Face lift

This article covers the effect of a face lift on the tissues of the mid and lower face, the choice of method, how the operation relates to the neck and to other facial procedures, recovery and risks.

What is a face lift?

A face lift is an operation performed to change the position of the loosened tissues of the cheek and lower face, to reduce sagging along the jawline and to adjust excess skin. Along with the skin, the underlying superficial muscular and fascial system is assessed. Different surgical procedures have been described for this structure, known as the SMAS.¹

Change in the face does not arise from loosening of the skin alone. Downward displacement of the tissues and loss of volume are separate problems. Lifting tissue and replacing lost volume therefore serve different aims.² The examination establishes which change predominates; not every line is expected to be resolved by the same operation.

A face lift and a neck lift are most often performed in the same session. This article covers the face. Corrections directed at the neck skin, at the neck muscle known as the platysma, and at the neck angle are the subject of the neck lift article. That distinction does not mean a face lift has no effect on the neck. Some SMAS and deep plane methods extend to the neck as well; the surgical scope is not determined by the name of the incision alone.³⁴

Who is it suitable for?

A face lift can be considered in people with loosening of the cheek and lower face tissues, sagging along the jawline, or an accumulation of tissue around the mouth. The decision is not made on age alone. The state of the tissues, general health, previous procedures and the person's expectations are assessed together.²

In a face where loss of volume predominates, the change achieved by lifting alone can differ from that in a face where sagging of tissue predominates. Assessing looseness, volume and the skin surface separately at examination helps to establish which aim is addressed by which procedure.² Choosing on the name of the procedure alone may not show that distinction.

Where there is active infection, an uncontrolled illness or something that prevents the recovery period being observed, those are addressed first. If the expected benefit does not convince the person, not having surgery is also an option. Deciding calls for understanding not only how the change will be made, but the scars and the risks as well.

What does the examination look at?

Cheek and the area around the mouth: Volume over the malar area, the position of the cheek tissues and the nasolabial fold, the crease running from the side of the nose to the corner of the mouth, are assessed. The lines below the corner of the mouth and the accumulation of tissue in the lower face are examined separately.

Jawline and neck: Looseness along the jawline and the state of the neck skin and muscles are recorded separately. The limit of the correction to be made in the face, and whether a procedure will also be added to the neck, are established.

Skin, ear and hairline: Excess skin, the natural creases in front of the ear, the earlobe, the sideburns and the hairline are examined. Preserving these structures and taking previous scars into account matter in choosing where the incision sits.⁵

Sensation and expression: The two sides of the face are compared at rest and during movement. Raising the brow, closing the eye, smiling and lower lip movement are assessed. Any numbness or difference in movement present before surgery is recorded.

Previous procedures and medical history: Previous facial, neck and eyelid operations, and thread procedures, fillers, fat transfer and energy-based treatments should be declared. When each was done, to which area, and whether any problem followed are stated. Medication, supplements and nicotine products you use are part of the assessment.

At the end of the examination the target areas, the method to be used, the incision sites and the expectations falling outside the scope are settled. The differences present between the two sides at the outset are taken into account; removing the same amount of tissue or pulling in the same direction is not a suitable plan for every face.

How is the operation planned?

Which areas will be corrected?

Aims relating to the jawline, the cheek and the nasolabial area are set separately. Some face lift methods are described as also moving the tissues of the midface.³ Where there is a specific expectation relating to the transition from the cheek to the lower eyelid, however, a midface lift is assessed separately. The effect of a face lift on the midface does not mean a second midface operation is performed in everyone.

For the outer brow and the temple a temporal lift, and for the forehead and eyelids the relevant procedures, carry separate aims. Adding a neck lift is a separate decision too. Operating together does not mean that all these areas will be corrected with the same technique or to the same degree.

Where is the incision made?

In this practice the incisions are made in front of the ear, behind the ear and in the hairline. The length of each part of the incision is determined by the excess skin and by the planned correction. The approaches around the ear and in the hairline are the incision routes described in face lift surgery.⁵

Closure in front of the ear, behind the ear and in the hairline is done with sutures; behind the ear staples, that is surgical clips, may also be used. Wound closure strips are applied to the areas operated on. The purpose and the removal time of the closure sutures differ from those of the temporary hemostatic net sutures described below.

What is done to the SMAS?

Depending on the tissue, SMAS plication or SMASectomy may be performed; the deep plane approach is also among the methods used. Which method is chosen is determined by the structure of the tissue and by the intended change.

