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Ultimate guide to facelift and necklift surgery

Demonstrates the SMAS layer in a facelift

Facelift and necklift surgery can make a big difference to your appearance, this guide goes though all the important facts that you need to know.

The face is a complex structure performing a staggering and intriguing number of functions. These functions include making facial expressions, tasting, hearing, smelling, and seeing. The face also houses erogenous zones, such as the lips. The human face’s proportions and expressions help identify origin, emotional tendencies, health qualities and some social information. From birth, faces are important for social interaction. Face perceptions are also very complex as facial expression and facial recognition involve vast areas in the human brain.

From childhood, we learn how to recognise the age of a face. As we grow older, this skill becomes more refined and people are usually able to determine age with surprising accuracy – generally to within a few years when the person being assessed is between 20 and 60 years old.

As both women and men spend significant time looking in the mirror, they can usually spot minor age-related imperfections as they develop. However, as not all faces age in the same way, different procedures may be required for rejuvenation. With each face ageing individually, some areas will remain more youthful than others. Treating each patient as unique, Dr. Beldholm takes a holistic approach to facial procedures, with all aspects of the ageing process considered from skin to bone level. Some factors such as smoking, sunburn and illness can lead to premature facial ageing. However, with an integrated approach, all patients can achieve a significant improvement.

How we age


To understand skin’s ageing process you need to know what it consists of. There are four basic layers:

  • The epidermis.
  • The basement membrane.
  • The dermis.
  • The subcutaneous layer.

New cells form from the lowest level of the epidermis, gradually rising upwards towards the outer layer (the stratum corneum). It is here where they are eventually worn off, with newer ones beneath replacing them.

As we become older, this outer layer of the epidermis becomes slightly thinner. The cells that are being made at a lower level are also dividing and replacing themselves more slowly. Therefore, healing time is affected, along with a decrease in the production of more new skin cells. This reduction in new cells causes some of the visible signs of ageing as the skin becomes thinner. Ageing affects nearly all of the structures in the skin.

  • Collagen becomes thicker and changes in character, leading to more wrinkle formation and less stretchy skin.
  • Elastosis (an accumulation of amorphous elastin material) occurs, leading to the characteristic loss of skin elasticity which is considered the hallmark of ageing.
  • With age, glycosaminoglycans (molecules in the skin that bind water) also decrease, leading to a less hydrated skin. (Dermal Fillers work in a similar way to glycosaminoglycans by binding water.
  • Melanin production also decreases with age, leading to older skin being more predisposed to sunburn. This is why it’s important to continue wearing sunscreen throughout life.
  • Loss of vascularity (blood supply) to the skin has a number of adverse consequences, including decreased blood flow and healing, diminished nutrient exchange, impaired temperature regulation, lower skin temperature and skin pallor.
  • Decreases in subcutaneous fat also lead to a loss in facial volume. Gravity also pulls facial structures down, leading to a number of characteristic changes including loss of cheek prominence, skin folds, lines, jowls and overhanging brows.


There are two main causes of wrinkles. As the muscles controlling facial expression are constantly at work, over time they produce dynamic wrinkles – that is lines only apparent when muscles are contracting. However, as we age, these wrinkles become deeper and deeper, finally becoming permanent or static wrinkles.

The most common examples of static wrinkles are frown and smile lines. Frown lines can lead to a person constantly looking angry or worried. Constant muscle contraction can also cause headaches. The most effective initial treatment for these wrinkles are muscle relaxing injections.

Fine wrinkles are formed by the gradual degeneration of ageing skin combined with the gravity-related fall of facial skin and the loss of subcutaneous fat. However, the most significant factor in skin ageing is sun exposure. Initially, a dermal filler can be used to plump up and hydrate the tissues. Other treatments such as skin peels and Dermaroller, in addition to specialised skin care products, can also improve the quality of the skin dramatically.


As we age, there are substantial changes in the bone skeleton of the face. For example, the cheekbones get smaller, thereby contributing to the loss of their youthful, plump appearance. The mandible (jawbone) also changes. Although there is a constant loss of bone with ageing, these changes can be accelerated by things like tooth loss.

The role of the sun in ageing

Without protection, just a few minutes of sun exposure each day can cause noticeable changes to the skin. Freckles, age spots, spider veins on the face, rough and leathery skin, fine wrinkles that disappear when stretched, loose skin, a blotchy complexion, actinic keratoses (thick, wart-like, rough, reddish patches of skin), and skin cancer can all be traced to sun exposure.

The amount of skin damage that develops depends on a person’s skin color and their history of long-term or intense sun exposure. People with fair skin who have a history of sun exposure develop more signs of damage than those with dark skin. In the darkest skins, damage is usually limited to fine wrinkles and a mottled complexion. Such damage occurs over a period of years.

With repeated exposure to the sun, the skin loses the ability to repair itself, and the damage accumulates. Scientific studies have shown that repeated ultraviolet (UV) exposure breaks down collagen and impairs the synthesis of new collagen. The sun also attacks our elastin. Sun-weakened skin ceases to spring back like skin protected from UV rays. Skin also becomes loose, wrinkled, and leathery much earlier with unprotected exposure to sunlight. People who live in sun-intense areas, such as Australia, can show signs of sun damage in their 20s.

