If fillers and injectables are the gateways to preventing and correcting minimal signs of aging, then the surgical facelift is the main event. The procedure’s history dates back to the 1900s when a German surgeon performed the first facelift on a Polish socialite. In the 1980s, facelifts became more mainstream. And as the ‘90s rolled around, scars got shorter, and 
the deep plane facelift was forging ahead. Since then, the procedure has evolved tenfold and continues to evolve.
During the facelift’s infancy it was surgery or nothing, since other youth-restoring treatments did not exist like they do today. Initially, this surgery was reserved for wealthy women wanting tighter skin, said board-certified plastic surgeon Jennifer Levine, MD (New York City, N.Y.). “It was a status symbol, so they didn’t mind looking done or tight.
“Back then, if you were 40 and didn’t like how your face looked, you got a facelift,” Dr. Levine continued. “Patients were doing them almost every ten years.”
“Originally, facelift techniques focused on the skin with little emphasis on the deeper structures, which created unnatural, short-lived results and obvious scars,” noted Justin
Cohen, MD, a double board-certified facial plastic surgeon in McLean, Va. However, complete facial rejuvenation is about more than just attending to the skin – the tissue, muscle and fat layers need to be addressed as well. “Our understanding of the face and neck have improved and so have the procedures.
As board-certified plastic surgeon, Renato Saltz, MD (Salt Lake City, Utah) explained, the facelift has moved away from just a skin lifting surgery to one that now operates at a deeper level and utilizes the superficial musculoaponeurotic system (SMAS), fascia and fat for improved results.
Facelifts are more in demand than ever, but according to Vincent McGinniss, DO, a board- certified facial plastic surgeon in Findlay, Ohio, “patients don’t want the stigma of the wind tunnel or overdone facelifts of the past.”
“Patients’ biggest fear is looking ‘weird,’” said Dr. Cohen. “However, social media and the overwhelming accessibility of before and after photos helps to diminish the worry when reassuring them they will look like themselves.”
While transparency surrounds facelifts, it is still the surgeon’s responsibility to educate patients on the ins and outs of the procedure and the correct type of facelift so that every facelift patient is happy in the end.
Facelift 2.0
Modern facelifts address various layers of the aging face, including skin, tissue, the SMAS layer, muscle and changes in facial volume. But with so many types of facelifts (and marketing misnomers), how can patients know if a simple or more complex lift is best?
“There are numerous variations – the ponytail lift, the mini lift, even procedures with the word lift that are not surgery,” said Joseph Niamtu, III, DMD, a board-certified cosmetic facial surgeon in Midlothian, Va. So even if a patient is adamant about having a specific type of facelift, ultimately, it is the surgeon’s decision if it is appropriate or not to do.
Some patients spend hours, even days, scouring every possible resource to pre-determine which type of facelift will benefit them. It is not uncommon for them to arrive at a consultation equipped with information, targeted questions and sc
reenshots of before and after photos. On the other hand, some patients can’t put their finger on what they want to fix, but know they need a refresh of some sort, Dr. Niamtu indicated. “Some ask for unnecessary things, and good surgeons have to say ‘no.’ I have 19-year-olds who think they need a facelift because of what they see on social media. Younger patients may want a lift, but most need to be educated on the options to make the right decision,” he shared.
Age knows no boundaries, and patients who elect surgery no longer fall into the 60+ age bracket. In Dr. Saltz’s experience, socially accepted facelifts bring younger people into his office. “I see more patients for primary facial rejuvenation in their late 40s and early 50s.” Dr. Saltz’s youngest facelift patient was 38 years old. “I will recommend surgery if a patient identifies aging features that I can improve with a facelift.”
So how do patients know when they are genuinely ready for a facelift, let alone which type of facelift? Dr. Levine attributed it to two things. “One, they have exhausted every option short of surgery, and the results are still not enough for them. Or two, they hate their neck and want it to be smooth again.” She also said patients now realize they want to be lifted. “For a long time, they thought they could achieve a similar result with volume, and while volume is important, it is not the answer to a lifted look.”
Options Abound
Facelift solutions run the gamut from mini lifts to advanced deep plane facelifts and everything in between.
Some patients may believe there is only one type of facelift to consider, no matter what. “There is this fallacy that certain techniques, like a deep plane lift, are the only way for them to get the results they want,” Dr. Niamtu began. “But I don’t perform deep plane facelifts on every patient because some people are not candidates for it.”
Naturally, some facelifts may be more appealing to patients than others. Take, for example, the mini lift. Many patients find its shorter scars and less downtime attractive. However, “mini lifts only work for some people with minimal signs of aging with little laxity,” Dr. Levine explained. “Using too small of an incision makes it difficult to correct the neck, and the neck is what most of my patients want to fix.” She added that in some instances patients are okay with not attaining the maximum result, and the patient and surgeon must always be on the same page.
