Why aren't the apples of the cheeks lifted vertically during a facelift?

Question

I have noticed that most deep-plane facelifts lift along a diagonal vector (closer to the ear). However, a lot of people are left with sagging cheeks. Why isn't the malar eminence area lifted vertically (closer to the lower eyelid) during a facelift? I see a lot of great results but they are partial because I see the apples of the cheeks still sagging

James M. Economides, MD, FACS · Answer

There is a natural vector that is followed with most deep plane facelifts that is more diagonal than vertical. It is possible to address the cheek or malar area with adding back volume via fat transfer. In that way you have the benefit of both the lifting of the SMAS and cheek.

Jonathan Kulbersh, MD · Answer

Hello, thank you for posting your question. The best facelift procedures pull the cheeks upward and outward for natural and long-lasting results. An incision should be made near the temple and hairline, lifted near the ear, and hidden with a natural crease line. The superficial muscular aponeurotic system (SMAS), which consists of deep tissue and muscle, is then lifted upward and outward. This process creates natural results and a small chance of future sagging skin and cheeks. It can be challenging to have similar results without both steps to the facelift. A board-certified facial plastic surgeon with skill and experience works closely with patients to explain the process and expected results.

Martin Jugenburg, MD · Answer

Hello, thank you for your question. Yes in some instances we can only lift so much of the face. For mid to upper face lifts, the incisions would have to be taken higher along the hair line. The mini facelift is an incision that starts by the tragus of the ear and wraps around the ear into the posterior hairline. We try our best to lift upwards but of course limited by the incision. So to achieve what you are looking for can be accomplished, but with higher scars.

David K. Isaacs, MD, FACS · Answer

A deep-plane facelift with ligamentous release and malar elevation should lift the apples of the cheeks.

Facelifts should have a vertical component and there are different opinions on the overall vector.

I performed an extended deep-plane facelift with ligamentous release and malar elevation when indicated.

Zoran Potparic, MD · Answer

Based on several long terms studies on aging, it appears that loss of cheek projection is primarily due a volume loss; as we get older, fat disappears from some areas of the face (periorbital) and that may be seen as a sagging. Instead of lifting cheeks, which may be necessary in some cases, volume addition by means of fat micro and nano grafts seems to be most natural way of rejuvenation. We combine this procedure in probably over 80% of our face/neck patients. Hope this helps.

Ronald J. Edelson, MD · Answer

I think you are over analyzing this and making it more complicated than it needs to be. But that’s not your fault. Plastic surgeons try to make it sound fancy and artistic to do a facelift. But it’s really pretty simple. Deep facelifts have been done for fifty years and never been shown to be better than a traditional facelift. Surgeons talk about vectors to sound scientific. When getting a facelift I advise you keep it simple. Go to a reliable surgeon who is experienced and doesn’t give you a big song and dance. And whatever you do don’t get fat injections because they like to push that on you too

Lina Triana, MD · Answer

Depends on the technique used how the traction will take place, I personally do the traction upwards as you suggest since when we age our face falls down because of earth’s gravity force,  and not forward into the midline

David M. Kowalczyk, MD, MBA, FACS · Answer

Good Morning! Great question. Typically, the vector is superolateral toward the temple area rather than toward the ear. If you lift the cheek mound too much, it can crowd the lower eyelid and make an odd-appearance to the face. This can happen especially in midface lifts if done improperly. The malar eminence usually returns to a nice position in a deep-plane lift with the correct vector. Hope this helps!

Karan Chopra, MD · Answer

Thanks for the great question @Carmeliana! For adequate tissue repositioning all the retaining ligaments are carefully released during the surgery. Also, if needed the deep and superficial malar fat compartments are augmented with fat.... because you cannot lift an empty space. I hope this clarifies some details and please follow me on instagram to see some more videos and pictures.

Richard P. Rand, MD, FACS (retired) · Answer

You have hit on the biggest difference between a SMAS lift and the deep plane lift. The SMAS is the more popular nationally because it allows the surgeon to work in 2 vectors of movement, elevating the deep tissues straight up to where they came down from, and the skin on a more natural line along the jawline and more horizontally the farther up you go. A much better option IMO. Check all my photos on my website randcosmeticsurgery.com for examples.