There are two main techniques for full facelift surgery: a SMAS lift and a deep plane facelift.
Both methods reposition the deep tissues of the face, primarily the SMAS (superficial musculoaponeurotic system), which is a sheet of firm facial tissue (fascia) covering the muscles of expression in the lower face. The platysma muscle of the neck is an extension of the SMAS; it too is resuspended during most facelifts.
While facelifts of old stretched and resized the skin only (often giving a windswept look), modern procedures, both SMAS and deep plane, address both the skin and the SMAS.
While plastic surgeons have long argued about which facelift technique delivers the most long-lasting and natural-looking result, no one style has been proven superior in a peer-reviewed study. What’s most important is finding a qualified, experienced surgeon with the skill to customize their approach for each patient's specific anatomy and aesthetic goals.
The type of facelift your surgeon performs will come down to the technique they’re trained in and feel most confident performing as well as your needs, anatomy (your skin thickness, the fullness of your face, the angles of your neck, your bone structure), and your desired results.
Regardless of which approach your surgeon favors:
- A facelift generally takes about 4 to 6 hours, depending on the complexity of the operation.
- This outpatient procedure can be performed under either general anesthesia or local anesthesia with IV sedation.
- Once you’re unconscious or sedated, your face will be injected with a mix of lidocaine, epinephrine, and tranexamic acid, to numb the area and minimize bruising.
- After surgery, you’ll be discharged with either bandages on your face and head or a drainage tube. You’ll be groggy, so make sure you have a trusted friend, partner, or family member take you home and stick around for the first night, to monitor how you’re feeling.
The SMAS facelift
All SMAS facelifts involve lifting up the skin and manipulating the SMAS to restore the contours of the face. During the procedure:
- Discreet incisions are made either inside the ear (tragal incision) or in front of the ear (pre-tragal incision), following the natural crease of your earlobe. A traditional facelift incision typically starts in the temporal hairline and, after traversing the ear, ends in the lower scalp behind the ears.
- The skin is raised off the SMAS, which is repositioned and tailored (sometimes folded, other times trimmed).
- Typically, the platysma is accessed and lifted via ear incisions. The central portion of the neck may also be addressed through a small incision under the chin, in what’s known as a platysmaplasty.“Fat deposits are removed from the neck as well,” says Dr. Portuese.
- During a deep neck lift, surgeons go underneath the platysma to reduce subplatysmal fat, submandibular glands, and digastric muscles, all of which can contribute to fullness under the chin and in the lateral neck.
- The skin is redraped and any excess skin is removed around the ears.
- The facelift incisions are closed with tiny stitches.
Under the SMAS umbrella, there are various kinds of facelift techniques, two of the more popular being the SMAS imbrication and the SMASectomy. Surgeons commonly put their own spin on these textbook procedures, extending the degree of dissection, mobilizing the SMAS to a lesser or greater extent, or adjusting the direction of lift (aka the vector).
Learn more about SMAS facelifts
The deep plane facelift
With a deep plane facelift:
- The surgeon creates a flap that includes skin, subcutaneous fat, and SMAS. The flap is lifted and repositioned as one composite unit.
- Often, the surgeon releases certain retaining ligaments in the face, to better mobilize and elevate the cheeks and jowls, which is why the deep plane approach is thought to give a better mid-facelift in addition to smoothing nasolabial folds more effectively.
- The muscular structure of the neck is also lifted and supported with tension-bearing sutures.The deeper fat, glands, and digastrics are sculpted when necessary.
- As with a SMAS facelift, the skin is redraped and trimmed before incisions are closed.
Proponents of the deep plane technique say the results are more natural-looking and longer-lasting, but certain studies have found no major differences between the two techniques in patients under 70 years old, even when comparing the results over a 10-year period.
When someone has thick facial skin and a very full face, a deep plane lift may provide better support. In the spirit of customizing the procedure to the patient, “many surgeons will vary their facelift technique depending on anatomic considerations, such as the width and shape of the face, the patient’s skin thickness, and the distribution of subcutaneous fat,” says Dr. Ridenour.
Learn more about deep plane facelifts
The endoscopic facelift
True endoscopic facelifts rely on tiny incisions hidden in the hair of the temples, through which surgeons insert a lighted camera that helps guide their dissection. This eliminates the need for long incisions around the ears, which are standard with open-style facelifts.
In the past, endoscopic facelifts were "subperiosteal," meaning surgeons worked directly above bone, treating the upper two-thirds of the face (essentially taking an endoscopic brow lift one step further to include the midface).
The most modern iteration of the so-called "scarless facelift" is a deep plane endoscopic facelift. It generally addresses the mid- and lower face through incisions in the hair and also, in some instances, behind the ears.
These procedures frequently include neck work, as well, via an incision under the chin.
“The most common elements [of an endoscopic facelift] are the elevation of the midface, cheek structures, and jowls using small incisions,” says San Francisco plastic surgeon Dr. Carolyn Chang.
Since classic endoscopic incisions allow for little to no skin removal, they’re most appropriate for young patients with early signs of aging or older patients with exceptional skin elasticity.
The popular “ponytail facelift” is a trademarked term for a specific type of endoscopic deep plane facelift developed by Dr. Chai Chi Kao, a plastic surgeon in Santa Monica, California. Despite the branding, providers commonly adopt the moniker for other kinds of limited or endoscopic lifts, but a true ponytail procedure follows a specific protocol and addresses the full face and neck, mainly through keyhole incisions.
The mini facelift
A short-scar or mini facelift involves making a limited incision, primarily in front of the ear and into temporal hair tuft, explains Dr. Ridenour. “The short-scar facelift is typically done in younger patients who have modest sagging of skin,” he says.
One type of mini lift is a lower facelift, which focuses primarily on the jawline and neck, explains Dr. Ridenour. “A lower facelift may tighten only the platysma, or neck muscles, rather than the entire SMAS layer, and can be good for younger patients with early aging of the lower face.”
While mini lifts vary in scope and intent, outcomes tend to be less dramatic and less durable than those of traditional facelifts.
Related: What Kind of Facelift is Right For You? Doctors Explain the Differences
