How Are Facelifts Performed?

A facelift, known medically as a rhytidectomy, is one of the most transformative procedures in facial plastic surgery. But the word "facelift" covers a broad spectrum of techniques, from a quick mini-lift under local anaesthesia to a multi-hour deep plane reconstruction that repositions the entire facial architecture. Understanding how facelifts are actually performed, not just in broad strokes but in genuine surgical detail, helps you ask better questions, set realistic expectations, and choose the right surgeon and technique for your face.

This guide takes you through the science and the steps, from the anatomy of why faces age, through every major surgical technique, to what recovery genuinely looks and feels like week by week.

Why Faces Age - The Anatomy You Need to Understand First

Before a surgeon can meaningfully lift a face, they need to understand exactly what has changed and why. Modern facelift surgery is built on a detailed understanding of facial anatomy that was largely unknown before the 1970s. That understanding is the foundation of everything that follows.

The Five Layers of the Face

The face is not a single layer of skin stretched over bone. It is a complex, interconnected structure of five distinct layers, and ageing affects all of them.

Layer 1 - Skin

The outermost layer. Over time, it loses collagen and elastin, becoming thinner, less elastic, and more prone to wrinkling. Sun damage accelerates this process significantly.

Layer 2 - Subcutaneous fat

Directly beneath the skin sits a layer of fat, which gives the face its youthful fullness. With age, this fat compartment deflates, descends, and redistributes, hollowing some areas (under the eyes, the temples) while creating heaviness in others (the jowls, the neck).

Layer 3 - The SMAS and muscle layer

This is the mechanical engine of the face. The Superficial Musculoaponeurotic System, almost always referred to simply as the SMAS, is a fibromuscular layer that connects the facial muscles to the overlying skin. It acts as a distributor of muscle contractions across the face. When the SMAS descends with age, it pulls everything above it with it. This is why jowls form, why nasolabial folds deepen, and why the midface flattens.

Layer 4 - The sub-SMAS space

Below the SMAS lies a space containing the facial nerve branches, blood vessels, and the retaining ligaments, the anchors that connect deeper facial structures to the skeleton. This layer is where the greatest surgical risk and the greatest surgical reward both live.

Layer 5 - Deep fascia and periosteum

The deepest layer, covering the muscles of mastication and the facial bones themselves. Some advanced techniques, called subperiosteal approaches, operate at this level.

The SMAS-Platysma Complex: The Key to Lasting Results

The SMAS extends downward into the neck, where it connects to the platysma, a broad, sheet-like muscle that runs from the chest up to the lower face. Together, the SMAS-platysma complex forms a continuous mechanical unit.

When this unit descends and loses tone, the effects are visible across the entire lower face and neck: jowling, a blunted jawline, neck banding (the vertical cords you see on an ageing neck), and a loss of the sharp cervicomental angle beneath the chin. This is why modern facelift surgery almost always addresses both the face and the neck together; they are part of the same system.

Retaining Ligaments: The Anchors That Hold and Then Let Go

Spread throughout the sub-SMAS space are a series of fibrous ligaments that anchor the soft tissues of the face to the underlying bone. In youth, these ligaments keep everything in its correct anatomical position. With age, they stretch and weaken, allowing the tissues above them to slide downward.

The four most surgically significant are:

• Zygomatic ligaments - anchor the cheek tissue to the cheekbone. When these stretch, the midface descends.
• Masseteric ligaments - anchor tissue over the masseter (jaw) muscle. Their weakening contributes to jowl formation.
• Mandibular ligaments - along the jawline, their laxity creates the jowl "pouching" effect.
• Cervical retaining ligaments - in the neck, contributing to neck laxity and banding.

In the most advanced facelift techniques, the surgeon deliberately releases these ligaments to allow tissues to be repositioned without tension rather than simply pulled.

Modern Facelift Techniques - From Conservative to Advanced

There is no single "facelift operation." The technique a surgeon chooses depends on the patient's anatomy, the degree of ageing, their goals, their tolerance for downtime, and the surgeon's own training and philosophy. Here is a clear breakdown of the main approaches, from least to most complex.

Step 1: Anaesthesia

Every facelift begins with anaesthesia. The choice is made between the surgeon and patient based on the complexity of the planned procedure and the patient's medical history.