Dr. Cohen recalls a 45-year-old patient with mild facial aging who only wanted a mini-facelift. “Her changes would have been so subtle, and we would be creating scars for no good reason. I explained to her that the best option was for her to save her money and put it towards a more rewarding procedure in the future. She gave me the biggest hug when she left,” he said. “Honesty is the best policy; I frequently turn people away if what they are asking for is inappropriate.”
When walking his patients through the facelift process to determine which method is best, Dr. Cohen likes to create a visual and compare the face to a peanut butter sandwich. “The top piece of bread represents the skin; the peanut butter is the deep skin attachment; and the bottom piece is the SMAS. Different techniques focus on different parts of the sandwich to varying degrees,” he explained.
“Traditional techniques take the top layer of bread, separate it from the peanut butter and pull it tight with tension,” Dr. Cohen continued. “SMAS facelifts peel off the top slice of bread and tighten the bottom bread from on top. Finally, deep plane facelifts keep the entire sandwich intact, pick it up, and gently slide it across the plate by tightening the bottom bread only. The result is a top slice of bread (the skin) that appears untouched,” he continued.
Regardless of the technique, Dr. McGinniss asserted that the SMAS plays a role in a successful facelift. “Making changes to the SMAS creates longer-lasting, natural results that take tension off the skin, so the incisions heal better. We understand how to strategically place incisions to camouflage them while minimizing the tell-tail signs of a facelift, like loss of sideburn hair, high hairlines, pixie ear deformities, and poorly placed scars that prevent ponytails,” he shared.
The Importance of Combination Procedures
The goal of a facelift is to refresh the face, so it looks natural. “Like painting an entire wall instead of just the bottom half, a facelift can be paired with complementary procedures to ensure the final result is seamless and balanced,” Dr. Cohen noted. Ignoring other facial features can emphasize tired-looking eyes or a droopy brow, necessitating additional surgeries to unify the face.
Each plastic surgeon has their preference as to which procedures they incorporate to garner the best result. For example, Dr. Saltz combines his facelifts with an endoscopic browlift or TCA peel to eliminate fine lines and wrinkles around the eyes and lips. Volume-restoring fat injections are also frequently part of a facelift; Dr. Saltz adds them to almost every one of his facelifts.
Dr. Niamtu is a fan of facelifts with aggressive laser resurfacing. In addition, blepharoplasties, brow lifts and even rhinoplasty can create a better facelift result.
Finally, Dr. Levine said chin implants are essential to consider. “A chin implant creates a better contour to the neck because there is improved projection and definition.”
Don’t Neglect the Neck
Addressing the neck is critical for a good facelift result. Some plastic surgeons bypass the neck, but most correct it since a facelift is genuinely about the lower face and the neck. “Ignoring the neck and only correcting the face is like having two separate faces – it always looks a little weird,” Dr. Saltz underscored.
Liposuction is an option for removing extra fat and creating a sharp delineation between the jawline and neck. But surgery is not the only way to revive the neck. Dr. Levine explained that the platysma muscle in the neck is a depressor of the lower face, “so injecting Botox regularly will help preserve the neck especially after surgery.”
Since the neck can be a bone of contention, nonsurgical options often reign supreme. However, treatments like radiofrequency (RF) microneedling, for example, can create scarred or fibrous tissue that is difficult to dissect during a face and neck lift, Dr. Saltz shared. “I did a face and neck lift on one of my master aestheticians who is our laser and treatment guinea pig. When I got to her neck, it was like I was doing a tertiary facelift. The tissues were tight and challenging to separate. It was like I was dealing with a different anatomical structure,” he explained.
Can You Fake a Facelift: Nonsurgical Options
Nonsurgical devices play a role in aesthetics and claim to lift and tighten without a single cut. Dr. Saltz relies on nonsurgical devices, like broadband light (BBL) and RF microneedling, to improve the skin’s quality and tighten it. While these procedures have their place, especially for those who are not ready for or are not facelift contenders, realistic expectations are critical. “We have great nonsurgical options to improve skin texture and elasticity, but they don’t rejuvenate everything,” Dr. Saltz stated.
Conversely, while a facelift may improve some lines, wrinkles and folds, it does not treat every wrinkle, so surgeons rely on other tools. “My practice has a large injectable component, allowing some patients to push surgery out a little later,” Dr. Desyatnikova shared. “I always stress the difference between injectables and surgery and how they can work together.”
