When a facelift is performed, do surgeons just pull the skin or both the skin and muscles in the face?

The photos that I see in my newsfeed of facelifts are very interesting - some look very natural (like everything was lifted) and some appear as if only the skin was pulled tightly and things underneath the skin weren't adjusted to match the skin being pulled - what is going on? Are the facial muscles and tendons to be lifted as well? I'm not nearly ready for a facelift, but I may be in the distant future and would like to know exactly what is, and what is not, lifted. Thanks!

Doctor Answers 46

Face lift

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Thank you for posting your questions. Post-surgical pictures taken at least three months after the procedure would result in more natural looks. During a face lift, the skin layer and SMAS layer are both pulled carefully. The face muscle and tendon are not pulled. There are various different techniques a physician can use for face lift, but the degree he/she pulls and sutures the skin and SMAS layers would determine how natural the result is. 

Bellevue Facial Plastic Surgeon
5.0 out of 5 stars 17 reviews

Both types of procedures are performed

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Some surgeons only pull the skin.  Many, like myself, perform muscle work (in addition to skin) to help optimize results.  I perform a S.M.A.S. (superficial muscular aponeurotic system) facelift.  In a SMAS facelift, the muscles and fascia are lifted and manipulated.  This provides a more natural lift, as well as a more enduring effect, than working only with the skin.  Best wishes.  -Gregory D Roberts, MD

Many different techniques for operation described as a facelift.

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Faceless can be very limited or very extensive depending on the problems being addressed by the operation as well as the philosophy of the surgeon. You can visit my website to see the technique that I use in the vast majority of my patients. Regardless, when you choose your surgeon the future make certain you understand the specifics of how the procedure will be performed.


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A facelift is a complex procedure of many layers of tissue with manipulation of the skin, the fat beneath the skin, and the fascia over the muscle. The face is very vascular so we can lift the skin off of the face and it will predictably survive much of this manipulation. Smoking is deadly to the skin and we generally reject patients who will not stop smoking. The heart of the surgery is the tightening of the fascia beneath the skin. The fascia is strong and has what we call high tensile strength. The skin is then re-draped over the tissue beneath it to create the new look. Nobody does a skin face lift anymore.

Talmage Raine MD FACS


Talmage J. Raine, MD, FACS
Chicago Plastic Surgeon

Facelift #faceliftrecovery #fatgrafting #beauty #tmbcosmeticsurgery #woundhealing

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Dear Persimmonfrost

Thank you for your question! A facelift is a misnomer- Facial Rejuvenation involves shaping of the deep layer of tissues and the addition of fat grafting to restore lost volume.  The technique depends on the surgeon - and the exact steps will vary from patient to patient.

With Warm Regards

Trevor M Born MD

Trevor M. Born, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 126 reviews

Performing a Facelift

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The technique utilized by a Surgeon will depend largely on his/her training, comfort level, knowledge of anatomy, and experience in facelift surgery.  Based on personal experience, I have found that the most effective and comprehensive procedure for facelift is the composite lift.  In your question, you mentioned that, "some appear as if only the skin was pulled tightly and things underneath the skin weren't adjusted to match the skin being pulled" and this is a very good observation.  In my opinion, the composite lift allows for the most natural results because the Surgeon is effectively lifting skin and SMAS together.  Some degree of separation of the two layers later in the case allows for what we as Surgeons refer to as a bilaminar pull.  The facial muscle should not be lifted in any form a facelift technique.  The layer sitting on top of the muscles or the "SMAS" is the fibro-fatty strength layer of the procedure. The analogy I use is that it is like pulling on the carpet liner so that extra carpet can be trimmed (skin).  Good luck in your research. 

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.9 out of 5 stars 104 reviews

Mini face lift vs facelift ... skin vs deeper layers and skin. What to choose?

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Thanks for sharing your question. I can appreciate your concern.

You hit the nail on the head. You are completely right. A deeper tissue pull will give you a more natural look will result from the procedure. some people jump into the simpler surgery for price and quick fix, However time always reveals that a more thorough procedure will last the test of time better. Cheaper and faster is not always better. 

Finally, make sure that you have a consultation with a board certified plastic surgeon.

Wishing you the best in your journey

When a facelift is performed, do surgeons just pull the skin or both the skin and muscles in the face?

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 Hi this is a very good question and one that I am frequently asked regarding differences between the many different names and types of facelifts.  In reality faces;its can be performed in "all" sorts of manners based upon the individual facelift surgeon.  

I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts.  Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.   

 Conversely, men look chiseled and handsome with angularity in the cheeks, chin and mandibular angles.   The following procedures would create a more ruggedly handsome face.

  • Cheek augmentation with cheek implants to add angularity to the cheeks and mid face.  This would be combined with liposuction to reduce the excess facial fat to further define the cheek shape.
  • Chin augmentation, using a chin implant, to add projection to the chin creating harmony and balance to the lower face.
  • Augmentation of the mandibular angles using a dermal filler (jaw implants have too many unwanted side effects IMHO) to add volume, angularity and flare to the jaw line.

A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.   I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.

 If you have "jowls” these are sagging facial tissues and an indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.

 My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:

**very small incisions
**minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned) can be **performed in 90 minutes or less, with or without general anesthesia
**no incisions within the hair = no hair loss
**excess fat can be removed
**excess skin removed
**cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
**most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.

Hope this helps.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

What is Lifted with a Facelift

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You are very observant. What is lifted depends on who is doing the facelift and the technique used. The Facelifts that look natural have had the underlying structures, the SMAS (an investing fascia) and fat, lifted and the skin is just placed back down and trimmed. Some surgeons can undermine the SMAS enough to get real elevation and maintain the fat. Because this requires significant skill, most surgeons simply pull and rotate the SMAS. This pulls backward and you look "pulled." Others, in order to save time and avoid undermining in an area where the facial nerve is, undermine a little, pull the SMAS some and use the skin to do the rest, which, as you have observed, results in a poor result. I personally prefer what I call the VACS Lift (Variable Access Cranial Suspension). It is based on the MACS Lift and truly elevates the SMAS, retaining the normal fat. The skin is then just trimmed to fit. The results are very natural. (See TodaysFacelift.com) When you are ready for a facelift, select your plastic surgeon very carefully.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Face lift - what is tightened?

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Thank you for asking about your face lift.

  • There are many different kinds of face lifts - and they should be selected according to what is needed.
  • But in general, the face lift tightens the skin and muscle in the neck, and the skin and SMAS layer in the face.
  • The SMAS layer is a tough supporting tissue but not a muscle.
  • In the face, no muscles or tendons are tightened or need tightening.
  • Face lift distortions can be caused from a range of problems, including, as you say, doing a skin-only face lift when deep tissues need tightening -
  • This is not an error that a Board Certified Plastic Surgeon would make.

Always see a Board Certified Plastic Surgeon. Best wishes  - Elizabeth Morgan MD PHD FACS

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.