What are the different methods of surgical Mid and Lower Facelifts performed today? (photos)

I primarily want to deal with my jowls and neck. I want to understand what type of lift might be best for me so that I have some way of determining which doctor I should choose to get a good result while keeping the procedure as minimally invasive as possible. How can I differentiate between the procedures the doctors recommend? I want the right amount of work: not too much or too little (& for it to last).

Doctor Answers 13

Lower face rejuvenation

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Lower face rejuvenation can consist of tightening skin of the neck, eliminating jowls and lifting cheeks. Start by looking at many many before and after photos that show beautiful and natural results.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Facelift Choices

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Minimally invasive techniques accomplish less durable and less dramatic improvements in your appearance. Your neck and jowls are significant and would be best treated with the routine SMAS lower facelift. 
Although you are concerned about the healing time and risk of complications, my patients can return to normal activities within 10 days.
Good luck!

Robert M. Freund, MD
New York Plastic Surgeon
4.8 out of 5 stars 34 reviews

Addressing the Midface, Lower Face, and Neck Together

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Thank you for the great question and your pictures. There are numerous approaches to facelifting, including endoscopic and minimal-invasive options. That said, to address each of the areas that you highlight (cheeks, jawline, and neck), in my opinion, the best option is a deep-plane facelift. This procedure uses incisions hidden around the ears to elevate the facial and neck soft tissues as a unit -- including the connective tissue and muscle layers. This gives a long-lasting and natural-appearing result.  In addition, this procedure improves the upper cheek area much more than a traditional or mini-facelift. As to your final point, there are many definitions of facelift and each surgeon uses a different method. The only way to know exactly what you are getting is to ask specific questions about the areas to be addressed and to examine postoperative photos during your consultation. Best of luck moving forward!

Facelift versus midface lift

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You are an excellent candidate for a facelift (neck and cheek) along with platysmaplasty and SMAS lifting. Midcheek lift will not address your neck and will not solve your jowling nearly as well. In some select patients I perform a mid-cheek lift along with a facelift, but almost never do I perform a mid-cheek lift in isolation. The longer term results do not seem to hold up in my experience.

Jan Zemplenyi, MD
Bellevue Facial Plastic Surgeon
5.0 out of 5 stars 17 reviews

Best facelift type

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Dear Susan,

You've raised an interesting question.  Highly invasive procedures can cause significant discomfort, take much longer to recover from and have a higher rate of complications. Neither patients nor doctors like the idea of excessive surgery. So, why would anybody do invasive procedures?  And more important question - how among the multiplicity of facelift techniques choose the one that is right for you?

I, among other surgeons, would like to keep my procedures as least invasive as possible.  However, as a surgeon specializing in facelifts, time and again I've seen some minimally invasive procedures fail to achieve significant and lasting rejuvenation.  Sometimes it becomes necessary to do a little bigger facelift initially rather than having to redo it a year down the road.  

Most experienced surgeons can give you a pretty good idea of how invasive your facelift should be to achieve the best results.  Every surgeon you speak with might prefer a different facelift technique or even suggest an entirely different procedure.  I think, your best strategy would be to find a surgeon who can show consistently good results with their before-and-after pictures.  If the surgeon can select the best procedure of other people and make them look good they should be able to do the same for you.

Best wishes!
Dr. Konstantin

Konstantin Vasyukevich, MD
New York Facial Plastic Surgeon
4.9 out of 5 stars 51 reviews

Different Facelift Options

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You are right, there are several different types of face-lifts that doctors perform and it can be confusing. A two-layer face-lift, the most common type, involves the tightening of the tissue under the skin, or SMAS (subcutaneous musculo-aponeurotic substance). With a mini-lift, only the lower face -- from cheek to chin -- is lifted, which effectively eliminates jowls and redefines the cheekbones.
As with a face-lift, the mini-lift is often accompanied by a neck lift, which removes fat from below the chin and tightens the neck's platysma muscles, all through a tiny incision under the chin. There are distinct advantages to having a neck lift along wih your face-lift: The incision is tiny and leaves virtually no scar; moreover, your smooth neck won’t be out of sync with your youthful face! The best candidates for the mini-lift are those who are unhappy with the contour of their lower face and neck, and whose skin has good resiliency. It's also an ideal procedure for a patient who is nervous about going all the way with a major overhaul.
You may also be a candidate for a Threadlift. A non-surgical face-lift that is minimally invasive and addresses signs of aging in the face, including droopiness of the skin of the brow, cheeks, jowls, and neck without incisions or scars. Threads are inserted painlessly under the skin to lift and contour the tissues, providing an immediate tightening. The procedure can be performed using local anesthesia, and most patients can return to normal activities the next day.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.6 out of 5 stars 10 reviews

What are the different methods of surgical Mid and Lower Facelifts performed today?

