Surgical Facial Rejuvenation Techniques: Are They All Scientifically Valid and Anatomically Justified?

Abstract

Background:

Face lift procedures have evolved significantly, largely based on theories such as bone resorption, fat atrophy, fat compartment shifting, and ligament stretching. However, recent evidence questions the validity of these assumptions and, by extension, many current surgical techniques. This review aimed to assess whether existing face lift methods align with the principle of correcting age-related changes while preserving unaffected structures.

Methods:

A literature review of PubMed, Embase, and Web of Science identified 54 relevant studies published since 2005. These included longitudinal interpersonal studies, as well as cadaver and live subject analyses grouped by age. However, few intrapersonal studies exist, and most available research offers conflicting data with generally low levels of evidence, making definitive conclusions difficult.

Results:

Despite these limitations, there is reasonable evidence that challenges the anatomical assumptions behind many face lift techniques. Key findings indicate that the facial skeleton remodels rather than resorbs; some fat compartments hypertrophy, and not all migrate or shift; and facial retaining ligaments are robust, nonelastic fibrous structures.

Conclusions:

In conclusion, a modern understanding of facial anatomy and aging calls for a critical reevaluation of traditional face lift methods. Techniques should be tailored to address true anatomical changes associated with aging, while sparing structures that remain unaffected.

Takeaways

Question: Do commonly practiced face lift techniques address signs or anatomical age-related changes?

Findings: Many face lift techniques are based on ill-founded assumptions. Scientific evidence challenges belief that facial bones resorb, fat compartments migrate, and retaining ligaments stretch with age. Evidence supports that aging is driven primarily by skeletal remodeling, compartmentalized fat hypertrophy or redistribution, and loss of skin elasticity, rather than fat atrophy or ligament failure.

Meaning: Effective facial rejuvenation requires anatomically targeted, segmental approaches that address true aging changes while preserving unaffected structures for safer, more natural, and longer-lasting outcomes.

INTRODUCTION

Few procedures have seen as much innovation as the face lift. Early techniques focused on skin strip excision. Subcutaneous undermining improved results but failed to address midface ptosis and was plagued by early recurrence. Superficial musculoaponeurotic system (SMAS) manipulation resulted in better outcomes but was still not very effective for midface rejuvenation. With the “deep-plane rhytidectomy,” better malar fat pad repositioning could be achieved. Modified as “composite rhytidectomy,” it allowed repositioning of sub–orbicularis oculi fat and improved the eyelid and cheek profile. Subperiosteal techniques were also developed for malar eminence suspension.^1–3

Deep-plane rhytidectomy was the trend for several decades. Shortly after its popularization, a counter-movement toward less invasive techniques occurred, favoring patient safety and more natural-looking enhancement.⁴ There is still, however, no consensus about which technique constitutes the “gold standard.”¹ Despite reported better and longer-lasting deep plane outcomes,⁵ a 10-year follow-up of identical twins who underwent different techniques, including deep-plane and SMAS plication, yielded similar patient satisfaction regardless of the technique.⁶ Another study confirmed this observation.⁷

Rather than addressing signs of aging by manipulating unchanged structures, rejuvenation should ideally aim at correcting real changes while preserving unaffected structures.^8–10 Undoubtedly, some techniques are very effective. Nevertheless, their validity should not rely on how effective they are, but on how conceptually correct they are. Precise diagnosis and treatment of underlying etiologies are basic therapeutic principles. Techniques based on arguments of skeletal and fat atrophy, fat compartment shifting, or retaining ligament laxity, even if effective, remain conceptually wrong, unless hypothesized changes are real. The current review is intended to analyze whether practiced face lifting techniques respect these principles.

