Different types of facelifts from mini to full facelift and neck lift

What are they? Facelifts have changed dramatically in the last 30 years. Current techniques produce a natural result, with less scarring and improved healing. The wind swept,“tight” look of the 1970s is completely out. The modern face lift elevates the muscles and fascia under the skin and only removes excess skin. The skin itself is not tightened or pulled. This approach produces a more natural result, in addition to providing a finer scar. A facelift (also called a rhytidectomy) is not a single or standard operation. Tailored to each individual, the procedure can range from a small mini-lift to traditional full facelift, and may include a number of other procedures to improve the final result. The operation elevates and re-drapes the facial skin and underlying musculature to eliminate laxity and sagging. It can also be designed to correct problems in the neck, under the jaw and/or chin and in the cheeks. A mid-face lift is so called because it addresses sagging in the cheek area or middle-third of the face. This procedure is popular with younger facelift patients, whereas older patients tend to require a full facelift to address ageing in the lower two thirds of the face and neck.

A facelift can:

  • Lift up your facial tissues below the eyes to a higher position, which combats sag.
  • Tighten your skin to remove wrinkles.
  • Stretch out your neckbands.

There are many different names and variations of facelifts that you may have researched online.

Some of these names are:

  • Skin only facelift (also referred to as Cutanous lift)
  • S – lift
  • MACS lift (Minimal Access Cranial Suspension lift)
  • Mini-facelift
  • Composite facelift
  • Extended full facelift
  • Full facelift
  • Deep plane facelift
  • Sub-SMAS facelift
  • Two layer facelift
  • Limited lift with SMAS manipulation
  • Rhytidectomy
  • Short scar
  • Baker flap facelift
  • Endoscopic facelift
  • Midface lift
  • Cheek Lift
  • Stem Cell facelift
  • Thread lift
  • Necklift
  • Liquid facelift
  • Traditional face lift
  • Brow lift
  • Coronal lift
  • Quick Lift
  • Subperiosteal Lift
  • Temporal Facelift
  • Platysmoplasty
  • Submentoplasty
  • Feather lift
  • Non-surgical facelift


If you are a patient researching which surgeon to see and what operation you think that you need, then it can be quite hard to figure this out when reading different websites. The terminology is confusing, and not all surgeons use the same terminology to describe the same operation. For example one surgeon may refer to a “mini” facelift as a skin only facelift, another may use this term for a SMAS plication facelift. Even when talking about a similar facelift, such as the skin only facelift, there can be wide variations as to what is actually done. A skin only, can be a facelift with no undermining of the skin (sometimes referred to as a S-lift), as well as one with wide undermining of the skin. So you may be talking about a facelift that takes one hour versus one that takes four hours, with vastly different results and recovery.

To be able to understand what facelift you are actually getting, it is important to look at what is done during the facelift, and not what the name of the facelift is. To be able to describe all the different facelifts in more detail, we need to first understand the SMAS (superficial musculo aponeurotic system), as this fascia is a critical structure in facelift surgery and determines what result you can expect and the recovery that you can expect.

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Anatomy of a facelift

To understand what a facelift does and is, it is necessary to understand the anatomy of the face. I will try to make this as clear as possible, mainly so that you can understand what we are trying to accomplish with a facelift.

Facelift Anatomy

Source: https://commons.wikimedia.org/wiki/File:Sobo_1909_260.png

The SMAS (superficial musculo-aponeurotic system)

This is a strong layer of tissue that sits just above the muscles of facial movement (Ref 6). It becomes the platysma muscle in the neck, and it blends into the fascia of the temporalis muscle. It contains all the fat pads of the face. When we age the fat pads in the cheeks fall down (creating a prominent tear trough). In the jaw the jowls are created, and towards the middle of the face you get more prominent nasolabial folds and marionette lines due to the descent of this structure.

Skoog (Ref 8) was a swedish plastic surgeon that first described going deep to this structure to create a facelift that was more long lasting. As with many things in medicine, it took a long time for other plastic surgeons to accept these techniques, and it was not until after his death, that the SMAS facelift became more popular.

Why is the SMAS so important in a facelift?

Skin is elastic and any facelift that uses skin only tends to not last as long. This has been proven with research (Ref 4). The early result from both deeper facelifts and more superficial facelifts tend to be very similar. However, the skin only facelifts tend to sag much quicker after the original operation. Trying to pull on the skin to make the facelift last longer just ends up with un-natural looking results.

The SMAS is a relatively inelastic layer in the face, and if this is lifted and repositioned then the results last longer.