SMAS plication: The SMAS is folded and tightened with sutures. The aim is to adjust the position of the tissues beneath the skin.

SMASectomy: A portion of the SMAS is removed and the remaining edges are joined. This is a different procedure from removing excess skin. Plication and SMAS excision are separate approaches described for adjusting the SMAS.¹

Deep plane: Work is carried out in the plane beneath the SMAS, releasing the tissues and moving them together. Which ligaments are released, and how far the work extends into the midface or the neck, vary with the method. In descriptions of the extended deep plane, the ligaments of the neck and the platysma are stated to be addressed alongside those of the face.³ That description does not show that all deep plane operations have the same scope.

In a review assessing 47 studies and 10,766 patients, only 1 study was reported to compare aesthetic outcomes directly.⁶ Another review of 17 articles states that superiority of the more medially extending deep plane methods could not be shown for midface appearance or for maintenance of the result.⁷ That does not mean the method has no effect on the midface; it is not suited to concluding that a single method is superior for every patient.

What do extended SMAS and limited incision mean?

In the extended SMAS approach the SMAS is released over a wider area. Applications in which the skin and the SMAS are moved separately, and the neck and jawline are addressed together, have been described.⁴ The names extended SMAS and deep plane should not be used as though every publication described the same operation.

Limited incision describes the length of the access in the skin; it does not by itself explain the work done in the deeper layers. Different SMAS adjustments can be made through short incisions.⁸ These options appear here for brief comparison. A short incision does not by itself mean less risk or the same correction.

Is fat transfer or another procedure added?

Where there is loss of volume, fat transfer can be assessed in the same session. Fat transfer carries a volume aim; it is not an equivalent alternative to lifting sagging tissue. Repositioning tissue and adding volume are described as separate components of a facial rejuvenation plan.²

Adding a neck lift, or a separate midface lift, is determined by what that area needs. Where procedures are performed together, the duration, the care and the risk assessment are planned together. An additional procedure is not needed in everyone.

Why is the hemostatic net used?

The hemostatic net is a technique in which temporary sutures passed through the skin close the potential space between the skin and the tissues beneath it. The aim is to eliminate the space in which a haematoma, that is a collection of blood, could gather.⁹ It is used in this practice; it is not a step that every surgeon applies or that is compulsory in every face lift. These sutures are removed at the clinic after 2 to 3 days.

In a study of 525 consecutive patients, the first 120 formed the control group from the earlier period in which the net was not used. In that group 17 haematomas, a rate of 14.2 per cent, were reported in the first 72 hours. In the 405 people who subsequently had the net applied, no haematoma was seen in that same early period.⁹ The 14.2 per cent is not a general face lift rate; it belongs to the earlier period of a single centre. That the groups come from different periods should be taken into account in interpreting the result.

In a meta-analysis of 8 studies and 1,617 patients covering face, brow and neck rejuvenation surgery, pooled rates of 0.14 per 100 observations were reported for haematoma and 12.70 per 100 for red suture marks. The estimates for persistent hyperpigmentation, that is darkening of the colour, and for loss of sensation were given as 0 per 100 observations.¹⁰ These are single-arm pooled results from groups in which the net was applied; they are not a comparison with a group without the net, and they do not mean the risk is zero in any one person.

In a randomised study in which 160 women undergoing deep plane facial surgery were assigned to net and drain groups of 80 each, no significant difference was found in haematoma and seroma rates.¹¹ The series also includes people who had a neck lift added and people in whom only the midface was lifted. One haematoma was reported in the net group and none in the drain group; 7 seromas were seen in each group. That result does not show that drains are unnecessary. In this practice a drain is used in selected patients.

Removing the net sutures early does not mean the marks on the skin will disappear the same day. Temporary red marks can last for weeks; how the marks develop is explained separately below.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹² Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹³ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁴ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁵ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁶ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁶ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Keeping blood pressure under control around the time of surgery is an important part of the measures assessed for reducing bleeding in face lift surgery.¹⁷ Changes in readings and any problems with treatment should therefore be reported to the surgical team. Medication is not adjusted on the person's own decision.

What is recovery like?

The operation is carried out under general anaesthesia. 2-3 hours are planned for the operation and 1-2 nights for the hospital stay. These ranges cover both a face lift alone and a face lift combined with a neck lift. Where a neck lift is added the periods can lengthen; the details of the neck technique are the subject of a separate page.

The first check-up is in the first week. For the hemostatic net sutures, a separate clinic assessment and removal of the sutures are planned after 2 to 3 days. For the other stitches, the 1 week given in the summary box is a short figure; they are removed within 7 to 10 days, with the incision checked. The staples behind the ear are assessed at the same check-up.

