u/DrDanGould

I’m going to explain something most patients never think to ask about, but probably should.

Not all surgical research is created equal. There are journals that will publish almost anything with a fee attached. There are journals with minimal peer review. And then there are journals that function as the actual scientific backbone of a specialty where the editorial board actively gatekeeps quality, where citations from other researchers confirm the work is being used to advance clinical practice, and where being appointed to the board means your peers have vetted your scientific judgment, not just your surgical results.

The Aesthetic Surgery Journal is that last category for aesthetic plastic surgery.

I sit on the editorial board. I was one of the youngest surgeons ever appointed. I’m telling you this not to credential-drop but because I want you to understand what it actually means in practical terms for a patient choosing a surgeon.

It means I’m reading and evaluating research before it becomes standard of care. It means I know what the data actually says not what a marketing team summarized. It means when I tell you something works, or doesn’t work, I’m drawing from the primary source.

Oxford University Press presented 2024-2025 impact data for ASJ today. Articles published in the last two years are already showing strong early citation growth meaning other researchers and surgeons are actively referencing this work in their own studies and clinical decisions. That’s how science moves into operating rooms.

When you’re researching surgeons, here’s a quick framework:

Does the surgeon publish original research or just consume it? Do they publish in peer-reviewed journals with real editorial standards? Are they close enough to the science that they’re shaping it, not just following it?

A surgeon who sits on an editorial board of a major journal isn’t just credentialed. They’re embedded in the mechanism that determines what the field does next.
That’s who you want operating on your face.

Gina’s case gives me a good opportunity to walk through what I actually do differently, because her result touches on nearly every element of my approach.

The core problem with standard deep plane

Most surgeons doing deep plane facelifts lift until things look good to them. The issue is that “looks good on the table” doesn’t always translate to natural long-term results. You can end up with a tight, pulled, or swept appearance whether you’re doing a SMAS lift or a deep plane. The technique label doesn’t protect you from a bad outcome if the execution isn’t anatomically grounded.

What I do instead

I map the retaining ligaments before I start and use them as anatomic landmarks throughout the dissection. The goal is repositioning tissue back to where it originated, not pulling it to where it looks better. When you restore the original anatomic position of the ligament complexes, it becomes very difficult to create a weird, tight, or unnatural result.

You’re working with the anatomy, not against it.

Once everything is repositioned, I remove the excess skin without applying tension to it. Skin tension is what creates a windswept appearance and what activates the fibroblastic response that leads to thickened, raised, or widened scars in front of the ear. No one wants that, and it’s entirely avoidable.

The neck: mastoid crevasse technique

I was one of the surgeons who co-authored the original paper describing the mastoid crevasse technique. It’s a dissection approach that defines the posterior jawline and neck in a way that standard deep plane simply can’t achieve. I include it in almost every case.

Part of that is submandibular gland management. I address the glands in nearly every patient. This is not controversial in the academic sense, it’s just technically demanding, and most surgeons don’t have the anatomic background to do it safely, so they avoid it. That’s probably the right call for them. But it’s a core part of what creates a truly refined neck contour, and I’m comfortable doing it because I understand the anatomy.

The upper face: endoscopic temple lift

I use an endoscopic approach to the brow and temple in most cases, meaning I’m operating with a camera, dissecting under direct visualization to release the retaining structures and allow proper repositioning. People call this a brow lift, but that’s not quite right. It’s a temple lift. The brow position is actually a downstream effect of the upper eyelid skin burden. When there’s excess skin above the lid, the frontalis muscle reflexively elevates the brow to keep the visual field clear. Once you address the upper lid and reposition the temple, the brow can relax into its natural position. It doesn’t need to be held up anymore.

Regenerative component: fat grafting and nanofat

Structural fat grafting restores volume in the midface and temple. Nanofat is a different preparation entirely. It’s emulsified and filtered to deliver concentrated growth factors and stromal cells directly into the skin. The goal isn’t volume, it’s biologic skin quality improvement. I use both in most cases.

What Gina’s result shows

She has a refined jawline, good midface elevation, improved periorbital opening, and meaningful skin quality changes. Those are four distinct outcomes from four distinct components of the operation.

Photos give you a snapshot. Videos show you how a face actually moves and reads in real life, which is the only thing that matters.

