A Guide to 21st Century Facelifts

A Guide to 21st Century Facelifts featured image
This article first appeared in the Spring 2023 issue of New Beauty. Click here to subscribe

Gone are the days of the super tight, windblown, exaggerated facelifts once reserved for those proud members of the upper echelon of society ages 60-plus. In their place comes the modern facelift, a natural iteration suitable for women and men of all ages. The once hush-hush surgery has had a facelift itself, with far better results and myriad options—there’s a facelift solution for everyone.

It’s not a matter of paint-by numbers, but rather understanding facial anatomy…


Facelift Basics

A comprehensive facelift is centered around correcting laxity and elasticity issues by repositioning the tissues and muscles to a more elevated and youthful position, replacing lost volume as needed and excising loose skin. For the face to appear natural and lifted without inferences of “work,” Delray Beach, FL facial plastic surgeon Miguel Mascaró, MD believes the underlying muscles must be released. “The ligaments of the face have to be repositioned to put the face back where it belongs.”

Even though facelift techniques have progressed and may now include the option for lighter anesthesia for faster healing and diminished complications, the surgery is still not one to take lightly. “It’s not a matter of paint-by numbers, but rather understanding and analyzing facial anatomy because individualization is key,” says La Jolla, CA, plastic surgeon Robert Singer, MD.

How the Facelift Has Changed

The precursor facelifts to what’s practiced now were skin-tightening procedures aimed at removing fine lines and wrinkles in older patients. Releasing and stretching the skin tightens the muscle a bit, but the technique notoriously stretched out the mouth and eyes. “That’s why so many patients looked strange and sported that fake, ‘wind tunnel’ face,” Dr. Mascaró says. Besides short-lived results, he adds that stretching the skin does not counteract aging because it doesn’t remedy the underlying muscles. “Horizontally pulling the skin as tight as possible won’t address problems underneath the skin.”

There’s been a revolution in how plastic surgeons view the face, shifting from a 2-D approach to a 3-D one, and using surgical methods that achieve more natural outcomes. Skin tightening aside, volume replacement is equally important. “A young face is like a plump, round grape that turns into a shriveled raisin as it ages,” says Beverly Hills, CA facial plastic surgeon Kimberly J. Lee, MD. “To make a face youthful again you can’t just remove skin, you must also revolumize.”

“The facelift is better yet different than it was 20 years ago. The fear of looking stretched or unnatural has been put to rest,” says New York facial plastic surgeon Konstantin Vasyukevich, MD. He explains that externally, the surgery still utilizes incisions around the ears to pull everything up, but on the inside, it’s different. “We don’t pull just the deeper structure (SMAS); we go deeper underneath to release the ligaments that hold onto the SMAS. This creates a lift with less obvious results, lasting significantly longer.”

New York facial plastic surgeon Dilip Madnani, MD transformed this 58-year-old patient with a facelift, necklift, upper blepharoplasty, and CO2 laser-resurfacing treatment. 

Directional Lift

The way surgeons pull and lift the skin has changed from a horizontal approach to one that’s vertical and upward. Pulling back creates a distorted appearance.

This 56-year-old patient underwent a deep-plane facelift, browlift, and upper and lower blepharoplasty with Newport Beach, CA plastic surgeon Sanjay Grover, MD for a refreshed look. 
Palo Alto, CA facial plastic surgeons David M. Lieberman, MD and Sachin S. Parikh, MD performed a deep-plane facelift and necklift on this 49-year-old patient to address skin laxity.

Improved Incisions and Scars

A facelift without scars doesn’t exist, but today’s are smaller and less visible. Dr. Mascaró explains that how the face is lifted necessitates incisions hidden along the sideburns, the ear and the hairline. Neck lift incisions are made under the chin, with barely detectable ones that wrap around the ears. “Older techniques would lift the sideburns so high that they would look fake. We’ve modified the incisions along that area, which has changed our understanding of tension.” Less tension on the skin equates to smoother, more inconspicuous scars with considerably less bunching.

