Secondary and revision facelift

What it treats

• Continued aging: the face keeps losing volume and the lifted tissue sags again over the years (PMID 21037861).
• Marks of the first lift: a pulled sideways look, hollow eyes, a pixie earlobe, moved hairlines and visible scars (PMID 9774028, PMID 39013675, PMID 32983758).
• Marks of fillers, threads and devices used after the first lift to put off a second one, which surgeons now see more often at revision (PMID 32983758).
• The neck: returning bands, fullness under the chin and drooping salivary glands are the most common reasons for a revision neck lift (PMID 41673281). Many neck problems come from overtreating the layers above the platysma and undertreating those below it (PMID 31587772).

Secondary facelifts are a rising share of facelift practice among board-certified plastic surgeons (PMID 38302713).

When people come back

• In published series, patients returned about 9 to 12 years after the first lift (PMID 42382704).
• In Bahman Guyuron's patients the average interval was about 8.5 years, with a range of 1 to 16 years (PMID 9326793).
• Among patients who returned to the same surgeon after a SMAS flap facelift, the average interval was about 12 years (PMID 20224461). About 1 in 5 of them came back within 5 years, most often because of poor skin elasticity (PMID 20224461).
• A second lift lasts about as long as the first: in a 20-year practice review, the time from second to third lift was similar to the time from first to second (PMID 23142942).

Early relapse, laxity returning within 2 years, is rarely reported; where it is, the typical rate is low (PMID 35534779). How often a small touch-up (a "tuck") is needed depends on the surgeon and the technique (PMID 9727459, PMID 39072376).

Where it came from

• 1997: Bahman Guyuron surveyed his secondary facelift patients and found they were slightly more satisfied after the second lift than the first and recovered just as fast; many had developed a new medical problem or started a new medication in between (PMID 9326793).
• 1998: Frank Kamer compared touch-ups after his own SMAS and deep plane lifts and found deep plane patients needed them far less often (PMID 9727459).
• 1998 to 2001: Sam Hamra argued that the hollow eyes and lateral sweep seen after conventional lifts should be corrected with a composite lift that moves the cheek and the lower eye muscle upward and inward (PMID 9774028, PMID 11727849).
• 2010: Patrick Tonnard described retightening a previous MACS lift (PMID 20108092).
• 2022 to 2026: series and reviews described what surgeons find under the SMAS at a second operation and showed complication rates close to first lifts (PMID 35511039, PMID 42382704).

How it is done

• The surgeon first separates marks of the first operation from normal aging since then, and plans the second lift around both (PMID 21037861, PMID 34121944).
• Rod Rohrich's group organizes the operation in five steps: remove excess skin and scar, release SMAS pulled in the wrong direction, refill with fat, reshape the SMAS and redrape the skin (PMID 23142942).
• Sub-SMAS lifts can be done again: in a reoperative series the SMAS was scarred, thicker or thinner, or stuck down in most patients, and the full dissection was still completed on nearly every side of the face (PMID 35511039).
• The direction of lift is set for each side after release; secondary faces showed more variation between stitches than first lifts, with a similar average direction (PMID 38657095).
• Specific repairs: a composite lift for lateral sweep and hollow eyes (PMID 11727849), earlobe repositioning for pixie ear (PMID 39013675), and platysma work for returning neck bands (PMID 41673281).
• Secondary patients add more procedures than they did at the first lift (PMID 9326793). Submandibular gland reduction is used more often in secondary lifts than in first lifts (PMID 25989302).

Results and how long they last

• Patients felt about 10 years younger after a secondary lift, slightly more than after their first (PMID 9326793).
• Every patient in a reoperative sub-SMAS series had a satisfactory outcome (PMID 35511039).
• Patients who had three to five facelifts with one surgeon mostly did not look operated on (PMID 18823831).
• Revisions within 18 months followed about 1 in 9 reoperative lifts in one series, more than reported after many first lifts (PMID 35511039, PMID 39072376).

Risks and how surgeons lower them

• Temporary facial nerve weakness is the most common complication of a second facelift. In one series it followed about 7 in 100 reoperative lifts, against about 2 in 100 first lifts by the same surgeon, and it was not linked to the amount of scarring (PMID 35511039). Across series it ranged up to about 12 in 100 (PMID 42382704).
• Hematoma is the other common complication; seroma, minor skin loss and slow healing also occur (PMID 42382704).
• Revision is harder after deep plane lifts and aggressive neck surgery, and after problems such as cobra neck, pixie ear or synkinesis (linked involuntary facial movement) (PMID 37827505).
• In revision neck lifts, complications were uncommon and mostly temporary, with no permanent nerve injury reported (PMID 41673281).
• Skin in a secondary lift usually has better blood supply than in a first lift and tolerates more tension (PMID 9326793).
• Surgeons lower risk by planning for the changed anatomy, since nerve landmarks and the SMAS are altered after the first operation (PMID 37827505), and by reviewing medical problems and medications that are new since the first lift (PMID 9326793).

Recovery

• Physical and social recovery after a secondary lift took about as long as after the first (PMID 9326793).
• Nerve weakness after a second lift was temporary in the reported series (PMID 35511039, PMID 41673281).

Questions to ask a surgeon

• Ask how many secondary and revision facelifts the surgeon does (PMID 42382704).
• Bring the operative report from the first facelift if possible, since the layers and nerve landmarks may have changed (PMID 37827505).
• Ask which problems come from the first operation and which from aging, and how each will be treated (PMID 21037861).
• Ask about the surgeon's rate of temporary nerve weakness in second lifts (PMID 35511039).
• Tell the surgeon about fillers, threads or device treatments since the first lift (PMID 32983758).
• Ask whether the neck needs deeper work this time (PMID 31587772).

Open questions

• Early relapse is reported in few facelift papers, so true rates are unknown (PMID 35534779).
• Nerve weakness in secondary lifts: higher than first lifts in one series (PMID 35511039), comparable overall in a pooled review (PMID 42382704).
• Whether a deep plane first lift reduces later revisions: touch-up data from 1998 suggest it (PMID 9727459); recent reviews have not shown a longevity gain (PMID 41100833).

Terms

• Secondary facelift: a second facelift after an earlier one (PMID 42382704).
• Revision or tuck: a smaller operation to correct or tighten an earlier result (PMID 9727459).
• Early relapse: laxity that returns within 2 years (PMID 35534779).
• Composite rhytidectomy: a facelift that moves the cheek and the lower eye muscle together (PMID 11727849).
• Cobra neck: a central neck deformity named as a revision problem (PMID 37827505).
• Synkinesis: involuntary linked facial movement after nerve injury (PMID 37827505).
• Stigmata: visible signs that a facelift was done (PMID 32983758).

Papers