Facelift
This operation repositions the cheeks, tissues around the mouth and jawline that have sagged with age or after foreign material removal, moving the deeper tissue together with the skin.
- Operating time
- Approximately 4–5 hours, according to UVOM Plastic Surgery’s guidance
- Suture removal
- Within 10 days
- Return to daily activities
- Approximately 2 weeks. Internal tissue adhesions, swelling and altered sensation may persist beyond this point.
- Surgeon
- Dr. Chang Min Kang, Medical Director
How the Approaches Differ
Conventional approach
The simplest approach to lifting a sagging face is to make incisions in front of and behind the ears, pull the skin and remove the excess. Those who find surgery burdensome may instead have a thread lift, in which inserted threads lift the tissue.
Limitations
Facial sagging involves more than the skin. The underlying fat and the tough layer surrounding it also descend. Pulling only the skin leaves the deeper tissue in place and concentrates tension at the incision. Scars may widen, or the effect may not last as long.
A thread lift cannot release the firm structures anchoring the tissue toward the bone, limiting how far the tissue can be moved.
Dr. Kang’s approach
The tough layer beneath the skin (SMAS) and the cord-like structures anchoring tissue in place (retaining ligaments) are addressed together. These attachments are released to allow the deeper tissue to move, after which it is repositioned and secured. Excess skin is trimmed last.
The cheeks, mouth area, jawline and neck sag in different directions. Release points and movement directions are therefore planned separately for each area. When facial foreign material must be removed, the sequence of removal and lifting is planned as well.
Benefits and considerations
Repositioning the deeper tissue distributes the load beyond the skin alone. This approach directly addresses the layer contributing to sagging.
This is a major operation lasting 4–5 hours, with a return to daily activities after approximately 2 weeks. Operating close to facial nerves carries a risk of nerve injury. Extensive dissection into deeper planes is not better for everyone; when sagging is mild, a more limited procedure or another treatment is recommended first.
Glossary
- SMAS
- A thin, tough layer beneath the skin that surrounds facial muscles and supports facial tissue.
- Retaining ligaments
- Cord-like structures anchoring facial soft tissue toward the bone. Releasing them allows the tissue to move.
- Deep plane
- A facelift technique that repositions tissue by entering the deeper plane below the SMAS.
- Dissection
- Separating attached tissue layers to create a space between them.
Why the Face Sags
Facial sagging has more than one cause. The following five factors interact, so the main contributors must first be identified for each person.
| Cause | Explanation |
|---|---|
| Loss of skin elasticity | With age, collagen that provides firmness and elastin that provides elasticity decrease, allowing the skin to stretch. |
| Weakening of the SMAS | The SMAS is an intermediate layer supporting facial contours. As it weakens, the overlying tissue sags and wrinkles develop. |
| Changes in facial fat position | Weight changes and aging cause fat in the cheeks, jawline and nasolabial areas to descend or lose volume, blurring the contours. |
| Bone changes | Loss of bone volume around the eyes, cheekbones and jaw weakens soft-tissue support, producing hollowing and deep folds. |
| Gravity and habitual expressions | Gravity continually acts downward, while repeated facial expressions deepen lines in certain areas. |
Dr. Kang’s Facelift Approach
A conventional facelift involves dissection beneath the skin, partial SMAS excision and lifting. Dr. Kang keeps the skin, fat and SMAS together as one unit and lifts the facial tissue from the deep plane beneath the SMAS.
Releasing the retaining ligaments is the key step in this approach. Adequate release of the midface and lower-face ligaments allows sagging fat and fascia to be repositioned, improving hollowing below the cheekbones, deep nasolabial folds and sagging inner cheek fat together. Because the operative plane is close to facial nerves, precise anatomical knowledge and careful dissection are essential.
Features of lifting tissue as one unit
- Reduces the appearance of skin being forcibly pulled and allows facial expressions to move naturally.
- Keeping the layers together lowers the risk of tearing the SMAS, even when thin skin makes separate SMAS dissection difficult.
- Lifting the deeper tissue rather than the skin can reduce excess skin and an unnaturally pulled appearance, even when skin elasticity is reduced.
- Lifting tissue to fill hollows below the cheekbones makes the cheekbones appear relatively less prominent. When the cheekbones project at the 45-degree angle, part of the SMAS that could become bulky is removed to avoid making them appear larger.
Layers of the Face
- Skin
- The outermost layer.
- Subcutaneous fat
- The fat layer immediately beneath the skin, with thickness varying between individuals.
