Continuing Education Activity

Cervicofacial rhytidectomy, commonly known as facelifting and necklifting, is a cornerstone surgical procedure for the management of facial aging and remains the second most commonly performed facial cosmetic operation after blepharoplasty. Age-related changes, including gravitational descent of soft tissues, ligamentous laxity, skin redundancy, fat atrophy, and progressive bony resorption, produce characteristic findings such as deep nasolabial folds, jowls, marionette lines, and platysmal banding. The facial aging process produces characteristic hollowing of the temporal, perioral, pre-jowl, and malar regions, and rhytidectomy is performed to rejuvenate the face by resuspending ptotic soft tissues to address hallmark signs of aging.

This activity provides an overview of the historical evolution of rhytidectomy, reviews clinically relevant anatomy, and examines common and procedure-specific complications. This activity also equips healthcare professionals with the knowledge and tools needed to distinguish among contemporary rhytidectomy approaches and technical considerations, supporting informed procedural selection and individualized patient care. A broad spectrum of facelifting techniques is reviewed, with emphasis on foundational anatomic principles, core surgical concepts, and the prevention, recognition, and management of complications. The activity also highlights the importance of interprofessional collaboration among healthcare providers in optimizing preoperative assessment, intraoperative safety, and postoperative recovery. Effective team-based care is emphasized as a critical factor in improving patient-centered outcomes, minimizing complications, and enhancing overall satisfaction in the surgical management of the aging face.

Objectives:

• Identify key anatomic landmarks and age-related structural changes that influence technique selection in cervicofacial rhytidectomy.
• Differentiate among SMAS, deep-plane, composite, and minimal access cranial suspension facelift techniques based on anatomic findings and desired surgical outcomes.
• Select an evidence-informed rhytidectomy approach that aligns with patient goals while minimizing the risk of complications such as hematoma, nerve injury, and skin necrosis.
• Collaborate effectively with the interprofessional healthcare team to optimize perioperative assessment, intraoperative safety, and postoperative care in facial rejuvenation surgery.

Introduction

Rhytidectomy, commonly referred to as facelifting, is a surgical procedure designed to reposition facial soft tissues to create a more youthful appearance. Although currently widely performed, rhytidectomy was relatively uncommon in the early 20th century because of negative public attitudes toward cosmetic surgery and the secrecy with which surgeons guarded their techniques.[1] The first documented facelift was performed in 1901 by Eugene von Holländer, who excised and reapproximated excess skin with minimal undermining. After World War I, the demand for reconstructive surgeries increased, and so did Western cultural acceptance of plastic surgery as a whole. However, it was not until after World War II, with the advent of antibiotics and the development of general anesthesia, that a more aggressive approach to facelifting became practical.

In 1969, Swedish plastic surgeon Tord Skoog was the first to describe a facelift technique in which dissection was performed along the superficial facial fascia, resulting in longer-lasting rejuvenation. This fascia was later defined as the superficial musculoaponeurotic system (SMAS) in an anatomical study by Mitz and Peyronie in 1976, which subsequently led to the development of the surgical technique now known as SMAS rhytidectomy.[2] This approach may involve SMAS plication, imbrication, transposition, advancement, or a combination thereof.

Today, numerous facelift techniques are available. Some surgeons favor more complex procedures that involve extensive soft tissue mobilization to comprehensively rejuvenate the face and neck. In contrast, others prefer minimally invasive approaches with shorter incisions and limited dissection. These techniques typically address more localized concerns but offer the advantage of faster recovery.[3] The "tri-plane" rhytidectomy was introduced by Hamra in 1983 to include subcutaneous elevation of cervical skin to improve neck contour. In 1990, he described the “deep-plane” rhytidectomy, which involves dissection of the zygomaticus musculature and repositioning of the malar fat pad to efface the nasolabial fold (NLF) and elevate the midface. In 1991, Hamra further developed the “composite” rhytidectomy, incorporating the orbicularis oculi muscle into the deep-plane dissection to enhance eyelid and cheek contour and allow repositioning of the suborbicularis oculi fat (SOOF), thereby smoothing and rejuvenating the transition zone between the lower eyelid and the cheek.[4]

In contrast to Hamra’s progressively more invasive techniques, Tonnard and Verpaele developed the minimal access cranial suspension (MACS) facelift in 2007, which uses a preauricular and temporal incision to provide access for 3 purse-string sutures that suspend the midface, jowls, and lateral platysma.[5] More recently, techniques emphasizing shorter incisions, often referred to as S-lifts, and reduced skin elevation through so-called preservation approaches have gained popularity. These methods shorten recovery time and minimize visible scarring, including scar-related limitations on hairstyling, making them appealing to younger patients seeking surgery to achieve subtle rejuvenation without prolonged time away from work.[6]

Anatomy and Physiology

Facial aging results from the combined gravitational effects on soft tissues, weakening of suspensory ligaments, increasing skin laxity, lipoatrophy, and bony resorption. This process produces the classic appearance of hollowing in the temporal, infracommissural, pre-jowl, and cheek areas. Sagging or descent of the facial fat pads and attenuation of their surrounding anchoring ligaments contribute to deepening of the NLFs, pre-jowl sulci, and nasojugal folds (see Image. Stigmata of the Aging Face).

Preferential bony resorption in the maxilla and the superomedial and inferolateral aspects of the orbits accentuates the tear troughs, deepens the NLFs, and lengthens the cutaneous upper lip. Loss of mandibular bone along the inferior margin results in decreased definition at the angle and retrusion of the chin.[7] Jowl formation from the descent of the buccal fat pad distorts the jawline and is a common reason people seek rhytidectomy. Jowls can often be addressed with SMAS rhytidectomy alone; however, if midface features such as nasojugal folds or NLFs require rejuvenation, a deep-plane or composite rhytidectomy may be more appropriate.

A thorough understanding of anatomy, particularly the relationships among fascial planes, is critical to surgical success and for minimizing complications. This is especially important in the face, where critical structures lie in close proximity, and injury can result in aesthetic changes that are difficult to conceal or reverse. Elucidation of the SMAS, in particular, has had a significant impact on rhytidectomy, shaping modern concepts of facial aging and guiding the development of contemporary techniques. The SMAS is a fibrofatty soft-tissue layer that overlies the fascia of the parotid gland and masseter muscle in the lateral face and invests the muscles of facial expression medially. SMAS is contiguous with the platysma inferiorly, and the temporoparietal fascia (TPF) or superficial temporal fascia is superior to the zygomatic arch. The SMAS attaches to the deep investing fascia of the sternocleidomastoid muscle (SCM) posteriorly (see Image. Fascial Planes of the Face). Please see StatPearls' companion resource, "Anatomy, Skin, Superficial Musculoaponeurotic System (SMAS) Fascia," for more information.