The other big factor is that all the important nerves run underneath the SMAS, such as the facial nerve that controls the movement of your facial muscles. Staying above the SMAS is very safe, as there are no nerves here (other than sensory nerves). The reason why the parotid gland is so important in the face, is that the facial nerve runs inside this gland. So when performing a SMAS facelift you start dissecting on top of the gland, which is very safe, once you get to the end of the gland the nerves emerge, and care has to be taken not to injure these.

Going deeper to the SMAS and trying to lift and stitch the deeper structures is called a deep plane facelift. Research has shown that there is no benefit in doing this either for the longevity of the result or the actual result (Ref 1). The risks and complications however are much higher with this type of facelift, as is the recovery from the surgery.

How to make sense of the different facelift techniques

The best way to make sense of all the different names and techniques is to think about how they relate to the SMAS. If the technique is working on the tissues superficial to the SMAS, then it is a superficial facelift. If it is working on the SMAS, then it is a SMAS lift. If it is working on the tissues under the SMAS, then it is a deep plane facelift. Additional neck lift is all about tightening the platysma muscle in the neck, and is therefore grouped together with the SMAS Lifts. Rhytidectomy is just another word for facelift.

Superficial facelifts

  • Skin only facelift (also referred to as Cutaneous lift)
  • S – lift
  • Mini-facelift
  • Short scar
  • Thread lift
  • Feather lift
  • Liquid facelift
  • Non-surgical facelift
  • Stem Cell facelift

SMAS lifts

  • MACS lift (Minimal Access Cranial Suspension lift)
  • Mini-facelift with SMAS plication
  • Quick Lift
  • Two layer facelift
  • Limited lift with SMAS manipulation
  • Full facelift
  • Baker flap facelift
  • Traditional face lift
  • Necklift
  • Submentoplasty
  • Platysmoplasty

Deep plane facelifts

  • Composite facelift
  • Extended full facelift
  • Deep plane facelift
  • Sub-SMAS facelift
  • Endoscopic facelift
  • Midface lift
  • Cheek Lift
  • Subperiosteal Lift

Superficial facelifts

  • Thread lift
  • Feather lift
  • Liquid facelift
  • Non-surgical facelift
  • Stem Cell facelift

Mini-facelift

This term has no real meaning, as it depends on what the surgeon means by a mini-facelift. Surgeons that perform skin only facelifts would refer to this as being a “mini” facelift. I personally refer to a mini-facelift when I perform a facelift with tightening of the SMAS without going deep to the SMAS (many would refer to this as a full SMAS facelift). So as you can see a mini-facelift in my hands is very different from a mini-facelift in another surgeons hands. It is therefore better to avoid this term and talk about the non-SMAS and SMAS facelifts.

Skin only, S-lift, Short scar facelift and skin only facelifts with skin undermining

These are all very similar facelifts.The skin only, S lift and short scar, usually do not involve any undermining of the skin. They usually involve cutting out around 1-2 cm of skin in front of the ear and then stitching this closed. They are super-simple operations and are very similar to the doctor excising a skin lesion.

The benefits of these operations are that they are very low risk and quick to do (taking around 30-60 min).
Many patients want to have the least invasive operation that they can have and still have a good result. The problem with these operations in my experience, and what I have seen with patients coming in for a second opinion, is that they provide minimal results and any results that they do provide tends not to last more than 6-12 months.

In my experience having fillers and muscle relaxants provide as good, if not better, results than these operations. In many cases a liquid facelift, with 10-12 ml of dermal fillers is far superior to these facelifts.

The next step up from the simple skin excision facelift, is the skin excision facelift with undermining of the skin. This takes around 2-3 hours to do and provides a significantly better result than the skin only excision facelifts. There is a longer recovery however, and the results don’t last as long as a SMAS lift. Considering that adding some tightening to the SMAS is a minimal additional step, there is very little benefit in these operations.

Mini-facelift with SMAS plication

If you are having a mini-facelift then to get a good result you need some tightening of the SMAS. Dr Beldholm performs his mini-facelifts with undermining of skin, as well as tightening of the SMAS, giving a longer lasting result as well as significant lift.

The operation is performed under a general anaesthetic and takes approximately 2-3 hours to do.

It gives approximately 60 percent of the result that a Full facelift would give.