While it may seem that the signs of such damage appear overnight, they actually lie invisible beneath the surface of the skin for years. UV photography captures the damage accumulating beneath the surface of the skin years before the signs actually appear.

To prevent excessive and premature ageing, Dr Beldholm recommends incorporating a daily sunscreen into your skin care regime. Generally, this is applied in the morning to the face and other exposed areas. Our Dermal Therapist can select a product for your skin type from our extensive range of non-greasy, user-friendly products. Please note that these top quality sunscreens are also suitable for acne-prone skin, whereas over-the-counter varieties may actually increase acne.

The role of smoking in ageing

Tobacco smoke contains over 4,000 chemical compounds including tar, carbon monoxide, nicotine, hydrogen cyanide, acetone, ammonia, arsenic, phenol, naphthalene, cadmium and polyvinyl chloride. Many of these agents are toxic and at least 43 can cause cancer, including nitrosamines and benzopyrines. Nicotine is the chemical responsible for the addictive nature of cigarette smoking but is not the major component associated with smoking-related disease. The many ill-effects of smoking are well documented. Smoking affects all of the body and considerably speeds up ageing. It is responsible for the deaths of 19,000 Australians each year. This is estimated to be 80 per cent of all drug-related deaths.

In cosmetic surgery, smoking causes many characteristic adverse effects on the skin and other structures. Tobacco smoking is the risk factor responsible for the greatest burden of disease (loss of health and premature mortality) in Australia, accounting for 12 per cent of the burden in males and seven per cent in females. About one in two regular smokers dies of a smoking-related disease. Those who die lose, on average, 16 years of life.

Tobacco is a known or probable cause of at least 25 diseases, including lung and other cancers, heart disease, stroke, emphysema and other chronic lung diseases. People who smoke also have higher rates of wound infection following surgical procedures.

Smoking prematurely ages skin by between 10 and 20 years. It also increases the likelihood of facial wrinkling threefold, particularly around the eyes and mouth. Smokers can look gaunt, often developing a sallow, yellow-grey complexion and hollow cheeks.

Smoking also doubles or trebles your risk of developing psoriasis. Although the damaging effects of cigarette smoke on skin are irreversible, it is likely that further deterioration can be avoided by stopping smoking. Second-hand smoke is also likely to have an ageing effect, albeit at a reduced rate.

Approach, treatment and evaluation of facial ageing

In assessing the face, it is easier to divide it into three sections.

Each section needs a different approach, with different surgical procedures to improve the appearance of each area. The appearance of the neck also needs to be taken into consideration.

The upper face

Signs of ageing in the upper face are generally as a result of muscle contraction, weakening of the ligaments and loss of fullness in soft tissue, causing the appearance of horizontal and vertical wrinkles. These include wrinkles around the eyes that form when we smile, and lines between eyebrows as a result of frowning. The height of the eyebrows also reduces over time, creating a tired or “hooded” look to the eye area.

The mid-face

Understanding the ageing of the midface is important as the perception of facial attractiveness is generally based around the synergy between the eyes, nose, lips and cheekbones. The primary causes of ageing here are changes in the bone structure, reduced soft tissue volume and the movement of fat. One of the first noticeable signs is the development of the “nasolabial fold” (the fold of skin that runs from the edge of the nose to the corner of the mouth). This is formed when the fat and soft tissue that normally sits high on our cheeks starts to lower. Such a change is often combined with the formation of “tear-troughs” – areas of volume loss under the eyes, often perceived as dark circles – and a general reduction in the youthful fullness of the cheek area.

The lower face

As muscle tone decreases in our 40s and 50s, the lower face generally begins to show visible signs of ageing. In the lower face, loss of volume and loosening of the ligaments cause soft tissue to accumulate near the jaw and chin, forming jowls. This loss of volume can also give the impression that the chin is widening. The lips are a key focus point when communicating, as well as in terms of attraction. Over time, the outer layer of the lips becomes thinner and the corners of the mouth can begin to droop into a mouth frown. The v-shaped area of the upper lip (known as cupid’s bow) begins to flatten out and lips become elongated, losing their youthful fullness. Vertical lip lines can also begin to appear (which is what causes lipstick to bleed).


No one wants a double chin or “turkey neck”. However, from late teens on, some people notice the hereditary feature of a chubby neck. Indeed, just looking at their relatives indicates that diet and exercise are not going to fix the problem! Liposuction is generally very effective for these fatty accumulations up to the age of about 40. After 40 years, men and women who are ageing relatively normally note a laxity of skin and sagging muscles under the chin. A mini-lift is the treatment of choice at this age and can result in a marked “firming” and tensioning of the underlying muscles of the upper neck. After about age 45, fat and sagging skin combine to make the problem more severe and at this stage a necklift or a facelift is a better option.

Face and neck lift

How Facelift Makes a Difference in Your Appearance

What can you expect after a facelift; This really depends on the type of facelift you are having and if we have decided to add any additional procedures. Quite often I will do combined procedures, such as necklift and upper blepharoplasty, in addition to the facelift. When performing a facelift, I am basically lifting and tightening the skin. Combining a necklift procedure with a facelift will address neck bands and loose skin on the neck. I will quite often perform liposuction on the neck as well. This is especially good for women that have a lot of neck fat associated with hanging skin (turkey neck). Adding liposuction and tightening the tissues of the neck makes a big difference to the definition of the jaw and neck area, rejuvenating this area substantially.