The Neck Isn’t an Afterthought

The neck deserves equal footing to create the best results. Therefore, most plastic surgeons recommend a neck lift in addition to a facelift for optimal rejuvenation. “Rejuvenating the neck is a common reason for a facelift because the options to rejuvenate the neck otherwise are limited,” Dr. Lee says.

“When I started doing facelifts, most patients were in their 60s,” Dr. Singer says. “Now, they’re in their 40s and 50s.” And younger patients choose surgery once they see the first signs of a loose jawline and minimal excess skin on their lower face. A facelift for a 40-something patient focuses more on tightening the muscles at the jawline and neck rather than removing a lot of skin because, typically, there’s not much loose skin.”

Fillers, microfat and injectables play a heavy role in most anti-aging routines and are often a patient’s firsthand account of correcting negligible aging before a facelift. “Many patients fathom the limitations of injectables, threads and radio-frequency treatments,” Dr. Mascaró says. “Or, they don’t get the results they want with these options. When younger patients admit they are ready for a facelift, they want to know what to do to achieve the results they want.”

Dr. Lee says patients in their 40s seek mini-facelifts to look refreshed instead of a more dramatic facelift when they are older. “The shift from correction to prevention is appealing to younger patients.”

One significant upside to a facelift early on is a faster recovery. “It’s safer to have surgery when you’re younger because, generally, younger patients are healthier,” Dr. Lee says. “They want to enjoy their results and have their face match their inner youth.”


Once patients reach the 35–55 age group, surgical activity increases.

Source: American Academy of Facial Plastic and Reconstructive Surgery

Which Facelift Is Right for You?

With so many types of facelifts, it isn’t easy to choose which one is best. So instead, make an informed decision with your plastic surgeon. “Artistry and individualization create good results says Dr. Singer. “There is no one specific technique that will produce good results in everyone.”

Dr. Mascaró performed a lower blepharoplasty and a deep-plane facelift with fat transfer on this 62-year-old patient to give her a natural-looking rejuvenation.

The Deep-Plane Facelift

With the deep-plane approach, tissue, skin and muscle are lifted vertically as one unit instead of as separate layers, for a natural, youthful rejuvenation.

The Endoscopic Facelift

This version of a standard facelift relies on an endoscope for additional visualization and elevation of the skin.

The SMAS Facelift

The SMAS lift is the gold-standard. Instead of lifting everything as one unit, the SMAS layer and skin are lifted separately to resuspend the tissues and provide lasting correction.

The Ponytail Facelift

This less-invasive facelift requires smaller incisions behind the ears and into the hairline to minimally lift the upper face.

The Mini-Facelift

Like a ponytail lift, a mini-facelift is best for younger patients with slight laxity in their lower face.

A Facelift Plus…

A facelift is good for solving some problems, like laxity, but it can’t correct everything. You may want to also consider correcting other features that have succumbed to the hands of time, too. These procedures are considered add-ons.

Fat Grafting

Dr. Singer says not everyone needs fat transfer, but those who do will get a smoother, more natural facelift result. “If you need volume but don’t add it, there can be areas of indentations after a facelift,” he explains. “Some surgeons try to overcorrect by pulling without volume, which leads to an unnatural, fake look.”


Injecting neurotoxin precisely above the brow can give some lift and open up the eyes. When more space needs to be created, a browlift is often preferred because it resets and lifts the brows.

Chin Implants

The chin often recedes with age and requires a bit of definition to create harmony and balance.

Lip Lifts

To shorten the distance between the base of the nose and the upper lip, which lengthens with age, a sliver of skin is removed from the area to lift the lip.


Freeing up the extra skin above and underneath the eyes gives a more awake and complete look.


Surgery alone doesn’t improve the texture or quality of the skin, which is why a laser treatment may also be recommended.


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