Dr Bernard Beldholm Cavitation Phenomenon Illustration

Thread lift and Feather lift

These lifts are performed by using barbed sutures that are pushed through the tissues. There are two types of these sutures available. The permanent sutures and the absorbable sutures. There are a long list of brand names for these sutures. A thread lift, is so called, because a thin needle is used to insert clear polypropylene threads with tiny barbs just under the skin.

  • Aptos threads
  • Contour threads
  • Promoitalia Threads
  • Silhouette Soft Face Lift
  • Happy Lift™ Revitalizing
  • Barbed suture lift

Threads were a trend in the early 2000’s. I personally performed these thread lifts for a period of about two years. However, it was clear to me in that period that there was no benefit to the patient. I had next to no happy patients from all the thread lifts that I had performed, be it with the permanent barbed sutures or the later absorbable sutures.

The premise of these lifts is very appealing; that you could get a facelift result by putting a few threads through the face and suspending the tissues. Unfortunately it does not work. There were so many problems with one of the threads (contour threads), that they were taken off the market in 2008. Few, if any specialist surgeons, would now be performing these thread lifts.

Studies have shown that benefits, if any, are secondary to swelling post procedure, and last as little as 3-6 months.

In one large study the conclusion of the researcher was:

“The thread-lift provides only limited short term improvement that may be largely attributed to postprocedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure”

They further proceed to state;

“..we cannot justify further use of this procedure for facial rejuvenation…:” (Ref 10)

These findings mirror closely my personal experience with these procedures.

Considering the very long list of problems with these threads:

  • Risk of facial nerve damage
  • Infection
  • Bunching of loose skin
  • Thread coming through the skin (extrusion of the thread)
  • Visible strings across the face
  • Palpable irregularities on the face

If you are considering having a thread lift – don’t. You are exposing yourself to a wide range of potential complications with minimal if any benefit. If you want a non-invasive options then choose a liquid facelift performed by a very skilled dermal filler injector.

SMAS lifts

MACS lift (Minimal Access Cranial Suspension lift), the Quick lift and plication of the SMAS

These lifts are all about suspending the SMAS in different ways (Ref 9). The skin is lifted off the SMAS. In the MACS lift and the Quick lift, a suture is used to lift the SMAS up and attach it to the temporal fascia or cheek bone. The suture is stitched into the SMAS the SMAS is pulled up like a concertina. The excess skin is then resected. The other option is to plicate the SMAS. This means to stitch over the top of the SMAS to tighten it.

These lifts are true SMAS lifts and have been demonstrated to provide good results that are long lasting,

Two layer facelift

This refers to a facelift where the SMAS is lifted in one direction and the skin is pulled in another direction. When performing a facelift you want to pull the deeper structures straight up to reposition them in a more youthful position. The skin is usually pulled backwards to soften up the Nasolabial lines and marionette lines. If the skin is pulled in the wrong direction then there may be abnormal wrinkles forming and the facelift might look very unnatural. It is therefore critical to take great care when the skin is closed.

Dr Bernard Beldholm Full Facelift Explanatory Image

Neck Lift, submentoplasty and platysmoplasty

Necklift Anatomy

Source: By Dr. Johannes Sobotta – Sobotta’s Atlas and Text-book of Human Anatomy 1909, Public Domain, https://commons.wikimedia.org/w/index.php?curid=29817198

This procedure, also known as a lower rhytidectomy, is commonly performed in conjunction with a facelift. A neck lift improves visible signs of aging along the jawline and neck. It also helps to eliminate loose neck skin, excess fatty deposits under the chin, and excess fat and skin located along the lower face that creates jowls.

The platysma is part of the SMAS muscle. As we age the muscle separates from the underlying structures and starts to sag. This causes the characteristic dynamic neck bands in the neck area as we age.

When performing a neck lift, a small incision is made under the chin area, and the platysma muscle is stitched together to tighten the area. The lower part of the platysma muscle is cut to allow it to drape better around the neck area.

The neck lift is usually performed as part of a facelift, as the platysma muscle and skin of the neck need to be stretched laterally to re-drape around the neck. Otherwise there will be loose skin in the neck area.

Dr Bernard Beldholm - Mini Facelift and Neck Lift - Explanatory Image

Facelift (Full), traditional facelift, Extended full facelift or Sub-SMAS facelift

As with most other terminology there is no set operation for this. It is also referred to as a Rhytidectomy. However, most of the time it refers to a facelift with full dissection of the skin and working on the SMAS, usually dissecting under the SMAS, to release ligaments and get a better mid-face lift. This should give a better lift as well as longer lasting results.