The relationship of the SMAS to the zygomatic arch is particularly important. At the inferior aspect of the zygomatic arch, the SMAS coalesces with the underlying parotidomasseteric fascia and periosteum. Superior to the zygomatic arch, these fasciae continue as the TPF, the superficial layer of the deep temporal fascia, and the zygomatic periosteum. Superficial to the SMAS lies a thin layer of subcutaneous fat that protects the subdermal plexus, which is the primary vascular supply to the skin. During rhytidectomy, elevation of a skin flap that excludes this thin fatty layer increases the risk of skin ischemia and, in severe cases, necrosis.

While the facial fascial layers provide visually distinct landmarks throughout the upper face, lower face, and lateral midface, there are several points at which osteocutaneous ligaments traverse these planes to anchor the dermis to the underlying bone. The most important of these are the masseteric ligament, the orbitomalar ligament, and the zygomaticocutaneous ligament, also known as the patch of McGregor.[8] 

The zygomaticocutaneous ligament arises from the periosteum of the zygoma, with medial extensions toward the maxilla, and extends through the SMAS and subcutaneous fat to insert into the dermis. Medially, it is located near the origin of the levator labii superioris and continues laterally along the inferior orbital rim and zygomatic body, where it interfaces with the zygomaticus minor and major muscles. The ligament then extends farther laterally as the zygomatic retaining ligament near the inferior border of the zygomatic arch.[9] The densest portion of the ligament is located just inferior to the origin of the zygomaticus major and approximately 40 mm anterior to the tragus. The main zygomatic branch of the facial nerve lies directly deep and caudal to this region, with smaller rami occasionally traversing the ligament to innervate the deep surface of the orbicularis oculi muscle. The transverse facial artery and the parotid duct are also in close proximity to the ligament, and surgeons must be cognizant of these structures during dissection. Transsection of the zygomaticocutaneous ligament is necessary to mobilize the malar fat pad and constitutes a defining feature of the deep-plane facelift technique.

The tear trough region is defined by the orbitomalar ligament, which extends from the inferior orbital rim to the orbicularis oculi muscle and its overlying skin. As pseudoherniated fat advances against the attenuated orbital septum, it presses against the inelastic orbitomalar ligament, resulting in tethering of the skin and formation of the tear trough.[10] Although the release of the orbitomalar ligament is not standard in all facelift approaches, it is commonly incorporated in fat-transposition lower eyelid blepharoplasty and composite rhytidectomy.

The labiomandibular, or "pre-jowl," sulcus that forms the marionette line at the anterior border of the jowl was historically thought to represent the location of a vertical mandibular retaining ligament. However, more recent studies have revealed that the mandibular retaining ligament serves primarily to anchor the depressor anguli oris (DAO) muscle, the platysma, and the depressor labii inferioris (which is actually an extension of the platysma beneath the DAO and up to the orbicularis oris) to the mandible, having no actual dermal component. As a result, the labiomental sulcus is formed by the lateral aspect of the insertion of the DAO directly into the dermis with minimal intervening fat. This mechanism is analogous to the formation of the NLF, which results from firm dermal adherence to the underlying perioral musculature of the upper lip rather than from an osteocutaneous ligament.[11]

Another major consideration in any facial surgery is the course of the facial nerve (see Image. Course of the Facial Nerve). The facial nerve exits the temporal bone of the skull via the stylomastoid foramen and travels through the parenchyma of the parotid gland, where it divides into its main branches at the pes anserinus, so-called because its branching appearance resembles that of a goose's foot. The facial nerve branches are classified into 5 major divisions: temporal (frontal), zygomatic, buccal, marginal mandibular, and cervical, although several different branching patterns have been described.[12] The facial nerve branches run deep to the SMAS and its contiguous layers and innervate the mimetic muscles from their deep surfaces, except for the levator anguli oris, buccinator, and mentalis muscles, which are located deeper within the face than the other muscles of facial expression. During rhytidectomy, the frontal and marginal mandibular branches are the motor nerves most commonly injured; however, injury to the great auricular nerve (GAN) occurs even more frequently.[13][14]

Cervicoplasty, or neck lift, is often performed concurrently with face lifting to achieve a balanced, rejuvenated appearance. The goal of cervical rhytidectomy is to restore a youthful contour with a cervicomental angle of 90° to 105° and often to reduce excess submental fat and/or reduce the appearance of vertical platysmal bands. Platysmaplasty is usually required to achieve a youthful neck contour.

Surgical Landmarks and Considerations

• Pitanguy's line: This line approximates the course of the frontal branch of the facial nerve. The line is drawn from a point 0.5 cm below the tragus to a point 1.5 cm superior to the lateral brow. The nerve travels deep along this course to the TPF and superficial to the superficial layer of the deep temporal fascia (see Image. Pitanguy Line).[15]

• McKinney's point: This point identifies the location of the GAN: one-third of the distance from the mastoid tip to the clavicular head of the SCM. The GAN is consistently found at this location, at the posterior border of the SCM, before branching into its anterior and posterior segments. The external jugular vein can also be found consistently 1 cm anterior to this location, parallel to the nerve.[14]

• Transverse facial artery: A branch of the superficial temporal artery can be consistently found 2.5 cm lateral and 3 cm inferior to the lateral canthus. Injury to this vessel may contribute to skin flap necrosis and delayed healing. Usually, the buccal branches of the facial nerve are superior and inferior to this vessel, and Stensen's duct from the parotid gland lies inferior to it but in the same fascial plane.

• Zuker's point: This landmark is used to identify the motor branch to the zygomaticus major muscle. This point lies at the midway along a line drawn between the root of the helix and the oral commissure, and the nerve crossing this point is typically the branch lying superior to the transverse facial artery (see Image. Course of the Facial Nerve).[16] In general, injuries to the facial nerve anterior to a vertical line through the lateral canthus will be less apparent than more proximal injuries due to redundancy and anastomoses between the buccal and zygomatic branches in the midface. As a result, such distal injuries usually do not warrant nerve exploration or repair.

• Marginal mandibular nerve: This nerve is located superficial to the facial vessels and is often closely associated with, or may wrap around, the facial vein. Posterior to the gonial notch of the mandible, this nerve can be found below the inferior margin of the mandible in 20% of patients and above it in 80%. Anterior to the gonial notch, the marginal mandibular nerve runs superior to the lower edge of the jaw in nearly all patients.[17]

• Cervical branch of the facial nerve: This branch is located 1 cm below the midpoint of a line running between the mentum and the tip of the mastoid process. The cervical branch innervates the platysma muscle as well as the depressor labii inferioris muscle.[18] Injury to this nerve results in lower lip asymmetry, with the affected side unable to depress the lower lip during smiling (see Image. Rhytidectomy Complications).

Indications

Rhytidectomy is one of several treatment options for patients with an aging face and is used to reposition soft tissues that have descended over time and reduce excess skin. Selection of the specific facelift technique is guided by the patient’s aesthetic goals, individual anatomy, and the surgeon’s experience.

