Endoscopic Deep Plane Facelift: A Classified Approach

Abstract

Background

Traditional facelift techniques, although effective in addressing facial aging, are often associated with visible scarring and stigmas. These factors contribute to patient hesitation and a growing preference for nonsurgical alternatives. In recent years, endoscopic approaches have gained popularity by offering scar-concealed access and deep plane dissection, but many techniques lack a standardized framework for patient selection and reproducibility.

Objectives

The aim of this study was to present a systematic endoscopic facelift technique which proposes a 5-group classification system to guide patient-specific surgical planning and optimize aesthetic outcomes.

Methods

A total of 393 patients underwent endoscopic facelift surgery performed by a single surgeon between 2020 and 2024. Patients were categorized into 5 groups based on facial aging patterns and anatomical needs, including brow lift, midface lift, lower facelift, and neck correction. The technique emphasized minimal skin undermining, vertical vector elevation, and cable suture suspension. All patients were followed for a minimum of 12 months postoperatively. Complications, revisions, and outcomes were recorded prospectively.

Results

There were no cases of permanent nerve injury. Revision surgery for cosmetic concerns was performed in 19 patients (4.8%), most of whom were among the first 100 cases.

Conclusions

This vertical vector endoscopic facelift technique demonstrates consistent aesthetic results with low complication and revision rates. By combining a classification-based surgical strategy with minimally invasive access and deep anatomical correction, this method offers a reproducible, safe, and natural-appearing alternative to traditional facelift approaches. Future studies will aim to incorporate objective assessments and patient- reported outcome measures.

Level of Evidence: 4

(Therapeutic)

Facial aging is a multifactorial process involving descent and deflation of the soft tissues, attenuation of retaining ligaments, and progressive loss of dermal elasticity.¹ Traditional facelift techniques have evolved significantly over the past decades, transitioning from skin-only lifts to deep plane and superficial musculoaponeurotic system (SMAS)-based approaches to achieve more natural and longer-lasting results.² Nevertheless, public perception of facelifting remains cautious, largely due to visible scarring and the stigma of an unnatural postoperative appearance, particularly in the preauricular area. These concerns often deter surgically ideal candidates from pursuing a facelift, leading instead to widespread adoption of nonsurgical alternatives that fail to address deeper structural aging.³

Endoscopic techniques have revolutionized brow and midface rejuvenation by enabling access to critical anatomical layers through smaller, concealed incisions.⁴ In recent years, interest in endoscopic facelift procedures has expanded, and several studies have emerged exploring its potential in full-face rejuvenation. Among them, the “ponytail lift” technique described by Chia Chi Kao introduced a vertically oriented, deep plane approach through limited incisions, offering a systematic method that emphasized minimal scarring, natural vector elevation, and structural repositioning.⁵

Building on this foundation, the present study aimed to refine and extend the systematic application of endoscopic facelift techniques by proposing a detailed patient classification system and a reproducible surgical method tailored to varying degrees of facial and neck aging. This approach incorporates SMAS suspension, midline platysmal plication, progressive contouring of the platysma, selective reduction of subplastysmal fat, digastric muscles, and submandibular glands, lower lid skin pinch blepharoplasty, autologous microfat grafting, and the use of cable sutures for vertical vector lifting, along with surgical netting to ensure controlled skin redraping and long-term tissue stability.

This paper outlines the surgical technique in detail, defines the anatomical and clinical rationale behind each technical step, and presents a classification framework that guides procedural planning. By integrating endoscopic access with advanced deep plane facial lifting maneuvers, this technique seeks to offer an effective and individualized solution for modern facial rejuvenation with imperceptible scars and optimized long-term outcomes.

This study aims to evaluate both the safety and efficacy of the technique across a wide range of clinical presentations, using a standardized surgical protocol and a clearly defined classification system.

METHODS

This study was designed as a retrospective review of patients who underwent endoscopy-assisted deep plane facelift surgery, performed by a single surgeon (M.F.), between January 2020 and December 2024. The study protocol followed the ethical principles outlined in the Declaration of Helsinki.

A literature search was conducted using the PubMed database (National Library of Medicine, Bethesda, MD) to identify relevant studies pertaining to endoscopic facelift and deep plane facelift, and neck lift techniques. Only articles published in English were included, and no specific time range was applied. The search was performed and reviewed solely by the author (M.F.). No additional reviewers were involved in the selection process.

Inclusion and Exclusion Criteria

Patients aged between 22 and 70 years who presented with aesthetic concerns related to facial aging and underwent endoscopic facelift with or without neck lift were included. The age distribution is summarized in Table 1. Exclusion criteria were: a history of major facial trauma, any congenital or acquired facial asymmetry, neuromuscular disorders affecting facial anatomy, or any systemic condition deemed to interfere with wound healing or recovery. In addition, patients with significant skin laxity—including those with a history of massive weight loss, severe actinic damage, genetically thin and inelastic skin, or genetically heavy faces—were excluded from this study.

Table 1.

Patient Distribution by Age

Age group (years)	Number of patients	Percentage (%)
20-29	69	17.6
30-39	161	41.0
40-49	123	31.3
50-59	33	8.4
60-70	7	1.8

Demographic, surgical, and outcome data were collected prospectively and analyzed retrospectively. Recorded variables included patient age, sex, group classification based on anatomical aging patterns, surgical details, adjunctive procedures (eg, fat grafting, blepharoplasty, submandibular gland reduction), and postoperative complications. All patients were followed for a minimum of 12 months postoperatively.