MATERIAL AND METHODS

A patient, intervention, comparison, outcome search of PubMed, Embase, and Web of Science English-language literature databases was conducted to identify studies demonstrating age-related facial changes. The search included studies published since 2005 involving human cadavers or live subjects. Medical Subject Headings search terms and keywords included “facial aging,” “face lift,” “rhytidectomy,” “retaining ligaments,” “fat compartment changes,” and “mimetic muscles,” as well as “three-dimensional imaging,” “MRI,” “CT,” and “ultrasound” imaging techniques. An additional unstructured search was conducted. Two investigators screened titles and abstracts, and then the full texts of selected articles were analyzed for eligibility. Discrepancies were resolved by consensus or consulting the senior investigator. Data extraction from eligible studies was then conducted. The inclusion and exclusion criteria are detailed in Table 1, and the search algorithm is illustrated in Figure 1.

Table 1.

Inclusion and Exclusion Criteria, and Literature Search Methodology

Criteria	Inclusion	Exclusion
Study design	• Peer-reviewed comparative intrapersonal longitudinal studies, comparative cadaver studies by age groups, or live subject comparative studies by age groups	• Reviews, case reports, comments, and letters to the auditors
Population	• Human cadaver or live subjects of any age or sex	• Studies not involving human subjects
Outcome	• Quantified age-related changes in facial skeleton, fat compartments and soft tissues, retaining ligaments, and mimetic muscles relevant to face lift surgery	• Age-related changes not relevant to face lifting (nose, eyelids, lips)
Methodological quality	• Clearly defined methodologies and measuring tools for determining age-related changes	• Studies with poor methodological quality or insufficient data
Publication date	• Studies published since 2015 to capture the most recent evidence related to age-related changes relevant to presently practiced face lift techniques	• Studies published before this timeframe
Language	• Studies published in English	• Non-English publications
Advanced search of PubMed, Embase, and Web of Science databases included the following Medical Subject Headings terms and keywords: ((“facial aging” OR “face lift” OR “rhytidectomy” OR “soft tissue changes” OR “fat compartment changes” OR “retaining ligaments” OR “mimetic muscles”) AND (“quantitative assessment” OR “three-dimensional imaging” OR “MRI” OR “CT” OR “ultrasound” OR “stereophotogrammetry”) AND (“age-related changes” OR “facial rejuvenation” OR “skeletal remodeling” OR “soft tissue ptosis” OR “facial volume loss” OR “ligamentous laxity”)). Additional unstructured searches were performed using various combinations of these terms.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram of systematic review of databases and registers.

RESULTS

Identified reports are listed in Table 2. (See table, Supplemental Digital Content 1, which displays study details and level of evidence, https://links.lww.com/PRSGO/E392.) Eight longitudinal interpersonal, 3 cadaver, and 43 live studies describing changes by age groups were retrieved for review. In most cases, age-related changes were measured with advanced imaging modalities including magnetic resonance imaging (MRI) and computed tomography (CT) scans. However, data collection was not blinded. It provided conflicting conclusions with a low level of evidence. Nevertheless, there is reasonable evidence that the facial skeleton does not resorb but remodels; some fat compartments hypertrophy and do not migrate or shift; and facial retaining ligaments are robust, nonelastic fibrous structures, seriously doubting the justifications for many described surgical techniques.

Table 2.

Studies Retrieved for Review

	Longitudinal Intrapersonal Studies	Cadaver Studies	Live Subject Studies
Fat compartments and soft tissues	Yang et al11	Cotofana et al12	Zhang et al13
	Boehm et al14	Mertens et al15	Jiang et al16
	Cevik Cenkeri et al17		Estler et al18
	Tower et al19		Eid et al20
	Tower et al21		Wang et al22
			Sarigul Guduk et al23
			Paluch et al24
			Wen et al25
			Tower et al26
			Sandamini et al27
			Kurosumi and Mizukoshi28
			Linden et al29
			Foissac et al30
			Jang et al31
			Watanabe et al32
			Wysong et al33
			Iblher et al34
			Wysong et al35
			Papageorgiou et al10
			Camp et al36
			Darcy et al37
			Gosain et al38
Retaining ligaments		Minelli et al39	Okuda et al40
			Okuda et al41
			Yang et.al42
			Bruneau et al43
			Papageorgiou et al10
Platysma and facial muscles			Frank et al44 Alfertshofer et al45 Engerer et al46 Cotofana et al4
Facial skeleton	Garib et al47		Lohakitsatian et al48
	Fourgeot et al49		Nur Kuzan and Yusuf Kuzan50
	Paskhover et al51		Okuda et al52
			Jeon et al53
			Ching et al54
			Frank et al55
			Kim et al56
			Cotofana et al57
			Cotofana et al58
			Richard et al59
			Kahn and Shaw et al60
			Mendelson et al61