MAC anaesthesia (Monitored Anaesthesia Care) - sometimes called "twilight sedation" - combines local anaesthetic injections with intravenous sedatives. The patient is deeply relaxed and unaware of pain, but is technically breathing independently. This is suitable for mini facelifts and some standard SMAS procedures.

General anaesthesia - the patient is fully unconscious and intubated. Required for longer, more complex procedures such as deep plane facelifts, especially when combined with neck work or other simultaneous procedures. A full deep plane facelift can take four to six hours on the operating table.

Step 2: Incision Placement

The incision pattern determines what can be accessed surgically and where the scars will ultimately sit. Incision design is one of the most important elements of facelift planning and varies by technique.

Standard facelift incision: Begins in the temporal hairline above the ear, curves in front of the ear (either in front of the tragus or concealed just inside the tragus for better scar camouflage), continues under the earlobe, then sweeps behind the ear and ends in the posterior hairline. An additional small incision is often made under the chin to access the neck directly.

Mini facelift incision: A shorter version, typically beginning at the temples and ending just below or behind the earlobe. The reduced incision limits the degree of access and, therefore, the degree of correction possible.

Hairline considerations: For patients with high hairlines or significant hair loss, incision placement is modified to avoid raising the hairline further or creating visible step-offs at the temples or behind the ear. This is especially relevant in male patients, where the beard-growing skin must be carefully managed to avoid pulling hair-bearing skin onto the face or ear.

Step 3: Skin Elevation

Once the incision is made, the skin is carefully lifted away from the underlying tissues, a process called skin flap elevation. The extent of this elevation depends on the technique being used.

In simpler procedures, the skin flap is elevated widely enough to allow tension-free skin repositioning. In deep plane surgery, the skin elevation is more limited because the real movement happens in the deeper layers, and the skin merely follows.

The surgeon works with fine dissection instruments, preserving the small blood vessels that supply the skin from below. Poor vascular supply to the skin flap is one of the primary causes of wound healing complications, which is why smoking is so damaging in the context of facelift surgery. Nicotine causes profound vasoconstriction and can lead to skin flap necrosis.

Step 4: The SMAS Techniques

This is where modern facelifts fundamentally differ from older approaches and from each other. What the surgeon does at the SMAS level determines the quality, naturalness, and durability of the result.

SMAS Plication

The most conservative SMAS technique. The SMAS is folded upon itself and sutured in its elevated position without being cut or lifted from the underlying layer. Think of it as tightening a tablecloth by folding and pinning it at the edge. It is technically simpler and carries lower risk than deeper approaches, but provides a less dramatic and less durable result.

SMAS Imbrication

Similar to plication, but involves removing a small section of SMAS tissue before suturing. Creates slightly more tension and lift than plication alone.

Lateral SMASectomy

A section of the lateral (outer) SMAS is removed entirely rather than folded. This thins and tightens the lateral face and jaw, and is particularly effective for improving jawline definition. It avoids the risks of deeper dissection but is limited in its ability to address the midface and nasolabial folds.

SMAS Flap Elevation

The SMAS is fully elevated from the deeper layer and repositioned as a free flap. This allows more significant repositioning than plication but still operates above the facial nerve, keeping risk relatively contained. Results are more durable than plication alone.

Step 5: The Deep Plane Facelift

The deep plane facelift, pioneered by Dr. Sam Hamra in the early 1990s, represents the most significant evolution in facelift surgery of the past several decades. It is now widely considered the gold standard for comprehensive facial rejuvenation.

The fundamental difference from SMAS-level surgery is this: rather than operating on the skin and SMAS as separate layers, the deep plane facelift treats them as a single composite unit. The surgeon dissects below the SMAS, entering the sub-SMAS space, and lifts the skin, subcutaneous fat, and SMAS together as one interconnected structure.

Why does this matter?

In a standard SMAS facelift, the skin is under tension to achieve lift. Over time, this tension causes the result to relax and the skin to stretch. The scar is also under greater tension, which can lead to visible scarring and distortion.

In the deep plane approach, the lift comes from repositioning the entire composite unit rather than pulling the skin. The skin is redraped with minimal or no tension. The result looks more natural, lasts longer, and scars heal with less distortion.

Ligamentous release: The key manoeuvre that makes the deep plane technique possible is the deliberate release of the zygomatic and masseteric retaining ligaments. Once these anchors are cut, the composite flap can be repositioned freely,  moved upward and backward to its original anatomical position rather than simply pulled laterally (which creates the "windswept" or operated look).