As much as possible we try to hide the scars so that when they heal up, even though you know they are there, they’re going to be difficult to spot.

How do we do this?

First of all, the incision is made around the ear and behind the ear, so that it is hidden around the natural lines of your ear and hairline. Depending on how much extra skin you have, if you have a lot of extra skin, we may have to do a little incision around the hairline. Most of the time we go into the hair, so the incision is well hidden inside the hairline. Basically, even at two weeks, when there’s a little red line, it’s hard to spot.

The one thing a facelift doesn’t address is the skin. Also the fullness of the skin or the volume of the skin. If you have significant sun damage, uneven skin tone, or open pores, you should see our dermal-therapist. She will be able to tailor a program to improve the quality of your skin, either prior to your face lift or after your face lift. This will make a huge difference to your end result. The other thing that the facelift doesn’t address is loss of volume in the face. If you have a lot of volume loss, especially in the cheek area, then a dermal filler will be optimal to give you the best result. Combining the dermal-therapy, the dermal fillers and the facelift together will give you the best result.

Different types of facelifts from mini to full facelift to Necklift

What are they? Facelifts have changed dramatically in the last 30 years. Current techniques produce a natural result, with less scarring and improved healing. The wind swept,“tight” look of the 1970s is completely out. The modern face lift elevates the muscles and fascia under the skin and only removes excess skin. The skin itself is not tightened or pulled. This approach produces a more natural result, in addition to providing a finer scar. A facelift (also called a rhytidectomy) is not a single or standard operation. Tailored to each individual, the procedure can range from a small mini-lift to traditional full facelift, and may include a number of other procedures to improve the final result. The operation elevates and re-drapes the facial skin and underlying musculature to eliminate laxity and sagging. It can also be designed to correct problems in the neck, under the jaw and/or chin and in the cheeks. A mid-face lift is so called because it addresses sagging in the cheek area or middle-third of the face. This procedure is popular with younger facelift patients, whereas older patients tend to require a full facelift to address ageing in the lower two thirds of the face and neck.

A facelift can:

  • Lift up your facial tissues below the eyes to a higher position, which combats sag.
  • Tighten your skin to remove wrinkles.
  • Stretch out your neckbands.

There are many different names and variations of facelifts that you may have researched online.

Some of these names are

  • Skin only facelift (also referred to as Cutanous lift).
  • S – lift.
  • MACS lift (Minimal Access Cranial Suspension lift).
  • Mini-facelift.
  • Composite facelift.
  • Extended full facelift.
  • Full facelift.
  • Deep plane facelift.
  • Sub-SMAS facelift.
  • Two layer facelift.
  • Limited lift with SMAS manipulation.
  • Rhytidectomy.
  • Short scar.
  • Baker flap facelift.
  • Endoscopic facelift.
  • Midface lift.
  • Cheek Lift.
  • Stem Cell facelift.
  • Thread lift.
  • Necklift.
  • Liquid facelift.
  • Traditional face lift.
  • Brow lift.
  • Coronal lift.
  • Quick Lift
  • Subperiosteal Lift.
  • Temporal Facelift.
  • Platysmoplasty.
  • Submentoplasty.
  • Feather lift.
  • Non-surgical facelift.

If you are a patient researching which surgeon to see and what operation you think that you need, then it can be quite hard to figure this out when reading different websites. The terminology is confusing, and not all surgeons use the same terminology to describe the same operation. For example one surgeon may refer to a “mini” facelift as a skin only facelift, another may use this term for a SMAS plication facelift. Even when talking about a similar facelift, such as the skin only facelift, there can be wide variations as to what is actually done. A skin only, can be a facelift with no undermining of the skin (sometimes referred to as a S-lift), as well as one with wide undermining of the skin. So you may be talking about a facelift that takes one hour versus one that takes four hours, with vastly different results and recovery.

To be able to understand what facelift you are actually getting, it is important to look at what is done during the facelift, and not what the name of the facelift is. To be able to describe all the different facelifts in more detail, we need to first understand the SMAS (superficial musculo aponeurotic system), as this fascia is a critical structure in facelift surgery and determines what result you can expect and the recovery that you can expect.

Anatomy of a facelift

To understand what a facelift does and is, it is necessary to understand the anatomy of the face. I will try to make this as clear as possible, mainly so that you can understand what we are trying to accomplish with a facelift.

The SMAS (superficial musculo-aponeurotic system)

Demonstrates the SMAS layer in a facelift

This is a strong layer of tissue that sits just above the muscles of facial movement (Ref 6). It becomes the platysma muscle in the neck, and it blends into the fascia of the temporalis muscle. It contains all the fat pads of the face. When we age the fat pads in the cheeks fall down (creating a prominent tear trough). In the jaw the jowls are created, and towards the middle of the face you get more prominent nasolabial folds and marionette lines due to the descent of this structure.