Bruising is expected to settle over 7-10 days and marked swelling over 2 weeks. These intervals do not mean everyone reaches the same appearance on the same day. Being fit to return to work can come before all the bruising and swelling has gone.

The shape becomes possible to assess over 2-3 months, while residual mild swelling can last up to 3-4 months. Assessing the shape therefore does not mean that all swelling has finished by that day. The direction of healing is monitored at check-ups; swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Dressing, garment and drain: A dressing is used until discharge; a compression garment is provided on discharge. How the garment is worn and for how long are determined by your surgeon's instructions. A drain is not routine; it is used in selected patients. Where a drain is present, its care and the timing of its removal are arranged according to the findings at check-up; it is not removed on your own. Carrying out dressing and drain care according to the instructions given to you is advised after a face lift.¹⁸

The incision and strips: The care instructions given for the sutures and strips in front of the ear, behind the ear and in the hairline are followed. The creases of the ear and the area behind the ear are not rubbed, and crusts are not picked off. Guidance from the surgical team is taken before changing the strips or applying any product around the incision.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your face: Washing the face is allowed within 3 to 7 days, after the incision and dressing have been checked. Which day and how to begin are determined by your surgeon's assessment. The instructions given for the wound closure strips and the hemostatic net sutures are followed.

Washing your hair: The hair is first washed within 3 to 7 days, in the way your surgeon says according to how healing is going. When the hair is washed, the care instructions given for the incision line and the strips are followed. Hair dye, salon treatments and applying products around the incision are also checked for suitability first.

Shaving and make-up: These begin after 2 weeks, at your surgeon's decision. Applications that rub the incision line or carry product onto an area that has not yet healed are avoided. The interval passing does not by itself mean it is suitable.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be tenderness, tightness and pain in the face and around the ear.¹⁹ The painkillers provided are used as instructed. Pain that keeps increasing, becomes marked on one side in particular, or comes with eye pain should not be watched and waited out. The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 2 weeks are set aside for returning to desk work; in physically demanding jobs healing is assessed separately. Return to sport is staged from 4 weeks. It begins with light activity; the surgeon's approval is awaited for movements that keep the head down for long periods, that require straining, or that carry a risk of impact to the operated area. The 6 weeks given for a full return to daily life does not mean the scar has also finished maturing.

Driving: A return to driving can be assessed after 1 week. The effects of the anaesthetic on attention and reflexes must have passed, and there must be no visual problem, dizziness or use of painkillers that cause drowsiness. You should be able to turn your head, follow the traffic comfortably and perform sudden manoeuvres without pain. Where those conditions are not met, no one drives even if the interval has passed. On discharge you go home accompanied.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and face, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising, tenderness and tightness in the face and around the ear, and numbness or altered feeling around the incision, can occur.¹⁹ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or a new loss of movement should not be judged as ordinary healing.

How do the scars change?

How are the scars around the ear and in the hairline followed?

Face lift incisions leave scars. Placing the incision in the natural lines around the ear or in the hairline does not mean there is no scar. A conspicuous scar and hair loss around the incision are among the reported risks of a face lift.¹⁹

Maturing of the scar is expected to take between 6 months and 1 year. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Silicone gel, silicone sheeting and massage are advised for the scars in front of and behind the ear. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. For the scalp scar, silicone gel, silicone sheeting and massage are not advised. The same care is not applied to every incision area.

The plan given by the surgeon is followed for care of the incision. The incision line is not strained when the hair is combed, and crusts are not picked off. Care is taken to protect the area from the sun. Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

When do the marks from the hemostatic net sutures fade?

The temporary marks at the entry points of the hemostatic net sutures are different from the incision scar around the ear. In the Ribeiro meta-analysis covering face, brow and neck rejuvenation procedures, red marks were reported to resolve completely within 2 to 3 months and not to progress to persistent darkening of the colour.¹⁰ That finding does not mean the skin will look free of marks as soon as the sutures are removed.

In a series of 300 people in an Asian population covering facial, brow and neck procedures, 90 per cent of the net marks were reported to have disappeared within 1 month, with some lasting up to 8 weeks. No persistent hyperpigmentation was seen in that series.²⁰ The study does not cover face lifts alone, and it includes selected people who complied with follow-up and care. These results do not constitute a personal guarantee that no lasting mark will remain.

Can hair loss or a change in the shape of the ear occur?