- SMAS
- A thin, tough layer surrounding facial muscles and supporting the contours.
- Deep fat
- A deeper fat layer that directly influences facial volume and sagging.
- Deep fascia
- A layer providing structural support beneath the muscles of facial expression.
- Deep plane
- The space below the SMAS and above the facial expression muscles and deep fascia. Incorrect dissection in this plane can cause serious complications, making anatomical understanding essential.
Suturing to Reduce Scarring
Scarring varies considerably with the surgical process and closure technique. Pulling the skin tightly during closure without adequately lifting the SMAS can distort the area in front of the ear.
UVOM Plastic Surgery uses vertical mattress sutures to reduce scarring. The suture passes through the skin twice, bringing the deep dermis and skin surface together to distribute tension evenly and precisely align the wound edges. This takes longer than a simple suture that passes through once before being tied.
Postoperative Care
- Intravenous fluids Help recovery by restoring fluid and electrolyte balance disturbed after surgery.
- Hyperbaric oxygen therapy Increases oxygen delivery to help reduce swelling and support wound healing.
- 1 shampoo session Keeps the scalp clean during the period when the surgical site makes washing the hair difficult.
- LED treatment Helps with swelling, bruising and wound healing.
- Ultrasound lifting care Supports lymphatic flow and the recovery of skin elasticity.
- Scar laser treatment and scar injections Soften scar tissue and reduce fibrosis.
Direction of Sagging and Surgical Planning
Facelift planning assesses the skin and deeper support layer separately. The SMAS is a thin, firm layer beneath the skin that surrounds facial muscles. Pulling the skin alone leaves the deeper tissue in its original position and may concentrate tension at the incision.
Dr. Chang Min Kang plans for the different directions of sagging in the cheeks, mouth area, jawline and neck. Fat in front of the cheekbones descends downward and inward, deepening nasolabial folds; tissue around the mouth forms marionette lines; and jawline tissue droops downward. The plan identifies which retaining ligaments to release for tissue mobility, the direction of SMAS repositioning and the amount of excess skin to remove, in that order.
Deep Plane and SMAS Procedures
A deep plane facelift enters the plane beneath the SMAS, releases retaining ligaments, and moves the skin and deeper tissue together. Not every face needs the same extent of dissection. Options include partial SMAS excision and suturing, folding and suturing, overlapping fixation, or broad dissection and repositioning. Selection depends on the location of sagging and adhesions from previous surgery.
A 2025 review of 47 studies involving 10,766 patients reported improvement with both SMAS-based procedures and deeper-plane facelifts, without concluding that one approach was superior for all patients. Explanations therefore focus on the actual extent of dissection, ligament release locations, SMAS movement direction and nerve-preservation criteria, rather than the operation’s name alone.
Combined with Foreign Material Removal
Over time, facial tissue around fillers, grafted fat or threads can harden and repeatedly swell, or the material and surrounding fat may descend, making the face appear heavy. Removing material that has provided volume for a long time can reveal hollowing or loose skin.
Ultrasound and, when needed, CT are used to assess the material’s tissue plane and the extent of inflammation. The surgeon then determines how much to remove, how to manage remaining skin and fat, and whether a facelift can be performed on the same day. With active inflammation and a high infection risk, inflammation is settled first and surgery is staged.
Who May Be a Candidate
- Those with pronounced midface sagging
- Those with deep nasolabial folds and marionette lines
- Those with loss of definition between the jawline and neck
- Those dissatisfied after previous facelift surgery
- Those seeking a lasting lift
- Those concerned about cheek sagging after cheek foreign material removal and seeking a combined facelift
When sagging is mild and the deeper support layer is not substantially lax, a more limited operation or another treatment is considered first.
Frequently Asked Questions
When does postoperative swelling subside?
Swelling may increase through day 3 after surgery. By 7–10 days, it decreases enough that social activities are not a major burden. Cold compresses are used only through day 3; repeating 15 minutes of cooling followed by a 30-minute break can help.
When does firm scar tissue soften?
Firm scar tissue develops in the dissected area. It is most noticeable at 1–3 months after surgery and naturally settles until it is barely noticeable after 6 months to 1 year.
How does a deep plane facelift differ from skin-only lifting?
A deep plane facelift enters the plane below the SMAS, releases retaining ligaments that restrict movement, and repositions the skin and deeper tissue together. It changes the position of the deeper support layer rather than concentrating tension only at the skin incision. The necessary extent varies with the condition of the face.