Skoog (Ref 8) was a swedish plastic surgeon that first described going deep to this structure to create a facelift that was more long lasting. As with many things in medicine, it took a long time for other plastic surgeons to accept these techniques, and it was not until after his death, that the SMAS facelift became more popular.

Why is the SMAS so important in a facelift?

Skin is elastic and any facelift that uses skin only tends to not last as long. This has been proven with research (Ref 4) The early result from both deeper facelifts and more superficial facelifts tend to be very similar. However, the skin only facelifts tend to sag much quicker after the original operation. Trying to pull on the skin to make the facelift last longer just ends up with un-natural looking results.

The SMAS is a relatively in-elastic layer in the face, and if this is lifted and repositioned then the results last longer.

The other big factor is that all the important nerves run underneath the SMAS, such as the facial nerve that controls the movement of your facial muscles. Staying above the SMAS is very safe, as there are no nerves here (other than sensory nerves). The reason why the parotid gland is so important in the face, is that the facial nerve runs inside this gland. So when performing a SMAS facelift you start dissecting on top of the gland, which is very safe, once you get to the end of the gland the nerves emerge, and care has to be taken not to injure these.

Going deeper to the SMAS and trying to lift and stitch the deeper structures is called a deep plane facelift. Research has shown that there is no benefit in doing this either for the longevity of the result or the actual result (Ref 1). The risks and complications however are much higher with this type of facelift, as is the recovery from the surgery.

How to make sense of the different facelift techniques

The best way to make sense of all the different names and techniques is to think about how they relate to the SMAS. If the technique is working on the tissues superficial to the SMAS, then it is a superficial facelift. If it is working on the SMAS, then it is a SMAS lift. If it is working on the tissues under the SMAS, then it is a deep plane facelift. Additional neck lift is all about tightening the platysma muscle in the neck, and is therefore grouped together with the SMAS Lifts. Rhytidectomy is just another word for facelift.

Superficial facelifts

  • Skin only facelift (also referred to as Cutaneous lift)
  • S – lift
  • Mini-facelift
  • Short scar
  • Thread lift
  • Feather lift
  • Liquid facelift
  • Non-surgical facelift
  • Stem Cell facelift

SMAS lifts

  • MACS lift (Minimal Access Cranial Suspension lift)
  • Mini-facelift with SMAS plication
  • Quick Lift
  • Two layer facelift
  • Limited lift with SMAS manipulation
  • Full facelift
  • Baker flap facelift
  • Traditional face lift
  • Necklift
  • Submentoplasty
  • Platysmoplasty

Deep plane facelifts

  • Composite facelift
  • Extended full facelift
  • Deep plane facelift
  • Sub-SMAS facelift
  • Endoscopic facelift
  • Midface lift
  • Cheek Lift
  • Subperiosteal Lift

Superficial facelifts

  • Thread lift.
  • Feather lift.
  • Liquid facelift.
  • Non-surgical facelift.
  • Stem Cell facelift.


This term has no real meaning, as it depends on what the surgeon means by a mini-facelift. Surgeons that perform skin only facelifts would refer to this as being a “mini” facelift. I personally refer to a mini-facelift when I perform a facelift with tightening of the SMAS without going deep to the SMAS (many would refer to this as a full SMAS facelift). So as you can see a mini-facelift in my hands is very different from a mini-facelift in another surgeons hands. It is therefore better to avoid this term and talk about the non-SMAS and SMAS facelifts.

Skin only, S-lift, Short scar facelift and skin only facelifts with skin undermining

These are all very similar facelifts.The skin only, S lift and short scar, usually do not involve any undermining of the skin. They usually involve cutting out around 1-2 cm of skin in front of the ear and then stitching this closed. They are super-simple operations that can be done under a local anaesthetic, and are very similar to the doctor excising a skin lesion.

The benefits of these operations are that they are very low risk and quick to do (taking around 30-60min). They can be done in a surgeon’s office.

Many patients want to have the least invasive operation that they can have done and still have a good result. The problem with these operations in my experience, and what I have seen with patients coming in for a second opinion, is that they provide minimal results and any results that they do provide tends not to last more than 6-12 months.

In my experience having fillers and muscle relaxants provide as good, if not better, results than these operations.

The next step up from the simple skin excision facelift, is the skin excision facelift with undermining of the skin. This takes around 2-3 hours to do and provides a significantly better result than the skin only excision facelifts. There is a longer recovery however, and the results don’t last as long as a SMAS lift. Considering that adding some tightening to the SMAS is a minimal additional step, there is very little benefit in these operations.

Thread lift and Feather lift

These lifts are performed by using barbed sutures that are pushed through the tissues. There are two types of these sutures available. The permanent sutures and the absorbable sutures. There are a long list of brand names for these sutures. A thread lift, is so called, because a thin needle is used to insert clear polypropylene threads with tiny barbs just under the skin.

  • Aptos threads.
  • Contour threads.
  • Promoitalia Threads.
  • Silhouette Soft Face Lift.
  • Happy Lift™ Revitalizing.
  • Barbed suture lift.

Threads were a trend in the early 2000’s. I personally performed these thread lifts for a period of about two years. However, it was clear to me in that period that there was no benefit to the patient. I had next to no happy patients from all the thread lifts that I had performed, be it with the permanent barbed sutures or the later absorbable sutures.