Patients whose primary concerns are with jowling or neck sagging, with or without platysmal banding, may be offered SMAS rhytidectomy and cervicoplasty. Alternatively, MACS lifting, which may be performed under local anesthesia, is well suited for patients who desire shorter incisions and a faster recovery and who demonstrate more limited facial aging without severe jowling or sagging of the neck. The typical age for patients undergoing S-lift rhytidectomy procedures, such as MACS facelifts, is in the range of 40 to 50 years.

If deep NLFs or significant malar fat descent are present, a deep plane rhytidectomy or adjunctive mid-face lift is indicated.[19] Composite rhytidectomy, which uses a deep-plane approach with additional repositioning of the SOOF, may be used to improve the lid-cheek junction further. Patients with thicker skin or heavier soft tissues need more aggressive techniques to obtain satisfactory results, and deep-plane rhytidectomy may be required.

Additionally, various rhytidectomy techniques can be combined with adjuvant procedures, such as brow lift, blepharoplasty, cervicoplasty, subcutaneous fillers or fat transfer, and laser resurfacing, to address facial aging holistically through a multimodality treatment approach.

Notably, while facelifting is most commonly considered a cosmetic procedure, it may be used unilaterally or asymmetrically to manage facial paralysis, particularly in older patients. In this setting, it may serve as a method of static suspension or be combined with other procedures, such as neurectomy or nerve transfer.[20]

Contraindications

Major medical comorbidities such as diabetes, immunocompromise, steroid requirements, bleeding diatheses, and connective tissue disorders can impede wound healing. Smoking is also a major risk factor for skin flap necrosis because of its adverse impact on perfusion. Nicotine cessation should begin at least 2 to 4 weeks before surgery and be maintained for a month afterward to promote optimal healing. Radiation therapy can have similar effects, and it is advisable to avoid elevating extensive skin flaps. Deep-plane and preservation techniques may be more appropriate and safer for these patients.[21][22] 

Anticipated weight change or weight instability is a relative contraindication, as postoperative weight loss may lead to recurrent skin laxity, while weight gain can result in the return of jowling and cervical fullness. A history of severe sun exposure with multiple burns may also predispose patients to wound-healing complications. Patients who are prone to hypertrophic scarring or keloid formation may not be ideal candidates for facelifting; however, careful observation and aggressive scar management with postoperative steroid injections and silicone sheeting may mitigate the risk.

Bleeding disorders, use of blood thinners, and uncontrolled hypertension can be particularly concerning because they increase the risk of hematoma formation, which is already one of the more common complications following rhytidectomy. Use of medications and herbal supplements with anticoagulant properties should also be discontinued, when possible, at least 2 weeks before surgery. Preoperative assessment of any psychiatric history is essential to determine the patient’s motivation in seeking surgery, with referral to a qualified mental health professional for patients with suspected body dysmorphic disorder before considering surgery. Additionally, any significant cardiopulmonary comorbidities that can be mitigated preoperatively should be addressed before undertaking cosmetic procedures, and patients who are poor candidates for surgery, in general, should not be offered rhytidectomy.

Equipment

A standard rhytidectomy instrument set should include, at a minimum:

• Facelift scissors, such as Gorney-Freeman, Kaye, Goldman-Fox, Peck-Joseph, and Castañares scissors
• Suture scissors, such as Mayo and iris or tenotomy scissors
• Needle drivers, such as Halsey or Webster; Haney needle drivers may be useful for platysmaplasty, and some surgeons prefer Castroviejo needle drivers for fine suturing
• Forceps, such as Adson-Brown, DeBakey, Gerald, and fine Castroviejo forceps
• #15 Blade scalpel and #3 handle
• Ferreira facelift or breast retractor, with or without a light carrier
• Headlight, if a light carrier is not integrated into the retractor
• Joseph or Freeman skin hooks
• Suction
• Bipolar and/or monopolar electrocautery

Sutures may include:

• 0 or 2-0 Polydioxanone, braided polyester, or polyglactin for suspension of the SMAS and platysma
• 5-0 Polypropylene or nylon for additional suspension of the SMAS flap after deep plane surgery
• 4-0 or 5-0 Polyglactin or poliglecaprone for deep dermal closure
• 5-0 or 6-0 Polypropylene, nylon, or gut for skin closure
• Staples for the portion of the postauricular incision within the hairline

Some surgeons may place drains and a pressure dressing with ice packs; others may avoid drains and consider using a fibrin tissue sealant or hemostatic net sutures to reduce dead space under the facial flaps.[23] If other procedures, such as blepharoplasty, brow lift, fat transfer, or laser resurfacing, are to be undertaken during the same anesthetic, additional equipment will be required.

Personnel

As for most surgical procedures, a surgical technologist and a circulating nurse are required. In most cases, rhytidectomy is performed under general anesthesia, which necessitates the presence of an anesthesia provider. A surgical assistant also improves the efficiency of the procedure by assisting with retraction, suture cutting, and bleeding management, among other tasks.

Preparation

A comprehensive preoperative evaluation should include assessment of skin quality, rhytids, scars, fat descent and atrophy, and underlying skeletal resorption to establish realistic expectations for surgical outcomes. Standardized facial analysis and photography, including frontal, lateral, oblique, and basal views, are essential and should document facial asymmetries, contour irregularities, and hairline position to ensure alignment between patient and surgeon expectations. Preoperative photography is particularly important in patients who have undergone prior facelifting and may demonstrate stigmata of surgery, such as pixie ear, cobra neck, or lateral sweep deformities.

While it is essential for the surgeon to prepare for the operation, it is equally crucial to prepare the patient. This process includes establishing appropriate expectations for outcomes and providing thorough counseling regarding the possible risks of surgery, what to expect after surgery, what the postoperative care regimen will require, and how to recognize developing complications that may require prompt evaluation and intervention.

Risks

• Dissatisfaction with appearance
• Postoperative depression
• Hematoma
• Seroma
• Nerve injury (sensory or motor), which may be temporary or permanent
• Infection
• Skin necrosis
• Unsightly scarring
• First bite syndrome

Expectations

• Pain
• Bruising
• Swelling
• Facial hypesthesia that lasts for several weeks
• Tightness
• Itching at the incisions
• Some degree of asymmetry in the swelling and bruising, at least for the first several days

Postoperative Care

• Scheduled non-narcotic pain medications for pain prophylaxis
• Opioid pain medications as needed for breakthrough pain
• Application of antibiotic ointment to incisions twice daily
• Arnica montana to reduce swelling and bruising
• Pressure dressing, with or without drains, for the first 24 hours
• Support garment for 1 to 2 weeks afterward, potentially for continued use at night or when at home
• Cold compresses as tolerated to decrease swelling and bruising
• Avoidance of activities that elevate blood pressure levels, including heavy lifting, strenuous exercise, straining, coughing, bending over, nose blowing, and vomiting; antiemetics should be used if nausea occurs
• Sleeping with the head of the bed elevated for 1 to 2 weeks
• Showering permitted after 48 hours, with gentle patting of incisions dry, followed by reapplication of ointment
• Avoidance of baths, swimming, or submersion until sutures are removed

Recognition of Complications

• Temperature ≥101.5 ºF (38.6 ºC)
• Increasing facial pain
• Rapidly increasing swelling, especially with bruising or bleeding through the incision
• Localized increase in swelling, particularly with a sensation of fluid collection under the skin
• Purulent drainage from an incision
• Crooked smile or inability to raise both eyebrows
• Chest pain
• Shortness of breath

Before surgery begins, the patient is positioned supine on the operating table. If the patient is intubated, suturing the endotracheal tube to one of the central maxillary incisors may help maintain airway security while providing sufficient access to both sides of the face and neck. Skin preparation may be performed with povidone-iodine or isopropyl alcohol. Ocular protection can be provided using adhesive film dressings, tarsorrhaphy sutures, or corneal shields, depending on whether concomitant blepharoplasty is planned. Many surgeons also infiltrate tumescent solution containing dilute local anesthetic before incision to reduce anesthetic requirements, enhance hemostasis, and minimize postoperative bruising.