Patient Group Classification

To guide surgical planning and ensure consistent procedural execution, all patients were categorized into 5 distinct groups based on age, degree of facial and neck aging, and soft tissue and skin laxity (Figure 1A). This classification system allowed for systematic adaptation of incision design, dissection extent, and additional procedures such as neck debulking, platysmal plications, or skin excision. Group allocation was determined preoperatively through clinical examination and standardized photographic analysis. The distribution of patients by group is shown in Table 2.

Figure 1.

(A) Patient groups and (B) procedural sequencing of the technique. Group 1: Patients in their twenties to thirties presenting with early signs of aging—periorbital hollowing, deep nasolabial folds, early jowling, and upper facial volume loss. All incisions were concealed within the scalp. Group 2: Patients in their thirties to early forties with early jowling and mild lower face laxity, but no significant neck aging. Incisions were placed in the temporal scalp and postauricular sulcus. Group 3A: Patients in their thirties to early forties showing full-face aging with submental and submandibular fullness or laxity. Incisions included the scalp, postauricular sulcus, and submental area. No skin excision was performed. Group 3B: Patients in their forties to fifties with facial aging and moderate lower face and neck skin laxity. The postauricular incision was extended into the occipital scalp, and a limited subcutaneous dissection facilitated skin redraping. Group 4: Patients in their fifties to sixties with advanced facial and cervical laxity and heavy jowling. Incisions were extended to the tragus and/or helix to allow for adequate skin excision and redraping. (B) Following completion of all dissections, the sequence begins with deep neck work and midline platysmal plication. Subsequently, the midface is elevated using 3 to 4 cable sutures. The lower face is lifted with 2 to 3 cable sutures anchored to the mastoid fascia. To redrape the bulge anterior to the ear, 3 to 4 additional cable sutures are secured to the deep temporal fascia. Brow lifting is then performed using cable sutures placed through paramedian incisions. Finally, progressive contouring of the cervical platysma is carried out.

Table 2.

Patient Distribution by Group

Patient group	Number of patients	Percentage (%)
1	169	43.0
2	34	8.7
3A	25	6.4
3B	128	32.6
4	37	9.4

Group 1: Early Facial Aging With Periorbital Deflation and Midface Descent

Group 1 included patients primarily in their twenties and thirties who exhibited early signs of aging, such as periorbital hollowing, deep nasolabial folds, and hooded upper eyelids. Many of these patients also presented with low-set brows and a fatigued appearance associated with volume loss in the upper two-thirds of the face. Treatment consisted of deep plane dissection through the forehead, temple, midcheek, and lateral cheek to achieve vertical elevation of the cheeks, brow, and temple. Pinch blepharoplasty and microfat grafting were performed selectively based on patient needs.

Group 2: Full Face Aging Without Neck Concerns

This group consisted of patients primarily in their twenties, thirties, and early forties presenting with early jowling and mild skin laxity in the lower face, with no significant neck aging. These patients desired comprehensive facial tightening. In addition to the procedures outlined in Group 1, a limited postauricular sulcus incision was made to permit endoscopic deep plane dissection of the lower face, the upper neck along the jawline, and the submandibular region. SMAS tightening was performed with cable sutures.

Group 3A: Full Face Aging With Submental and Submandibular Fullness

Group 3A included patients in their thirties and early forties who demonstrated aging changes throughout the face along with soft tissue fullness and mild skin laxity in the submental and submandibular regions. This patient group exhibited minimal cervical aging signs in the neutral position; however, clinical concerns were primarily related to fullness and laxity that became more apparent with anterior neck flexion. In these cases, a submental incision was added to allow for deep neck contouring, including resection of subplatysmal fat, digastric muscle, and, if indicated, the superficial lobe of the submandibular gland. Midline platysmal plication and progressive contouring, as described by Sozer et al, were performed to define the jawline.⁶ Subcutaneous undermining in the neck was performed in a limited fashion, creating a tunnel between the postauricular incisions and the submental incision. No skin was excised in this group, and the ear incision was limited to the postauricular sulcus.

Group 3B: Facial and Neck Laxity With Moderate Skin Excess

Group 3B comprised patients in their forties and fifties who exhibited both facial aging and moderate skin laxity of the face and neck. To address skin redundancy, the postauricular incision was extended posteriorly into the scalp. A limited subcutaneous dissection of the lower face and neck was performed, bounded superiorly by a line from the tragus to the oral commissure, and inferiorly by a line 1 cm below the lowest neck fold. A surgical net was placed over undermined areas to facilitate skin adaptation and improve redraping. A perilobular incision was used, but the tragal area was not disturbed.

Group 4: Advanced Aging With Significant Skin Laxity and Redundancy

Group 4 included patients in their fifties and sixties with heavy jowling and advanced skin laxity of the lower face and neck. During redraping, a surgical net was applied progressively from the submental region toward the incision site while the assistant applied posterior traction with skin hooks. After ensuring proper adaptation, excess skin was excised from the postauricular region. Anterior skin bunching was encountered and addressed by extending the incision to the tragus or helix based on intraoperative assessment of skin redundancy. Incisions in the sideburn or hairline were avoided in all cases.