The premise of these lifts is very appealing; that you could get a facelift result by putting a few threads through the face and suspending the tissues. Unfortunately it does not work. There were so many problems with one of the threads (contour threads), that they were taken off the market in 2008. Few, if any specialist surgeons, would now be performing these thread lifts.

Studies have shown that benefits, if any, are secondary to swelling post procedure, and last as little as 3-6 months.

In one large study the conclusion of the researcher was:

“The thread-lift provides only limited short term improvement that may be largely attributed to postprocedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure”

They further proceed to state;

“..we cannot justify further use of this procedure for facial rejuvenation…:”

(Ref 10)

These findings mirror closely my personal experience with these procedures.

Considering the very long list of problems with these threads:

  • Risk of facial nerve damage
  • Infection
  • Bunching of loose skin
  • Thread coming through the skin (extrusion of the thread)
  • Visible strings across the face
  • Palpable irregularities on the face

SMAS lifts

MACS lift (Minimal Access Cranial Suspension lift), the Quick lift and plication of the SMAS

These lifts are all about suspending the SMAS in different ways (Ref 9). The skin is lifted off the SMAS. In the MACS lift and the Quick lift, a suture is used to lift the SMAS up and attach it to the temporal fascia or cheek bone. The suture is stitched into the SMAS the SMAS is pulled up like a concertina. The excess skin is then resected. The other option is to plicate the SMAS. This means to stitch over the top of the SMAS to tighten it.

These lifts are true SMAS lifts and have been demonstrated to provide good results that are long lasting,

Dr Beldholm’s Mini-facelift using SMAS plication (sometimes also referred to as limited lift with SMAS manipulation)

What is called a mini facelift varies vastly from surgeon to surgeon. There is no established terminology that definitively states what a “mini-facelift” is. Some surgeons call a skin only facelift a mini-facelift. Some call a skin only facelift that elevates the skin a “mini”. Some refer to a mini, when the SMAS is plicated but not cut.

When I refer to a mini-facelift, in many cases other surgeons would refer to them as a full facelift. This is why the terminology is very confusing.

When you discuss your facelift with your surgeon it is therefore best to talk about what is actually done in the operation and what results you will get.

Dr Beldholm’s mini facelift

  • This facelift involves an incision around the ear and down the back of the ear, and in many cases extending in the hairline in the back
  • To get a long lasting result the SMAS is tightened with sutures
  • Excess skin is resected and then the skin closed

Doing anything less than a Dr Beldholm’s mini-facelift will usually not give you a significant result.

The benefit of the mini-facelift vs a full facelift is the recovery and the time it takes to perform. A mini facelift takes around 2-3 hours to do and only requires a day stay in hospital. If you combine this operation with Tissue glue the recovery can be as little as one week. Because the SMAS is tightened you get around 80 percent of the result and longevity that you would get from a Full facelift. The ideal candidate for this operation is in their 40-50’s and has noticed early ageing changes.

Two layer facelift

This refers to a facelift were the SMAS is lifted in one direction and the skin is pulled in another direction. When performing a facelift you want to pull the deeper structures straight up to re-position them in a more youthful position. The skin is usually pulled backwards to soften up the Nasolabial lines and marionette lines. If the skin is pulled in the wrong direction then there may be abnormal wrinkles forming and the facelift might look very unnatural. It is therefore critical to take great care when the skin is closed.

Neck Lift, submentoplasty and platysmoplasty

Source: By Dr. Johannes Sobotta – Sobotta’s Atlas and Text-book of Human Anatomy 1909, Public Domain,

This procedure, also known as a lower rhytidectomy, is commonly performed in conjunction with a facelift. A neck lift improves visible signs of aging along the jawline and neck. It also helps to eliminate loose neck skin, excess fatty deposits under the chin, and excess fat and skin located along the lower face that creates jowls.

The platysma is part of the SMAS muscle. As we age the muscle separates from the underlying structures and starts to sag. This causes the characteristic dynamic neck bands in the neck area as we age.

When performing a neck lift, a small incision is made under the chin area and the platysma muscle is stitched together to tighten the area. The lower part of the platysma muscle is cut to allow it to drape better around the neck area.

The neck lift is usually performed as part of a facelift, as the platysma muscle and skin of the neck need to be stretched laterally to re-drape around the neck. Otherwise there will be loose skin in the neck area.

Facelift (Full), traditional facelift, Extended full facelift or Sub-SMAS facelift

As with most other terminology there is no set operation for this. It is also referred to as a Rhytidectomy. However, most of the time it refers to a facelift with full dissection of the skin and working on the SMAS, usually dissecting under the SMAS, to release ligaments and get a better mid-face lift. This should give a better lift as well as longer lasting result.

Deep plane facelifts

Composite facelift, Deep plane facelift, Endoscopic facelift, Midface lift, Cheek Lift or Subperiosteal Lift

One of the limitations of the SMAS lifts is that they do not address the midface or under the eye area. The deeper facelifts go deep onto the bone, detach facial muscles, and do a lot of work in the under the eye area.

