Learning Center: FACELIFT, NECK LIFT, AND BROW LIFT

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WHAT IS A FACELIFT?

In brief

A facelift, neck lift, and brow lift reposition tissues that have descended with age: the cheeks and jowls, the neck and jawline, and the eyebrows. They are often combined with each other or with eyelid surgery, but each has its own techniques and risks. Most patients are highly satisfied, and results remain visible for roughly a decade, although aging continues. The most common serious complication of a facelift is a hematoma (a collection of blood under the skin), and its risk is linked to blood pressure and male sex; any nicotine use substantially raises the risk of wound-healing problems. For a broader overview, see aging and aesthetic conditions and aging and aesthetic treatments.

How the face ages

Facial aging involves every layer, from bone to skin. The facial skeleton loses bone in predictable areas, particularly the midface, parts of the eye socket rim, and the prejowl area of the jaw, removing support from the tissue above it [1]. The fat under the skin is divided into separate compartments that lose volume and shift at different rates, which is part of why the cheek flattens and the jowl forms as a distinct bulge [2].

Between the fat and the facial muscles lies a fibrous layer called the SMAS (superficial musculoaponeurotic system), which connects to the platysma muscle of the neck [3]. Most modern facelifts reposition the SMAS rather than pulling on skin alone, which is what allows the jowl to be lifted without a tight, wind-swept look. A facelift does not change skin texture, fine lines, or pigment, which are treated with skin resurfacing. Lost volume is addressed with fat grafting or fillers, and a weak chin with a chin implant or genioplasty.

Facelift techniques

A facelift (rhytidectomy) uses an incision in or along the temple hairline, in front of the ear, around the earlobe, and behind the ear. The skin is lifted, the deeper layer is repositioned, and excess skin is trimmed and closed without tension. The techniques differ in how the SMAS is handled:

  • SMAS plication and imbrication. The SMAS is folded and stitched on itself (plication), or a strip is removed and the edges sutured together (imbrication). These involve less dissection near the facial nerve branches.

  • SMAS flap. The SMAS is cut, elevated as a separate layer, and advanced.

  • Deep plane facelift. The skin and SMAS are released together as one unit, freeing the ligaments that tether the cheek so the midface and jowl can be moved more directly [4]. Dissection is closer to the facial nerve branches.

  • Short-scar facelift. Techniques such as the MACS (minimal access cranial suspension) lift use a shorter incision that ends near the earlobe and suspend the SMAS with sutures, often under local anesthesia [5]. They correct less neck skin.

Does one technique work better?

High-quality comparative evidence is limited. A systematic review found only 10 studies that directly compared the effectiveness of facelift techniques and five that compared complications [6]. In one randomized study, 21 patients had a less extensive SMAS facelift on one side and a more extensive procedure on the other; independent surgeons could not tell the sides apart at 6 and 12 months [7]. In a small study of identical twins, short-scar and full-incision facelifts looked similar at about one year, but the full incision gave a better neck at about five years [8].

Recent meta-analyses compare deep plane and SMAS facelifts, mostly using single-surgeon case series. A 2025 review of 47 studies (10,766 patients) found similar safety, with hematoma in 3% of deep plane and 2% of SMAS facelifts; most nerve injuries were temporary, and only one study directly compared aesthetic results [9]. Another reported satisfaction of 94.4% after deep plane and 87.8% after SMAS facelifts, but also more pooled complications with deep plane (17.2% versus 10.3%) [10]. A 2026 meta-analysis of deep plane facelifts alone (10,784 patients) reported temporary facial nerve weakness in 1.2%, hematoma in 1.8%, skin necrosis in 0.1%, and no permanent nerve injuries [11]. A meta-analysis of 183 studies found only small differences in complications between SMAS techniques and concluded that technique should be chosen for the quality of results [12]. In practice, the surgeon's experience and the match between technique and anatomy matter more than the name of the operation.

