English edition

facelift

The facelift arrived in this practice from an unusual direction. It was not added as a separate offering. It became necessary because removal kept producing a second problem. A filler or a fat graft that has occupied the midface for years is load-bearing whether anyone intended it to be, and the tissue around it has often already descended. Removal answers the first question. The lift answers the one that follows.

01Why this operation sits at the end of a removal plan

A patient who comes for foreign body removal is rarely asking about a facelift. By the time the plan is written, the two are often one conversation.

The reason is mechanical. Skin over a long-standing deposit has stretched to accommodate it, and the retaining ligaments underneath have been working against that load for years. When the material comes out, the skin does not shrink back, and descent the bulk partly disguised becomes plain.

This does not mean every removal needs a lift. It means the question is asked before the removal, because the answer changes the order of operations. The clinic’s stated sequence is to establish inflammation and infection risk first, then map the bone, the material and the soft tissue as separate problems, and only then decide between a combined and a staged operation.

Where material is localised, inflammation has settled and the expected dissection is within acceptable limits, removal and lifting may be done at one sitting. Where inflammation is active, where material is spread across several layers, or where skin perfusion is compromised, staging is safer.

Reconstruction taught him how to rebuild. The facelift taught him how to re-position. Removal is where the two meet.

02What the deep plane differs in

Facelift techniques are distinguished mainly by what they do with the SMAS, the fibrous sheet between the subcutaneous fat and the muscles of expression, which carries the tension of a lift.

In the more common approaches the skin is first elevated off the SMAS, and the SMAS is then plicated, imbricated or partly excised and pulled: two layers, each under its own tension. In the deep plane approach, as the clinic describes its technique, skin and SMAS are never separated. The dissection passes beneath the SMAS, into the plane between it and the facial muscles, and skin, SMAS and deep fat move as a single block.

The clinic gives two reasons. Where skin is thin, the SMAS beneath it is often thin too, and separating two thin layers risks tearing the one that has to hold tension. And because the block is repositioned without being detached from the muscles beneath, expression is still carried by muscle working in its own plane.

The names describe planes, not results. A well-executed SMAS procedure and a well-executed deep plane procedure can produce similar results in the same face. Where they differ most is in what they can reach.

03Why deep plane is not automatically better for every face

The deep plane is often presented as the advanced option, with everything else implied to be a lesser version of it. The evidence does not support that framing.

A 2025 systematic review compared SMAS-based and deep plane facelift techniques across 47 studies and 10,766 patients. The two showed comparable safety, with haematoma reported in about 3 per cent of deep plane cases against 2 per cent of SMAS cases and comparable rates of infection and nerve injury. Only one study compared the two directly, and it reported better midface rejuvenation with the deep plane technique, which is too little to generalise from. The review’s own conclusion is that the choice of technique should be individualised.

What follows is practical. Where laxity is limited, a deeper dissection buys little and costs proximity to the facial nerve. Where previous surgery, thread lifting or injected material has made the deep plane adherent, the safer choice may be a technique that stays above it. Where the midface has descended, the deeper release is what the problem requires.

The deep plane also carries a risk inherent to it rather than to any surgeon. Branches of the facial nerve leave the protection of the parotid and become superficial where the ligaments are released. That is why the plane is defined precisely, and why dissection stops where it can no longer be identified. Risk cannot be reduced to zero in any technique.

04What releasing the retaining ligaments means

The retaining ligaments are fibrous structures running from bone or deep fascia out to the dermis. They are why the soft tissue of a face sits where it does instead of sliding downward. When they loosen with age, tissue descends. While they are intact, tissue being lifted cannot be repositioned past them.

Releasing them means dividing enough of those fibres for descended tissue to move along the vector the surgeon intends, and no more. It is the step that separates a lift which moves a block of tissue from one that stretches skin across an unchanged framework.

Zygomatic retaining ligaments

Run from the zygoma to the skin at the front of the cheek. Until they are released, the midface and the upper nasolabial fold cannot be repositioned upward. Zygomatic and buccal branches of the facial nerve lie close by.

Masseteric cutaneous ligaments

Attachments along the anterior border of the masseter, tethering the SMAS to the fascia over the muscle. Release here is what allows the jowl and lower cheek to move.

Mandibular ligaments

Anchor the skin to the mandible near the chin and define the front edge of the jowl. The marginal mandibular branch of the facial nerve runs nearby.

Cervical retaining ligaments

Tether the skin of the neck, and matter when the jawline and neck are addressed together.

What is released is decided by what needs to move. A lift aimed at the jawline does not need the same release as one aimed at the midface, and releasing more than the correction requires brings the dissection closer to structures worth avoiding.