Is deep plane surgery superior to every SMAS procedure?
Current evidence does not establish superiority for every patient. The 2025 review reported improvement with both groups of techniques, but direct comparisons and assessment methods were limited. The method is selected according to the location of sagging, adhesions and nerve-related risk.
Can I have a facelift after cheekbone surgery or a thread lift?
It may be possible, but the assessment of difficulty and risk changes. Previous osteotomy lines, thread positions, injected materials and adhesions may alter normal anatomical planes, requiring the dissection route to be replanned using imaging and examination. Removal, bone assessment and lifting may be staged if necessary.
What principles help reduce nerve injury?
The fundamentals are maintaining the correct anatomical plane, avoiding forced progression through planes altered by adhesions, and limiting dissection to what is necessary. Imaging helps anticipate risk areas but cannot eliminate risk completely.
How long does recovery take?
Recovery depends on the location and extent of removal, whether lifting is combined, inflammation and adhesions, anesthesia and other procedures. The point at which swelling and bruising subside enough for social activities differs from when internal tissue stabilizes. An individual recovery estimate is provided after the surgical plan is established.
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Recovery Timeline
| Timing | Typical course |
|---|---|
| Day of surgery | The operation takes approximately 4–5 hours. |
| Through day 3 after surgery | Swelling may increase. Use cold compresses through day 3, placing cooling pads around the eyes and neck for 15 minutes followed by a 30-minute break, repeated. |
| 7–10 days | Swelling decreases enough that social activities are not a major burden. |
| Within 10 days | Sutures are removed. |
| Approximately 2 weeks | Swelling and bruising diminish, allowing a return to daily activities. |
| 1–3 months | Firm scar tissue in the dissected area is most noticeable. More extensive dissection may produce more of this tissue. |
| 6 months–1 year | The scar tissue softens until it is barely noticeable. |
| Afterward | Regardless of visible recovery, internal tissue adhesions, swelling and altered sensation settle over several months. |
The course may vary with the individual’s condition and the extent of surgery.
Questions Answered by Dr. Kang
Questions answered directly by Dr. Chang Min Kang in the Doctor Column.
Does more extensive dissection produce a better facelift result?
No. More extensive dissection alone does not mean a better result. What matters is obtaining enough mobility to move the target tissue in the required direction within the chosen surgical technique.
Answered by Dr. Chang Min Kang · Why does the extent of dissection matter in a facelift?
Will the face sag again quickly if less dissection is performed?
That cannot be assumed. Long-term changes after a facelift are not determined by dissection extent alone.
Recent systematic reviews have not found evidence that techniques extending sub-SMAS dissection farther medially than the retaining ligaments provide significantly greater long-term durability than other SMAS techniques.
It is therefore difficult to simplify the relationship to “wider dissection lasts longer” or “limited dissection leads to early sagging.”
Answered by Dr. Chang Min Kang · Why does the extent of dissection matter in a facelift?
Which matters more: the extent or the plane of dissection?
It is difficult to assess either one in isolation.
Dissection extent describes how far the approach reaches; the dissection plane describes the anatomical layer used. Facelift planning must consider both together, based on the target tissue and direction of movement.
Answered by Dr. Chang Min Kang · Why does the extent of dissection matter in a facelift?
Is the same extent of dissection used in revision facelifts?
Not necessarily. Scarring and adhesions from previous surgery may have altered the tissue, so the dissection plane and extent may need to be individually planned according to the earlier technique and current tissue condition.
Answered by Dr. Chang Min Kang · Why does the extent of dissection matter in a facelift?
Do repeated filler injections make a facelift impossible?
No. A history of repeated filler injections alone does not make a facelift impossible. However, preoperative assessment and technique may vary with the filler type, location, remaining amount and surrounding tissue condition.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
Must all filler be dissolved before surgery?
No. Dissolving treatment is selectively considered when residual filler distorts facial contours or interferes with planning. There is no need to routinely dissolve all asymptomatic filler outside the operative area.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
If filler was injected a long time ago, hasn’t it all disappeared?
Not necessarily. Some filler can remain in the tissue even after the visible effect has diminished. If there have been repeated treatments, swelling, nodules or asymmetry, examination and imaging when needed can assess this.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
Can I have a facelift immediately after dissolving filler?
There is no standard waiting period for every patient. Surgery should be scheduled after swelling and tissue reactions from dissolving treatment have settled and the underlying facial volume and sagging have been reassessed.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
Can all filler be removed during a facelift?