These facelifts were quite popular in the late 1990 and 2000’s as surgeons were looking for better and longer lasting results.

However, research has show that the more aggressive facelifts do not have better results, and do not actually lead to longer lasting results. However, what they do do is massively increase the complication rates and recovery from the facelift operation. Because of this most surgeons performing facelift surgery would have moved away from these more severe operations.

(Ref 7)

What a facelift will not do

While these procedures do an amazing job at helping patients dramatically look and feel younger, you must have reasonable expectations. These procedures won’t:

  • Change the fundamental appearance of who you are. Dr Beldholm’s goal is to make sure the results of your surgery are “natural looking.” You should look younger and more refreshed. No one should know you’ve had surgery when you go home and have fully healed.
  • These surgeries don’t stop the aging process. As long as you’re alive, your body will continue to age. However, that’s a good thing considering the alternative!
  • A facelift doesn’t restore volume in the face. This is why Dr Beldholm usually recommends either dermal fillers or fat injections in the areas that have lost volume with age.
  • The skin is a very important factor in having a healthy youthful look. To get the optimal result from your facelift, Dr Beldholm usually recommends that you combine it with our anti-ageing skin treatments. These range from laser treatments to anti-ageing home care treatments.
  • Many women opt for other simultaneous procedures complementary to facelift surgery, such as a brow lift, chin augmentation, or eyelid surgery, to achieve a more uniform and complete look.
  • Ultimately, anyone in good standing health, who are beginning to notice the signs of aging on their face, are good candidates for the above mentioned procedures. There are no age limits.

You may also be wondering, “Which procedure is right for me?” Remember, no two patients are the same. Therefore, no two facelifts are the same. In helping a patient to make decisions about plastic surgery for facial rejuvenation, Dr. Beldholm will examine and assess how each aesthetic area of the patient’s face contributes to their individual overall appearance. An individualised surgical plan is then developed, which addresses each patient’s specific concerns and needs.

Consult an experienced cosmetic surgeon, like Dr. Beldholm, who is skilled in both surgical and non-surgical facial rejuvenation, to determine the treatment plan that is best for you.

Suitable candidate for a facelift or necklift

Is a face & neck lift right for you?

With the face being the most prominent, unique, and expressive area of your body, the aging process can be particularly hard to come to terms with.

Individuals who come to us with sagging and wrinkled facial skin and a permanent ‘tired’ looking appearance are sometimes low on self-confidence too.

The loss of collagen from the skin and the harmful effects of the sun and smoking can be partially reversed with a long-lasting procedure that reduces wrinkles and sagging, and restores a natural-looking, more youthful appearance.

A face and neck lift uses advanced techniques to improve the appearance of the jaw, chin and cheek areas of the face, as well as the neck. If you are looking to reduce wrinkles and restore elasticity to the skin in a natural-looking way, you will usually benefit from this procedure.

When should you consider a facelift and what procedure should you have?

From age 40 onwards both men and women whose faces and necks have started to sag may be good candidates. A facelift restores a more pleasing contour to the face and neck. It can be done alone, or in conjunction with other procedures such as a forehead lift, eyelid surgery, or nose reshaping. Facelifts have been successfully performed on patients as young as 40 and as old as 80.

The whole idea of waiting until 60 for a one-off facelift has gone. There’s now a growing trend for people in their late 30s and early 40s to actively seek facelifting procedures. In this age group, the skin starts to give way to gravity — the brow may droop a little and the skin around the eyes loosen.

However, muscle and ligament tone is still quite elastic and patients usually require less extensive rejuvenating techniques.

Usually some tightening of the underlying muscle and ligament tissue is enough. The jowls and neck area can also be tightened, and the browlift procedure used to elevate the corners of the eyes and tighten the upper cheek area. Although patients will need another lift at a later stage to keep their youthful looks, it’s unlikely to be the same type of facelift – rather a touch-up procedure about 8 to 12 years after the first, during which the old incisions are revisited and the sagging tissues tightened.

If you are committed to staying youthful, look after your first facelift by not smoking or taking drugs and by avoiding excessive sun exposure.

Patients in their early 40s

Within this group, ageing tends to be primarily facial, with possible early jowling and slight neck laxity. There may also be some excess neck fat. A mini-lift with neck liposuction tends to be ideal for this age group. Involving an incision in front of the ear, the skin is then elevated and the deep tissues lifted and repositioned to a more natural and youthful position. Any excess fat in the neck is liposuctioned to optimise its contour. The recovery period tends to be around two to three weeks, with the final result obvious at around three to six months when the scars have faded.

Patients in their late 40s to late 50s

Moderate jowls and more excess neck skin may be obvious in this group, along with possible excess neck fat and a drooping chin. A more extensive facelift is usually required, providing more necklift and some resectioning of excess neck skin. A chin implant may also be beneficial to restore a more youthful facial contour. The incision will need to be slightly longer than for younger age groups, and extend behind as well as in front of the ear. More skin is elevated and the underlying tissues may require resectioning and elevation to provide the best results. An incision under the chin will be required if a chin implant or tightening of the neck muscles is necessary. Due to the longer and more extensive nature of this operation, the recovery period can be from two to four weeks.