Even post-facelift results require maintenance, and nonsurgical options like RF microneedling, chemical peels, injectables, fillers and lasers can sustain them. “There is this misconception that a facelift does not require maintenance,” Dr. Levine expressed. “The face continues to age, and maintenance with reasonable amounts of volume and good skincare is key to looking good.”
If fat grafting isn’t part of a surgical plan, a liquid facelift can fill in volume-deficient areas that need refining. The liquid facelift uses a mix-and-match cocktail of fillers and injectables to add volume, structure or balance. While it can reinstate volume and revitalize the face, it will not change its underlying structure or remove loose skin like a facelift. Even so, Dr. Desyatnikova shared that years of filler use can accumulate in parts of the face, and explained these should be removed during surgery to avoid unappealing bulges and distortions.
Second-generation thread lifts also have their place in the nonsurgical domain. A thread lift uses the directional pull of a single thread to create an instantly chiseled jawline, modelesque brows and a tight neck without any incisions or scars. But, a thread lift is not without risks, like scarring, puckering, bunching, dimpling, irregularities and visibility under the skin (when placed superficially or in thin skin). Dr. Cohen explained that scar tissue replaces the threads over time, which can complicate a future facelift.
Moving into device-based treatments that claim to lift and tighten the skin, one of the newer devices is the FDA-cleared Ellacor® System with Micro-Coring from Cytrellis® (Woburn, Mass.), which uses hollow needles to remove full-thickness micro-cores of small tissue segments of mild to moderately loose skin (in Fitzpatrick skin types I-IV). The 30-minute treatment treats moderate to severe wrinkles in the mid and lower face.
MyEllevate® is another minimally invasive treatment that enhances the jawline and neck without cutting into it. Performed under local anesthesia, MyEllevate uses a light-guided suture to elevate the underlying structure without incisions. It can be done as a standalone procedure or with submental liposuction or other fat-reducing modalities.
Dr. McGinniss said RF or ultrasound devices can enhance the effects of procedures that elevate the tissues.
Even BTL Aesthetics (Marlborough, MA) is getting in on face tightening with their new needle-free device, Emface®. Like Emsculpt®, which stimulates muscle contractions in the abdomen and buttocks for increased tightness and definition, Emface uses High Intensity Facial Electromagnetic Stimulation (HIFES) energy, which promotes hypertrophy and hyperplasia for a lifting effect, to contract facial muscles in four, 20-minute treatments.
Other options include Morpheus8 (InMode), an RF microneedling procedure that tightens the skin while reducing excess fat along the jawline and chin; minimally invasive FaceTite (InMode), which relies on RF technology to contract and contour the tissue; and Renuvion® (Apyx Medical), a minimally invasive procedure that harnesses the power of proprietary helium plasma and RF to create tighter skin on the neck and jawline without surgery.
Still, these treatments are not for everybody, and many plastic surgeons feel they are limited in what they can actually achieve.
The Future of the Facelift
While no plastic surgeon has a crystal ball to predict how the facelift will evolve, the doctors we spoke with have a few predictions. “If the literature is accurate, more people will have facelifts earlier and not wait until they are sagging. This will also make for a safer procedure because patients will be younger,” explained Dr. Saltz. “Everyone is taking better care of their skin, not just to look better, but also to prevent skin cancer, so I think we will see fewer poor results because of better skin quality,” he added.
Dr. Niamtu suggests age-retarding drug products or injectables may exist. “There may be medications we can put on the tissue inside the face to promote faster healing, less bleeding and decrease recovery time. We may also see laser tissue welding, where we can approximate tissues without doing old-fashion stitches. Anesthetic advances and biomaterials will continue to evolve. For facial implants, I think there will be big changes.”
Will technological advances supersede surgery and, maybe, one day replace it? “Perhaps,” Dr. Cohen said. But, of course, only time will tell.
References:
1. https://www.sciencedirect.com/science/article/pii/ S2095881115300287
2. https://www.vogue.com/article/ marc-jacobs-plastic-surgery-face-lift-aging
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579162/
4. https://www.cnn.com/style/article/plastic-cosmetic-surgery- history-scn/index.html
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635200/
6. https://www.plasticsurgery.org/news/blog/ is-a-liquid-facelift-right-for-you
7. https://www.cytrellis.com/technology/
8. https://myellevate.com/
9. https://www.prnewswire.com/news-releases/btl- announces-disruptive-technology-to-revolutionize-facial- aesthetics-301460009.html
10. https://inmodemd.com/technologies/ full-body-fractionated-anti-aging-morpheus8-technology/
11. https://inmodemd.com/technologies/technologies-facetite/
12. https://www.renuvion.com/