Data about changes in fat compartments reveal high variability and region specificity as well as differences between superficial and deep compartments. Though atrophy in some compartments has been documented,^11,14,17 numerous studies describe no change or significant hypertrophy.^{10,13,18–23,25,26,30,31,37,38} One study described upper lip aging changes,³⁴ and 6 reported changes in periorbital tissues.^{10,33,36,42,43} Skeletal remodeling with significant gender differences is also well documented.^{37,48–52,54–60,62} One histological cadaver dissection demonstrated lengthening of the superficial subcutaneous short fibers of the mandibular retaining ligament.³⁹ Two other fresh cadaver studies demonstrated a constant position of deep midfacial fat compartments¹²; atrophy of these compartments occurs only in patients with a body mass index of less than 20.¹⁵ Two studies reported decreased SMAS thickness and increased laxity with age.^40,41 Decreased thickness of the orbicularis muscle with increased width was also reported.⁴² Though overall eyebrow volume does not change, as women age, fat volume increases and soft tissue volume decreases; in men, the shift from soft tissue to fat volume is less pronounced.¹⁰ In the neck, skin elasticity decreases while its firmness generally increases.^44,45 Conflicting changes in facial muscle activity with surface-derived electromyography recordings are reported; however, age does not significantly influence signal, baseline noise, or signal-to-noise ratio.^4,23,45,46

DISCUSSION

Health, genetics, and extrinsic environmental factors all contribute to facial aging^63,64 characterized by changes in cutaneous elasticity whose onset and rate of progression vary among individuals with different Fitzpatrick skin types and extent of photodamage, in addition to craniofacial structural remodeling and apparent volume loss.^{4,30,46,65,66} Whether facial alterations are due to sagging or real downward shifting of tissues, or are caused by actual atrophy, deflation, or simple attenuation, is debatable.³⁰ Some confusion also exists about the structures that are basically responsible for apparent changes. It is not clear whether changes at a particular level are primary or secondary to deeper structural changes, or whether implemented surgical interventions are correcting the “real” changes or just addressing the apparent manifestations of aging.

Though incompletely appreciated and somewhat controversial,^8,16 some changes have been well documented. Contrary to numerous reports, bone volume loss seems not to largely occur with aging except in the maxillary bone secondary to dental disease or tooth loss.^67,68 Facial skeleton primarily remodels due to continued resorption and deposition with differential growth and clockwise rotation of the midface relative to cranial base throughout adulthood, causing more acute bony angles that affect the position of overlying soft tissues.^{37,49,58–60} There is also some confusion as to whether deflation of adipose tissue, sagging, or actual downward shift occurs. The assumption that fat loss is a key contributor to aging may probably be incorrect.^{13–15,17,30,69} In contradistinction to the volume loss theory equating ptosis to lipoatrophy,^4,23,30,36 some compartments undergo hypertrophy or do not change noticeably.^{10,18,19,23,24,26,31,32,34,37,38,69} Claims that deep compartment deflation leads to loss of superficial support are being challenged.^19,30,63 Though volume addition definitely yields a more youthful appearance, it seems unlikely that volume loss is a primary driver of midfacial aging. Age-related deflated appearance is largely due to skeletal remodeling.^{9,30,40,47,49,64,67} With a decrease in midface height and changing angles and projection, overlying tissues realign in an inferior and medial position.^{4,30,59,63,64,66} Furthermore, though decreased fat elasticity occurs with aging,²⁴ inferior displacement, mostly reported for some superficial fat, has not been observed in deep compartments that maintain a constant position even when smiling. Their apparent inferior migration is mainly a differential volume shift of sometimes hypertrophied fat.^4,12,30,70 Addressing these changes seems to be more appropriate²³ than volume enhancement, which in many instances results in a highly unaesthetic “cushion face.”⁶⁹

