My facelift: never finished, always better

A facelift is not a fixed technique that a surgeon learns once and then repeats unchanged for years. It evolves with new anatomical insight, with personal experience and with what a surgeon sees from colleagues in the operating room. In this article, I explain why my Deep Plane Facelift is a different operation today than it was five years ago, and why that is exactly the point.

I have just returned from Los Angeles, where I once again spent several days with colleagues who focus almost exclusively on aesthetic facial surgery. Yet this story does not begin in Los Angeles, nor did it begin this year. Over the past five years, I have made a habit of visiting other facial plastic surgeons and observing their surgical work up close. That has taken me to New York, Beverly Hills, Los Angeles, London and Rome.

I do not do this to find one new facelift technique that I can then copy at home. The more facelifts I see and the more surgery I perform myself, the clearer it becomes that a facelift is never one standardized operation. What does exist is an operation that keeps evolving. To me, that may well be the most fascinating aspect of facelift surgery.

A field in constant motion

The anatomy of the face does not change. The facial nerve (nervus facialis) runs no differently today than it did twenty years ago. The same is true of the retaining facial ligaments, the SMAS and the platysma. The SMAS is the layer of connective tissue and muscle beneath the skin of the face, and the platysma is the broad, superficial muscle of the neck. The deep neck structures and the various fascial layers are also still exactly where they have always been. Anatomy therefore remains the compass.

Our knowledge of that anatomy, however, keeps growing more refined, and above all the way we approach it surgically is constantly changing. New anatomical studies appear and existing techniques are adjusted. Surgeons modify their dissection (the release of the tissues), their vectors (the direction in which the tissues are repositioned) and their fixation. The way the different layers are treated shifts as well. Sometimes a concept presented as new turns out to build on something that was already described twenty or thirty years ago.

That is exactly what makes facial rejuvenation surgery so fascinating to me. It constantly looks ahead, without letting us forget to look back. After all, progress does not mean that everything done in the past was suddenly wrong. Progress often arises precisely because we understand old principles better and integrate them differently into modern surgery.

Learning by observing

That is why I try to visit other surgeons regularly. In recent years, I have spent time with Neil Gordon, Andrew Jacono, Ben Talei, Mike Nayak, Dominic Bray, Keon Parsa and Marc Levin, among others. I have also visited Michele Pascali in Rome and Greg Bran in London. They are surgeons with different backgrounds and different techniques, and above all with their own way of looking at the same anatomical problem. That is precisely what makes these visits so valuable.

One surgeon treats the neck differently from another. One places more emphasis on releasing the ligaments, another has a very specific way of handling the SMAS. The vectors differ, the extent of the dissection differs, and the deep structures are approached differently each time. Sometimes I see something and immediately think it could be an improvement. Sometimes I only understand much later why someone performs a particular step. And sometimes I see something and decide that I do not want to do it myself. That, too, is learning.

My recent visit to Los Angeles was therefore not a separate study trip. It was the next step in something I have been doing for years: observing, comparing and then deciding critically what fits within my own surgical approach.

Not a copy, but a mosaic

If someone asks me today which facelift technique I perform, that is hard to sum up in a single word. My facelift is not an operation I learned from one surgeon. It is more of a surgical mosaic. Certain ideas come from operations I saw in New York, others from Beverly Hills or Los Angeles, and some principles from London or Rome. On top of that come my own training in head and neck and craniomaxillofacial surgery (surgery of the skull, jaws and face), my anatomical background and the scientific literature. And above all: everything my own patients and their results have taught me over the years.

This is exactly where the term Deep Plane becomes interesting. Many surgeons use that term today. It would therefore seem reasonable to expect more or less comparable results when everyone performs a Deep Plane Facelift. They are anything but. The results of so-called Deep Plane Facelifts vary enormously, because one deep plane is not necessarily the same as another.

How extensively are the retaining ligaments released, and how far does the dissection extend? Which vector is used, and how is the platysma treated? What happens to the SMAS outside the dissection area, how is the deep neck addressed, and how are the layers brought back into balance? A single operation contains hundreds of such small surgical decisions, and it is precisely those decisions that ultimately make the difference.

To me, a sufficiently extensive release, meaning the freeing of the deeper retaining ligaments, is a fundamental part of modern facelift surgery. Aging tissues do not sag only because the skin loosens. They also remain anchored to those ligaments. Failing to release that anchoring adequately limits the ability to truly reposition the face anatomically.