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Dear Susan
Thanks for your question. Although you live in the US and I practice in Sydney, Australia, I am struck by the similarity in patient's questions, regardless of where we live.

Our work is highly technical, based on many years off training as a Doctor, and then further training as a Board Certified Plastic Surgeon(referred to as Plastic Surgeon in Australia). That expertise, combined with years of experience, helps us to offer solutions to you with regards to your treatment.
Also, every patient is different- in my 20+ years of experience I have never had 2 patients present exactly the same.
So, the proposed surgery needs to be quite specific to each person.

For you to find types of surgery, does not do justice to the need for a face-to-face consultation with a Plastic Surgeon. At consultation, the Surgeon can do a proper detailed assessment, and listen to your concerns, questions and contributions. All of this will help him(or her) determine solutions and options.

Then you can ask your questions, have your discussions with your Plastic Surgeon, and make your decisions based on appropriate information. Just trawling the internet and using online forums will not, I believe, do justice to your research.

Good luck in your surgery.

Lower Facelift

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A lower facelift addresses the jowls and the neck as well. The neck is treated with Platysmaplasty and tightening of the skin and the jowls are pulled back as part of the lower facelift. It is important not to get lost in the different names of the lifts and techniques etc but to describe in detail to a surgeon what is it that you wish to accomplish and then let her/him describe to you what they can do for you. Get two consults at least and then go with your gut. 

Tanveer Janjua, MD
Bedminster Facial Plastic Surgeon
5.0 out of 5 stars 126 reviews

Comprehensive lower face and neck lift

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The photograph presented shows significant  jowls, neck fat, skin laxityin the face and neck. A comprehensive lower face and neck lift will address tightening the neck muscles in 3 locations, removing the fat above and below the platysma muscle in the neck, tightening up the jowls and facial SMAS layer and tightening excess face and neck skin. It is very important to and giving natural look so that you do not look "done". For many examples, please see the link below to our extensive face lift photo gallery

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

The necklift is the foundation for the Facelift.

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Hi Susan,

Since the jowls/jawline and the neck are next to each other it makes sense to treat them together.  I consider the neck the "foundation" facial rejuvenation.  Often times walking around the Upper East Side of Manhattan I see people who have had facelifts and their jawlines are taut, but their neck is still sagging.

Often times the neck was not really treated properly.  A short scar facelift lifts a short area of skin around the ear and the fat/muscle (SMAS Superficial MusculoAponeurotic System) is tightened with sutures, and this causes the "excess skin" to over lap with the incisions around the ears and this skin is tailored away for a nicely camouflaged incision.  Since only a small amount of skin was lifted up, the remainder of the skin and tissues along the jawline and neck were essentially untouched.  This results in a "tug of war" between the treated area which is trying to lift up the jowls/jawline against the untreated neck.  Initially the tightening around the ears that the surgeon performs wins the early battle, and the early result looks good, however, in the following months, the neck and jawline tissues which were essentially untouched will pull back over the remainder of the time and cause the jowls to reform.  

For this reason, it is my opinion that the neck needs to be treated to ensure that the profile is improved and the skin under the chin is fully released.  When this skin under the chin is fully released, then the skin can be lifted along the sides of the face to ensure the skin under the chin is snug against the newly contoured profile.  A comprehensive necklift usually entails a "platysmaplasty" or tightening of a thin sheet like muscle that lines the neck skin from the jawline to the collar bones.  Often times the "stringy" bands and what appears to be loose skin is actually this platysma muscle "bowstringing" through the neck skin and this appears to be loose skin.  To test for this, I will have my patients clench their jaw and show their lower teeth.  This will cause the platysma bands to protrude from the neck and I can see if the "skin bands" coincide with the platysma muscle bands.

The improvement in profile for the necklift is consistently delivered by a "corset" platysmaplasty which involves tightening the left and right platysma muscle along the center of the neck to create a cleaner profile.  The skin then "hugs" the newly contoured platysma muscle shape to create the nice profile.  This is what I mean by the neck is the foundation of the lower face and necklift.  The skin passively mimics the shape of the muscle underneath.  Since this neck skin is fully released and connected to the SMAS or Deep Plane facelift around the ears, then there is no "tug of war" between the neck and the SMAS tissues around the ears.  The skin of the cheek and jawline slide up the side of the face without resistance from skin connections from an untreated neck.