Temporary or permanent hair loss can occur around an incision involving the scalp.¹⁹ Displacement of the hairline and the sideburns, and retraction of the earlobe, are also problems that need assessing.¹² New thinning, retraction of the earlobe or a scar becoming more prominent should be shown at a check-up. How it develops is monitored; a decision on further correction is made according to healing and the existing structure.

Risks and complications

Risks are assessed according to the method, the extent of the operation and the person's situation. The name of a technique does not express the same level of risk in every patient. The results of studies covering different operations and additional procedures should likewise not be merged into a single figure for success or safety.⁶

Problems of shape, symmetry and scarring

A difference remaining between the two sides, the appearance not meeting expectations, a conspicuous scar or distortion at the ends of the incision can develop.¹⁹ A difference during the period of swelling and asymmetry remaining after healing are assessed separately.

Residual or recurring sagging of the jawline can call for further assessment.² A decision on a new procedure is not made before establishing whether the problem relates to tissue position, volume, the scar or early swelling.

Problems of sensation and facial movement

Sensation: Numbness or altered feeling on touch can develop around the ear and near the incision. The great auricular nerve carries sensation from the earlobe and the area around it; it is different from the facial nerve that works the muscles of expression.¹ Feeling and movement are assessed separately at check-ups.

The facial nerve: The temporal branch, also called the frontal branch, relates to movement of the forehead and brow; the zygomatic and buccal branches to movement around the eye, the cheek and the mouth. The marginal mandibular branch matters for lower lip movement. Where work extends into the neck, the cervical branch enters the assessment as well.¹ Involvement of these branches can lead to temporary or permanent weakness of movement.²¹

In a meta-analysis covering 67 publications, 15,404 patients and 15,441 procedures, the overall rate of motor nerve damage was reported as 0.66 per cent and of sensory damage as 0.39 per cent. The pooled estimate for permanent motor damage is 0.047 per cent and for permanent sensory damage 0.045 per cent.²¹ These groups cover different face lift techniques, revision operations and other facial procedures performed alongside; the figures are not the personal risk rate of the operation described here alone.

Most motor problems have been reported to be temporary.²¹ Nonetheless, a new loss of movement should be assessed without delay. The overall motor and sensory rates do not belong to a particular nerve branch, and permanent events are not added to the total as a separate additional risk.

Problems of bleeding, the wound and fluid collection

Bleeding and haematoma: A collection of blood in the operated area can cause swelling and tightness.¹⁷ Where swelling increases rapidly on one side in particular, or pain becomes steadily more severe, the scheduled check-up is not waited for. Further intervention may be needed depending on the examination.

In the review of 47 studies and 10,766 patients, the haematoma rate was reported as 3 per cent in the deep plane group and 2 per cent in the SMAS group.⁶ These are rates pooled from different sets of studies; they do not show a definite difference in risk between two options for any one person. In another review of 20 articles and 4,451 patients examining limited incision methods, total complications were reported at 3.2 per cent and haematoma at 2 per cent.⁸ The rates in that second review do not apply to all face lifts or to deep plane surgery alone.

An expanding haematoma can affect the blood supply to the skin and may call for rapid intervention.¹⁷ Using a hemostatic net or a drain does not remove the possibility of bleeding.¹¹

Infection and the wound: Infection, fluid collection, delayed healing of the wound and tissue loss can develop.¹⁹ Where redness spreads, or there is discharge, fever or separation of the incision edges, assessment by the surgeon is needed. Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone.

Seroma: Tissue fluid can collect in the operated area and may need draining by the surgeon.¹¹ A new swelling cannot be distinguished as blood or tissue fluid without examination. Do not press on the area yourself or try to drain the fluid.

Anaesthetic and general surgical risks

Risks relating to general anaesthesia are considered together with the medical history and the anaesthetic assessment. General surgical risks such as cardiac and respiratory problems are also part of the assessment.¹⁹

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Risks relating to added procedures

Where fat transfer, a separate midface lift or a neck lift is added, the risks and care requirements of those procedures are assessed as well. In series involving combined procedures it is not possible to attribute every complication that develops to the face lift alone.²¹ Which procedure is added, for what aim, and how it affects the care plan are explained before surgery.

How does the result change over time?

The same number of years cannot be given to everyone for the result of a face lift. In long-term research, a change maintained at a particular follow-up point does not show exactly when the result will be lost in that person.

