Current Trends and Perspectives on Facelifts
Current Trends and Perspectives on Facelifts
As I attend various academic conferences, both presenting and listening to other speakers, I find myself reflecting deeply on the field. Rather than blindly following facelift techniques developed primarily for Western patients, I believe it's time we start critically evaluating the strengths and limitations of each approach. From there, we can begin to redefine these methods from our own perspective.
Historically, facelifts began as techniques focused primarily on lifting the lower face. However, with advances in facial anatomy—particularly our understanding of the SMAS layer and retaining ligaments—facelifts have evolved to address both the lower and midface regions simultaneously.
Examples of this evolution include Dr. Hamra’s Deep Plane and Composite Rhytidectomy, Dr. Barton’s High SMAS Facelift, Dr. Stuzin’s Extended SMAS Facelift, Dr. Aston’s FAME Technique, Dr. Baker’s Lateral SMASectomy, and Dr. Tonnard’s MACS Lift. While each of these methods differs in theory and surgical approach to facial aging, they all share a common goal: expanding the concept of a facelift beyond the lower face to achieve rejuvenation of the midface as well.
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| Hamra, S.T., & Choucair, R.J. (2008). Extended Superficial Musculoaponeurotic System Dissection and Composite Rhytidectomy. Clinics in Plastic Surgery, 35, 607–622. |
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| Baker, D.C. (2013). Facelift: Lateral SMASectomy. In Aesthetic Surgery of the Face (Section I, p. 232). Neligan, Elsevier. |
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| Jewell, M.L. (2013). Facelift: Facial Rejuvenation with Loop Sutures, the MACS Lift and Its Derivatives. In Aesthetic Surgery of the Face (Section I, p. 223). Neligan, Elsevier. |
Another notable aspect in the history of facelifts is that nearly all major surgical techniques were developed by Western surgeons for Western patients. Compared to Westerners, East Asians generally have broader, fuller facial structures, with thicker and more fibrous skin and soft tissue—factors that make achieving good facelift results more challenging.
Improving the midface, which is anatomically complex and difficult to access, presents even greater difficulty in East Asian patients. While certain techniques may yield excellent outcomes in Western patients, they often prove less effective—or even unsuitable—for East Asian faces.
Despite rising demand in Asia due to economic growth and an aging population, there is still a noticeable lack of research focused on facelift techniques tailored specifically to the anatomical characteristics of East Asian patients.
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| Shirakabe, Y., Suzuki, Y., & Lam, S.M. (2003). A new paradigm for the aging Asian face. Aesthetic Plastic Surgery, 27, 397–402. |
In my practice, I’ve applied and studied the strengths and limitations of the various facelift techniques mentioned above. While it’s true that East Asian patients often present anatomical challenges that can make achieving optimal results more difficult, I believe we have a responsibility to continue striving for better outcomes.
One approach I’ve taken is to combine historically significant techniques in a thoughtful and meaningful way. In particular, by integrating the strengths of methods that emphasize both lower and midface rejuvenation, I believe we can begin to see more promising results—even in the midface, which remains one of the most challenging areas to improve.
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In particular, midface sagging becomes even more prominent in patients who experience cheek sagging after facial bone contouring surgery. I believe that by combining various proven facelift techniques, we can achieve more effective correction in these complex cases.
With that goal in mind, I developed my own approach by integrating three techniques—High SMAS facelift, Extended SMAS facelift, and the FAME technique—all of which have been validated over nearly three decades in the U.S., Europe, and Australia for addressing both the lower and midface. I also incorporated Dr. Mendelson’s facial anatomy concepts to enhance the precision of the procedure.
Over the years, I’ve had the opportunity to present and lecture on this approach at both domestic and international conferences. Fortunately, this work was also published in the Aesthetic Surgery Journal (SCI), the official journal of The Aesthetic Society in the United States.