Surgical Technique

Preoperative Marking

Preoperative markings include the bony architecture of the zygoma and maxilla. Pitanguy's line is drawn to identify the danger zone for the frontal branch of the facial nerve.⁷ When dissection is performed in this area, special caution is taken by making gentle spreading maneuvers with scissors to prevent neuropraxia. When lower face and neck dissection is indicated, the mandibular border and lower border of subcutaneous neck dissection are also marked accordingly (Supplemental Figure 1).

Anesthesia and Infiltration

All procedures were performed under general anesthesia. All patients were intubated to ensure airway protection. No gas sedation was used; total intravenous anesthesia with propofol-based sedation was preferred. Local infiltration was performed with 400 mL of a solution containing 4 mg of epinephrine. No local anesthetics were used in the infiltration to allow intraoperative observation of nerve twitches, such as movement of the brow or oral commissure during dissection near motor branches. This approach enables safer dissection while minimizing nerve injury. Care was taken to avoid overinfiltration to reduce swelling and tissue distortion.

Sequencing of the Procedural Steps

Sequencing of each procedural step is essential to achieve maximal lifting and proper execution (Figure 1B; Table 3). After all dissections are completed, the sequence starts with deep neck work and midline platysmal plication. This is followed by vertical vector lifting of the face with cable sutures. Finally, progressive contouring and skin excision in the neck are performed as needed.

Table 3.

Sequencing of the Surgical Steps

Surgical step
1	Temporal and midface dissection
2	Lateral cheek dissection
3	Forehead dissection
4	Submental approach and deep neck contouring (including subplatysmal fat, digastric muscle, and submandibular gland reduction when needed, and midline platysmal plication)
5	Cable sutures and suspension of the face
6	Brow elevation and temple tightening
7	Skin pinch blepharoplasty
8	Progressive contouring of the platysma
9	Microfat transfer
10	Skin management (skin redraping with surgical net and excision if needed)

Temporal and Midface Dissection

A 2.5-cm incision is made in the temporal scalp, behind the hairline. With scissors, the deep temporal fascia is encountered, and the skin is retracted with hooks. Blind dissection is performed anteriorly with scissors and posteriorly with sharp dissectors until adequate space is created for the tip of the endoscope. Endoscopic dissection is then carried out in the temple until reaching Pitanguy's line, where dissection slows to avoid neuropraxia of the frontal branch and to protect the sentinel vein. The superior temporal septum, inferior temporal septum, and temporal lateral adhesions are released. Dissection is extended inferiorly both above and below the sentinel vein to release the lateral orbital thickening and, if necessary, the lateral canthal tendon (Figure 2A). Before reaching the cheek, dissection proceeds inferiorly to the zygomatic arch to create space for the tip of the endoscope and dissection scissors.

Figure 2.

Comprehensive deep plane dissection of the face. (A) Temporal dissection. Through the temple incision, endoscopic dissection is performed to release the superior temporal septum, temporal lateral adhesions, and inferior temporal septum, lateral orbital thickening and, if necessary, the lateral canthal tendon. (B) Midface dissection. Upon reaching the zygoma body, horizontal scissor spreading is performed to facilitate dissection between the SOOF and the OOM. Dissection proceeds inferior to the ORL without releasing it. In the midface, dissection proceeds over the SOOF and beneath the OOM superiorly, and over the zygomatic muscles and beneath the malar fat pad inferiorly. (C) Lateral cheek dissection. The lateral cheek dissection proceeds inferiorly between the superficial temporal artery and the frontal branch of the facial nerve. The dissection advances carefully over the parotid-masseteric fascia and continues into the masseteric space. (D) Forehead dissection. On the forehead, dissection proceeds toward the superior orbital rim, where the periosteum and galea are carefully released. Medially, the corrugator and procerus muscles are selectively released, while laterally, the orbicularis oculi muscle is addressed to facilitate effective brow elevation. (E) Lower face dissection. Through a 3-cm postauricular incision, the sub-SMAS plane is entered and extended anteriorly over the buccal fat pad and facial vessels. Subplatysmal release is then carried out over the gonial angle, mandibular border, and submandibular gland with respect to marginal mandibular nerve. OOM, orbicularis oculi muscle; ORL, orbicularis retaining ligament; SMAS, superficial musculoaponeurotic system; SOOF, suborbicularis oculi fat.

Upon reaching the zygoma body, horizontal scissor spreading is performed to ease dissection between the suborbicularis oculi fat and the orbicularis oculi muscle. Dissection proceeds inferior to the orbicularis retaining ligament without releasing it. Once the zygomaticus major muscle origin has been identified, care is taken to avoid excessive lateral deviation to avoid injury to the branches of zygomatic nerve to the orbicularis oculi muscle. Dissection over the zygomaticus major and minor muscles is carried out in a controlled manner to minimize the risk of injury to the buccal branch of the facial nerve because the dissection may inadvertently deepen in this region, placing the nerve at risk of injury. The dissection then continues over the suborbicularis oculi fat and zygomatic muscles, below the mobile SMAS and orbicularis oculi muscle, toward the nasolabial fold (Figure 2B; Video 1).⁵

Lateral Cheek Dissection

Following completion of the midface dissection, surgical focus is redirected to the lateral cheek and zygomatic arch region. Using fine-tipped scissors, the fascia overlying the zygomatic arch is carefully incised and released to gain access to the sub-SMAS plane. Dissection proceeds inferiorly between the superficial temporal artery posteriorly and the frontal branch of the facial nerve anteriorly. In this anatomically constrained area, horizontal spreading maneuvers are performed with scissors to maintain the correct tissue plane and avoid inadvertent entry into the parotid gland. The dissection advances over the parotidomasseteric fascia, remaining beneath the fixed SMAS. Once the masseteric space is reached, the tissues become looser and the dissection proceeds more easily using a Trepsat dissector. The dissection is extended inferiorly over the masseteric fascia until reaching the gonial angle, completing the exposure of the lateral lower face (Figure 2C; Video 2).