Complications

In a prospective database of 11,300 facelifts, major complications (requiring an emergency visit, admission, or reoperation within 30 days) occurred in 1.8%; hematoma (1.1%) and infection (0.3%) were the most common [13].

Hematoma. Larger hematomas need prompt drainage to protect the overlying skin. Consistent risk factors are male sex and high blood pressure. In one series, male sex and a preoperative systolic pressure above 160 mmHg were independent risk factors [14]. In 1,089 facelifts using a strict blood pressure protocol (systolic 140 mmHg or less), the hematoma rate was 0.9%: 5.2% in men versus 0.05% in women [15]. An evidence review found that controlling blood pressure, pain, and nausea, using local anesthesia, and using fibrin sealants reduce hematoma, whereas drains and compression dressings do not [16]. A recent matched comparison using modern protocols, including tranexamic acid (a medication that reduces bleeding), found similar hematoma rates in men and women [17].

Facial nerve injury. The branches of the facial nerve, which move the muscles of expression, lie beneath the SMAS. A 2025 systematic review reported injury in 0.5% to 5% of facelifts; about 70% of affected patients recovered fully within six months, and roughly 10% had a lasting deficit [18]. Permanent injury risk did not differ between SMAS techniques [12]. Temporary numbness of the cheeks and ears is expected.

Skin necrosis and smoking. The lifted skin heals on a reduced blood supply, so anything that constricts small vessels raises the risk of skin loss. Among smokers in a prospective study, failing to stop smoking after surgery was strongly associated with skin slough [19], and a meta-analysis found that smoking predisposes to skin necrosis, delayed healing, and infection [20]. In more than 15,000 cosmetic surgery patients, any nicotine exposure, including e-cigarettes and nicotine replacement, was associated with wound complications in 15.2% versus 3.8% of nonusers [21].

Satisfaction and longevity

In a long-term survey, 97.8% of respondents rated their improvement as very good or beyond expectations at one year and 68.5% at an average of 12.6 years, though fewer than a quarter of the original patients responded [22]. With standardized photographs 5.5 years after surgery, jowl correction was largely maintained (21% relapse) while the neck relapsed more (69%), and 76% of patients still looked younger than before surgery [23]. In a prospective comparison, median recovery time was about 25 to 30 days [24].

WHAT IS A NECK LIFT?

The neck often shows age earlier and more noticeably than the face. Three features drive most concerns: excess fat under the chin (submental fat), loose skin, and vertical cords running down the front of the neck called platysmal bands. The platysma is a thin sheet of muscle just under the skin of the neck that is continuous with the SMAS of the face. With age, its inner edges separate and become visible as bands, and the angle between the chin and the neck (the cervicomental angle) becomes blunted. A weak chin can also blunt the angle. More on these changes is on the aging neck and neck treatment pages.

Surgical options

The right operation depends on which layers are contributing. One useful framework: younger patients with good skin elasticity and fat above the platysma can be treated with liposuction alone; patients with fat beneath the platysma or mild to moderate muscle and skin laxity do well with removal of fat through a small incision under the chin combined with a platysmaplasty; and patients with marked skin excess need a procedure that removes skin, usually a facelift with neck lift. In a series of 33 patients treated this way, 61% improved by one grade of neck contour and 36% by two grades through an under-the-chin incision alone [25].

  • Neck liposuction removes fat above the platysma through small incisions. It works best when the skin is elastic enough to contract afterward.

  • Platysmaplasty sews the inner edges of the platysma together in the midline (sometimes with a horizontal release lower in the neck), tightening the neck like a sling and treating platysmal bands.

  • Lateral platysma suspension pulls the back edge of the platysma toward the ear and is done with a facelift. One published approach combines skin undermining, removal of fat under the chin, midline platysmaplasty, lateral suspension, and release of the ligaments along the jaw in a defined sequence [26].

In practice, a "neck lift" usually means a lower facelift with platysma work, because loose neck skin is removed through the incision behind the ear. Results in the neck relapse more than those in the jowl [23]. Among 1,089 neck lifts in one practice, about 10% of patients had a secondary procedure, an average of 10.3 years after the first; recurrent platysmal bands (87%) and recurrent jowling (48%) were the most common reasons [27].