Determining whether to recommend a SMAS facelift versus a Deep Plane facelift depends on the patient and the severity of the Jowling/sagging jawline.  In general, I think my colleagues would agree that a Deep plane facelift is more comprehensive release of the SMAS layer as a "sheet" all the way to the edge of the "jowl" and thus tightens the jowl more than a simple SMAS tightening which does not release the SMAS and simply tightens the surface of the SMAS so that its it "drum tight" but without releasing the SMAS from any underlying attachments.

Not all plastic surgeons offer a deep plane facelift, since it is technically more difficult, and finding the layer under the SMAS towards the jowl is not easy and increases the risk for facial nerve weakness/paralysis.  For this reason many surgeons only offer the SMAS facelift to reduce this risk.  A well known facelift surgeon Daniel Baker in Manhattan is a proponent for the SMAS facelift without increasing the risks to the facial nerve, while his equally famous facelift surgeon Sherrell Aston, is a proponent for his FAME facelift which is a type of Deep plane facelift where he finds a space under the SMAS and under the cheek fat pad and lifts this as a unit.  Whether one is far superior than the other, is still under debate.

Having said that, I will recommend a modified deep plane facelift for my patients with moderate to severe jowling, and a SMAS facelift for mild to moderate jowling.  If the patient only has mild jowling, but would like me to tighten the jawline as much as I am technically able to perform, then I will also perform a modified deep plane facelift for those patients.  But for the majority of patients with mild jowling, a SMAS facelift should deliver a long lasting result for those patients and some surgeons might argue that the deep plane is too much surgery for a patient with such mild jowling.  I think this is a good reason to be able to offer different levels of face/necklifts for different patient anatomy which we encounter.

A deep plane facelift additionally offers more lifting of the cheek than a traditional SMAS lift, since the cheek fat pad is released and lifted in an upwards direction.

I think if you had a short scar type facelift with minimal skin elevation with SMAS tightening, but with your neck area untouched from an incision under the chin, this would not be the "right amount of work" for you.

As far as the midface is concerned, my philosophy is simple.  I don't believe in strongly lifting the cheek fat pad really high.  Instead I prefer to blend the lower eyelid and upper cheek to reduce the shadows of the lower eyelid and upper cheek so that it appears as seamless as possible.  One of the photos which I take during a consultation is a smiling photo to go along with non-smiling photos.  This photo helps me to determine the volume of the cheek when the patient is smiling.  I suspect that your cheeks are already pretty full, even though you are not smiling in your photos.  Adding additional fat to your mid face may be over the top.  Instead adding filler or very small quantities of fat to blend the upper cheek and tear trough can smooth the area without adding much volume to the face which can create the "pillow face" look (google Kim Novak Oscars.)  So much fat is added to the midface, that it looks good when they are not smiling, meaning the lower eyelid and cheek look seemless, but as soon as they smile it is clear that there is too much fat in their cheeks.  I have consulted with many patients who felt their other surgeons overly fat grafted their cheeks which makes them feel self conscious and the try as much as possible not to smile anymore.  I find this to be very sad.

The volumes needed to smooth the lower eyelid to the upper cheeks is usually in the range of 1-3 cc's for most patients whether it is filler or fat.

Of note, you also have something called a malar ligament which causes an indentation just below the top edge of the cheek.  This can form a small pouch of fat which is called a malar crescent.  If the indentation and fat folds over the ligament, then this would be called a malar festoon (which you do not have.)  This is a harder problem to fix.  Often times, when I review the patient's younger photos, they already had these malar ligament creases even in their younger years and sometimes this does not bother them very much so they are not overly concerned with eliminating this problem.  Malar crescent/festoon/ligments would be an extensive discussion in itself, which I will not go into here.

One thing I would like to comment on, is that your upper eyelid creases look very youthful. One of my main criteria for a youthful appearance is to have "paralllel" upper eyelid crease/folds.  If you go back into your younger photos, I would guess that your upper eyelids/eyebrow area has not changed very much through the decades, other than some minor wrinkles that form between the eyebrows and forehead.  If this area already looks similar or the same as it did in youth, then I have the philosophy of "if it ain't broke, don't try to fix it."  More eyelid showing is not necessarily more youthful.  Review younger photos of yourself and most likely you will find this to be true.

I hope this discussion will help you on your plastic surgery journey and possibly help others who have asked themselves the same question.  Thank you for the question..


Dr. Yang

George Yang, MD
New York Facial Plastic Surgeon
4.8 out of 5 stars 35 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.