Patients in their 60s and onwards

Most signs of ageing are usually present in this group, including significant jowls, deep lines and bands, excess eyelid skin, potentially dropped eyebrows, significant neck skin laxity, dropped chin, and lack of mid-cheek fullness. To provide the best results, a skin resurfacing procedure and full facelift is usually required. The full facelift is usually combined with eyelid surgery and a brow lifting procedure. For further information, please refer to our separate information sheets on these procedures. The incision is made behind and in front of the ear and extending into the hair line. As the procedure is quite extensive, full recovery generally takes around four weeks.

Some special cases that a facelift may be beneficial in

The Rhytidectomy and Neck lift after weight loss

Not only can you lose volume in the face, resulting in loose skin, after shedding your old body, this can also happen in your neck too. You might have noticed there is a lot of excess skin in your neck area, and it makes you look about 20 years older than others your age. If you want to know how to fix saggy skin in the neck region, then the neck lift is it.

Neck liposuction with a neck lift and facelift for “turkey neck” or excessive fullness in the neck area

A neck lift is the solution to your difficult problem – alternative therapies such as beauty creams, straight neck liposuction, or even “neck yoga” are simply not going to do the job. Sometimes combined with a face lift, neck lift surgery is generally the only answer when it comes to your neck. This surgery will remove the excess skin and fat causing the wattle, and firm up the entire area, transporting your neck region to a younger version of you.

Recovery after facelift and necklift surgery

Recovery after facelift surgery isn’t very long or stressful. However, patients should be aware that results are not visible immediately. Normally the face looks a bit pale, swollen and bruised, possibly even worse than prior to surgery. Please keep in mind that this is normal, and should disappear in a few weeks.

The skin of the face may also feel numb but this should fade away in around two months, although the face will usually feel a bit tingly prior to sensation returning. Usually there is mild pain after a facelift. This responds well to pain medications and Dr Beldholm usually provides a pain medication pack.

Dr. Beldholm usually reviews patients the day after surgery. Facial bandages are removed at this stage along with drains or drainage tubes. Swelling and bruising is controlled by a head garment that puts pressure around the surgical sites.This head garment is measured up prior to the operation and is included in the post-operative care. Any oozing of fluids can be removed with pads. Facial stitches are removed around five to six days after surgery. Any stitches around the scalp area may have to remain in longer as healing is slower in this area. Restricting exercise immediately after surgery and resting will limit the amount of bruising and swelling, although gentle walking is fine after one or two days.

The healing process

Following facelift surgery, patients feel some pain for the first couple of days, especially when moving around or coughing. Although most patients are up and about in a day or two, it’s common for the face to ache occasionally for a couple of weeks.

Full recovery will take up to one month. During this recovery period you may feel tired as your body adjusts and heals. Patients may also experience random, shooting pains for a few months during the recovery process. The bandages are removed a day or two after your facelift, though patients continue wearing a supportive head garment around the clock for several weeks until the swelling and bruising subsides.

Activity should be kept to a minimum for a week or two, with only light activities such as gentle walking or light home duties. No vacuuming or regular bending to pick things up should be performed during the first week.

Heavy lifting or pushing should also be avoided for three to four weeks following the procedure. If your facial skin becomes very dry, apply moisturiser several times a day, being careful to keep the suture area dry. As stamina levels will be reduced following your procedure, limit exercises to stretching, bending, and swimming until your energy increases. Please note that it is normal for a small amount of fluid to drain from the wound, or for some crusting to occur.

Return to work

Most patients can return to work and social activities in about two weeks, if their work is of a non-strenuous nature. However, please note, that at this time, there will still be bruising. This can usually be well hidden with makeup by this stage. Generally, this bruising should be gone by approximately week four. Patients whose work requires strong physical activity, may be wise to plan for four to six weeks of recovery time.

Getting back to normal is a gradual process that may take up to four to six weeks, and patience is very important during this healing process. Patients should be realistic about their expectations from facelift surgery, bearing in mind that the results are not noticeable straight away. Scars are concealed, usually hidden by the hair or by the natural lines of the face and ears. Either way, scars usually fade away to become invisible with time. Therefore, one should not be worried by visible scars during the healing process, as it usually takes around six (and sometimes up to 12 months) for these to fade.

What to expect

Initially, patients’ faces may look different as swelling and puffiness can change facial features. Bruising may also persist for up to a month. As the skin is very sensitive and numb soon after surgery, it also feels strange in the beginning. Additionally, patients may feel stiffness in facial movements and get exhausted very easily. In the first few months the face may feel hard and lumpy, but this usually settles down in around three to six months. There is not usually any visible lumps and the skin surface is usually smooth. It is only when you feel accross the face that this firmness can be noted.

Usually by the end of the third or fourth week, patients appearance and mood have greatly improved, with most able to return to work about two or three weeks after their procedure. At this stage, any remaining bruising can be masked with makeup. Special care should be taken with the face and hair during the recovery period.

Strenuous exercise, sexual intercourse and heavy housework should also be avoided for at least two weeks. Patients should remain alcohol-free for a few weeks postoperatively. Steam baths and saunas are also to be avoided for the same period. Hair around the temples may be thinner and facial skin dry and rough for a few months. Since the hair-growing skin is moved up behind the ears and neck during facelift procedures, men may then have to shave in these areas. Please note that men should avoid shaving for one week after the procedure.