Forehead Dissection

Two paramedian incisions are made on the forehead. The scalp is dissected blindly in the posterior direction up to the vertex. The endoscope is then inserted. Dissection proceeds toward the superior orbital rim, and the periosteum and galea are released. The supraorbital and supratrochlear nerves are visualized and protected. Dissection continues above the orbital septum and beneath the orbicularis oculi muscle and the retro-orbicularis oculi fat. Depending on the amount of release desired, dissection continues inferiorly to reach the tarsal plate. Medially, the corrugator and procerus muscles are released selectively. Laterally, the orbicularis oculi muscle is released with a sharp dissector to enhance brow elevation and minimize relapse (Figure 2D; Video 3).⁵

Postauricular Incision and Lower Face Dissection (Group 2, 3A, 3B, and 4 Patients)

First, subcutaneous dissection continues through the ear incision until reaching the sub-SMAS plane previously dissected through the temple. A dissector is introduced through temple incision to guide entry into the sub-SMAS plane through the postauricular incision. The tissue overlying the dissector is incised with a No. 15 blade, and the sub-SMAS plane is entered and extended anteriorly over the buccal fat pad and facial vessels (Video 4). Subplatysmal release continues over the gonial angle, mandibular border, and submandibular gland, preserving the marginal mandibular nerve (Figure 2E; Video 5).

Submental Approach and Deep Neck Contouring

In Group 3A, 3B, and 4 patients, before placement of the cable suspension sutures, a 3-cm submental incision is made slightly posteriorly to allow easier access to the submandibular gland. To minimize delamination, skin undermining is limited to 1 cm below the lowest visible skin crease with the neck flexed. Skin is undermined immediately above the platysma to preserve the fat attached to the skin. After skin elevation, the platysma is elevated for about 2 cm and the digastric muscles are visualized. Digastric muscles and subplatysmal fat are freed with scissors. Performing a meticulous anatomical dissection and ensuring clear exposure of each structure within a clean surgical field are critical steps in determining the appropriate extent of deep neck debulking.⁸ This phase of the procedure plays a pivotal role in achieving optimal neck lift outcomes.⁹ Resection of deep tissues is performed using a harmonic scalpel (Ethicon, Raritan, NJ). Interdigastric fat is preserved. After resecting the lateral digastric muscle and the subplatysmal fat, the digastric muscles are plicated with 3-0 Vicryl (Ethicon). Scissor dissection is performed lateral to the digastric tendon to enter the submandibular gland capsule. Reduction of the superficial lobe of the submandibular gland is done with the harmonic scalpel. No capsule closure or oversewing is performed. Then, 16 units of botulinum toxin is injected into the remnants of each gland.¹⁰ After completion of the deep work in the neck, midline platysmal plication is performed with 3-0 Vicryl interrupted sutures.

Cable Sutures for Suspension

Midface suspension begins with the placement of a cable suture in the most distal part, around 1.5 cm behind the nasolabial fold. A second suture is placed to erase the dimple created by the first. Next, an additional 1 or 2 sutures are added to complete the midface lift (Video 6). Two cable sutures are placed in front of the ear, in the lateral cheek area, within the sub-SMAS plane between the superficial temporal artery and the frontal branch of the facial nerve. These cables enable vertical suspension of the middle third of the face (Video 7).

In patients belonging to Groups 2, 3A, 3B, and 4, these 2 lateral cheek sutures are not placed. Instead, the endoscope is reintroduced through the postauricular incision. The first suture is anchored to the SMAS at the level of the oral commissure to lift the jowl region, followed by placement of 1 or 2 additional sutures (see end of Video 5). These sutures are fixed to the mastoid fascia, creating a temporary bulge in front of the ear. The endoscope is then reintroduced through the temporal incision, and 3 or 4 additional cable sutures are placed to move the bulge upwards (Video 8). These sutures are fixed to the deep temporal fascia to absorb the bulge. All cable sutures used are 4-0 Prolene nonabsorbable sutures (Ethicon). Figure 3A shows the cable suture sequence.

Figure 3.

