Book:The Facelift Letdown- Why Are Surgeons Not Doing Composite Face Lift?

I have read several posts indicating that clients are getting to wrapped up in the type of procedure. But it appears to me from this book there should be only 1 procedure. How can one identify the work of a plastic surgeon without knowing how he/she does a facelift? Looking at before/after pics does not tell me what the patient looks like, 3-5 years or longer, later.

Doctor Answers 15

Is there one type of face lift which is better than the rest?

To answer your question about composite face lift, one has to first understand the difference between the various types of face lifts.

  1. Mini face lift. The least invasive of the lifts. It involves a shorter incision. In addition, most of the lift comes from removing excess skin rather than lifting the deeper SMAS layer. Results are less dramatic. These are ideal for younger patients who need minimal results. Results can look unnatural and pulled if too much tension is placed on the skin especially in older patients where a deeper lift would have been a better approach as the skin can't hold up the sagging SMAS and deeper facial structures.
  2. SMAS face lift. This involves tightening the deeper facial structures. It is less invasive than a deep plane face lift as the SMAS is not separated (or to a minimal extent) from the underlying facial muscles. Sutures are used to tuck the SMAS at a higher level. This is approach is safer than the deeper lift but at a price- there is less lifting of the mid face and toning of the jaw line. This type of lift is easier to perform than a deep plane lift.
  3. Deep plane lift. The SMAS layer is separated from the underlying facial muscles and sutured at a higher position on the face. This gives more of a lift along the mid face and jaw line than a standard SMAS lift. There is a slightly higher risk of facial nerve injury. This procedure should be performed by plastic surgeons who have a lot of experience with this technique. There is an ongoing debate as to superiority of results vs your SMAS lift. In my opinion, results are superior along the jaw line and cheeks which have more of a lift. Neither the SMAS or Deep plane lift have a substantial effect on the nasolabial folds (parenthesis lines) and fillers are used to smooth those out in both cases.
  4. Subperiostial face lift. This is not a popular technique as it results in prolonged swelling. In this technique the entire mid face is lifted off the cheek bone in an endoscopic (small temple incision) approach. It works well to lift the cheeks but falls short in treating the neck and jaw line. It can be combined with a SMAS lift if the surgeons wants to use the subperiostial lift to lift the cheeks rather than the deep plane approach (for the cheek lift)

There are two types of deep plane face lifts.

  1. Multiplanar Deep Plane Lift: the skin and SMAS are lifted independently from the underlying muscle.
  2. Composite Deep Plane Lift: the skin and SMAS are lifted as one layer. This is less than ideal in that a) it will often result in raising of the temple hairline and b) the ideal direction of lift for the SMAS layer is different from that of the skin. If they are lifted as one layer, the two vectors can't be established. It is for this reason that the Multiplanar Deep Plane lift is more popular than the composite deep plane lift.

One final note. It is not so much the type of lift that determines the end result but the skill of the surgeon and the use of other concomitant rejuvenating procedures to balance out the rejuvenation process. In addition, I wouldn't would use viewing pre and post op photos from prospective surgeons more as a tool to see if you find their results esthetically pleasing and not overdone. The type of face lift used is less important in viewing these photos. I would agree, that it would be helpful to see the photos 3 to 5 years out from the procedure but this is usually not possible as many patients don't come back after their final post op visit for additional photos. The modern day face lift utilizes volume restoration as the cornerstone to a more natural lift. Less lifting is needed once lost volume is replaced with either fat, Sculptra or other products. Youthful skin adds a lot to a face lift result. My preferred skin resurfacing approach is with Fraxel laser. Remember, a face lift doesn't rejuvenate the skin.

I hope this is helpful.

Good luck.

Manhattan Facial Plastic Surgeon
4.8 out of 5 stars 153 reviews

Top 5 reasons to get or not get a Composite Facelift

Hi Catalina,

Here are my thoughts on the interesting question that you have posed. I will present them in a Top 5 format of reasons to get (or not get) a Composite Facelift:

1. Longer lasting results - certainly one of the premises of doing a Composite Facelift (CF) is that the deeper repositioning of the tissues results in longer lasting results. This is true in a general sense but be aware that the deeper dissection comes with higher risks and that not all patients need a CF - they may achieve equally durable results with a "simpler" procedure.