When filler is spread across several tissue planes, complete removal is difficult and it may be indistinguishable from normal tissue. For hyaluronic acid filler in particular, hyaluronidase treatment is generally considered before surgical removal.
Surgical removal is considered in limited situations, such as non-degradable foreign materials or nodules.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
Do repeated fillers necessarily increase facelift complications?
Current research does not establish that they necessarily do.
Some surgeon surveys report greater operative difficulty, but objective comparative patient data are limited. Previous filler treatments and current tissue condition therefore require individual assessment.
Answered by Dr. Chang Min Kang · Can a face with repeated filler injections undergo a facelift?
How many months after a facelift can revision surgery be performed?
There is no single revision timeline that applies to every patient.
Revision to improve an aesthetic result is considered after early swelling and tissue stiffness have sufficiently subsided and the result has stabilized.
Scar correction or extensive revision may require careful observation of scar and surrounding tissue maturation. Timing is not decided simply by the number of months since the first operation; swelling, scarring, adhesions, skin blood supply and the extent of correction are assessed together.
Answered by Dr. Chang Min Kang · When is revision facelift surgery needed? Timing and surgical methods
Can the original incision be reused?
Sometimes, but not always. Incision placement is determined after assessing scar position, available skin and changes to the hairline and ear shape.
Answered by Dr. Chang Min Kang · When is revision facelift surgery needed? Timing and surgical methods
Is the SMAS corrected during revision surgery too?
This depends on the layer responsible for current sagging and how the SMAS was managed in the first operation. It may be resutured or partially adjusted, but another approach may be needed if tissue is thin or adhesions are severe.
Answered by Dr. Chang Min Kang · When is revision facelift surgery needed? Timing and surgical methods
Can scars and asymmetry be completely eliminated?
Existing scars can be made less noticeable and asymmetry can be reduced, but complete scar removal and perfect symmetry cannot be guaranteed. The achievable improvement depends on available skin, adhesions and existing tissue condition.
Answered by Dr. Chang Min Kang · When is revision facelift surgery needed? Timing and surgical methods
What exactly are facial retaining ligaments?
They are fibrous structures supporting facial soft tissue, including the skin and SMAS, by connecting it to fixed structures such as the periosteum or deep fascia. They occur in multiple areas, including the cheekbones, cheeks, jawline and around the eyes.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Does loosening of retaining ligaments cause facial sagging?
Changes in support structures, including retaining ligaments, can contribute to facial aging, but sagging cannot be explained by changes in retaining ligaments alone. Changes in the skin, fat compartments, SMAS, muscles and skeleton all interact.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Must retaining ligaments always be cut during a facelift?
No. Depending on the technique and extent of correction, selected retaining ligaments may be released, or a facelift may be performed while preserving some structures.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Does cutting more retaining ligaments lift the face farther?
It is not that simple. The purpose of ligament release is to obtain the tissue mobility needed; cutting more is not itself the goal of a facelift.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Does releasing retaining ligaments make a facelift last longer?
Whether ligaments are released does not by itself determine how long a facelift lasts. SMAS management, tissue movement and fixation, individual anatomy and tissue condition all contribute.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Does a deep plane facelift cut all retaining ligaments?
No. Even among deep plane techniques, the actual extent of dissection and retaining ligament release can vary with the method.
Answered by Dr. Chang Min Kang · Why are retaining ligaments important in facelift surgery?
Is a skin-only facelift ineffective?
No. It may be appropriate when sagging is limited or depending on skin condition. The more suitable approach is determined through clinical assessment.
Answered by Dr. Chang Min Kang · How does a skin-only facelift differ from a facelift that also addresses the SMAS?
Does addressing the SMAS make the result last longer?
In general, addressing tissue beneath the skin can help distribute tension. However, durability can vary with individual skin condition, the rate of aging and other factors.
Answered by Dr. Chang Min Kang · How does a skin-only facelift differ from a facelift that also addresses the SMAS?
Does every facelift address the SMAS?
No. The plan can vary with facial anatomy and the degree of sagging; the same approach is not applied to every patient.
Answered by Dr. Chang Min Kang · How does a skin-only facelift differ from a facelift that also addresses the SMAS?
Does pulling the skin more tightly make someone look younger?
Pulling the skin strongly does not necessarily produce a good result. Planning should consider overall facial balance and a natural appearance.
Answered by Dr. Chang Min Kang · How does a skin-only facelift differ from a facelift that also addresses the SMAS?