Facelift — it lifts the layer under the skin, not the skin

A face does not fall by skin alone. Under the skin is a fascial layer called the SMAS, under that is fat, and ligaments hold it all in place. With age the whole set descends together.

So skin-only lifts are not done now. Pulled skin stretches again, and in the meantime the face just looks pulled. That is largely why old facelifts looked unnatural.

The current approach raises the skin, pulls and fixes the SMAS beneath it, then lays the skin back without tension. The pull is carried by the layer below rather than by skin.

Names vary by extent — from jawline and neck only, up through the midface, to including the forehead and brows.

The incisions follow the hairline and around the ear. Those are inconspicuous places, but it is not the same as having no scar.

This has among the longest recoveries on this site. You can be out in public at two to three weeks, but the line of the face takes six months to a year to settle.

Sensation changes for a while. Numbness around the ear and cheek is common and usually returns over months, though some can persist.

Rarely, the facial nerve can be injured. The nerves that move expression run just beneath the SMAS. Most such injuries are temporary, but this is the heaviest risk of the operation.

Haematoma is the most common early complication — blood collecting under the lifted area, which has to be drained promptly. High blood pressure and smoking raise the risk.

Scars and the hairline can shift. The incision in front of the ear can widen, and the sideburn can ride up.

If swelling suddenly grows on one side, if pain worsens, or if one side of the face will not move, report it immediately.

Not smoking weighs especially heavily here. Once the skin is lifted it survives on blood flow from its edges. Smoking reduces that flow and sharply raises the risk of the skin dying (skin necrosis). Many places make a period of abstinence a condition.

Lost volume and descent are different problems. If a face looks older because it has hollowed, pulling alone can make it look gaunter. That is why fat grafting or filler is often considered alongside.

This operation does not change skin quality. Pigment, fine lines and texture stay as they are. Those belong to fractional laser and pigment lasers.

Decide in advance whether the neck is included. Lift the face and leave the neck, and the boundary shows.

Sort out blood pressure and current medications beforehand. They bear directly on haematoma risk.

It does not turn the clock back; it sets the clock once. The state at the time of surgery improves, and ageing continues. How long it holds varies with age, skin and how you live.

It cannot be undone. A fixed fascial layer and excised skin do not return.

Non-surgical procedures share the goal but not the scale. Ultherapy, Thermage and thread lifts recover quickly but change less; this is the reverse. They are not substitutes for each other but different steps.

There is usually no reason to hurry the age. Done too early, the odds of repeating it within its own lifespan go up.

Whether to have it done is settled with a doctor, and it is better not to settle it on one consultation alone.