An example of a tumescent solution recipe is as follows:[24]

• Normal saline (1 L)
• 1% Plain lidocaine (50 mL)
• 0.25% Plain bupivicaine (50 mL)
• 8.4% Sodium bicarbonate (50 mL)
• 1:1000 Epinephrine (1 mL)
• Tranexamic acid (1 gm)

Patients undergoing surgery without general anesthesia may not be suitable candidates for injecting large volumes of tumescent solution. If general anesthesia is planned, a continuous intravenous propofol infusion may reduce postoperative nausea and, when combined with strict blood pressure control (<120 mm Hg systolic pressure), it reduces the risk of postoperative hematoma as well.[25]

Technique or Treatment

Preparation

Marking incisions

The exact incision pattern varies by surgeon preference and patient anatomy; however, the Blair facelift incision follows a well-established course. The incision typically begins within or along the inferior border of the temporal hair tuft and extends toward the root of the helix (see Image. Blair Rhytidectomy). At that point, the incision follows the junction of the auricle and the facial skin toward the tragus. From there, the incision may proceed just medial to the posterior margin of the tragus (using a posttragal approach) or within a natural skin crease anterior to the tragus (using a pretragal approach). The posttragal approach may provide a superior concealment of the scar but carries a risk of lateral winging of the tragus and obliteration of the subtle pretragal sulcus postoperatively, whereas the pretragal incision may result in a more apparent scar (see Image. Blair Rhytidectomy Incision). In male patients, a pretragal incision is generally preferred to avoid advancement of hair-bearing skin onto the tragus during skin closure.

The incision then curves around the junction of the lobule and the cheek, typically extending 1 to 2 mm onto the cheek skin rather than lying directly within the sulcus to prevent webbing. From there, the incision proceeds superiorly along the posterior surface of the auricle, approximately one-third of the distance from the postauricular sulcus to the helical rim. This positioning allows the postoperative scar to be pulled into the middle of the postauricular sulcus as it contracts. The incision should then turn gently through a 90-degree angle to enter the postauricular hairline across the narrowest portion of non-hair–bearing skin behind the ear, usually at the level of Darwin's tubercle. From this point, the incision travels inferiomedially as far as necessary to prevent a standing cutaneous cone during closure, traveling either along or parallel to the hairline within the hair-bearing scalp.[26][27] 

For patients undergoing S-lift procedures, the incision follows a similar initial course but ends at the auricular lobule, thereby avoiding a long postauricular scar. Although short scar approaches provide adequate access to reduce jowling and elevate the midface, they cannot effect significant recontouring of the neck.

• For revision operations, which occur with some frequency due to patients' desire for renewed rejuvenation, following the scars from the prior procedure may help avoid devascularizing small portions of skin between incisions. Additionally, repeat facelifting can be used as an opportunity to revise thickened or unsightly scars, particularly in the postauricular area.

• Some surgeons also mark the extent of skin elevation, typically not more than 4 to 6 cm anterior to the auricle, for SMAS flap techniques.
• • Deep-plane rhytidectomy: The deep-plane entry line may be marked between the angle of the mandible and the lateral canthus (see Image. Rhytidectomy Incision Patterns).

• Marking surgical landmarks: Some surgeons find it helpful to mark the paths of the frontal, marginal mandibular, and great auricular nerves prior to making the incision, as well as to mark the angle of the mandible. Marking the vertical platysmal bands with the patient sitting upright may also be helpful if a platysmaplasty is planned.

Cervical liposuction

Liposuction may be used in patients with excess subcutaneous adipose tissue, and, when needed, liposuction should be performed prior to flap elevation, as effective suction with liposuction cannulae becomes difficult once the flaps are raised. Three-millimeter cannulae are introduced via stab incisions in the submental crease and inferior to the lobules within the marked rhytidectomy incisions. With the ports facing away from the dermis, gentle outward pressure is provided to tent the skin, thereby avoiding damage to the subcutaneous layer and preserving the subdermal plexus (see Image. Submental Liposuction).

Incision and flap elevation

With a number 15 blade scalpel, the incision is carried down to the subcutaneous layer (see Image. Facial Flap Development). A subcutaneous flap is then raised with facelift scissors, keeping a thin layer of fat beneath the dermis. If the flap is elevated too thinly, the skin may be prone to ischemia due to damage to the subdermal plexus. Conversely, if the flap is too thick, the SMAS layer will be thinned and may not be robust enough to support facial suspension. The operating room light is directed at the skin surface for transillumination, thereby helping the surgeon maintain a consistent flap thickness. Counter-tension retraction is critical for this dissection to avoid buttonholing the skin, while the surgeon also applies tension with a multipronged skin hook (see Image: Facial Flap Elevation). The extent of the skin elevation depends on the selected technique, with most SMAS approaches requiring approximately 4 cm of elevation, and the deep-plane dissection transects and dives below the SMAS along a line between the angle of the mandible and the lateral canthus. 

Superficial musculoaponeurotic system suspension

The SMAS can be addressed in several ways and to varying degrees, ranging from suture-based suspension to flap elevation and advancement, depending on the patient's needs and the surgeon's experience.

• Minimal access cranial suspension lifting: After skin flap elevation and exposure of the SMAS, 2 to 3 purse-string loops of sutures are placed, depending on the extent of the patient's facial aging. Each of these loops is created using a 0 polydioxanone suture, taking 1 to 1.5 cm bites of SMAS along a specific course. The sutures are then tightened maximally to achieve the desired lift before being securely tied (see Image. Minimal Access Cranial Suspension Facelift).

  • The first loop is approximately 1 cm wide, a U-shaped loop that runs vertically through the SMAS, from the temporalis muscle fascia at a point 1 cm anterior to the helical rim and 1 cm superior to the zygomatic arch, down to the platysma just below the angle of the mandible, and back up again. Anchoring the suture to the temporalis fascia requires making a window in the TPF, which improves the security of the suture suspension and also helps to bury the knot.
  • The second loop originates from the same point on the temporalis fascia and takes a more circular course downward toward the jowl, at an approximately 30-degree angle offset from the first loop, with the goal of improving jawline definition.
  • The last loop, which may be omitted in patients who do not require midface elevation, originates at the temporalis fascia just lateral to the lateral orbit and inferior to the course of the frontal branch of the facial nerve. Anchoring the suture at this location requires creation of a small window in the orbicularis oculi muscle. This loop is narrow and courses anteroinferiorly into the malar fat pad before returning to its point of fixation, thereby effacing the NLF.

