Facelifting surgery has undergone both a revolution and an evolution in the last 25 to 30 years. Prior to the work of Mitz and Peyronie, which first highlighted the importance of the SMAS layer in re-suspending the musculature of the face, practically all facelifts were carried out simply by elevating a skin flap and re-draping it to take out the skin excess. Although in good hands this often produced excellent results there was a relatively quick relapse rate and the potential to over tighten the skin resulting in poor scars and less expression in the face. The SMAS facelift initially seemed to be the answer to this problem by taking the tension on the underlying muscular aponeurotic layer.

Over the following 20 years the number and variety of SMAS techniques was limited only by the number of surgeons prepared to find a new way to reposition or tighten the SMAS and publish it. I include myself in this number. Early SMAS lifts however were found to produce their own problems and re-directing the SMAS with an unnaturally lateral vector often gave rise to the so-called lateral sweep deformity which was very stigmatic of a SMAS facelift. There were also surgeons who argued that by tensioning the SMAS there was a tendency to flatten the face and ignore the natural “ogee” curve with prominent cheek bones and softer nasolabial folds.

There then followed a period where it seemed that the plane of facelift dissection got deeper and deeper. The work of Tessier in reconstructive surgery was adapted and popularised in aesthetic surgery by Darina Krastinova in Paris and the so-called mask lift enjoyed some years of popularity. It adhered to the idea that facelifting was not all about skin excision and that the improvement was achieved by re-suspending the entire face on the facial skeleton. I remember this era very well and was an enthusiastic proponent of the mask lift myself for particular cases. These included correction of problems related to lower eyelid surgery, transgender facelifts and so-called orthomorphic facelifts where the emphasis was on creating a better face shape rather than rejuvenating the face. At the same time a variety of deep plane facelifts also came into vogue.

It is interesting that now in the middle of the second decade of the 21st Century the popularity of many of these techniques has dwindled largely due to the extended downtime and facial swelling which can be protracted and last for several months. In addition in less than expert hands the mask lift could often give a very stigmatic appearance of a different type to the over-pulled skin lift but stigmatic nonetheless.

So, following this period and a careful analysis of long-term results there has been a trend back to conservatism with facelift surgery and currently the strong emphasis is on the additional gestures of replacing volume in the face. The so-called lift and fill facelifts consist of some form of SMAS gesture but in conjunction with 20 to 30 ml of fat harvested from the abdomen or the thigh and prepared in a variety of ways and re-injected into the face with the idea of replacing the volume of youth.

The same trend to conservatism is, I think, also seen with contemporary surgery to the neck. Although the very extensive procedures, which involve opening the neck under the chin, removing the fat deep to the muscles, sometimes removing muscles and even part of the salivary glands, can produce a very sharp neck but again at the cost of an increased downtime and complication rate.

The ideal operation should be relatively straightforward to carry out and relatively easy for the patient to tolerate and return to normal activities within a few weeks. In addition it is desirable for patients to be able to recognise themselves and look refreshed and natural. I often think that facelifts are less about reversing the chronological age but more about improving the femininity and shape of a female face.

Male facelifts are subtly different but just as important to have a natural non-stigmatic result which means that modifications of scar design are employed.

The benefits of the experience of the last 20 years are that experienced surgeons can choose from a variety of techniques that are designed specifically for each individual patient. Using this principle I would still say that in my practice over 80-85% of patients will undergo a SMAS lift with some liposuction to the fat in the neck. The SMAS procedure will usually be a plication without removing any SMAS particularly if the face is thin although with a fatter face some SMAS may be removed. Although I often use some fat transfer I am generally very cautious in reflating the face with large volumes of fat. Although this can produce a full youthful volume it is often a very significant change in the patient’s appearance which can be more than they would want. In my practice at the moment I will often use a little fat to augment the chin by a few millimetres and to help to clean the line of the jaw. I will also sometimes make the cheekbones look a little larger. However I rarely use more than 5-10 ml of fat at the same time as a facelift.

Scars have also changed in the sense that we now try to keep the scars to the smallest length possible. However I do think that it is important not to carry out a short scar facelift when there is a lot of excess skin in the neck or this can result in bunching of the scar behind the ear which takes a long time to settle down.

Lastly I am still a great advocate of gentle balancing lateral brow lifts for many patients who have facelifts as the overall effect is greatly enhanced by having balance throughout the face. The lateral brow lift is now a much smaller procedure than it used to be and I never remove muscles from in between the eyebrows.

Modern facelifting requires a great deal of experience in knowing what kind of results will be achieved by different gestures. Essentially it is always important to remember that a patient has a social, personal and professional life to return to and facelifts which are significant procedures need to be tailored to minimise the downtime. In this respect patients also have a responsibility to eat well and to avoid smoking and alcohol and dietary supplements that include active ingredients that impact on blood clotting.

A facelift only affects structural changes in the face caused by gravity. It is extremely important to take a holistic view about rejuvenation and to include skin care in the overall treatment. This often means a careful skin assessment prior to surgery and some tailored treatment either with antioxidants, gentle exfoliative treatments and pigment regulation. If we have learned anything over the last 25 years it is that an integrated holistic approach with the minimal surgical gesture possible is our aim. Strangely we have almost come full circle since the 70s in terms of the degree of surgery that is being carried out but with a much greater level of sophistication.

It is always difficult to know what the future holds and whether there will be further advances in surgical facial rejuvenation. My feeling is that most of the advances will be adjuvant treatments which improve skin quality and also help to maintain the results of surgery, either with some form of internal suture techniques or some form of externally applied energy that will maintain collagen production in the face. The rate of change is accelerating and the future is exciting.