Cable sutures, brow lift and progressive contouring of the neck. (A) Cable suture sequence. In endoscopic deep plane facelifting, a systematic sequence of cable sutures is applied to achieve vertical vector lifting. The procedure begins with cable sutures placed in the midface to lift the nasolabial folds. Subsequently, 2 or 3 cable sutures are placed in the lower face to lift the jowls. To address the resulting bulge in front of the ear, 3 or 4 additional cable sutures are placed and anchored to the DTF facilitate vertical redraping of the skin. (B) Brow elevation and temple tightening. Following adequate release of the forehead, temple, and periorbital regions, hooks are placed at each paramedian incision site to facilitate controlled lifting. Cable sutures are then anchored and fixed to the DTF to secure the elevated brow and temple position. For additional benefit in temple skin tightening, a temporal patch is created and fixed to the DTF. (C) Progressive contouring of the neck. In patients classified as Group 3A, 3B, and 4, progressive contouring of the neck platysma is performed after the completion of cable suture suspension. The procedure begins from the mastoid region using 3-0 barbed sutures. The gonial angle is defined with back-and-forth plication of the platysma, and the needle is advanced toward the submental incision to continue the plication anteriorly along the jawline. DTF, deep temporal fascia.

Brow Elevation and Temple Tightening

For brow shaping and temple skin tightening, Kao's technique is adopted.⁵ A 2-0 Ethibond suture (Ethicon) is anchored to the periosteum and galea on the left side of the left paramedian incision. Using long clamps, the cable suture is first passed to the right paramedian incision and subsequently directed to the right temple incision. Next, the right paramedian incision is retracted with a hook placed on the right side. A second cable suture is applied and advanced from the right paramedian to the left paramedian incision and then to the left temple incision using long clamps. Hooks are then placed into the paramedian incisions and gently pulled by the assistant to control suspension. The sutures are then fixed to the deep temporal fascia, after which the hooks are removed (Figure 3B). For additional benefit in temple skin tightening, a temporal patch is created and fixed to the deep temporal fascia, as described in the literature.⁵ All of these maneuvers result in a predominantly vertical vector of elevation in the brow and temple regions, which aligns with the aesthetic preferences expressed by the patients included in this study.

Skin Pinch Blepharoplasty

With the help of meticulous dissection in a bloodless field, there is minimal swelling in the lower eyelids. No local anesthetics are applied before the procedure to better assess the amount of skin to be removed. Using 2 fine-tipped forceps, repeated pinching maneuvers are done to evaluate the excess skin.¹¹ Fine-tipped scissors are used to excise the excess skin (Video 9). If bleeding occurs, gauzes soaked in local anesthetic are applied. Cauterization is avoided. Closure is done with 6-0 rapid Vicryl interrupted sutures.

Posterior Neck Dissection and Progressive Contouring

In Group 3A, 3B, and 4 patients, posterior neck subcutaneous dissection is performed following the completion of cable suture suspension. The endoscope is introduced through the postauricular incision to connect the posterior subcutaneous neck dissection with the midline subcutaneous neck dissection. Endoscopic visualization facilitates precise undermining of the skin above the platysma while preserving the subcutaneous fat layer. Once the anterior and posterior dissection planes are united, progressive platysmal plication is carried out, beginning from the mastoid region. Anterior and posterior platysmal myotomies are performed prior to the progressive contouring phase. Notably, a platysmal sling is not created in this technique. Using 3-0 barbed sutures, the gonial angle is defined with back-and-forth plication of the platysma, and the needle is advanced toward the submental incision to continue the plication anteriorly along the jawline (Figure 3C). This maneuver effectively tightens submandibular and submental platysmal laxity and has been well described in previous literature.⁶

Skin Excision and Redraping

In Group 3B patients requiring neck skin removal, the postauricular incision is extended posteriorly into the scalp, avoiding hairline incisions. The skin is adapted progressively with a surgical net while the assistant gently pulls the skin towards the postauricular incision using hooks.⁶ After adaptation, the excess skin is excised from behind the ear. In Group 4 patients with significant skin excess in the lower face and neck, additional skin bunching may occur in front of the ear. In such cases, anterior incision extension to the tragus or helix is performed for proper redraping. Sideburn and temporal hairline incisions are strictly avoided.

Microfat Grafting

The most preferred area for fat harvest is the inner thigh, followed by the abdomen and lateral thigh. The fat is harvested using a 10-mL syringe by hand suction, similar to the Coleman technique.¹² After decantation for 10 minutes, the fat is centrifuged for 2 minutes at 1500 rpm. The average fat grafting volumes are summarized in Table 4.

Table 4.

Average Fat Grafting Volumes by Target Area

Target area	Volume (mL)
Brow	1 mL per side
Temple area	3-4 mL per side
Forehead	6-8 mL
Nasolabial fold	1 mL per side
Lower lid-cheek junction	2 mL per side
Upper eyelid	0.5-1 mL per side

Total fat grafting volume, 20-25 mL.

Drains, Surgical Net, and Skin Closure

After completion of the procedures, a surgical net is applied to the areas of skin undermining.¹³ Through the temple incision, 3 drains are placed for the forehead scalp area, midface dissection area, and lateral cheek dissection area reaching the lower face. Endoscopic visualization is used to insert the drains in the correct locations (Video 10). Placement of drains significantly reduces postoperative swelling. Surgical net application reduces fluid collections and enhances skin redraping.¹⁴ Skin closure of temporal, paramedian scalp, postauricular, and submental incisions is performed with 5-0 rapid Vicryl absorbable running sutures. Patients are hospitalized for 3 or 4 nights, and all drains and nets are removed before discharge. Postdischarge follow-ups occur every 2 days during the first week. Each check-up includes lymphatic drainage massage, cleaning of incision sites with antibiotic solution, and draping the face with elastic bandages.¹⁵ On postoperative day 10, patients are advised to wear an elastic face mask for 1 month.