Considering the retaining ligaments, despite argument that their developing laxity with aging results in soft tissue descent,^4,65,71 there is to date no strong evidence to this effect. On the contrary, ligaments are robust, nonelastic structures. Their dimensions and biophysical properties do not vary with age. The zygomatic ligament is the strongest and is biomechanically the stiffest. Upper masseteric and upper key masseteric ligaments show minimal change. Mandibular major ligament develops minimal, if any, laxity; only some weakening occurs in its fibrous extensions superficial to the SMAS. Whether the medial mobile SMAS descends with aging is also questionable.³⁹

In the neck, the skin and platysma constitute a single unit with tight connections remaining constant with aging. Downward and forward sliding of the position of the junction between vertical and horizontal muscle fibers with overlying skin occurs secondary to the loss of structural support. Moreover, the strong attachment of the platysma borders to the deep cervical fascia makes displacement of the medial border, as previously described, highly unlikely. Furthermore, claims that repetitive platysma contraction progressively tensions the muscle forward as the underlying deep fascia stretches over time remain largely unproven. Furthermore, anterior soft, adynamic platysma bands develop as pleats lateral to the medial muscle border. Hard dynamic bands are also not due to fibrosis or rigidity; rather, they indicate longitudinal hyperfunction.^{18,23,72–74}

Regarding facial mimetic muscles, changes in muscle tone and signs of senescence with decreased muscle contractility are consistently observed in almost all facial muscles,⁶⁴ but the full effect of aging has unfortunately been generally neglected.⁷⁵ Muscles lengthen and have shorter contraction amplitude, but their resting tone increases in net contradiction to the decreased axonal load of the facial nerve and neuroactivity upon forceful contraction, which may suggest reduced muscle tone.^18,46,76 In fact, age does not significantly influence the signal-to-noise ratio; absolute facial muscle activity does not seem to be significantly affected. Exceptions are reduced activity of zygomaticus major and increased activity of procerus and corrugator supercilii.⁴ On the other hand, muscle atrophy with aging occurs in the temporal muscle, whereas the frontal muscle is less affected, probably because of more repeated contractions despite the reported decreased surface-derived electromyography signal.^30,45

As it seems from cumulated evidence, aging changes occur in all facial tissue layers, but the relationship between layers have been shown to remain consistent. Currently, there is no consensus regarding the best face lift approach. The proper suspension vector with the greatest distraction and minimal redundancy is still debated.⁷⁷ It seems, from this review, that many lifting techniques, despite their unquestionable efficacy, have been based on assumptions proven to be at least partly incorrect. Deep plane techniques, whether with standard access incisions or endoscopically assisted, are conceptually flawed and incongruous despite the fact that ligament release has demonstrated superior rejuvenation results with less dependence on ancillary volumization measures.^71,77–80 Most ligament changes occur in multiple superficial subcutaneous fine retinacular branches. Violating normal anatomy in a sub-SMAS dissection and repositioning in an abnormal location deserves to be reconsidered. To address the exact level of aging changes, superficial subcutaneous undermining may be the most anatomically justifiable approach. It is possible, however, that due to skeletal remodeling, the origin of ligaments and their course become altered.^32,59,62,71 This can possibly be corrected by strategically planned filler injections at their base.^81,82 On the other hand, ligament release and anatomical reconstruction proposed by some may be associated with an increased rate of temporary nerve paralysis.⁸³

The argument that retaining ligament release preserves original deep fascial antigravity orientation is well taken. Nevertheless, higher flap fixation creates a shift in tissue support with a net mechanical disadvantage on the highly mobile midfacial and perioral areas.⁸³ The effect of deep face lift on mimetic muscle facial dynamics must not be overlooked. Reduced contraction invariably occurs if muscle fibers become either shortened or stretched.⁷⁵ Apart from 3-dimensional facial rejuvenation with the face at rest, facial dynamics must constitute a fourth dimension for natural, balanced results.⁸⁴ Aging structural changes that impact muscle tension and contraction vectors may probably be corrected by restoring lever mechanical advantage by myomodulation with fillers.^66,75,85