05Is a wider dissection better?

No. The aim is not the area dissected but the mobility achieved where the tissue actually has to move.

Dissection is a cost as well as a means. Every additional centimetre of undermining adds swelling, adds the time tissue takes to settle, adds surface for fluid to collect beneath, and in the deep plane brings the dissection nearer to nerve branches.

There are faces where the necessary release is wide, and in those faces the dissection is wide. There are others, many with previous surgery or injection, where the plane cannot be followed safely beyond a point. The correct decision there is to stop and accept a smaller correction rather than continue into tissue with no recognisable layers.

06A face with a long history of filler and fat grafting

This is the ordinary situation in this practice rather than the unusual one, and it is where the standard description of a facelift stops being accurate.

The number of injections matters much less than what they left behind. Three sessions of hyaluronic acid filler ten years ago may leave nothing. One session of a semi-permanent material, or a fat graft that fibrosed, can change the entire midface.

Adhesion

Material that has provoked a foreign body reaction is surrounded by scar. Scar does not separate along tissue planes; it separates where it is cut. Dissection that should proceed by gentle spreading becomes sharp dissection, and the layer has to be re-established repeatedly rather than assumed.

Unpredictable planes

The deep plane is a plane because two surfaces slide against one another. Where injected material and its capsule cross that interface, the surfaces are stuck, and in places the plane is not there at all. A dissection can enter the correct layer laterally and lose it entirely in the midface.

Altered landmarks

Surgeons find the plane by recognising structures. Fibrosed graft, migrated filler and thread residue sit where those structures are supposed to be, and a normal anatomical map becomes unreliable at exactly the point where the nerve branches are most superficial.

The response is not a different technique but more information beforehand. Ultrasound maps the material by layer and depth, and CT is used where bone is involved. Where the mapping shows extensive adhesion, removal and lifting are separated in time.

07What changes after previous facial bone contouring

Previous zygomatic reduction, mandibular angle resection or genioplasty changes three things that matter to a lift.

1. The origins of the retaining ligaments. Ligaments that ran from a bony surface since cut, moved or removed no longer run from where a standard description places them, and some were divided at the first operation and healed as scar.
2. The planes themselves. Scar from the earlier approach, intraoral, temporal or preauricular, crosses the layers a lift has to pass through.
3. The platform. A framework that has been narrowed or shortened supports the same envelope differently, and part of what looks like laxity is envelope too large for the frame beneath it.

Imaging comes before planning here rather than after it. The consequence is usually a more conservative dissection in the scarred areas, and a clear account beforehand of which part of the complaint should respond to lifting and which follows from the skeleton and will not.

08When a revision is needed

A second facelift is considered for two distinct reasons, and confusing them produces disappointment.

The first is recurrence. Tissue continues to age after a lift, and descent that returns years later is the same process continuing from a different starting point. A revision here is a further lift, usually with a more limited dissection, because part of the release is done and the planes are scarred.

The second is an unsatisfactory result from the first operation: a correction that did not reach the area the patient cared about, asymmetry, a widened or migrated scar, or an appearance the patient calls pulled rather than lifted. Repeating the same operation for a problem not caused by insufficient lifting will not help.

Timing is decided by tissue rather than the calendar. Swelling and induration from the first operation take months to resolve. Where the concern is a scar or a single discrete asymmetry, the correction is often small and local rather than a repeat of the whole procedure.

09When a neck lift is added

The jawline is the boundary between two areas a patient experiences as one. Lifting the face without addressing the neck sharpens the contrast where they meet, which is why the decision is made together.

• Laxity of the skin of the neck, rather than fullness under the chin alone.
• Loss of definition at the jawline, where the border between face and neck has become indistinct.
• Visible platysmal banding when the neck muscles are contracted.
• A submental contour that the lift will not change and that becomes more conspicuous once the face above it has moved.

Where the complaint is fat under the chin in an otherwise firm neck, a neck lift may not be the answer. Where the skin itself is lax, tightening deeper structures without addressing the skin will not produce a clean jawline. The addition lengthens both the operation and the recovery.

10How this differs from thread lifting

Both are described as lifting, and the word does a great deal of work in both cases.

Where descent is mild, thread lifting can produce a change worth having and is a reasonable choice. Where the ligaments have loosened and the midface has come down, threads pull against structures that have not been released, and the result is usually modest and short-lived.

There is a second consideration here. Threads already in a face do not always disappear as described, and the fibrosis around remnants alters the dissection plane of any later lift in the same way injected material does.

11Recovery beyond the first two weeks

Most accounts of facelift recovery stop at two weeks, when sutures are out and swelling has settled enough for ordinary company. That is the point at which recovery becomes less visible, not the point at which it ends.