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| Ryu, M.H., & Moon, V.A. (2015). High Superficial Musculoaponeurotic System Facelift with Finger-Assisted Facial Spaces Dissection for Asian Patients. Aesthetic Surgery Journal, 35(1), 1–8. Commentary by Aston, S.J., pp. 9–10. |
Let’s briefly look at my surgical approach and the theoretical foundations behind it. The High SMAS facelift involves dissecting the SMAS layer above the zygomatic arch, rather than below it. This higher approach allows for more effective lifting of the midface, which makes it particularly suitable for addressing midface sagging.
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| Barton, F.E. (2013). Facelift: SMAS with Skin Attached – The “High SMAS” Technique. In Aesthetic Surgery of the Face (Section I, p. 256). Neligan, Elsevier. |
The Extended SMAS facelift involves dissecting the zygomatic and masseter retaining ligaments beneath the SMAS layer, with a focus on improving the midface. This approach places particular emphasis on rejuvenating the midface area.
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| Stuzin, J.M. (2008). Facelifting. Plastic and Reconstructive Surgery, 121(1). |
The FAME technique involves finger-assisted dissection and lifting of the malar fat pad, aiming for midface elevation.
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| Warren, R.J., Aston, S.J., & Mendelson, B.C. (2011). Facelift. Plastic and Reconstructive Surgery, 128, 747e. |
The three techniques mentioned above differ slightly in their theories and approaches to facial aging, but they share a common focus on midface lifting. By integrating the strengths of each method, I believe it’s possible to achieve better outcomes, even in the challenging anatomical conditions of East Asian patients.
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Facelift surgery relies heavily on facial anatomy, and the foundation of my approach is based on Dr. Mendelson's theory. According to his model, the face is divided into five layers, with the third layer consisting of the SMAS, the orbicularis oculi muscle, and the platysma muscle. Beneath that, we have the facial nerve, other muscles, and safe facial spaces. By applying Dr. Mendelson's theory in surgery, I aim to combine both safety and improved results.
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Over the years, I have worked to integrate and apply the theories and methods mentioned above, striving to maximize their strengths and minimize their weaknesses. Recently, the focus has shifted toward not merely combining all of these methods indiscriminately, but rather selectively applying them based on the individual situation in order to achieve both excellent results and rapid recovery.
In cases where both the midface and lower face exhibit significant sagging, all of the aforementioned methods can be applied. However, when midface sagging, such as cheek ptosis after facial bone surgery, is more pronounced, I choose techniques that specifically target that area while reducing dissection in other regions to facilitate faster recovery. Similarly, if the primary concern is lower face sagging, with no desire for midface improvement, there is no need to dissect the midface retaining ligaments or zygomatic area. Ultimately, the key is not to force a patient into a one-size-fits-all approach, but to select the most appropriate methods based on their unique condition and needs.
I believe that choosing methods according to the patient’s specific circumstances and needs should always be the priority. My approach to facelift surgery is built around adapting the proven techniques to fit the individual patient’s situation, ensuring flexibility in the application and striving for both excellent results and a quicker recovery time.
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At domestic and international conferences, I often observe speakers who rigidly adhere to a single technique. While learning from the masters and following their methods is valuable, blind adherence should be avoided. The primary goal of a facelift is to improve facial contours by lifting sagging tissues, and there are multiple interpretations of this, with each method having its strengths and weaknesses. Blindly following one method and applying it universally is no different than trying to fit the patient into a mold that doesn’t work for them.
Since the anatomical conditions of East Asians differ from those of Westerners, it is crucial to flexibly apply various methods that consider these specific characteristics. The approach should always be patient-centered, adapting to their needs, rather than forcing the patient to fit into a singular method. Even when utilizing the techniques of renowned experts, it’s essential to view them critically and, from an East Asian perspective, reinterpret and refine these methods. I believe our task is to absorb the strengths of historical techniques while improving upon their limitations.
A deep understanding of the history of facelifts, particularly those developed by Western surgeons, is undeniably important, and acquiring knowledge of these techniques is essential. However, excessive obsession with one specific method limits flexibility and becomes an obstacle to progress. Moving beyond the blind imitation of Western facelift techniques, it is time we redefine a method tailored to the unique characteristics of East Asians, developed by East Asians, for East Asians.
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