Signs of a bad facelift

Each sign and its repair

Where the "facelifted" look came from

For most of the 20th century facelifts pulled skin, and later the SMAS layer, toward the ear. In 1998 and 2000 Sam Hamra described what that does over time: the jawline is held tight while the cheek, which was never moved, keeps falling over it, producing the lateral sweep; a crescent-shaped mound over the cheekbone appears because the lower eye muscle was not repositioned; and removing lower eyelid fat leaves the eyes hollow (PMID 9774028, PMID 11802570). He argued that the cheek should be lifted upward and inward instead (PMID 11802570).

Patients came to know the signs too. People asking for a facelift often say they do not want to look "done," usually because of scars or deformities they have seen on someone else: unnatural hairlines, a pulled tragus, a distorted earlobe, an irregular neck and an overall lifted look (PMID 16085288). Surgeons answered with incisions hidden in the natural creases of the ear and the hair (PMID 12873871), deeper lifts that move the cheek itself (PMID 9774028), and fat grafting to replace lost volume (PMID 31907534).

The pulled look and the lift direction

• A pull that runs only sideways tightens the jaw and leaves the cheek behind; this is the lateral sweep, and lifting the cheek up and inward corrects it (PMID 11802570, PMID 9774028).
• Too vertical a pull can also look wrong: Andrew Jacono described a vertical sweep deformity after facelift (PMID 28006056).
• The right direction is set for each face. Ben Talei measured the lift in deep plane facelifts and found that the direction needed differs from patient to patient and between the two sides of one face, so the surgeon releases the tissue and lifts against the direction it fell (PMID 38657095).
• In one surgeon's deep plane facelifts, measurements of the skin confirmed that the pull was more vertical than horizontal (PMID 37358617).
• The joker line, a groove from the mouth corner toward the ear, gives a harsh, pulled look. Most patients who develop it show a version before surgery that light finger traction on the cheek brings out, so a surgeon can spot it at the consultation and fill it with volume (PMID 18971739).

Ear and earlobe

• Pixie ear: the earlobe is pulled down and forward and looks stuck to the cheek. It follows removing too much skin below the lobe, sewing the facial skin directly to the lobe, or heavy scarring (PMID 23486143).
• Surgeons prevent it by taking the tension off the lobe: in one method the lobe's attachment is released and set in with a free lower edge left to heal on its own, and no patient developed a pixie ear (PMID 19338847).
• The repair is a second small operation: the traditional approach cuts the lobe free and reattaches it higher, and a newer one lifts and trims the skin below the ear through an incision behind it (PMID 36068695).
• A facelift can move the whole ear. With hidden incisions, fat injection and barbed sutures, one surgeon raised ear position in most patients and lowered or distorted it in a few (PMID 19717057).
• An unnatural tragus, the small cartilage flap in front of the ear canal, is a sign of a poorly placed incision (PMID 12873871). Trimming and stitching the tragal cartilage during the facelift kept the tragus natural in a recent series (PMID 41972770).

Hairline and sideburn

• When loose skin is lifted, hairless cheek skin can be moved up into the sideburn, so the sideburn disappears (PMID 9811026).
• A facelift can also move the temple and neck hairlines, scars inside the hair can widen, and incisions along the hairline can widen or turn paler than the skin (PMID 17205255).
• Surgeons prevent this by planning incisions that keep the sideburn and hairline in place; one surgeon's patients who had three or more facelifts mostly kept a normal hairline and did not look operated on (PMID 18823831, PMID 12873871).
• Hair transplantation repairs it: single follicles placed into a moved hairline or a scar satisfied most patients (PMID 17205255, PMID 30934179), and grafts placed at a sharp angle rebuild a lost sideburn in one session under local anesthesia (PMID 9811026).

Scars and skin

• Scars show when incisions are placed poorly or closed under tension; surgeons close the skin without tension, with the deeper layers holding the lift (PMID 12873871, PMID 36068695, PMID 41972770).
• Injecting fluid into the tissue before dissection (tumescent infiltration) was followed by less skin loss, less hair loss and fewer thick or stretched scars in a large comparison (PMID 14707665).
• Nicotine cuts blood flow to the lifted skin and raises the risk of skin loss; one surgeon gave nicotine users oral niacin and topical nitroglycerin to protect the skin (PMID 40842797).
• Laser resurfacing at the same operation had low complication rates in pooled studies; using full energy over skin that was lifted is linked to more skin loss (PMID 41063540).
• Repeated thread lifts leave scar tissue and fused layers that make the later facelift harder, with uneven skin and dimpling in most of one surgeon's patients (PMID 40775188).