Rhytidectomy surgery is frequently a great success, resulting in younger-looking, firmer and tighter facial skin. A facelift, however, does not stop the ageing process. Consequently, a patient may require additional facelifts during his or her lifetime. Even so, it’s important to realise that the need for another procedure generally only becomes apparent after 10 to 20 years.

Complications from facelift surgery

General risks

As with any surgical procedure, patients can suffer a number of complications unrelated to their specific operation. However, for those who are healthy and do not take any medications, these complications are very rare. The risks increase for those with a number of health problems and can include:

  • Heart problems (although very uncommon with modern anaesthetic techniques).
  • Lung problems — small areas of the lungs may collapse, increasing the risk of chest infection. Such problems may require antibiotics and physiotherapy.
  • Other potential lung complications are quite rare.
  • Clots in the legs with pain and swelling. Rarely, part of such a clot may break off and go to the lungs, causing fatal complications.
  • Allergic reactions to medications.

Specific risks


Patients are advised that smoking before a facelift will increase complication rates threefold. During a facelift, a large area under the skin is undermined and the blood supply to the skin depends on blood vessels that are very far from the site of healing. Please note that the blood supply to the area being operated on is reduced, even in a young non-smokers with no health problems. Nicotine, carbon monoxide, and many other toxic tobacco by-products clearly interfere with the dynamics of normal wound repair.

Their adverse effects can include:

  • Causing direct tissue injury within the microvasculature (network of tiny blood vessels).
  • Inhibiting cellular populations involved in propagating healing.
  • Producing hormones that actually retard wound repair.
  • Reducing blood flow and oxygen delivery to the skin and extremities.
  • Necrosis (skin death) To optimise your surgical results, Dr. Beldholm requests patients stop smoking for four weeks before and four weeks after surgery.

These recommendations are based on conclusive medical findings. Nicotine patches or gum should not be used to take the place of cigarettes or cigars as they are also associated with increased complications.

Mild complications

Wound infection is perhaps the most common complication. Such infections, which generally respond well to antibiotics, are usually superficial. Although small areas of wound breakdown sometimes occur, these heal well over a few weeks if the wound is dressed regularly.

Uncommon and rare complications

As with every surgical procedure or operation, there are always risks and, in very extreme cases, fatalities.

Serious complications of a facelift are uncommon but include:

  • Copious bleeding, which may require a return to theatre, to remove the blood and seal the blood vessels.
  • Seroma or excessive fluid build-up under the skin of the operated area. Although this condition may require drainage with a needle, it usually settles down without the need for a further operation.
  • Fat necrosis occurs when fat cells lose blood flow and die. The liquefied fat cells can then harden underneath the skin over time, causing lumpiness.
  • Poor wound healing (hypertrophic or keloid scar). In these instances, the scar can permanently thicken, turn red, be painful and disfiguring. Usually it takes up to 12 months for a wound to heal and demonstrate the final result. Please be aware that, with Dr Beldholm’s techniques, scars are minimised.
  • Necrosis (skin death) generally occurs in patients who have not stopped smoking before their operation. With this condition the skin dies and there is an open wound. Generally, if this wound is dressed daily, it will heal up in a couple of months, with the final result usually quite acceptable.
  • An additional procedure such as a brow lift may be required after a facelift has been performed.
  • Loss of sensation in the skin.
  • Asymmetry. Although asymmetry of the face, cheeks or other areas will have been present prior to the procedure, it may become more visible following the operation.
  • Chronic pain can be a very rare complication.
  • Hair loss may occur in areas of the face where the skin was elevated during surgery. The likelihood of this is not predictable.
  • There is the possibility of a poor result from facelift surgery. Such an outcome would include risks such as unacceptable visible deformities, loss of facial movement, wound disruption and loss of sensation. You may be disappointed with the results of surgery and, infrequently, it is necessary to perform additional surgery to improve your results.

Nerve injuries

The two main sets of nerves that can be injured during a facelift are sensory nerves and motor nerves to the muscles controlling facial expression. These injuries are rare (that is in the order of less than one per cent). Although most nerve injuries are temporary, resolving over a few months, some can be permanent and difficult to treat.

Facial nerve

The facial nerve supplies the muscles of facial expression, coming out through the parotid gland. It is generally well protected and has five main branches. If an injury occurs, it usually involves one of the peripheral facial nerve branches. Such injuries can lead to conditions such as droopy eyebrows or an asymmetrical smile.

Sensory nerves

These supply sensation to the skin. The most commonly injured nerve is the great auricular nerve, which supplies sensation to the ear lobe. Although usually this is not a major concern as sensation will return, sometimes the nerve develops a neuroma (painful nerve ending) that will require further treatment.

Parotid duct fistulas

Parotid duct fistulas are abnormal connections between the parotid salivary gland and the skin caused by damage to the parotid gland during surgery. This is a very rare complication.

Pixie ear

Pixie ear is a term that refers to pulling down of the earlobe after a facelift. This is one of the signs of a poorly done facelift and to get a natural result the key is to avoid this issue.


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