• Superficial musculoaponeurotic system plication/imbrication/transposition

  • Plication: A 1 to 2 cm wide vertical strip of supra-SMAS adipose tissue is excised from the periauricular region to expose the SMAS and make room to fold it without producing visible subcutaneous fullness at the end of the procedure. Care must be taken to avoid the path of the frontal branch of the facial nerve during this step. The SMAS is folded onto itself and secured with sutures in a superolateral vector, with care taken to avoid placing sutures through the parotid gland or near branches of the facial nerve. In patients with a thick SMAS, this technique may create an unnatural bulk along the line of plication, even with adipose tissue excision. Please see StatPearls' companion resource, "SMAS Plication Facelift," for more information.
  • Imbrication: The SMAS is incised in a J-shaped pattern approximately 1 cm anterior to the ear and undermined anteriorly for 1 to 2 cm. The free edge of the SMAS is then advanced in a superolateral vector and secured with sutures. When necessary, a strip of SMAS may be resected to avoid significant overlap and the creation of unnatural soft-tissue thickness beneath the skin.

  • Transposition: An inferiorly based J-shaped SMAS flap approximately 1 cm wide is elevated about 1 cm anterior to the auricle, extending from the zygomatic arch to the angle of the mandible (see Image. Inferiorly Based SMAS Flap). The flap is then transposed posteriorly behind the auricle. Tension is applied parallel to the mandibular ramus, which effaces the jowl, and then the flap is sutured under tension to the mastoid periosteum with at least 2 half-mattress sutures (see Image. SMAS Flap Transposition). The defect in the preauricular SMAS is then closed primarily, with or without additional SMAS undermining, to provide additional lower facial suspension similar to that achieved with the imbrication technique.
  • The type of sutures used to suspend the SMAS is determined by the surgeon's preference, but is typically a 2-0 to 3-0 suture of polyester or polydioxanone, although some prefer a shorter-lasting polyglactin.

• Superficial musculoaponeurotic system flap advancement: The "extended" SMAS or "2-flap" facelift technique involves elevating a SMAS flap separately from the overlying skin flap (see Image. Superficial Musculoaponeurotic System Flap). After skin elevation, a vertical incision in the SMAS is made approximately 2 cm anterior to the tragus, and a plane is developed below the SMAS, along the parotidomasseteric fascia—the "deep plane." If this plane is followed anteriorly past the parotid gland, facial nerve branches will be seen coursing over the masseter muscle fascia and through the fat of the anterior face on their way to their target muscles. Caution is required when elevating the SMAS flap, as the tissue thins progressively as the dissection extends anteriorly, making longer flaps more tenuous and liable to tear when tension is applied.

  • If desired, buccal fat pad reduction may be performed through this approach to slim the cheek (see Image: Buccal Fat Pad Reduction). The buccal fat pad lies below the plane of the facial nerve and must therefore be approached carefully to avoid traumatizing the buccal branches that course over it. The fat pad is dissected gently and bluntly, and then transected with conservative bipolar electrocautery to prevent both bleeding and thermal injury to nearby nerves.
  • If desired, the malar fat pad may be dissected off the underlying zygomaticus muscle and elevated into the skin flap, providing midfacial lifting when the skin is redraped, similar to the effect achieved with a deep-plane rhytidectomy. This is sometimes termed a "hybrid" facelift because it combines elements of SMAS flap and deep-plane rhytidectomy techniques.[28]
  • Inferiorly, sub-SMAS dissection proceeds deep to the platysma muscle, which provides access to the submandibular glands for debulking when necessary to achieve a refined jaw contour. This plane may also be connected to subplatysmal neck elevation when a preservation approach to neck lifting is performed.[29] Caution is required when debulking the submandibular gland from this approach, as the marginal mandibular branch of the facial nerve runs across its superficial surface and may be injured. In contrast, approaching the submandibular gland via the submental incision typically used for submentoplasty and platysmaplasty provides exposure to the anterior aspect of the gland and permits dissection along its deep surface, thereby reducing the risk to the nerve.
  • Once SMAS flap elevation and any adjunctive maneuvers are complete, the flap is suspended in a superolateral vector to the remaining preauricular SMAS. Some surgeons will split the SMAS flap longitudinally and direct the inferior portion under the lobule to secure it to the mastoid periosteum and efface the jowl. Other surgeons may create and transpose a J-shaped flap as described in the SMAS transposition section above and then develop the main SMAS flap for advancement at the anterior edge of the SMAS defect created by elevating the J-flap. SMAS suspension is accomplished with 2-0 to 3-0 polyester, polydioxanone, or polyglactin. 

• Deep-plane dissection: Deep-plane rhytidectomy is functionally similar to extended SMAS facelifting, but is technically simpler because it does not require elevating 2 separate flaps on each side of the face. The thicker flap created during deep-plane facelifting contains a more robust blood supply than that of the subdermal flap and is therefore potentially less prone to vascular insufficiency during healing. The procedure begins with an abbreviated facial skin elevation in a subdermal plane, carried only to the predefined deep-plane entry line. At this point, the dissection proceeds deep to the SMAS, allowing elevation of the malar fat pad off the underlying zygomaticus major muscle and incorporation of this tissue into the flap (see Image. Deep Plane Rhytidectomy).[30] 

  • Sub-SMAS dissection under the flap also provides access to the buccal fat pad when indicated. This portion of the dissection is typically performed bluntly to reduce the risk of injury to facial nerve branches and is carried anteriorly to the level of the NLF. The zygomaticocutaneous and masseteric retaining ligaments are then divided sharply to fully mobilize the superficial soft tissues of the midface and lower face.[31] The masseteric ligament, located anterior to the masseter muscle and extending from the maxilla to the dermis lateral to the NLF, is comparatively medial and difficult to access with techniques that elevate skin flaps, which is why it is most commonly addressed during deep-plane facelifting.
  • Throughout the dissection, care must be taken to avoid violation of the parotid gland to prevent postoperative complications such as sialocele or first-bite syndrome.[32] Once mobilization is complete, the composite flap is resuspended in a superolateral vector, with sutures anchoring the edge of the SMAS component of the flap to the preauricular SMAS, followed by redraping and tailoring of the skin. Please see StatPearls' companion resource, "Deep Plane Facelift," for more information.