That, however, is not where the operation ends. Deeper layers, beyond the deep plane, can also show signs of aging, such as laxity, volume change or localized tissue excess. Within a modern Deep Plane Facelift, additional techniques may therefore be needed to further refine those layers. These include a SMASectomy (removing a strip of SMAS) or a SMAS plication (folding and suturing the SMAS). Imbrication (suturing tissue in an overlapping fashion) and selective suspension (targeted suspension of tissue) are also among the options. One surgeon uses these techniques very sparingly, another far more extensively.

That is exactly why two surgeons can both perform a Deep Plane Facelift and still deliver completely different operations with completely different results. My current facelift has therefore become a combination of principles that I have come to find anatomically logical, reproducible and effective over the years.

“The same name, but not the same operation.”

Why Los Angeles?

Los Angeles, and Beverly Hills in particular, has an exceptionally high concentration of surgeons who devote themselves almost exclusively to aesthetic facial surgery. That means not only a great deal of experience and high volume, but also competition. When so many specialized surgeons treat the same patient population in a relatively small area, an environment emerges in which techniques are constantly compared and refined remarkably quickly.

The differences rarely lie in spectacular new operations, but in nuances. A dissection that extends a few millimeters further, a different vector or a slightly different way of releasing the ligaments. A different treatment of the platysma or the SMAS, a modified sequence of the operation, a different approach to the deep neck. One detail does not change a surgical approach. Hundreds of details, gathered over many years and from many operating rooms, ultimately do.

That is precisely why I keep going to observe. Not to bring a Hollywood facelift home, but to add a few new pieces to my own surgical mosaic each time.

Progress sometimes means looking back

Aesthetic surgery has a particular fondness for the word new: a new facelift, a new plane, a new technique, a new name. New, however, is not necessarily better. Many principles applied in modern facelift surgery today were already described decades ago. SMAS plication and SMASectomy are examples of this.

On their own, I no longer consider such techniques a complete solution for facial aging. When the deeper layers show signs of aging, that problem, in my view, must also be treated in that deeper layer. That does not mean, however, that these older techniques have lost their value, quite the contrary. Within a modern Deep Plane Facelift, they can be exactly the additional instrument needed to address a problem in another anatomical layer. It is therefore not about old versus new, but about understanding which principle makes sense in which place.

I am convinced that we can only keep moving forward if we also understand where current surgery comes from. Today's best ideas are rarely complete revolutions. They are usually refinements of concepts that have existed for much longer, and that is true in every field. To me, progress therefore does not mean constantly replacing everything. It means keeping what works, letting go of what works less well, adding new insights and sometimes rediscovering an old principle within a modern anatomical approach.

“Anatomy determines what is needed, not the name we give the operation.”

Has this changed my facelift?

Without a doubt. My facelift today is not the same operation as the facelift I performed five years ago. Yet there has never been a single moment when I stepped off a plane and decided to do everything differently from Monday onward. In my view, that is rarely how surgical evolution works. It consists of hundreds of small changes.

One dissection becomes slightly more extensive, another step more limited. A vector changes, a ligament is released more consistently and the way the SMAS is treated evolves. I look at the transition between face and neck differently, working more extensively in one area and more conservatively in another. Some steps are added, others disappear. And sometimes, after years, I come back to a surgical principle that has long existed, but that I now understand far better than the first time.

On their own, these changes seem small. When hundreds of such decisions accumulate over five years, the result is ultimately a considerably different operation. And that is exactly the intention.

The best facelift I have ever performed

Perhaps that is ultimately my simplest yardstick. I hope that the last facelift I performed is the best I have done up to that point, and that the next one is slightly better again. Not because surgery ever becomes perfect. Every patient has a different anatomy, and every operation remains a sequence of choices. But every patient does add something to my experience.

Every operation I observe with a colleague and every anatomical dissection changes a small part of how I look at the next patient. The same is true of every scientific publication, every conversation and every result I reassess months or years later.

My facelift is therefore not a finished technique. It is an operation built over the years from anatomy, experience, literature and ideas I have seen in operating rooms around the world. Not a copy of one surgeon and not a collection of isolated tricks, but a mosaic in which all those influences have ultimately become one operation. And that mosaic will keep changing.

“Never finished. Always better.”

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