Though arguments for wide ligament release abound,⁷¹ evidence regarding immediate outcomes of contrasting ligament “no-release” or “extensive-release” techniques confirms that both approaches are equivalent in the hands of experienced surgeons.^65,83 It may be argued though that no-release techniques tend to reorient retinacula, making them mechanically unable to exert antigravitation function, potentially limiting outcome longevity.⁶⁵ Arguments of effectiveness and outcome longevity remain highly hypothetical. Relapse can occur after any approach. None has proven to be effective and durable in every patient, nor resistant to weight fluctuations and constant mechanical stress.⁸³ There is no proven advantage of a sub-SMAS dissection on the final outcome in older patients with loose skin. More superficial dissection can yield equivalent results, provided that tissue volumes are adequately managed.^65,83

A superficial approach cannot be more appropriate than when correcting the jowl crease that relates to the dermal insertion of lower lip depressors. Contrary to previous belief, the mandibular ligament does not constitute the anterior jowl border. It is not osteocutaneous and exists only in the deep subplatysma plane. It does not develop any significant aging changes. Weakening and lengthening occur only in short subcutaneous fibers superficial to the SMAS. Safe release of the true broad mandibular ligament can only be performed through subperiosteal release and a submental incision. Risking injury to the marginal mandibular nerve by ligament release seems to be counterintuitive. It is also arguable how the release of a ligament distal to the zone of tissue sagging can improve contour by proximal traction.^39,86

For neck rejuvenation, disrupting the unchanged tight cutaneous-platysma relationship could nowadays be considered anachronistic. Widespread practice of subcutaneous undermining and skin separation from the underlying platysma is not anatomically justified.^73,74 Techniques proposed to correct the presumed displacement of the medial platysma border with medial plication are also anatomically ill-founded. Moreover, the necessity for subplatysma undermining and release of the medial and lateral cervical retaining ligaments in all cases is questionable. The subplatysmal loose plane may allow adequate gliding.⁷² Fixing cervicomental crease to the deep cervical fascia in a gap created by platysma sectioning⁸⁷ is also debatable. Unfortunately, the upper platysma location is frequently neglected.⁸⁸ Relocation of platysma angle to its youthful position together with skin-platysma displacement in both vertical and lateral vectors with closed myotomy of dynamic bands, rather than partial or complete muscle transection,⁷² seems to be most logical and safe. For optimal tightening, principles of plastic surgery recommend targeting the region of greatest laxity for increased efficiency (in accordance with Hooke law).⁸³ The platysma anchoring point could be placed as anteromedially as possible at the cervicomental angle level, making the release of the posterolateral retaining ligament probably irrelevant. However, skin-platysma displacement in patients with heavy necks may not be possible. In some cases, liposuction tunneling creates adequate cutaneous sliding, making neck contouring possible through differential skin and platysma displacement.

For lateral periorbital rejuvenation, it is essential to make a distinction between the target organ (muscle) and the organ of desired effect (skin surface). The “dynamic discord with aging” concept relates to the interplay between mimetic facial muscles and the overlying deteriorating skin envelope. Due to the firm connection between the orbicularis and the overlying thin skin, muscle contraction creates dynamic expression wrinkles.^4,64 Failure to separate muscle from skin would yield a suboptimal rejuvenation. On the other hand, the preservation of the lateral orbicularis oculi’s delicate network of innervation must not be overlooked. Though total muscle denervation is unlikely,^89,90 partial denervation by wide submuscular undermining is possible, resulting in unbalanced contraction. By including the orbicularis muscle in the composite plane face lift flap,² damage to this network may occur, resulting in temporary loss of eyelid margin support with consequent scleral exposure or frank ectropion.⁶⁷ This, however, still needs to be objectively confirmed by electrophysiological assessment. Moreover, upper orbicularis weakening secondary to lateral canthal manipulation may cause permanent nocturnal lagophthalmos, dry eye symptoms, and delayed or incomplete blinking. Canthal dissection may also interrupt the delicate lymphatic system.⁶⁷