2. Addresses more areas of the face - by providing more exposure and deeper dissection it is technically easier with CF to address areas like the nasolabial folds, buccal fat and midface. However not everyone needs this and increasingly we are able to achieve these same results by employing various less invasive procedures.

3. You get what you pay for - a central axiom is that if something costs more it is worth more. CF are at the high end of the cost spectrum because of the skill required but also because of the anesthesia, post-op care required, drains, etc. Again though not all patients need a CF - the very same results can be achieved through a less invasive procedure which is associated with lower costs and risks.

4. It is the "best" type of facelift - while certainly representing the most aggressive and thorough repositioning of facial tissues to achieve a more youthful appearance it is not "the best" facelift. More important is to choose the "correct facelift" for your anatomy and needs.

5. Superspecialized is supergood - while I do support the practice pattern of focusing in specifically "niche areas" of practice, I do not support facial plastic surgeons who only do one type of facelift over another. An experienced surgeon should be comfortable with all types of facelifts and be able to recommend the one that will best fit your anatomy, needs, available recovery time and budget.

Thanks for the great question!

Kamran Jafri, MD
New York Facial Plastic Surgeon
5.0 out of 5 stars 11 reviews

The Facelift Letdown

I appreciate the question, which relates to Dr. Sam Hamra's recently released book. Dr. Hamra is distinctive pioneer in Facelift surgery.

Although not all high quality Facelift surgeons use Hamra's exact technique, many rely on elements of the composite approach in treating their patients. However, I feel that one of the major points of his recent book is as follows: many patients are choosing highly marketed, quicker, cheaper procedures (ie Thread lifts, Lifestyle Lift, Quicklift, etc) which are purported to be advances in Facelift surgery. It doesn't take long on this website or others, which report on the public's opinions of plastic surgery, that there are a high percentage of patients who are less than thrilled by their results.

The book is encouraging patients to review long term results, not rely on statements such as, "I saw a change instantly". A quick Facelift procedure may offer a result right away, but will this change hold up in 6 months? If a result doesn't match expectations of quality and longevity, the patient is left with scars and without a sense of satisfaction.

It is important to note that every surgeon, at some point in his career has to perform revisions for one reason or another. It is also important to note that some patients age at faster rates than others. However, it is most important to use your judgment and follow the advice of word of mouth, in addition to advice on this site.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.8 out of 5 stars 93 reviews

Composite Facelift

A good facelift surgeon will use many different techniques and combinations of techniques individualized for the needs of each patient. Results are more important than technique. An experienced surgeon can show long term results. I recently saw two patients with 25 year rhinoplasty results and several others with 15 year results from facial rejuvenation. To answer your original question, some patients complain about the extended recovery after the composite lift.

Richard W. Fleming, MD
Beverly Hills Facial Plastic Surgeon
4.9 out of 5 stars 38 reviews

Which facelift technique is right for you

The facelift technique that each surgeon employs is generally based on a risk versus reward scale. The composite facelift is a wonderful procedure when well executed. The problem with the technique is that there are many potential pitfalls in the procedure that can occur even in the most experienced surgeons hands. Most of the comparitive studies that have been done on facelift techniques have demonstrated no increased longevity of results using this technique versus other less invasive techniques. Many surgeons feel that the increased risk of nerve injury, bleeding, and significantly prolonged patient edema following the procedure does not justify the possibility of longer lasting results.

Philip S. Schoenfeld, MD, FACS
Chevy Chase Facial Plastic Surgeon
4.7 out of 5 stars 30 reviews

Which facelift type is best?

I would agree with the previous answers -- no one surgical techinique is superior, or even appropriate, in every patient and circumstance.