Midface lifting

Elevation of the malar soft tissues to restore upper cheek volume and efface the NLFs can be achieved using several techniques. As described above, this may be achieved through dissection and suspension methods incorporated into deep-plane facelifting or MACS rhytidectomy. Midface lifting is also commonly performed endoscopically in conjunction with brow lifting, or combined with lower eyelid blepharoplasty to provide midface support and reduce the risk of postoperative ectropion (see Image. Midface Lift Using a Resorbable Tine Prosthesis). In many cases, midface lifting is performed as a standalone procedure, separate from other components of rhytidectomy. Please see StatPearls' companion resource, "Midface Lift," for more information.

Platysmaplasty

Platysmaplasty may be performed either before or after facial elevation, depending on the surgeon's preference and the overall operative plan. The submental liposuction incision is typically extended to 2 to 4 cm, and a subcutaneous plane is developed. The medial edges of the platysma muscle bellies are identified, and a subplatysmal dissection is carried inferiorly until the anterior border of the submandibular gland is encountered. Visible vertical bands in the anterior neck indicate midline platysmal dehiscence and the need for platysmaplasty (see Image. Midline Dehiscence of the Muscles). In selected patients, partial submandibular gland reduction may be performed to prevent ptotic glands from becoming apparent after the neck skin and soft tissues are tightened.[33] 

If the anterior bellies of the digastric muscles are prominently visible through the skin, limited debulking may be considered, particularly when removal of submental fat increases their visibility. The central deep neck fat compartment between the platysmal bellies is poorly suited to liposuction and is therefore typically reduced under direct visualization using electrocautery. Overly aggressive removal of this deep central neck fat compartment should be avoided, as it can result in a postoperative cobra neck deformity; if recognized intraoperatively, this may be mitigated by replacing a portion of the resected fat.[34] Excess medial platysma length is trimmed, and the platysmal bellies are sutured together in the midline, extending inferiorly beyond the level of the hyoid bone. Some surgeons will also divide the platysma transversely at the level of the hyoid to improve the acuity of the cervicomental angle with or without suspension of the cut platysma edges to the hyoid (see Image. Endoscopic View of the Platysma After Suturing).

The remainder of the neck is then elevated in a subdermal plane, and the platysma is plicated laterally to tighten the anterior neck and restore a more acute cervicomental angle. Alternatively, the same sub-SMAS plane developed in the face may also be carried inferiorly into the subplatysmal plane of the neck if the goal is to limit skin flap elevation. The platysma is then dissected away from the SCM and parotid tissue, which are connected by the cervical retaining ligament, otherwise known as the platysma auricular ligament. Separating this ligament permits vertical manipulation of the platysma muscle. Please see StatPearls' companion resource, "Neck Rejuvenation," for more information.

Hemostasis

Meticulous control of bleeding should be maintained throughout the dissection using conservative bipolar electrocautery, typically at settings of 20 watts or less. Particular caution is required when addressing bleeding near visible nerve branches or the known courses of major nerves. If cautery is performed in the deep plane, the assistant should closely observe the patient’s face for any twitching and immediately alert the surgeon if it occurs. Electrocautery should be avoided on the undersurface of the skin flap and near hair follicles to prevent skin burns or alopecia.

Beyond avoiding blood vessels and cauterizing bleeding as it arises, prevention of bleeding during rhytidectomy is critical as well. Tumescent solution injection, particularly with tranexamic acid, reduces diffuse oozing, as does maintaining permissive hypotension through anesthetic drug selection. At the conclusion of the procedure, hematoma prevention focuses on eliminating dead space beneath the skin flap. Strategies include short-term placement of Blake suction drains, use of fibrin sealants, or hemostatic net suturing, in which running nonabsorbable sutures quilt the skin to the underlying tissue and are removed 24 to 48 hours postoperatively. Drains are generally incompatible with fibrin glue because of obstruction, and hemostatic net suturing may also be challenging to combine with drain placement. Equally important, performing extubation in a deep plane of anesthesia helps prevent coughing and straining during emergence, thereby minimizing perioperative blood pressure spikes.

Flap trimming and closure

The skin flap is redraped and secured with suspension sutures at 2 to 4 points along the incision, typically using interrupted sutures, although staples may be used within the hair-bearing scalp. Common locations for these sutures are the level of the root of the helix, the level of the intertragal incisura, and the apex of the postauricular flap. If, after skin redraping, dimples appear, they may be released subdermally. Excess skin is then excised, and the skin edges are closed with care to avoid overresection, which can lead to tragal winging, pixie ear deformity, and scar widening. Peck–Joseph scissors are well-suited for following the contours of the auricle and precisely trimming skin around the tragus (see Image. Facelift Flap Tailoring). At the temporal and occipital ends of the incision, stabilizing the end of the incision with a single-prong skin hook and excising the excess skin with a number 15 blade may be easier than using scissors.

• Suture selection is based on the surgeon's preference, and placement of deep dermal sutures is optional. In general, fine sutures, such as 6-0, are used for preauricular and postauricular skin closure, while the occipital hairline may be closed with staples or absorbable sutures.
• The continuity of the hairline is preserved to the greatest extent possible.
• Excessive tension at the inferior border of the lobule should be avoided to prevent pixie ear deformity.
• Skin advanced onto the tragus should be gently thinned and anchored to the soft tissue just anterior to the cartilage to recreate the pretragal sulcus.
• For the MACS lift and other S-lift techniques, the skin flap is pulled vertically to avoid creating a standing cone deformity posterior to the ear, which would require additional dissection to address.
• A limited amount of excess submental skin can be removed prior to closure, although overresection will result in submental standing cutaneous cone deformities. Most excess cervical skin should be removed via the postauricular aspects of the Blair incisions.

Dressing

Antibiotic ointment is applied to the incisions, followed by placement of a compressive dressing to reduce the risk of hematoma formation. Various dressing techniques may be used, although a traditional Barton dressing is effective and commonly employed. Cold packs or ice-filled gloves may be applied externally over the dressing to keep the face cool and help reduce edema and postoperative swelling.

Postoperative care

The patient is typically evaluated on postoperative day 1 for removal of the dressing and any drains, and again around day 7 for suture and staple removal. Cold compresses and appropriate analgesics are recommended for comfort. Antibiotic therapy beyond the first 24 hours is used at the surgeon’s discretion and is not routinely required. Postoperative photographs are generally obtained approximately 3 months after surgery. Patients should avoid heavy lifting and strenuous exercise for 4 to 6 weeks, sleep with the head of the bed elevated, and refrain from nose blowing during the early postoperative period.

Complications

As with any surgical procedure, complications may occur after rhytidectomy despite careful preoperative optimization of medical comorbidities and meticulous intraoperative technique. Similar to other aesthetic procedures, the most common adverse outcome of facelifting is dissatisfaction with the cosmetic result. This may stem from scarring, asymmetry, contour irregularities, or an appearance perceived as overcorrected or undercorrected, as well as from inadequate expectation management or underlying psychosocial factors. Establishing a strong preoperative rapport allows the interprofessional team to better support patients through postoperative challenges and may improve satisfaction and reduce the risk of conflict or litigation in the setting of a suboptimal outcome.