What the deep plane addresses that SMAS techniques cannot:

• Deep nasolabial folds (by directly lifting the tissue that creates them)
• Midface volume loss and descent (by repositioning the malar fat pad)
• Jowling from masseteric ligament laxity
• Neck definition, when combined with the platysma, works

Composite facelift: A variation of the deep plane in which the orbicularis oculi muscle (the muscle encircling the eye) is included in the composite flap, allowing simultaneous improvement of the lower eyelid and cheek junction. It requires a higher level of surgical skill.

Step 6: Advanced Technique Variations

The DeepFrame Facelift

The DeepFrame technique uses multi-vector lifting, meaning the tissues are repositioned in multiple directions simultaneously, rather than simply pulled in one lateral direction. The vectors are chosen to be perpendicular to the natural lines of descent caused by gravity, restoring the face's natural structural framework rather than simply tightening it. This approach is designed to produce results that look like a younger version of the same face, not a different face.

Vertical Restore

The Vertical Restore approach treats the face as a single interconnected system, from brow to neck, rather than a series of separate anatomical regions. Rather than horizontal tightening, it focuses on vertical repositioning: lifting descended tissues back toward where they originated. It addresses the brow, midface, jawline, and neck in one coherent surgical plan, with each component designed to reinforce the others. The emphasis is on restoring the vertical height of the face that is lost with age.

The Mini Facelift

The mini facelift, sometimes called a short-scar facelift or S-lift, uses a shorter incision and a more limited dissection to address early or moderate lower facial sagging, particularly jowling and early neck laxity. It is performed under local anaesthesia with sedation, typically takes one to two hours, and involves significantly less downtime than a full facelift.

It is best suited for patients in their late 30s to early 50s who have early signs of descent but do not yet need the full architectural correction of a deep plane procedure. It is not a substitute for a full facelift in patients with significant skin laxity, deep nasolabial folds, or significant neck changes.

Step 7: Neck Work

For most patients, meaningful facial rejuvenation requires simultaneous attention to the neck. The neck ages in ways that the face alone cannot address, and leaving the neck untreated while lifting the face creates an incongruent result.

Platysma plication: The platysma muscle is tightened in the midline using sutures, either bringing the two edges of the muscle together (platysmaplasty) or creating a corset-like tightening along the length of the muscle. This sharpens the cervicomental angle and reduces neck banding.

Subplatysmal work: In more advanced neck ageing, the surgeon goes beneath the platysma to address deeper structures. These can include subplatysmal fat deposits, the digastric muscles (which create fullness beneath the chin), and, in some cases, the submandibular glands, which can be partially reduced when they contribute to neck heaviness. This level of neck surgery is the most demanding and most powerful component of comprehensive lower facial rejuvenation.

Step 8: Skin Redraping and Closure

Once the deep work is complete, the skin is redraped over the repositioned framework. In well-executed surgery, particularly deep plane surgery, very little skin needs to be removed, because the skin is not under tension. Any excess is trimmed conservatively.

The incisions are closed in layers. Deep sutures are placed to close the SMAS and subcutaneous layers; fine sutures or staples close the skin itself. The objective is for incisions to sit in the hairline, in front of and behind the ear, and in the natural skin creases, making them essentially invisible at conversational distance once healed.

A surgical drain may be placed to prevent fluid accumulation. A soft compression garment is applied around the face and jaw to support the tissues, reduce swelling, and help the skin conform to its new position.

Are You a Candidate? What Good Patient Selection Looks Like

Not everyone is suited for facelift surgery, and the patients who achieve the best results are those whose expectations, health status, and anatomy align well with what the procedure can deliver.

Signs That Suggest You Are a Good Candidate

• Visible jowling along the jawline
• Descent of the midface and cheek tissue, creating deepened nasolabial folds
• Neck laxity, banding, or loss of the cervicomental angle
• Skin that retains reasonable quality, not severely sun-damaged or paper-thin
• Realistic expectations about the nature and limits of the result
• Good general health with no uncontrolled medical conditions

Medical Screening and Preparation

A thorough medical consultation precedes any facelift. The surgeon will review all medications and supplements, several of which need to be paused before surgery. Blood thinners (both prescription anticoagulants and over-the-counter preparations such as high-dose aspirin, ibuprofen, and fish oil) increase the risk of haematoma, the most common surgical complication.

