Facelift and Necklift

What is a facelift?

The term ‘facelift’ is commonly used to describe a surgical procedure to ‘lift’ and rejuvenate the face.  Naturally one would assume that this means rejuvenation of the face from top (forehead) to bottom (neck).  To a surgeon, however, the term denotes a specific procedure, called a rhytidectomy, which literally means wrinkle (rhytid) removal (-ectomy).  This is an unfortunate term, as a modern rhytidectomy is not designed to remove wrinkles.  Wrinkle removal is better treated with injectables or skin peels.  Furthermore, strictly speaking, a rhytidectomy does not rejuvenate the eyes or forehead. These are treated with a blepharoplasty and browlift respectively.  So, what exactly does a rhytidectomy do?

A rhytidectomy (or facelift, and we may use the terms interchangeably here) is used to rejuvenate the cheek/midface/jawline/neck areas. The technique has evolved greatly over the years. The popular notion of this technique is that the skin is simply removed and pulled under tension towards the ears. This is actually more or less how a standard rhytidectomy was performed throught the decades leading up to the mid-1980s.  Something happened, however, that changed the way we do rhytidectomy surgery.

In 1975, Mitz and Peyronie published a seminal article describing the anatomic structures of the face. They performed an anatomic dissection of several human cadavers, and described the a layer of tissue they called the superficial musculo-aponeurotic system (SMAS). This SMAS layer was proposed to be important in the suspension of the tissues of the face, and perhaps in transmitting motion from facial muscles and associated tissues. The importance of this discovery was that it was posited that tightening this layer, rather than just the overlying skin, would be a better method for facial rejuvenation during facelift surgery.

As with any new discovery, it took some time for this discovery to take hold clinically. But, by the mid-1980’s to early 1990’s, the SMAS was routinely tightened during rhytidectomy. A few techniques were espoused. These included simply using sutures to tighten it up (SMAS imbrication/FIGURE), to actually cutting a piece of it out and using that to tighten it. The extended-SMAS lift includes elevation of the SMAS prior to tightening.

In the 1990s, some surgeons took this a step further and advocated that the SMAS should be cut and actually undermined for several centimeters in order to better allow it to be elevated.  Doing so would free up the tissues even more, allowing a more robust and long-lasting rejuvenation.  This would come to be called a deep-plane facelift.  Various versions of this exist, which we do not need to get into here.  Suffice to say that most facial plastic surgeons would agree that this is the ‘gold standard’ for a surgical facelift.

In my practice I perform my own, unique version of the deep plane facelift.  In this technique, the SMAS is elevated anteriorly all the way towards the corner of the mouth, allowing reduction of jowling along the jawline.  While the original description (and commonly used version) of the deep plane lift involves no dissection of the platysma muscle, in my technique, I elevate this muscle and tighten it.  This muscle is continuous with the SMAS, and so in my technique this allows continuous elevation, tightening, and rejuvenation of the neck. In my experience, this gives a superior neck tightening to my patients.

Once the SMAS and platysma are elevated, they are secure using absorbable sutures in the cheek and behind the ear, to the mastoid bone. Sometimes a single permanent suture is used behind the ear as well. At this point, there will be excess skin present. This is trimmed to fit precisely, and sutured meticulously to create a hard-to-see incision line/FIGURE (drawing and pt close-up).


How long does this surgery take?

Rhytidectomy, when done as described as above, can take 3 to 4 hours.


What kind of anesthesia is used during a facelift?

We recommend a ‘light’ general anesthetic. This is more more well-tolerated, as patients wake up quickly and are more comfortable for the procedure.  If you have specific concerns about this, feel free to speak to our staff or Dr. Most.


What is the typical recovery from a facelift using his technique?

The typical patient who undergoes this surgery has bruising and swelling of the neck and cheeks that peaks on the third day after surgery. This is usually resolved by 2.5 to 3 weeks after surgery. Individuals will vary in their recovery time, however. Some patients can look great at 1.5 weeks after surgery, and some take a bit longer than 3 weeks.  


What can I do to speed recovery after a facelift?

Rest, elevation, and icing are all important in reducing swelling and bruising after facial surgery of any type. Please see our Facelift Postoperative Instruction Sheet for specifics.


What does a facelift achieve?

The potential benefits of facelift surgery are improvement of the neck, the jawline, the labiomandibular fold (marionette line in the jowl area), the lower portion of the nasolabial fold (the ‘parantheses’ at the oral commisure).  It does not treat facial wrinkles--that is typically done with injectables or peels.


What about these ‘weekend’ facelifts I hear about?

You may hear of doctors who perform quick ‘facelift’ surgery procedures under local anesthesia. A number of names for these exist, such as ‘S-lifts’, ‘minilifts’or other such terms.  In most cases, these involve minimal to no SMAS elevation, and provide short-term fixes with potential scarring due to the tension placed on the skin.  While these may work for some patients, we strive to provide high-quality, long-lasting results for our patients with our facelift techniques. Many doctors have taken to naming facelifts that are minor modifications (or not modifications at all!) simply for marketing purposes.  We have specifically chosen not to do so with our techniques--we let our results speak for themselves.


What are the potential risks of facelift/rhytidectomy surgery?

While it is impossible to be all-inclusive here, some of the potential risks are bruising and swelling that lasts longer than 3 weeks, scars that heal poorly, numbness of the ear/face/cheek, paralysis of a portion(s) of the face, and ear deformity.  

The numbness of the cheek and area behind the ear are relatively common and typically recovers within weeks/months.  It may present a minor nuisance.  The ear itself more rarely is affected, and may indicate the greater auricular nerve has been affected.  This also typically recovers, in most cases within 1 year.  Residual deficits after one year are much less common but can occur.

Paralysis of the a portion or portions of the face occurs in about 1% of patients.  Why?  The facial nerve is closely associated with the tissues dissected in facelift surgery.  Even in the most expert hands, this nerve can be injured, resulting in difficulty moving a portion of the face. In these cases, the nerve usually recovers within one year.  

Please note that in addition to facial rejuvenation surgery, Dr. Most is known for treating patients with facial paralysis and has a research program in this area.


I am interested in facelift!  How do I learn more?

We are happy to see you in consultation. Please contact our Care Coordinator, Amy Mladineo, at (650) 736-3223.  At your visit, you will meet our care team and spend time with Dr. Most. During your consultation, Dr. Most will help you determine if this procedure is right for you.  


About Dr. Most

Dr. Sam Most is a highly trained specialist in plastic surgery of the head and neck. His training has included:

  • facial cosmetic surgery
  • complex reconstruction after head & neck cancer resection, and
  • craniofacial trauma reconstruction

His specialization in plastic surgery of the head and neck allows him to concentrate on delivering the most up-to-date techniques to his patients.

Schedule a Consultation

(650) 736-FACE (3223)