Hematoma

Hematoma is the most common complication following rhytidectomy, with a reported incidence of 0.2% to 8% (see Image. Upper Neck Hematoma).[35] Hematomas can be categorized as either major (expanding) or minor. Major bleeding episodes often occur within 24 hours of surgery with symptoms of subcutaneous mass, pain, and ecchymotic skin discoloration, often developing rapidly after a straining, coughing, or vomiting event; these episodes require surgical intervention to control the hemorrhage. If these episodes occur in the neck, airway compromise may ensue, and the wound should be opened emergently.

In contrast, minor bleeding tends to be delayed and may result from oozing of the subdermal plexus. These episodes can often be managed with watchful waiting or bedside aspiration using a fine, sterile suction tip, such as a 10 Fr Frazier, introduced through the postauricular aspect of the incision after removing one of the cutaneous suspension sutures. Regardless of the acuity of the hematoma, it should be addressed promptly and assessed regularly for recurrence for several days after its initial appearance. If left untreated, hematomas may predispose the patient to wound infection, cause necrosis of the overlying skin, or even result in skin expansion with subsequent cutaneous ripples that persist after healing is complete, and which can be extremely challenging to fix.

Several factors, including hypertension, male gender, coagulopathy or use of anticoagulants, postanesthesia nausea, vomiting, and pain, increase the risk of hematoma. Male skin is more vascular than female skin due to its greater density of hair follicles, which increases the risk of bleeding. The use of anticoagulants, antiplatelet medications such as aspirin and nonsteroidal anti-inflammatory drugs, and herbal supplements that are known to increase bleeding, such as Ginkgo biloba, turmeric, St John's wort, ginseng, high-dose vitamins (C and E), fish oils, garlic, and glucosamine, should also be discontinued 2 weeks before surgery.[36]

Hypertension remains the most significant risk factor for postoperative hematoma formation, and maintaining a systolic blood pressure below 120 mm Hg has been shown to be effective in preventing them.[23] Baker et al demonstrated a reduction in the overall incidence of postoperative hematoma in male patients undergoing rhytidectomy from 8.7% to 3.97% with strict blood pressure control, and Bassiri-Tehrani et al showed a drop in hematoma rate of all facelift patients from 3.8% to 0.5%.[37][25] Preoperatively, sympatholytic medications, such as valium or clonidine, may be administered to this end. Intraoperatively, meticulous hemostasis should be achieved before closure. Postoperatively, factors that can increase agitation in recovering patients, such as nausea and pain, should also be addressed promptly. The effect of drain placement on hematoma incidence remains unclear; however, drains may help reduce the risk of seroma formation.

Skin Necrosis

Skin necrosis occurs as a result of microvascular compromise from seroma or hematoma formation, or excessively thin skin flap elevation, and comorbid conditions such as smoking and diabetes. Laser skin resurfacing performed on the lateral cheek under the same anesthetic as the rhytidectomy will also increase the risk of skin necrosis. Necrosis can involve only partial-thickness of the skin or the full-thickness of the dermis with eschar formation (see Image. Full-thickness Skin Flap Necrosis). In partial-thickness necrosis, patients present with skin discoloration and desquamation. This usually resolves with conservative wound care and heals well without scarring. Nitropaste or dimethylsulfoxide may be considered to improve perfusion. Full-thickness necrosis will lead to prolonged healing time with skin abnormalities such as dyspigmentation, contour irregularities, and scarring, and may require further intervention. Wounds should be allowed to heal completely, and early debridement should be minimized to avoid further damage.

The most significant risk factor for skin necrosis among rhytidectomy patients is smoking. Cigarette smoke contains nicotine, carbon monoxide, hydrogen cyanide, and nitric oxide, all of which have detrimental effects on microvascular oxygen transport and impair wound healing. In 1984, Rees et al reported a skin sloughing rate of 7.5% in smokers compared with 2.7% in nonsmokers who underwent rhytidectomy. A smoking cessation for 2 to 4 weeks before and after surgery is strongly recommended to avoid skin necrosis.[38][39] Another way to potentially minimize skin necrosis in smokers is the use of deep-plane facelift surgery. Because deep-plane surgery preserves the skin, subcutaneous tissue, and SMAS as a composite flap, it maintains better blood supply, thereby reducing the rate of skin necrosis.[40] Medications that can alter wound healing, such as chemotherapy and steroids, are also essential to consider prior to rhytidectomy. Patients taking these medications should delay rhytidectomy until some time after completing their course or consider canceling the procedure.

Lastly, skin closure should be performed without tension to minimize the risk of ischemia at the wound edges. The distal portions of the flap, particularly in the preauricular and superior postauricular regions, are most susceptible to ischemic injury and, therefore, at greatest risk for developing skin necrosis.

Notably, patients undergoing revision rhytidectomy may have a lower risk of skin necrosis, as prior surgery effectively delays skin flaps and enhances perfusion through dilation of choke vessels.

Nerve Injury

With a reported incidence of approximately 0.7% to 2.5%, nerve injury can be avoided through a detailed understanding of facial anatomy and meticulous surgical technique.[37] Awareness of the key surgical landmarks described above is essential while performing facial dissection. Although intraoperative nerve monitoring can aid injury prevention, facial nerves are more commonly damaged by aggressive retraction or electrocautery, particularly when controlling bleeding from nearby vessels, such as the facial vein or external jugular vein, adjacent to the marginal mandibular nerve or GAN, respectively.

If a nerve is transected and the injury is recognized during surgery, immediate microsurgical epineurial repair is recommended. Motor nerve injuries may take a year to recover or may never fully recover; however, they can often be managed in the meantime with botulinum toxin injections into the contralateral facial muscle groups to improve symmetry, particularly in cases of frontal or marginal mandibular branch injury.

The GAN is the most commonly injured nerve during rhytidectomy, particularly during posterior skin flap elevation. This can cause anesthesia to the inferior pinna and mastoid skin, with patients reporting difficulty placing earrings, using telephones, or combing their hair.[14] The most common motor nerve injuries involve the frontal and marginal mandibular branches of the facial nerve, resulting in brow paralysis with or without ptosis and a crooked lower lip during smiling, respectively.[13] Careful elevation of the subcutaneous flap over the zygomatic arch and the sub-platysmal flap around the angle of the mandible will help avoid injury to these nerves. If bleeding occurs in these areas, pressure and a clotting agent, such as thrombin or cellulose, should be applied rather than electrocautery.

Surgical Site Infection

Fortunately, cellulitis or abscess formation is a rare complication due to the robust blood supply of the face. Wound infections are most commonly caused by gram-positive cocci, such as Staphylococcus and Streptococcus, and generally resolve with antibiotics targeting skin flora.

Scarring and Skin Irregularities

Although facelift incisions are typically long, careful incision placement usually minimizes their visibility postoperatively. When scar widening occurs, it most often affects the postauricular region, where it is generally well concealed. More conspicuous preauricular scars that are widened, erythematous, or hyperpigmented may be treated with laser resurfacing, intralesional steroid injections, or topical agents such as hydroquinone. Strict avoidance of sun exposure during the first 12 months after surgery also helps reduce the risk of prominent scarring. Hypertrophic or keloid scars may benefit from silicone sheeting or, if persistent, surgical revision after 6 to 12 months.