RESULTS

A total of 393 patients underwent endoscopic facelift surgery during the study period. Of these, 372 were female (94.6%) and 21 were male (5.4%), with a mean age of 38.1 years (range, 22-70 years). All patients were followed for a minimum of 12 months postoperatively and the average follow-up was 16.4 months (range, 12-36 months). The patients’ images have not been previously published and are presented here with written patient consent for publication (Figures 4-8). Comprehensive data on complications, including reoperations and revision procedures, were prospectively recorded. The reasons for secondary interventions were also documented and analyzed.

Figure 4.

Case example, Group 1. This 29-year-old female patient presented with concerns of periorbital hollowing, a fatigued appearance of the eyes, hooded brow skin, and midfacial ptosis. She underwent an endoscopic lift targeting the upper and middle third of the face through concealed scalp incisions, combined with autologous microfat grafting to the tear troughs, cheeks, temples, and orbital hollows. These interventions collectively contributed to a more refreshed and rejuvenated appearance with no visible scarring. A concurrent revision rhinoplasty was also performed to harmonize overall facial proportions. (A, C, E) Preoperative images. (B, D, F) Photographs of the patient taken 18 months postoperatively.

Figure 8.

Case example, Group 4. A 57-year-old female patient presented with concerns of heavy, hooded brows, generalized facial and cervical heaviness, and significant skin laxity affecting both the face and neck. She was also dissatisfied with the square appearance of her face and sought a more youthful, V-shaped contour. To address these concerns, the patient underwent a panfacial lifting procedure with deep neck contouring and comprehensive platysmal manipulation. Skin laxity was managed through tailored skin excision, utilizing incisions placed in the tragal area and extended into the helix to allow effective redraping. The sideburns and temporal hairline were left untouched. (A, C, E) Preoperative images. (B, D, F) Photographs of the patient 16 taken months postoperatively.

Figure 5.

Case example, Group 2. This 29-year-old female patient presented with complaints of a tired facial appearance, sagging cheeks, and early jowling, expressing dissatisfaction with the overall heaviness and fatigue perceived in her facial expression. She had previously undergone a temporal lift but was now seeking a more comprehensive facial rejuvenation without visible scarring. She underwent an endoscopic full facelift, including a brow lift, performed through concealed incisions within the scalp and postauricular sulcus. Autologous fat grafting was performed in the under-eye and temple regions to restore volume. A neck lift was not performed in this case. Vertical elevation of the mid and lower face resulted in significant improvement in cervicomental definition. (A, C, E) Preoperative images. (B, D, F) Photographs of the patient taken 14 months postoperatively.

Figure 6.

Case example, Group 3A. This 39-year-old female patient presented with concerns regarding periorbital skin laxity, hooded brows, deepening nasolabial folds and marionette lines, and cervical laxity. She underwent a full endoscopic facelift, including a brow lift and a neck lift via a submental approach. No skin excision was performed in this patient. Autologous fat grafting was utilized to restore volume in the under-eye, cheek, and temple regions. The procedure achieved notable rejuvenation and structural correction in the neck without skin resection in a patient exhibiting mild soft tissue laxity. (A, C, E) Preoperative images. (B, D, F) Photographs of the patient taken 17 months postoperatively.

Figure 7.

Case example, Group 3B. This 47-year-old female patient presented with concerns of facial and cervical heaviness, marked skin laxity of the neck, and a fatigued periorbital appearance. She sought comprehensive rejuvenation with an emphasis on minimizing visible scarring. The patient underwent a panfacial deep plane facelift combined with deep neck contouring. Cervical correction included submental access for subplatysmal work and platysmal plication. Skin excision was performed via an extension of the postauricular incision into the posterior scalp and a perilobular incision, while preserving the tragal area. A revision rhinoplasty was also performed in the same session. (A, C, E) Preoperative images. (B, D, F) Photographs of the patient taken 14 months postoperatively.

There were 3 (0.8%) cases of limited neck skin necrosis, all of which healed with serial dressing changes. Twenty patients (5.1%) experienced transient neuropraxia of the frontal branch of the facial nerve. Eight patients experienced transient lower lip weakness. All cases resolved spontaneously within 3 months. There were no cases of postoperative alopecia related to extensive undermining of the scalp. Other complications are outlined in Table 5.

Table 5.

Postoperative Complications

Complication	Prevalence (n, %)	Revision
Hematoma	1 (0.3%)	Evacuation performed
Limited neck skin necrosis	3 (0.8%)	Dressing changes and local antibiotics
Infection	1 (0.3%)	Dressing changes and local antibiotics
Sialocele of submandibular gland	1 (0.3%)	Resolved spontaneously
Transient lower lip dysfunction	8 (2.0%)	Resolved spontaneously within 2-3 months
Transient neuropraxia of frontal branch	20 (5.1%)	Resolved spontaneously within 2-3 months
Delayed wound healing at postauricular incision	8 (2.0%)	Dressing changes and local antibiotics

A total of 19 patients (4.8%) underwent revision procedures for cosmetic concerns. The most common indication for secondary surgery was persistent skin excess in the lower face and neck, observed in 7 patients (1.8%). Notably, 5 of these cases occurred within the first 100 patients in the series. These cases were managed successfully with relifting and additional skin excision. Persistent nasolabial folds were noted in 6 patients (1.5%), for whom endoscopic midface lifting was performed as a secondary procedure. Cheek contour irregularities, characterized by indentation or volume asymmetry, were noted in 6 patients (1.5%). These were effectively corrected with autologous fat grafting. Two patients (0.5%) developed herniation of the postseptal upper eyelid fat pads; one required surgical intervention for reduction (Supplemental Table 1). No cases of functional deficit or major revision were observed.