In a study assessing 50 people 5.5 years after their first face lift, 21 per cent of the elevation achieved by surgery in the sagging tissues of the jawline was reported to have relapsed. In the same study, 69 per cent of the correction achieved in the neck angle was reported to have relapsed.²² These do not mean that 21 per cent or 69 per cent of patients had a recurrence; they describe how much of the correction obtained at the outset had returned. That series, in which the neck result was also assessed, shows that the face and the neck do not have to follow the same course over time.

In the overall appearance scoring, 76 per cent of people were reported still to look younger 5.5 years later than they had before surgery.²² That is not a percentage of patient satisfaction, nor a guarantee of durability that can be given to any one person. The study's follow-up period is likewise not a recommended timetable for further surgery.

The 5 years in the title of another series of 60 people on the extended SMAS is the period over which the study recruited patients; the mean patient follow-up is 8.3 months.⁴ Separating the study period from the follow-up after surgery matters for reading information about durability correctly.

Where further correction is needed, residual looseness, newly developing change, the scar and loss of volume are assessed separately. A decision on further surgery is not made on the number of years that have passed alone.

What can be expected from the result?

The aim is a correction that assesses the position of the mid and lower facial tissues and the jawline together with the person's facial structure. The appearance of the nasolabial area can change; no promise can be made that this fold will be erased entirely. Improvement having been reported in that area in a long-term series does not mean every method gives the same result in every person.²²

Displacement of the tissues, loss of volume and changes on the surface of the skin are separate aims. Adding fat transfer or another procedure is therefore assessed separately.² A wider operation is not assumed to give a better result in every situation.⁷

Assessing the shape, returning to daily life and the maturing of the scar are not completed on the same date. The result is assessed by monitoring early swelling, the balance of the two sides, expression, sensation and the appearance of the incision together.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Rapidly increasing swelling and tightness in the face or around the ear, on one side in particular
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• New marked pallor, darkening or blistering of the skin
• New loss of brow, eye closure, smile or lower lip movement
• Pain, pressure or swelling increasing under the dressing or garment

Bleeding, impairment of the blood supply to the skin and new nerve findings can call for early assessment.¹⁷²¹ Where rapidly increasing swelling in the face and neck is accompanied by difficulty breathing, urgent assessment should not be delayed.² Sudden change in vision or severe eye pain should not be waited out either.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing or visual problem in particular, urgent assessment is not delayed while trying to reach the surgeon.

About the numbers in this article

The intervals given for the operation, the hospital stay, stitch removal, returning to work and activity, and for swelling, the shape settling and the scar maturing are a framework of clinical practice. The summary box covers both a face lift alone and a face lift combined with a neck lift. The removal time of the net sutures is separate from that of the other stitches.

Numbers of patients and of procedures in the research are not the same unit. The results of combined procedures are not counted as the result of a face lift alone. A single-arm meta-analysis is not a comparison with an untreated group; an event not being reported does not mean the personal risk is zero.

Loss of correction measured at long-term follow-up does not mean that the same proportion of patients had a recurrence. The follow-up period is not presented as a promise of durability or as a timetable for further surgery.

The studies on stopping smoking cover different operations. The relative risk reductions in those studies do not amount to a complication rate specific to a face lift, or to separately proven effects for every nicotine product.

References

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3. Jacono A, Bryant LM. Extended deep plane facelift: incorporating facial retaining ligament release and composite flap shifts to maximize midface, jawline and neck rejuvenation. Clin Plast Surg. 2018;45(4):527-554. doi:10.1016/j.cps.2018.06.007 ↩ ↩² ↩³

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8. Amador RO, Hamaguchi R, Bartlett RA, Sinha I. Limited incision facelifts: a contemporary review of approaches and complications. Aesthet Surg J. 2024;44(3):NP218-NP224. doi:10.1093/asj/sjad344 ↩ ↩²

9. Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg. 2014;38(1):1-9. doi:10.1007/s00266-013-0202-5 ↩ ↩²

10. Ribeiro LF, De Freitas LR, Udoma-Udofa OC, et al. Efficacy and safety of hemostatic net in facelift and rejuvenation surgeries (browlift and necklift): a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2026;116:118-130. doi:10.1016/j.bjps.2026.03.029 ↩ ↩²

11. Ismail M, Ghoraba S. Hemostatic net versus surgical drain after deep plane facelift surgery: a prospective randomized controlled trial. Aesthetic Plast Surg. 2025;49(16):4572-4578. doi:10.1007/s00266-025-04745-8 ↩ ↩² ↩³

12. American Society of Plastic Surgeons. Managing the risks of smoking in plastic surgery patients. Practice reference, 9 October 2024. Accessed 5 September 2026. plasticsurgery.org ↩

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