Overdone and hollow faces

• Removing lower eyelid fat in a traditional eyelid lift can leave a hollow eye, which Hamra listed with the lateral sweep as a frequent facelift sequel (PMID 9774028).
• Faces lose volume compartment by compartment with age, and a lift alone does not replace it; modern lifts combine moving fat with the SMAS and adding fat where it was lost (PMID 31688754, PMID 31907534).
• A buccal fat pad that has slipped forward can bulge beside the mouth after the lift if it is left untreated (PMID 41083893).
• In the neck, surgeons tend to overtreat what is easy to reach above the platysma muscle and undertreat what lies below it, which leaves an unbalanced neck (PMID 31587772). Too much liposuction can leave a dent under the chin (PMID 35420070).
• Bands and jowls that come back are the main reasons a neck lift is redone, usually many years later (PMID 27018694). Traditional neck lifts often leave the deep neck untreated (PMID 39652837).
• Skin texture is a problem SMAS facelifts have not solved, so a lifted face can still show aged skin; surgeons add fat grafting or resurfacing for it (PMID 24142113, PMID 41063540).

Facial weakness

• Weakness at the corner of the mouth after a facelift is often pseudo-paralysis: injury to the cervical branch of the facial nerve, which the patient can tell apart because the lower lip can still be pushed out (PMID 419214, PMID 12794490).
• In one large practice it followed about 1.7 in 100 SMAS-platysma facelifts, and every patient recovered fully within 3 weeks to 6 months (PMID 12794490).
• Injury to the forehead branch leaves one side of the forehead unable to lift (PMID 2748749).
• While a nerve recovers, botulinum toxin in the working side of the face restores symmetry; injecting earlier than 2 weeks after surgery can overshoot (PMID 34373897).

How often patients are unhappy

• On a patient review site, about 1 in 13 facelift reviews were negative (PMID 39090310). Most negative reviews named the result, and about half named the surgeon's bedside manner (PMID 39090310).
• Satisfaction was high after both deep plane and SMAS facelifts in pooled studies (PMID 40801931).
• In facelift malpractice cases, a poor cosmetic result was claimed in most and missing informed consent in about a third (PMID 28199538). Lack of informed consent was linked to cases lost by the surgeon (PMID 41501428).
• Unrealistic expectations, very small deformities and a history of repeated surgery predict an unhappy patient (PMID 26017596).

What can be revised

A second facelift fixes most of these signs. Before planning it, the surgeon separates the marks of the first operation from normal aging since then (PMID 23190821). Rod Rohrich's group organizes the repair as five steps: remove excess skin and scar, release SMAS that was pulled in the wrong direction, refill with fat, reshape the SMAS and redrape the skin (PMID 23142942).

• In that practice, complications after secondary facelifts were few, and a third lift lasted about as long as the second (PMID 23142942).
• Daniel Marchac reviewed patients who had three to five facelifts with him; most did not look operated on and had no scars visible at conversational distance (PMID 18823831).
• Revision is harder than a first lift: scar, a moved SMAS and shifted nerve landmarks, and problems such as cobra neck, pixie ear and synkinesis, add risk, more so after deep plane and aggressive neck surgery (PMID 37827505).
• Returning neck bands and jowls are corrected by opening the area under the chin, joining the platysma edges and redraping the skin (PMID 27018694).

Questions to ask a surgeon

• Ask to see results from the side and from behind, where earlobes, hairlines and scars show (PMID 16085288).
• Ask which direction the lift will pull and how that is decided for each side (PMID 38657095).
• Ask how the earlobe is set so it does not pull down (PMID 23486143).
• Ask where the incisions go relative to the sideburn and hairline (PMID 12873871).
• Ask whether lost volume will be replaced with fat (PMID 31907534).
• Ask how the deep neck will be assessed and treated (PMID 31587772).
• Tell the surgeon about any thread lifts, smoking or nicotine use (PMID 40775188, PMID 40842797).

Open questions

• Deep plane against SMAS: higher satisfaction and higher complication rates for deep plane in pooled studies that did not compare them head to head (PMID 40801931).
• Deep neck surgery carries more nerve weakness than traditional neck lifts, and few studies measure the result objectively (PMID 39652837).
• Lateral sweep and cobra neck are described by surgeons without measured rates (PMID 9774028, PMID 37827505).
• Thread lift scarring outlasts the threads, from a small series (PMID 40775188).

Terms

• Lateral sweep: cheek tissue sagging over a jawline tightened by a sideways pull (PMID 9774028, PMID 11802570).
• Vector: the direction in which the surgeon lifts the tissue (PMID 38657095).
• Composite rhytidectomy: a facelift that lifts the cheek and the lower eye muscle upward and inward (PMID 11802570).
• Joker line: a cross-cheek groove from the mouth corner toward the ear (PMID 18971739).
• Pixie ear: an earlobe pulled down and forward and attached to the cheek (PMID 23486143, PMID 36068695).
• Tragus: the small cartilage flap in front of the ear canal (PMID 41972770).
• Pseudo-paralysis: lower lip weakness from cervical branch injury, with a working chin muscle (PMID 12794490).
• Cobra neck: a neck deformity named among the problems that make revision harder (PMID 37827505).
• Tumescent infiltration: fluid injected into the tissue before dissection (PMID 14707665).
• Flap ischemia: poor blood flow to lifted skin, which can lead to skin loss (PMID 40842797).

Papers