The single biggest key to getting consistent, natural, beautiful resuls is not which procedure I choose to use -- it is truly examining and identifiying what changes each specific patient's face requires to achieve a natural, refreshed look.

Once the patient's specific circumstances -- bone structure, skin type and tone, fat distribution, medial health, etc have been taken into account, then and only then can a surgeon choose what approach or procedure is most likely to be the best choice.

I, for one, am glad that there isn't one "best" procedure that works in every case, no matter what. I enjoy using my artisitic and medcal judgment on a case by case basis!

Laxmeesh Mike Nayak, MD
Saint Louis Facial Plastic Surgeon
5.0 out of 5 stars 199 reviews


Not having read the book, I have to disagree that there is only one way to do a facelift. That's like saying, if you have only on hammer everything is a nail. You must have more than one tool in your toolbox to fix things. Composite facelift are right for one kind of patient and a minilift is right for another.

For example, a busy executive that has minimal excess of the jowl and neck area but doesn't have time to recovery for 3 to 4 weeks will do great with a minifacelift. As long as the surgeon is upfront with the limitations of the procedure and the patient understand, then this is the right procedure. On the other hand, if a patient has excessive jowling and neck excess then a minifacelift will not be the appropriate procedure. Whether the patient has a composite lift or any other type of extensive facelift, they have to be ready for the cost and recovery time.

There was a scientific study comparing SMAS flap ( elevation of the face muscle) vs. plication of the SMAS in the same patient and showed no difference in the outcome of either techniques.

So in short, the right procedure for the right patient with the right surgeon. Every patient is unique and will require a slightly different procedure.

Lastly, your surgeon should be able to perform any of the procedures and be able to explain and offer them to you, understanding the limitations, risks and outcomes.



Oleh Slupchynskyj, MD, FACS
New York Facial Plastic Surgeon
4.8 out of 5 stars 272 reviews

Again it is the surgeon not the surgery that makes the difference

Dear Catalina

Everyone is looking for the exact formula. The reality is that a great surgeon can do almost anything with any technique. Having said that there has been a realization that higher risk facelift have not produced more profoundly improved results. Deep plane and composite facelifts increase the risk of facial nerve damage. How high is the risk compared to a SMAS flap facelift? One or two percent compared to essentially a zero incidence. Is the risk justifiable? Time has told us that no it is not. Consequently facelift surgeons have been modifing their facelift procedures accordingly. Over pulled and unnaturally contoured face lift results are now giving way to more conservative and natural results. We recognize that there is no one right way to do a facelift and these structural surgeries do not replace the need for the expanding use of facial fillers, and skin resurfacing procedures.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Type of Facelift

The Composite Facelift to which you refer is just one of a number of SMAS facelifts. It was developed by Dr. Sam Hamra and is one of the best SMAS lifts there is. It is also one of the hardest for most surgeons to get safe, reliable results. It also has a prolonged recovery in my experience. We have adopted the MACS lift which we have modified. This techniqiue does not elevate below the SMAS and has a much more vertical lift. By doing this, we have been able to get superior results with significantly faster recovery and results that last longer than previously. It also allows us to correct many problems created by the SMAS techniques. In the end, it is not the technique (many techniques can get good results in the right hands), it is the surgeon and his or her artistry and how that person applies the technique to you as an individual for your particular problem.

Robert T. Buchanan, MD
Highlands Plastic Surgeon
5.0 out of 5 stars 6 reviews

The results depend on the patients aging and the surgeon.

The most important issue is the surgeon. I have been doing facelifts for more than 30 years and use different combinations of techniques for different patients. Experienced facelift surgeons should be able to show you patients who are long term.

We developed the irregular, trichophytic forehead lift 30 years ago to prevent the shifts in a womens hairline and actually lower the hairline at the same time. Thus, we never remove any of a womens hair, only bald skin. Composite lifting does not do this and can cause a much longer recovery.

The bottom line is choose an experienced facelift surgeon and let him give you the pros and CONS of different ways of fixing the aging you have.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 34 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.