DISCUSSION

Patients seeking facial rejuvenation often express hesitation about undergoing surgical intervention due to fears of visible scarring and the stigma historically associated with traditional facelift techniques.¹⁶ As a result, many patients initially pursue nonsurgical treatments such as dermal fillers, threads, and energy-based modalities, despite the limited capacity of these approaches to address true tissue descent and structural aging. The advent of endoscopic techniques offers a paradigm shift by prioritizing scar concealment and preserving natural facial landmarks.^5,17 By addressing the major deterrents to surgical facelifting, endoscopy holds the potential to reposition surgery as a primary, rather than a last-resort, option for patients—particularly those in earlier decades of aging. In recent years, there has been a noticeable paradigm shift in the age demographics of patients seeking facelifting procedures, with increasing interest observed among individuals in their late twenties and early thirties who present with genetically determined early signs of aging or structural heaviness, rather than age-related laxity alone. Importantly, although nonsurgical interventions can offer volume restoration and skin texture improvement, true lifting and repositioning of deep facial structures can only be achieved through surgery.

In the pursuit of comprehensive facial rejuvenation, the midface plays a critical role, particularly the region extending from the lower eyelid to the corner of the mouth.¹⁸ Although modern techniques for jawline and neck treatment have achieved impressive results, the midface remains a challenging area that significantly influences overall facial harmony.¹⁹ Incorporating an endoscopic sub-SMAS midface lift allows for vertical elevation of descended tissues, effectively addressing the low lid-cheek junction and restoring youthful facial proportions. Treating the midface is therefore essential to complement improvements in the lower face and neck, ensuring a balanced and natural rejuvenation.

Historically, the application of endoscopy in facial rejuvenation was pioneered by some surgeons, primarily in the context of endoscopic brow lifting.^20,21 Their contributions laid the groundwork for broader applications of endoscopic techniques through hidden incisions. Subsequent advancements by Renato Saltz and Oscar Ramirez expanded the use of endoscopic methods to include midface rejuvenation.^22,23 Nicanor Isse's introduction of cable sutures marked a pivotal innovation, enabling soft tissue suspension through cable sutures.²⁰ This technique inspired a new generation of surgeons to explore more global facial rejuvenation strategies, integrating deep plane dissection with cable suture support for comprehensive repositioning of facial structures. The longevity and stability of cable sutures largely depend on proper tissue release and suture application technique. For midface elevation, we ensure sub-SMAS dissection extending toward the nasolabial fold. Similarly, for the lower face, the sub-SMAS plane is carefully mobilized. This extensive mobilization allows for tension-free tissue repositioning, which is fundamental for achieving durable fixation and preventing complications such as cheese-wiring. Our technique involves the progressive placement of cable sutures in a stepwise fashion, allowing for precise, controlled elevation of the desired facial subunits. This method avoids overcorrection and distributes tension evenly, enhancing long-term outcomes.

In the last few years, endoscopic techniques for facial rejuvenation have gained substantial momentum, emerging as a prominent trend in modern facelift surgery. Among recent contributions, a few techniques merit particular attention. Marc Mani's endoscopic composite deep plane lift introduces a vertical-lateral pull,¹⁷ which, in our opinion, predisposes patients to skin bulging in the preauricular area—a challenge that may compromise both the aesthetic outcome and the reproducibility of the technique. In contrast, our approach utilizes cable sutures to initiate elevation from the lower face, intentionally generating a controlled bulge in front of the ear. This bulge is then sequentially resolved using additional cable sutures placed anterior to the ear, providing precise vertical vector suspension. In older patients with persistent skin excess, a limited subcutaneous lower face dissection is added to help with skin redraping, after which any remaining excess skin is addressed in a stepwise approach.

The vertical vector of elevation used in our approach facilitates more effective skin redraping and improves correction of midface and lower face aging compared with lateral or vertical-lateral vector techniques. It also helps prevent common facelift stigmas such as the unnatural lateral sweep and laterally displaced oral commissures, and maintains more natural facial contours and expressions.²⁴

Although our technique shares conceptual alignment with Kao's ‘ponytail lift’ it differs in execution. Kao's method avoids cable sutures in the lower face and instead relies on wide subcutaneous dissection of the lower face and neck to achieve redraping. In our experience, such extensive skin undermining may unnecessarily prolong postoperative recovery and increase the risk of skin redraping problems. By incorporating patient-specific surgical classifications, particularly in Groups 2 and 3A where no facial skin undermining is performed, we demonstrate that powerful lower face elevation can be achieved without extensive subcutaneous dissection. This tailored approach supports both procedural safety and individualized aesthetic outcomes, while minimizing the risks associated with wide subcutaneous undermining.

