How is a facelift performed?

Many people picture a facelift as an operation that simply pulls the skin tighter. When I explain how it works, I begin with what lies underneath. Skin changes are only part of facial aging. Lost volume, the position of deeper tissues, and changes in the neck also influence what you see in the mirror.

I spent three years training with Professor Ivo Pitanguy, caring for patients at his private clinic and at the 38th Ward of Santa Casa de Misericórdia in Rio de Janeiro. One principle from that experience still guides me: bring out a person’s features while respecting their identity. This is a goal that shapes my planning, not a promise of an identical outcome for every patient.

What do I assess before choosing the approach?

During the consultation, I examine each area and then consider how the face and neck work together. I ask what bothers you, what treatments you have had, and what you hope will change. Your health and expectations are part of this assessment, not separate details to consider later.

I also look at fine lines around the mouth, lines between the eyebrows, and skin quality. Examining an area does not mean recommending surgery for it. Some concerns need a different treatment, and some changes may remain even after an appropriately planned facelift.

What happens at the beginning of facelift surgery?

In my practice, I use total intravenous general anesthesia, or TIVA, with an anesthesiologist overseeing anesthesia care. We discuss any planned additional procedures before surgery. I do not treat being under anesthesia as permission to add a different cosmetic operation.

When fat grafting is part of the plan, I begin by collecting and preparing the patient’s own fat. I use it to restore volume in selected areas. Adding volume and repositioning descended tissues serve different purposes; one does not automatically replace the other.

The use of fat grafting alongside facial rejuvenation surgery is described in the medical literature. That does not mean every part of the face needs more volume. I plan differently for a face with substantial hollowing than for one that already has enough fullness. [1]

Which procedures may come before the deep plane lift?

When indicated, I move on to eyelid surgery, brow elevation, and fat grafting beneath the eyes. Each has its own purpose. The two sides may also need different adjustments because facial anatomy is not perfectly symmetrical.

I then address areas where volume replacement is appropriate. In my practice, these can include the forehead, temples, nasolabial folds, marionette lines, lips, and lines around the mouth. I may also graft the cheeks or chin if the assessment supports it. My aim is to restore what is missing, rather than add volume everywhere.

For some patients, I include a lip lift to shorten the distance between the nose and upper lip. Lip proportions and anatomy guide that decision. It is not a routine requirement of a deep plane facelift.

Why do I usually assess the neck and face together?

A less defined jawline may reflect both descended facial tissues and changes in the neck. Addressing only one area can leave another part of the concern untreated. I explain this relationship before recommending a combined approach.

The platysma is a thin muscle layer in the neck. Depending on the findings, I address laxity in this muscle and fat beneath it. I also assess whether selected reduction of the digastric muscles or submandibular salivary glands is appropriate when those structures contribute to fullness.

These are not automatic steps for every neck. I do not reduce muscle or gland tissue simply because it is present. I explain why a particular approach may help, along with its specific risks. The extent of surgery should follow the anatomy, not the assumption that a larger operation must be better.

How is a deep plane facelift performed?

For the deep plane portion, I work beneath the SMAS, a supporting tissue system associated with the facial expression muscles. Rather than relying on skin tension alone, I mobilize a composite layer that includes skin, tissue beneath the skin, and the SMAS.

This requires releasing the retaining ligaments included in the surgical plan. The published description of the extended deep plane technique identifies four important groups: zygomatic, masseteric, mandibular, and cervical retaining ligaments. These act as attachment points. Releasing them allows the tissue layer to be repositioned. [2]

How do I reposition the face without just tightening the skin?

In the technique I use, repositioning follows a mainly vertical direction, adjusted to the needs of each region. Once the supporting tissues have been moved, I fit the skin over them and remove excess skin around the ears and along the hairline. We discuss incision placement and scars before surgery.

My goal is to limit unnecessary skin tension and improve the relationship between the cheeks, jawline, and neck. This does not remove the possibility of scars, complications, or individual differences. It also does not let me promise an exact number of years of rejuvenation.

Does every patient have the same combination?

No. In selected patients with a substantially recessed chin, I may include a silicone chin implant. That is a different decision from using fat to replace a smaller volume deficit.

I may also perform selective buccal fat reduction when the size and position of that fat justify it. Jowls are not simply another name for an enlarged buccal fat pad. I do not recommend removing buccal fat for everyone who has lost jawline definition.

The sequence here describes my usual approach and can change with the individual plan. A facelift, fat grafting, eyelid surgery, and deeper neck procedures should not be treated as a package that every patient needs.

What should you understand before deciding?

I discuss the changes we hope to achieve and the limits of treatment. Scars, asymmetry, bleeding, altered sensation, and nerve injury are among the risks we consider. Health assessment and anesthesia planning also matter. The American Society of Plastic Surgeons explains the procedure in stages, including anesthesia, incisions, and closure. [3]

During a consultation with me, I can explain which steps suit your face and which I would not recommend. Understanding how a facelift is performed helps you ask why each part of the proposed surgery belongs in your plan.

Illustrative image; not a patient or surgical result.