Subdermal contour irregularities represent a related concern and most commonly result from SMAS plication or imbrication, particularly when the overlying skin flap is thin. These irregularities often improve with massage and steroid injection; however, fat or filler injection may be required to correct deeper concavities.

Additionally, several characteristic deformities may result from improper soft-tissue manipulation during facelifting. A "pixie ear" deformity occurs when excessive tension is applied across the skin closure inferior to the auricular lobule, causing the lobule to stretch inferiorly and appear elongated and attached (see Image. Pixie Ear Deformity). Treatment often requires V-to-Y advancement of the lobule combined with re-elevation of the neck flap to relieve tension on the closure. A "cobra neck" deformity occurs when too much adipose tissue is removed from the central submental region, between the anterior bellies of the digastric muscles, without removing a commensurate volume from the lateral submentum and upper neck. This hollowed, cobra hood–like appearance beneath the chin provides its name (see Image. Cobra Neck Deformity). This deformity is typically improved with autologous fat grafting or injections.

The "wind-swept" deformity, most commonly seen after deep-plane facelifting, arises from excessive lateralization of the malar fat pads or overly aggressive tension on the cheek flaps, leading to widening the distance between the oral commissures. Correction is challenging, but it may be improved with a revision facelift performed several months later, providing enough time for tissue relaxation to permit redraping of the facial flaps without tension. A related aesthetic stigma is the "lateral sweep" or "swoosh" sign, characterized by curvilinear rhytids in the lower face that resemble the Nike swoosh symbol, running from the prejowl region toward the auricle. This appearance results from insufficient elevation of the midface with excessive lateral suspension of the lower face. As with the wind-swept deformity, this is best addressed with time and operative revision.

Alopecia and Malposition of the Hairline

This condition is caused by injury to hair follicles during incision, aggressive use of electrocautery, or closure under excessive tension. Beveling the scalpel blade during incision, either parallel or perpendicular to the hair follicles, may minimize the appearance of the scar. Surgeons should also inform patients of the possibility of postsurgical telogen effluvium—a stress-related diffuse hair loss that occurs approximately 3 months after surgery. This condition can be observed or treated with minoxidil, but should resolve spontaneously within 6 months. If alopecia occurs, allow 6 to 12 months for healing before considering hair transplantation to rule out telogen effluvium as the etiology.

When planning incisions, it is important not to disrupt the natural hairline, which can occur if attention is not paid to avoiding a step-off of the hairline when redraping postauricular skin before closure. A pretragal incision should be used in male patients to avoid posteriorly displacing the sideburns too close to the auricle or even onto the tragus.

First Bite Syndrome

This complication has been reported after deep-plane rhytidectomy and is thought to result from injury to postganglionic parasympathetic fibers supplying the parotid gland, similar to mechanisms described following deep lobe parotidectomy or parapharyngeal space surgery.[32] Aberrant reinnervation results in a painful hypercontraction of myoepithelial cells within the parotid gland at the beginning of meals, with pain that typically diminishes after the first few bites. Although distressing for patients, symptoms can often be managed with botulinum toxin injections and typically resolve spontaneously within 6 to 12 months.

Patient Dissatisfaction

Patient dissatisfaction is among the most common complications following rhytidectomy. Up to 30% of patients may experience postoperative depression, ranging in severity from transient mood changes requiring reassurance to symptoms necessitating antidepressants.[41] Careful assessment of psychiatric history during the preoperative evaluation is therefore essential, as underlying mood disorders may increase the risk of postoperative depression and negatively influence perceived surgical outcomes.

In some cases, dissatisfaction may occur despite technically successful surgery. Minor revision or “tuck-up” procedures are commonly required within 1 to 2 years to address isolated areas of persistent or recurrent soft-tissue ptosis. In general, well-performed facelifts provide favorable results, with many patients not requiring repeat rhytidectomy for 5 to 10 years.

Clinical Significance

According to the American Society of Plastic Surgeons, rhytidectomy was the second most common cosmetic surgical procedure performed on the face in 2024, following blepharoplasty. Despite the expense and recovery time associated with facelifting, its popularity may increase in the near future due to the growing demand for glucagon-like peptide 1 (GLP-1) receptor agonists for weight loss and diabetes management. Patients undergoing rapid weight loss may experience facial fat loss, bone resorption, and reduced skin elasticity, features commonly associated with facial aging.[42] Consequently, rhytidectomy and autologous fat grafting are important surgical considerations for addressing facial aging in this patient population.

Each facelift is an individualized procedure, with outcomes dependent on patient selection, surgical approach, and postoperative management. A comprehensive medical history and thorough physical examination are essential to identify appropriate candidates for the procedure. Medical comorbidities such as diabetes and hypertension, as well as exposures such as nicotine and herbal supplements, can significantly increase the risk of complications. Additionally, surgical outcomes and patient satisfaction are optimized when a strong physician–patient relationship is established and realistic expectations are set preoperatively. 

Determining the ideal approach to rhytidectomy depends on the patient's aesthetic goals, the effects of aging on their soft tissues, and the surgeon's experience. Variations of rhytidectomy, such as SMAS rhytidectomy, deep-plane rhytidectomy, and the MACS lift, address different facial subunits to varying degrees. Notably, it is essential to recognize that facelifts are only one of many treatment modalities for facial rejuvenation. Adjuvant therapies, such as blepharoplasty, cervicoplasty, liposuction, injectable treatments, and skin resurfacing, should be considered at the time of initial consultation to optimize outcomes. 

Lastly, meticulous postoperative care is critical. Ensuring that patients adhere to postoperative instructions and have ready access to the operating surgeon or a knowledgeable nurse if concerns arise helps minimize adverse outcomes through prompt recognition and timely intervention.

Enhancing Healthcare Team Outcomes

Rhytidectomy is a primary surgical option for addressing facial aging and, as an elective aesthetic procedure, benefits from a coordinated, healthcare team-based approach to achieve optimal results. In the preoperative phase, establishing a strong rapport with the patient is essential, as it facilitates communication, supports adherence to recommendations, and helps manage concerns should complications arise. Clear discussion of the patient’s aesthetic goals and realistic expectations also helps in optimizing postoperative satisfaction.

Effective coordination with primary care providers and relevant specialists is necessary to identify and optimize medical comorbidities before surgery, particularly cardiopulmonary conditions, as proceeding with elective surgery without appropriate risk mitigation increases the likelihood of adverse outcomes. Smoking status requires specific attention, as nicotine use is strongly associated with impaired wound healing and increased risk of skin necrosis. Smoking cessation for 2 to 4 weeks before and after surgery has been shown to significantly reduce the risk of skin necrosis.[39]

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Disclosure: Albert Yang declares no relevant financial relationships with ineligible companies.

Disclosure: Marc Hohman declares no relevant financial relationships with ineligible companies.