Another critical refinement aimed at minimizing risks associated with subcutaneous undermining involves limiting the extent of skin dissection in the neck. Recent studies have demonstrated that minimizing skin undermining, when combined with a strategically tailored surgical plan, can yield excellent aesthetic outcomes while significantly reducing the risks associated with extensive subcutaneous dissection.²⁵ Rather than performing wide anterior and lateral neck dissection, our technique utilizes a subcutaneous tunnel created between the postauricular incisions and a submental incision. This corridor provides adequate exposure for instrumentation and enables precise anatomical correction while preserving surrounding tissue integrity. In this framework, we adopted elements of Sozer's progressive contouring technique, particularly the emphasis on progressive platysmal plication along the jawline, following selective reduction of subplatysmal structures such as the subplatysmal fat, digastric muscles, and the superficial lobe of the submandibular gland.⁶

Unlike some traditional neck lift techniques that rely on laterally pulling the platysma and anchoring it to the postauricular mastoid fascia, our approach avoids direct suspension of the cervical platysma.^26,27 Instead, once the deep neck contouring has been completed, platysmal laxity is managed with a 2-step strategy consisting of midline platysmal plication followed by progressive contouring along the jawline. Various suture contouring approaches for platysma have been described in the literature,^28,29,30,6 This maneuver reshapes and retensions the platysma in a more anatomical direction, reinforcing jawline definition and contributing to a smooth, natural cervicomental contour without reliance on skin tension or posterior platysmal anchoring.³¹

An additional technological adjunct utilized during the procedures was the harmonic scalpel (Ethicon) for the reduction of deep neck structures. The use of this device enabled near bloodless dissection, significantly minimizing intraoperative bleeding. Consequently, a cleaner surgical field facilitated more precise volumetric reduction of the targeted tissues, contributing to improved aesthetic outcomes. The harmonic scalpel, which has also been used in salivary gland surgeries, seems to be equally effective in this context by ensuring safe and efficient tissue handling.³² Importantly, the harmonic scalpel generates less thermal energy than traditional electrocautery, thereby minimizing collateral thermal injury to surrounding tissues.³³ This reduction in thermal damage contributes to decreased postoperative swelling and lowers the risk of seroma and sialocele formation.

Another notable advantage of endoscopic facelift surgery, as demonstrated in our experience, is the ability to apply lifting vectors in closer proximity to problem areas such as the nasolabial folds and jowls through the use of strategically placed cable sutures. We believe that anchoring the lift nearer to the areas of concern results in more direct and effective correction.³⁴ This approach not only enhances the precision and impact of the lift but also contributes to minimizing the overall size and length of surgical incisions.

Like all surgical approaches, endoscopic facelift surgery presents its own set of advantages and limitations. This technique requires a comprehensive understanding of facial anatomy, as well as advanced hand-eye coordination to navigate the confined endoscopic planes effectively. The learning curve is steeper than in conventional facelift procedures, and operative time is generally longer. The operative time is 3 to 4 hours for Group 1 patients, 4 to 5 hours for Group 2 patients, 6 to 7 hours for Group 3A patients, and 8 to 10 hours for Group 3B and 4 patients. The surgeon must maintain a high level of focus and physical stamina throughout the procedure. Additionally, although the method minimizes the need for long or multiple incisions, it relies on more aggressive internal dissection to achieve vertical lift and effective skin redraping. In our experience, this has been associated with increased postoperative swelling than encountered with traditional open techniques. As a result, patient management demands greater vigilance and often requires a highly experienced surgical team—including trained scrub nurses and postoperative care staff—as well as a longer duration of hospitalization in selected cases.

A limitation of this study is the absence of objective outcome measures and validated patient-reported outcome data to quantify the success of the procedure. Although the clinical and aesthetic results appear consistent and reproducible, future research will focus on incorporating standardized evaluation tools to assess both surgeon-reported and patient-reported outcomes in a more systematic manner. This study has a relatively limited follow-up duration, which does not yet encompass extended follow-up outcomes. However, we believe that the stability observed in 12- to 18-month postoperative results provides meaningful evidence of the durability of the endoscopic techniques, and further longitudinal follow-up is planned to evaluate their extended efficacy.

Recent publications have expanded the role of endoscopy beyond isolated procedures into more comprehensive strategies for facial rejuvenation.^5,17 Based on our experience, we believe endoscopic surgery represents a safe, effective, and increasingly viable option when performed with sufficient anatomical knowledge and technical expertise. As the field continues to evolve, the integration of endoscopic techniques is likely to play a central role in the future of aesthetic facial surgery. Regarding concerns over the longevity of endoscopic outcomes, Kao et al have provided valuable insights in their publication, particularly supporting the durability of endoscopic brow lift results over time.⁵

CONCLUSIONS

The described endoscopic facelift technique offers a comprehensive and systematic approach to facial and neck rejuvenation, emphasizing vertical vector lifting, deep tissue remodeling, and minimal visible scarring. By integrating cable suture suspension, anatomical neck contouring, and a structured patient classification system, this method provides consistent aesthetic outcomes with a low complication and revision rate. With adequate experience and a multidisciplinary team, the procedure is safe, reproducible, and capable of addressing key concerns that deter patients from undergoing traditional facelift surgery.

Supplemental Material

This article contains supplemental material located online at https://doi.org/10.1093/asj/sjaf110.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.