional laser over the lifted skin, full ablation elsewhere: one approach uses fractional CO2 on the undermined skin and fully ablative CO2 on skin that was not undermined (PMID 25028109); another uses a lighter erbium setting over the flap (PMID 25839172).
• Limited undermining: the skin flap is kept short so the cheek keeps its blood supply, and the full face can then be lasered (PMID 11129194). The RSVP facelift stops undermining short of the fold beside the mouth to spare the vessels feeding the skin (PMID 11084693).
• Deeper lifts: endoscopic subperiosteal and deep plane lifts leave the skin attached to thicker tissue, which tolerates resurfacing better (PMID 9111888, PMID 8278488).
• Peels: TCA up to 40% produced a predictable, controlled burn on undermined skin; deep phenol-croton oil peels should not be put on undermined skin (PMID 28732800). Phenol-croton oil is used around the mouth, where the skin is not lifted (PMID 24165626).
• Plasma: helium plasma was applied over undermined skin during facelifts without serious adverse events (PMID 36046720).
• Staging: resurfacing can wait. In pigs, lasering a flap a week or more after it was raised healed like untouched skin (PMID 11743457).

Results

• Satisfaction after laser with facelift was about 98% in pooled studies (PMID 41063540). Reviews conclude that resurfacing at the time of the facelift adds to the result without adding morbidity in selected patients (PMID 31461045, PMID 33845493).
• In the RSVP series, patients who had laser added estimated that they looked several years younger than patients who had the lift alone (PMID 11084693).
• A perioral phenol-croton oil peel with the facelift shortened the upper lip, which stayed unchanged in matched patients who had the lift alone (PMID 41433344); patients who had the peel looked younger than their age and had fewer wrinkles (PMID 24165626).
• Deep plasma resurfacing with face and neck lifts also shortened the upper lip slightly (PMID 41218171).

Risks and how surgeons lower them

• Full-thickness loss of lifted skin occurred in about 1 in 10,000 patients in pooled studies (PMID 41063540). Skin slough, loss of the surface layer, occurred in about 2 in 1,000 (PMID 41063540).
• Slough was more likely when undermined skin was lasered at the same energy as the rest of the face (PMID 41063540). In one series, distal flap necrosis occurred only in patients whose entire undermined flap was lasered (PMID 11910322).
• Smoking raises the risk of skin loss on the lifted flap (PMID 11214079, PMID 12437427).
• Pigment: temporary darkening is common after ablative laser (PMID 15355357, PMID 11910322), and lasting pigment change occurred in about 1 in 300 in pooled studies (PMID 41063540). Phenol peels left permanent lightening in a small share of patients in one combined series (PMID 27320171).
• Lasting pigment change was more common with SMAS and biplanar lifts than with endoscopic subperiosteal lifts (PMID 41063540).
• Thick scars were rare and less common when plastic surgeons performed the procedures than when dermatologists did (PMID 41063540).
• Herpes infection can follow full-face resurfacing done with a lift (PMID 9111888).

Recovery

• After full-face CO2 laser with a facelift, a silicone film dressing stayed on for about a week, the skin healed in 7 to 10 days, and patients went back to their activities at 2 weeks (PMID 10227909).
• Fractional CO2 over the lifted skin healed within a week; a few patients had redness for more than 2 weeks (PMID 26144639).
• Apart from redness, recovery was similar to a facelift alone (PMID 10742461), and patients went through one recovery period instead of two (PMID 9858190).

Questions to ask a surgeon

• Ask whether resurfacing will be done the same day or later, and why (PMID 11743457).
• Ask how the settings change over the skin that is lifted (PMID 41063540).
• Ask which peel or laser will be used around the mouth (PMID 24165626).
• Ask about the risk of lasting pigment change for this skin (PMID 41063540).
• Tell the surgeon about smoking or nicotine use (PMID 11214079).

Open questions

• How much energy undermined skin can take: same-energy lasering raises slough (PMID 41063540), and a deeper hybrid fractional laser showed a rise in complications that did not reach significance (PMID 41200268).
• Deep peels on lifted skin: histology advises against phenol-croton oil on undermined skin (PMID 28732800).
• Plasma devices have data only from single-surgeon series (PMID 36046720, PMID 41218171).
• The timing rule for staged resurfacing comes from pigs (PMID 11743457).

Terms

• Undermined flap: facelift skin separated from the tissue beneath it (PMID 9500404).
• Skin slough: loss of part of the skin surface of the flap without full-thickness death (PMID 12437427, PMID 41063540).
• Full-thickness necrosis: death of the whole skin thickness in part of the flap (PMID 11910322).
• Ablative laser: a laser that removes the outer skin layers, such as CO2 or erbium (PMID 15355357).
• Fractional laser: a laser that treats columns of skin and leaves intact skin between them (PMID 26144639).
• TCA peel: a medium-depth chemical peel with trichloroacetic acid (PMID 28732800).
• Phenol-croton oil peel: a deep chemical peel (PMID 24165626).
• Plasma resurfacing: helium or nitrogen plasma energy used to resurface skin (PMID 41218171).
• RSVP facelift: a facelift that spares the blood vessels feeding the skin (PMID 11084693).
• Philtrum: the groove between the nose and the upper lip, which lengthens with age (PMID 41433344).

Papers