Deep plane facelifts

Composite facelift, Deep plane facelift, Endoscopic facelift, Midface lift, Cheek Lift or Subperiosteal Lift

One of the limitations of the SMAS lift is that it does not address the midface or under the eye area. The deeper facelifts go deep on to the bone, detach facial muscles, and do a lot of work in the under the eye area.

These facelifts were quite popular in the late 1990 and 2000’s as surgeons were looking for better and longer lasting results.

However, research has shown that the more aggressive facelift does not give better results, and do not actually lead to longer lasting results. However, what they do do is massively increase the complication rates and recovery from the facelift operation. Because of this most surgeons performing facelift surgery would have moved away from these more severe operations. (Ref 7)

What a facelift will not do

While these procedures do an amazing job at helping patients dramatically look and feel younger, you must have reasonable expectations. These procedures won’t:

  • Change the fundamental appearance of who you are. Dr Beldholm’s goal is to make sure the results of your surgery are “natural looking.” You should look younger and more refreshed. No one should know you’ve had surgery when you go home and have fully healed.
  • These surgeries don’t stop the aging process. As long as you’re alive, your body will continue to age. However, that’s a good thing considering the alternative!
  • A facelift doesn’t restore volume in the face. This is why Dr Beldholm usually recommends either dermal fillers or fat injections in the areas that have lost volume with age.
  • The skin is a very important factor in having a healthy youthful look. To achieve the optimal result from your facelift, Dr Beldholm usually recommends that you combine it with our anti-ageing skin treatments.
  • These range from laser treatments to anti-ageing home care treatments.
  • Many women opt for other simultaneous procedures complementary to facelift surgery, such as a brow lift, chin augmentation, or eyelid surgery, to achieve a more uniform and complete look.
  • Ultimately, anyone in good standing health, who is beginning to notice the signs of aging on their face, are good candidates for the above mentioned procedures. There are no age limits.

You may also be wondering, “Which procedure is right for me?” Remember, no two patients are the same. Therefore, no two facelifts are the same. In helping a patient to make decisions about plastic surgery for facial rejuvenation, Dr. Beldholm will examine and assess how each aesthetic area of the patient’s face contributes to their individual overall appearance. An individualised surgical plan is then developed, which addresses each patient’s specific concerns and needs.

Consult an experienced Specialist Surgeon, like Dr. Beldholm, who is skilled in both surgical and non-surgical facial rejuvenation, to determine the treatment plan that is best for you.

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Reference:

  1. Dane M. Barrett, MDa,*, Deniz Gerecci, MDa , Tom D. Wang, MDb,* “Facelift Controversies”, Facial Plast Surg Clin N Am 24 (2016) 357–36
  2. Audrey C. Ko, MDa , Bobby S. Korn, MD, PhD, FACSa,b , Don O. Kikkawa, MD, FACSa,b, “The aging face” survey of ophthalmology 62 (2017) 190 e202
  3. Rohrich RJ; Narasimhan K., “Long-Term Results in Face Lifting: Observational Results and Evolution of Technique.” Plastic & Reconstructive Surgery. 138(1):97-108, 2016 Jul.
  4. Antell DE; May JM; Bonnano MJ; Lee NY. “A Comparison of the Full and Short-Scar Face-Lift Incision Techniques in Multiple Sets of Identical Twins.” Plastic & Reconstructive Surgery. 137(6):1707-14, 2016 Jun.
  5. Derby BM; Codner MA. ”Evidence-Based Medicine: Face Lift.” Plastic & Reconstructive Surgery. 139(1):151e-167e, 2017 Jan.
  6. Wan D; Small KH; Barton FE. “Face Lift.”, Plastic & Reconstructive Surgery. 136(5):676e-89e, 2015 Nov.
  7. Chang S; Pusic A; Rohrich RJ.. ”A systematic review of comparison of efficacy and complication rates among face-lift techniques. “. Plastic & Reconstructive Surgery. 127(1):423-33, 2011 Jan.
  8. Skoog T. Plastic surgery: new methods and refinements. Philadelphia: W.B. Saunders; 1974.
  9. Tonnard P; Verpaele A.”The MACS-lift short scar rhytidectomy.” Aesthetic Surgery Journal. 27(2):188-98, 2007 Mar-Apr.
  10. Rima F. Abraham, MD; Robert J. DeFatta, MD, PhD; Edwin F. Williams III, MD ”Thread-lift for Facial Rejuvenation. Assessment of Long-term Results” ARCH FACIAL PLAST SURG/ VOL 11 (NO. 3), MAY/JUNE 2009