Face the facts: The truth about facelifts

By Consultant Plastic, Reconstructive & Cosmetic Surgeon Charles Nduka

Face lifting has evolved from simple tightening of the facial skin to the realisation that working on the deeper structures of the face and restoration of volume is necessary for a long-lasting result. The windswept look of over-tightened skin should be a thing of the past with modern techniques and a skilled surgeon.

Ageing is more than skin deep

Whilst lines and wrinkles are the obvious signs of ageing, the key effects are loss of fat, loosening of supporting structures and changes to the facial skeleton. Under the skin of the face there is a layer of muscles and fibrous tissue known as the superficial muscular aponeurotic system (SMAS). Tightening the SMAS lifts the features of the face without needing to stretch the skin excessively. This can itself make the cheeks fuller and restore volume, but further volume can also be provided by fat transfer to other areas of the face.

Where are the scars?

In order to get to the SMAS, incisions have to be made in the facial skin. Classically, these go around the front and back of the ears and earlobes, and extend into the hair-bearing scalp in the temples and behind the ears. The scars in front of the ear and under the earlobe can be beautifully concealed, but this partly depends on your surgeon. The scars behind the ear may be visible to your hairdresser, or whenever you wear your hair up. Short scar techniques reduce the extent of these skin scars, but may limit what can be done because of the reduced access.

What are the options?

Irrespective of the incisions used in the skin, the SMAS can be tightened by a number of different ways.

SMAS Plication gathers folds of loose SMAS along a line and stitches these folds together to tighten. The direction of tightening can be purely upwards (vertical plication), or upwards and outwards.

MACS Lift (minimal access cranial suspension lift) is a SMAS plication method with a unique way of tightening that uses two to three loops of stitch to draw up the SMAS in the cheek hollow and in front of the ear, in upward and outward directions.

SMASectomy facelifts involve cutting out a strip of loose SMAS and stitching the cut edges together to tighten it. This is an alternative to gathering up and stitching the loose SMAS as with the SMAS plication or the MACS lift.

SMAS Lift involves lifting the SMAS off the cheekbone area, where it is tethered down because some surgeons believe that the SMAS needs to be freed up more to achieve better lifting of the face.

All of the above techniques are capable of producing excellent results in face lifting so long as your surgeon is experienced and has selected the correct procedure. Because the face does not age in one area only, a facelift is commonly performed together with a brow lift and/or eyelid surgery. My personal approach is to make sure that the ligament that attached the skin to the jawline is divided, to ensure that the jowl is smoothed without looking unnatural. This requires significant skill and patience as there are important structures nearby. Less experienced surgeons, or those performing the MACS type of facelift typically avoid this manoeuvre, which is why their results often disappoint. Undue tension may cause distortion of the ears (pixie ear deformity) if the skin is closed under tension, something that I have corrected for unfortunate patients.

What you need to know

Common to all facelift techniques are the side-effects of bruising, swelling, numbness. Recovery times vary according to the extent of the work on the deep tissues, but an average of two to three weeks is not unreasonable for SMAS-type lifts. In addition to previously mentioned risks of nerve injury, all operations carry a risk of bleeding, infection and delayed healing, irregular or lumpy surfaces and asymmetry. The scars may also be more conspicuous if the skin is closed with excessive tension or if infection and/or delayed healing occur. Whilst a facelift will rejuvenate and support your face, it won't stop time: you will continue to age.  You can maintain your result by avoiding excess sun, smoking and drastic weight loss.

Facelift information

Best for: Reducing jowls, defining jawline, improving cheek contour.

Not for: Improving skin texture, reversing sun damage.

Side effects: Temporary bruising, swelling, reduced skin sensation. Rarely permanent nerve injury, asymmetry.

Recovery: Two to four weeks.

A facelift improves the contour of your jowls, cheeks and jawline:

CHEEKS: with ageing, fat descends from its youthful position high on the cheek

NASOLABIAL FOLD: falling cheek fat accumulates above this line as the skin around the lips is tightly fixed to the muscles. Early changes can be reversed with fillers

JOWLS: descent of facial fat causes a squaring of the jawline

NECK: the SMAS layer (see text) continues into the neck as a layer of muscle just beneath the skin. This is why neck lifts are commonly combined with a facelift

Did you know?

The first facelift was performed in Berlin on a Polish aristocrat in 1901.

Did you know?

Last year 3453 facelifts and neck lifts were performed by British Association of Aesthetic Plastic Surgeons (BAAPS) members.

How to look good for your age

Avoid tanning: Excess UV exposure leads to wrinkles and loss of skin elasticity. You can get your regular fix of vitamin D from a healthy diet rich in oily fish, and moderate sunlight exposure.

Keep your weight stable: Just as repeated pregnancies stretch tummy skin, yo-yo dieting stretches facial skin.

Get some beauty sleep: Many of the body's repair processes occur overnight, and sleeping on your back can reduce the pressure on your nasolabial fold

Love your curves: Over the age of about 40, most faces look better with a little more fat.

Choose your parents carefully: An estimated 75 percent of ageing is genetic (skin type and bone structure).

Further facelift information

If you are still undecided about surgery, you can read Charles Nduka's article: "Should I have a facelift abroad?" This article outlines the cost of surgery and the implications of having surgery abroad.

Page last reviewed on 07/01/2020