Nonsurgical options

Deoxycholic acid injections. Deoxycholic acid (ATX-101, sold as Kybella) is a naturally occurring bile acid that destroys fat cells when injected into fat under the chin. Two large placebo-controlled trials established its effect. In REFINE-1, 70.0% of treated patients versus 18.6% of placebo patients improved by at least one grade on both clinician and patient rating scales, and magnetic resonance imaging confirmed volume reduction in 46.3% versus 5.3% [28]. REFINE-2 found similar results (66.5% versus 22.2%) [29]. Several sessions are usually needed: in REFINE-1, 55% of treated patients had improved by at least one grade after two treatments and 75% after four [28]. Side effects were mostly swelling, bruising, numbness, and tenderness at the injection site, and were temporary. Temporary weakness of the marginal mandibular nerve, which causes an uneven smile, occurred in 4.3% of treated patients in REFINE-1 and resolved without lasting effect [28]. Among patients who responded, the improvement was maintained in most at three years [30]. It treats fat, not loose skin or bands.

Neuromodulators for platysmal bands. Botulinum toxin injected into the platysma relaxes the bands and can sharpen the jawline. In a phase 3 placebo-controlled trial, 32.3% of patients treated with onabotulinumtoxinA versus 1.9% with placebo reached the trial's combined definition of success at day 14, with no reported swallowing difficulty [31]. Like other neuromodulator treatments, the effect is temporary and must be repeated to be maintained. See injectables for more on neuromodulators.

WHAT IS A BROW LIFT?

Brow ptosis means a low or drooping eyebrow. The frontalis muscle of the forehead lifts the brow, while muscles around the eye and between the brows pull it down. A descending outer brow adds to upper eyelid hooding and a tired look. Brow aging is not uniform: in one photographic study, the inner and middle brows of women aged 50 to 60 sat higher than those of women aged 20 to 30, and the authors concluded that lifting the outer brow is usually more rejuvenating than lifting the whole brow, which can look surprised [32]. See forehead conditions and forehead treatments for related topics.

Brow lift and upper eyelid surgery

A heavy upper eyelid can come from excess eyelid skin, a low brow, or both, and the distinction matters. Removing eyelid skin when the real problem is a low brow can pull the brow down further. A meta-analysis found that the brow position drops after upper eyelid surgery, on average about 0.7 mm after simple blepharoplasty and about 2 mm after eyelid ptosis repair [33]. For this reason the brow is assessed before blepharoplasty, and the two are often done together.

Brow lift techniques

  • Endoscopic brow lift. Several short incisions are made behind the hairline, and the forehead tissue is released from the bone with a camera and then fixed in a higher position. The scars are hidden, but the hairline moves up somewhat. In 31 patients measured 5.4 years after an endoscopic brow lift, a subtle elevation of under 5 mm persisted everywhere except the tail of the brow, and 64% were still judged to look better than before surgery [34].

  • Coronal brow lift. An incision runs across the top of the scalp from ear to ear. It raises the hairline and leaves a long scar with numbness behind it, and is used less often now.

  • Pretrichial (hairline) brow lift. The incision follows the front hairline, so the forehead can be shortened rather than lengthened. It is preferred for people with a high hairline. A 2026 comparison found that the endoscopic approach produced more elevation early on (21% versus 13% change in brow height), but long-term brow height and complication rates were the same, and the authors recommended choosing based on hairline position and forehead length [35].

  • Temporal (lateral) brow lift. Incisions in the hair-bearing temple lift only the outer brow, often combined with endoscopic release. One series of 71 endoscopic temporal brow lifts reported a mean elevation of about 1.8 mm and a complication rate of 1.4% [36].

  • Direct brow lift. Skin is removed directly above the brow hairs. It gives precise, durable lift and is useful in older patients, men with receding hairlines, and people with facial paralysis, but it leaves a scar at the brow [37, 38].