Recent reevaluation of fascial layers has indirectly challenged the concept of spaces and ligaments described by Mendelson et al⁹¹ as well as surgical techniques based on this concept. Deep fat compartments are simply local areas of fat interspersion not distinct from the deep fascia.⁶⁵ The view of constant superficial and deep fascial layer relationships, ligament release, deep fat compartment mobilization, muscle origin relocation, or subperiosteal techniques, associated with nonnegligible complications, may be considered an anachronic approach.⁶⁵ Furthermore, how manipulated positions of certain facial structures may affect mimetic emotional expression and nonverbal communication^92,93 remains largely unknown. It certainly deserves to be investigated. Altered facial expression may lead to changes in social relationships.⁹⁴ Unfortunately, some well-accepted face lifting techniques often result in the “nameless beauty” phenotype with the loss of the patient’s individual identity. Preservation of ligaments and SMAS tethering, the “guardians of facial identity,” has been proposed to avoid such an outcome.⁹⁵

“The modern facelift surgeon must achieve consistently excellent results with reasonably little downtime while being aware of methods to improve the safety of this popular elective procedure.”⁹ Furthermore, naturalness and restoration of reference face with rebuilding a close link between image and personality should not be neglected. This entails recreating a state of mind rather than stereotypical beauty.^86,95 Theoretically, approaches that combine preservation of natural facial boundaries and fixation points,⁹⁵ with various interventions reported to be successful,^84,87,96,97 into a single comprehensive surgical technique that addresses rejuvenation in segments, each requiring a specific targeted customized approach to deal with the true underlying causes of deformities while preserving unaltered relationships and structures, seem to be most logical.⁹⁸

LIMITATIONS

Historically, facial aging assessment was based on 2-dimensional photography and the surgeon’s clinical judgement.³⁶ In recent years, 3-dimensional evaluations have been performed with advanced imaging modalities including CT, MRI, and ultrasound to objectively identify aging changes. CT is most suitable for deeper facial structures, such as the bony skeleton, but has the disadvantage of using ionizing radiation. MRI is noninvasive with much higher soft tissue contrast resolution and provides both qualitative and quantitative data.³² Both these modalities have been mainly used in the reviewed studies. However, the primary limitation of these studies is that they are from a single institution. Furthermore, heterogeneity of studies, in addition to CT and MRI differences in device performance and sequence acquisition that may carry a high selection bias, seriously limit analysis and interpretation. The number of intrapersonal studies is also very small. Most other studies comparing cadavers or individuals of different ages provided conflicting results with a low level of evidence, making the determination of actual aging changes with certainty rather difficult.

CONCLUSIONS

In the quest for natural, balanced results, a paradigm shift has been observed lately from an idealized standardized notion of beauty toward a more natural outcome. This change in perspective challenges the unrealistic and artificial results sought a few decades ago. The current trend represents a fundamental shift in societal attitudes celebrating natural beauty with individual uniqueness. Far from denying the benefits of procedures such as deep and composite face lifts, equivalent satisfactory results may probably be achieved by less aggressive approaches. The argument of outcome longevity becomes less critical when natural outcome, safety, and short downtown become the main objectives of rejuvenation. There is now reasonable evidence that facial retaining ligaments are rigid, nonelastic structures, and that changes in fat compartments are not primary in the development of complex aging features, seriously doubting the justifications for some lifting techniques. An anatomically targeted segmental approach with the preservation of unaffected structures provides theoretically a logical, safe, and effective alternative that still needs to be clinically demonstrated with well-designed studies. Nevertheless, it seems to be reasonably attractive. It can be custom-tailored to each patient and complemented whenever indicated by additional interventions to meet patients’ expectations.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.