The clinic describes the early course as follows. The operation takes around four to five hours, under sedation or general anaesthesia. Swelling is most noticeable on the morning after surgery and may increase until about the third day, then subsides, with most patients socially presentable between seven and ten days. Sutures are removed within about ten days.

Two things about that timetable are worth stating plainly. The firm tissue at one to three months is expected rather than a complication, and it is the commonest reason a patient returns worried in the second month. And the extent of all of it scales with the extent of dissection.

Where a lift has been combined with foreign body removal, recovery cannot be predicted from the facelift alone. Inflammation present beforehand, the extent of adhesion, anaesthetic time and any simultaneous procedure all affect it.

Facelift at this clinic

Where it sits

After removal, within the same plan, not as a separate speciality

Technique described

Deep plane facelift: skin, SMAS and deep fat elevated as one block with release of the retaining ligaments, as the clinic describes it

Operating time

About four to five hours, under sedation or general anaesthesia (the clinic’s stated protocol)

Sutures

Removed within about ten days

Ordinary company

Commonly seven to ten days; individual variation is considerable

Induration

Most noticeable at one to three months; softens over six to twelve months

State of the evidence

A 2025 systematic review of 47 studies and 10,766 patients found the two approaches comparable in safety; only one study compared them directly, and the review concludes that the choice should be individualised

Not stated here

A fixed duration of effect; the figures in circulation are not reliably sourced in our records

Descriptions of technique, operating time and recovery on this page are the clinic’s own account of its protocol and are given as such; they are not outcome data. Facial nerve injury, haematoma, delayed wound healing, scar problems and asymmetry are possible with any facelift technique, and no dissection plane removes those risks.

The descended composite of skin, SMAS and deep fat, once the retaining ligaments holding it in place have been released. Tension is carried by the fascial layer rather than by the skin, and skin left over is removed afterwards rather than being the thing pulled.

Not as a general statement. A 2025 systematic review across 47 studies and 10,766 patients found SMAS-based and deep plane operations comparable in safety. Only one study compared them directly, reporting better midface rejuvenation with the deep plane technique, which is too little to generalise from; the review concludes that the choice should be individualised. Here it depends on where the descent is, how adherent the tissue is, and the nerve risk in that face.

Often, yes. What matters is the current state of the tissue rather than the number of sessions. Where adhesion is extensive, the plane has to be re-established as the operation goes on, and it may be better to remove the material first and lift later.

No, but it changes the planning. Ligament origins, dissection planes and the bony platform under the soft tissue have all been altered, and imaging is used before the plan is fixed rather than after.

That is the expected course rather than a complication. Induration at the dissection sites is most noticeable between one and three months and softens over the following months. It is worth reporting, but in most cases what is described is the normal sequence.

Sutures come out within about ten days and most people are in ordinary company between seven and ten days, as the clinic describes it. Firmness peaks at one to three months and softens over the following six months to a year. Where a lift is combined with removal, the timetable is less predictable.

Either because tissue has continued to age and descent has returned, or because something about the first result was unsatisfactory. Those need different operations, so the cause is established first.

ReferencesVayalapra S, Guerero DN, Sandhu V, Happy AA, Imantalab D, Kissoonsingh P, Khajuria A. Comparing the Safety and Efficacy of Superficial Musculoaponeurotic System and Deep Plane Facelift Techniques: A Systematic Review and Meta-analysis. Ann Plast Surg. 2025;95(5):582-589.PMID 4060082247 studies, 10,766 patients. The two approaches were comparable in safety. Only one included study compared them directly, reporting better midface rejuvenation with the deep plane technique; the review’s conclusion is that technique selection should be individualised.Kang CM, Shim JS, Park SH, Jeong YJ, Seol KH, Kwak SG. Volume Change of Muscle and Fat Portions of Latissimus Dorsi Myocutaneous Flap after Breast Reconstruction. Plast Reconstr Surg Glob Open. 2021;9(4):e3536.PMID 33868878Sixteen patients after breast reconstruction; muscle and fat portions of one flap changed volume at different rates. Methodological background only. It does not examine facial tissue and is not evidence for any facelift technique.Kang CM, Shim JS. Volume Change of Pedicled Latissimus Dorsi Muscle Flap after Partial Breast Reconstruction. J Reconstr Microsurg. 2018;34(8):651-657.PMID 30099736Eleven patients, followed on CT for five years after partial breast reconstruction. Methodological background for measuring change rather than describing it. The population is breast reconstruction, not the face.

The removal work that precedes this operation, and the reasoning about what comes out and what stays, is set out separately. The two are parts of one plan.

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