Outcomes and complications

There are no randomized trials comparing brow-lift approaches. A systematic review found no clear evidence that open brow lifts are inferior to endoscopic ones [39]. Another review of 76 studies found that each approach has its own complication profile: the highest revision rate was with the hairline lift (7.4%), the highest rate of numbness with the direct lift (5.5%), and the highest rate of hair loss along the incision with the endoscopic lift (2.8%) [40]. Other risks include asymmetry, prolonged scalp numbness, and weakness of the frontal branch of the facial nerve. In a review of 628 endoscopic brow lifts, 70% of patients were satisfied, but only half of the surgeons surveyed were pleased with long-term results, reflecting concern about relapse [41].

Neuromodulator brow shaping

Botulinum toxin can produce a modest, temporary "chemical brow lift" by relaxing the muscles that pull the brow down, allowing the frontalis to lift it. In a prospective series, injections into the outer orbicularis muscle raised the outer brow by an average of 4.8 mm [42]. Treatment of frown lines between the brows can also elevate the brow [43]. The effect lasts months, not years. More detail is on the injectables page.

Functional brow lift

When a low brow pushes skin down over the upper eyelid far enough to block the upper field of vision, a brow lift can be functional rather than cosmetic. In a small series of direct brow lifts done for this reason, all patients reported relief of their visual field obstruction and the sensation of a heavy brow [37].

COST OF FACE, NECK, AND BROW LIFTS

The cost of a facelift, neck lift, or brow lift is quoted individually at consultation, because it depends on what is actually being done. The main factors are:

  • The extent of surgery. A short-scar facelift and a full facelift combined with neck, brow, or eyelid surgery differ considerably in operating time. Combining procedures in one session can reduce total facility and anesthesia time compared with staging them, but in a large prospective database it also raised the rate of major complications from 1.5% to as much as 3.7% [13].

  • Anesthesia. Many facelifts and most short-scar lifts can be done under local anesthesia, with or without oral or intravenous sedation, which avoids an anesthesia fee [44]. More extensive or combined procedures are often done under general anesthesia, which adds an anesthesia professional's fee.

  • The facility. An office operating room, an ambulatory surgery center, and a hospital have different facility fees. The type of facility was also an independent predictor of hematoma in the CosmetAssure database, so the setting should be chosen for safety as well as cost [13].

  • Unplanned care. In a multistate study of 6,089 facelifts, 3.6% of patients returned to a surgery center, emergency department, or hospital within 30 days, most often for a hematoma; such visits can add unexpected cost [45].

  • Maintenance. Results last years, not forever, and many people use neuromodulators and fillers or resurfacing afterward to maintain the skin and volume that surgery does not address.

Insurance

Facelift, neck lift, and cosmetic brow lift are elective cosmetic procedures and are not covered by health insurance. The exception is a functional brow lift, done when a drooping brow pushes skin down far enough to obstruct the upper field of vision. Coverage in that situation generally requires documentation such as visual field testing and photographs, and criteria vary by insurer; the same applies to functional upper blepharoplasty. Insurance does not pay for the cosmetic portion of a combined procedure. For help preparing for an aesthetic consultation, see making the most of your aesthetic visit.

Summary

  • A facelift repositions the SMAS layer to correct jowls and lower facial sagging. Evidence that any one technique is superior is limited and mixed [6, 9].

  • Major complications occur in about 2% of facelifts. Hematoma is the most common and is reduced by blood pressure control; facial nerve weakness is usually temporary; nicotine raises wound complications [13, 15, 18, 21].

  • A neck lift treats fat, platysmal bands, and loose skin; deoxycholic acid injections and neuromodulators are nonsurgical options for fat and bands, respectively [28, 31].

  • A brow lift treats a low brow, which should be identified before upper eyelid surgery. The best approach depends largely on hairline position and forehead length [35].

  • Most patients remain satisfied for many years, though the neck tends to relapse more than the jowl [22, 23].

Last reviewed: October 4, 2026

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