Smoking cessation is non-negotiable. Smoking must be stopped at least four to six weeks before surgery and must not resume during recovery. The damage nicotine does to small blood vessels dramatically increases the risk of skin flap necrosis, where sections of elevated skin lose their blood supply and die. Even e-cigarettes and nicotine replacement products carry risk at this stage.

Blood pressure must be well controlled before and after surgery. Hypertension is a significant risk factor for post-operative haematoma and must be managed proactively.

Recovery - Week by Week

Facelift recovery is frequently discussed in overly optimistic terms. The reality is manageable and the outcome well worth it for the right patient, but it helps enormously to know what is actually coming.

The table below shows the facelift recovery procedure based on stages, timings and what's happening: 

Stage

Timeframe

What's Happening

Immediate Recovery

First 48 hours

A compression garment is applied. Drains removed within 24 hrs. Swelling begins immediately and peaks by morning.

Turning the Corner

Week 1 (Days 3–7)

Peak swelling days 3–5. Bruising may spread to the neck and chest. Sutures/staples removed days 5–7.

Social Readiness

Weeks 2–4

Bruising fades significantly. Swelling becomes less obvious to others. Early contours of the result begin emerging.

The Settling Phase

Months 2–6

Deeper swelling gradually resolves. Sensory nerve fibres regenerate. Scars mature from pink and raised to flat and faded.

Final Result

Months 6–12

Swelling fully resolved. Scars settled. Full architectural result now visible.

You Should Still Look Like You

A successful facelift does not produce a different face. It produces a younger, more rested version of the same face, one that reflects how the patient feels on the inside rather than the accumulated weight of decades on the outside. Patients who achieve the best outcomes are those who approached surgery with a clear understanding of what it can deliver, selected their surgeon on the basis of skill and philosophy rather than price, and committed to the recovery process with patience.

The face that emerges at twelve months, fully settled, naturally contoured, and free from the stigmata of an over-operated result, should look, to most observers, simply like someone who has aged exceptionally well.

Frequently Asked Questions

How long does a facelift operation take? 

A mini facelift takes one to two hours. A standard SMAS facelift typically takes two to four hours. A comprehensive deep plane facelift, particularly when combined with neck work, fat grafting, or other simultaneous procedures, can take four to six hours or more.

Will I have visible scars after a facelift? 

All surgery leaves scars. A skilled surgeon places incisions within the hairline, in the natural crease in front of and behind the ear, and under the chin,  locations that are either concealed by hair or hidden within natural anatomical folds. At conversational distance, and with normal hairstyling, facelift scars are typically not visible to others.

What is the difference between a SMAS facelift and a deep plane facelift? 

A SMAS facelift operates on the SMAS layer separately from the skin, tightening both independently. A deep plane facelift lifts the skin, fat, and SMAS as a single composite unit from a deeper anatomical level, releasing the retaining ligaments that tether the tissues. The deep plane delivers more natural and more durable results but requires greater surgical expertise and longer operating time.

At what age should I consider a facelift? 

Age is less important than the degree of visible change and the patient's goals. Mini facelifts are often appropriate for patients in their late 30s to early 50s with early descent. Full deep plane facelifts are most commonly performed in the 50s to 70s. There is no absolute upper age limit, though medical fitness for anaesthesia is a key consideration.

Can a facelift be combined with other procedures? 

Yes and it frequently is. Blepharoplasty, brow lifting, fat grafting, laser resurfacing, and neck lifting are all commonly combined with facelift surgery in a single operating session, delivering a more comprehensive result than any single procedure could achieve alone.

How do I avoid the "windswept" or operated look? 

Choose a surgeon who operates in the deep plane or who uses genuine SMAS repositioning rather than skin tightening. Ask to see a large portfolio of their results, specifically looking for patients whose faces look natural and whose ears and hairlines appear undistorted. A natural result is the sign of a technique that supports tissues from within rather than pulling the skin from outside.

Is a facelift permanent? 

No surgical procedure stops ageing. A facelift significantly reverses existing changes and repositions tissues to a more youthful baseline. Ageing continues after surgery from that improved starting point. Results from deep plane surgery typically last ten to fifteen years before meaningful further descent occurs.