Results in movement:

https://www.instagram.com/reel/DXMrAzJAXzD/?igsh=NTc4MTIwNjQ2YQ==

Full results:

https://www.tiktok.com/t/ZP8g9QRhs/

Patient testimonials:

https://www.instagram.com/s/aGlnaGxpZ2h0OjE3ODc3NDAzOTY1NDM5OTkw?story\_media\_id=3877484532262192209&igsh=NTc4MTIwNjQ2YQ==

If you’re considering this type of procedure and want to understand whether you’re a candidate, you can reach out through the contact page on our website.

This is something you don’t often see I wanted to show before and after on the table

Most surgeons don’t show their before and actors on the table because the patients don’t look good on the table

But I feel like in these before, and after you can see the transformation already in the jawline

There’s also a photo at the end that’s the immediate postop day one

People are afraid of how they’re gonna look the day after surgery, but this is a good example of someone who is early in healing process

Although it’s scary, it helps to show you exactly how you could look on day one

Take a look at how already her jawline looks so much better

Although there’s a little bruising and a little swelling, she looks pretty darn good for day one

It’s a scary process, but these photos are designed to help you to see what you may look like early on

I want to be upfront about something before I walk through this case.

A few people in past posts have called out AI writing. Fair. I've been cleaning up my posts for clarity and it shows. This one is me, written the way I'd explain it across a consult table.

She came in with a specific complaint. Not "make me look younger." She said she didn't recognize herself anymore. The structure had shifted, the neck had changed, and she felt like the face looking back at her wasn't hers. That framing matters because it tells you exactly what the surgical goal is: return, not transformation.

She had also had a prior upper and lower blepharoplasty done elsewhere. She wasn't happy with it. The eyes looked hollowed, slightly tight, and the lid-cheek junction had that particular quality that's hard to name but immediately recognizable & operated. This is one of the most common presentations I see in revision cases. The original surgery was technically executed but conceptually subtractive. Fat was removed. Volume was taken away from a zone that was already deficient. The result was a lid that looked done rather than rested.

The full procedure was a deep plane facelift, temple lift, neck lift with deep gland work, endoscopic temple and midface lift, periorbital fat grafting to revise the prior blepharoplasty, full face fat transfer including nanofat, and CO2 laser resurfacing. I approach all of this through VECTARA, which is the framework I use to plan and execute structural facial rejuvenation.

VECTARA stands for five things: endoscopic brow and midface elevation along natural vectors, tension-free closure at every layer, deep neck contouring including gland management when indicated, the mastoid crevasse technique for posterior support, and structural fat grafting with nanofat transfer for volume and skin biology. It isn't a brand. It's an anatomy-first planning system that tells me what to move, in what direction, and how to support it so the result ages well rather than unraveling.

Here's what I actually did and why.

The periorbital revision is worth explaining in detail because it's the part of this case that most directly contradicts how eyelid surgery is still being taught and performed.

The prior blepharoplasty had removed orbital fat from both the upper and lower lids. This is standard technique in a lot of practices. The logic is straightforward: fat equals fullness equals bag, so remove it. The problem is that orbital fat isn't excess tissue. It's structural volume. When you remove it, you don't just flatten the convexity — you create a hollow directly adjacent to where the fullness was. The eye socket becomes visible. The tear trough sharpens. The upper lid loses the fullness that separates a youthful lid from a skeletonized one. The patient ends up trading a bag for a different kind of aging, one that reads as operated rather than rested, and one that is much harder to fix than the original problem.

My approach here was to add volume back. Structural fat was placed into the periorbital zone to restore what the prior surgery had removed. The endoscopic temple lift reframed the lateral brow and orbital rim. The midface elevation rebuilt the structural support beneath the lower lid from below. The combination of these three interventions fat grafting, temple lift, midface elevation addressed the periorbital aging at every anatomic layer simultaneously rather than treating the lid in isolation.

This is why the eyes look the way they do in the postoperative photos. There's no tightness. No hollowing. No change in aperture. The lid-cheek junction has a smooth arc. That arc is structural, not cosmetic.

The endoscopic midface lift is the part most surgeons skip, and it's the part that changes everything about how the upper and middle face relate to each other. The midface descends in a vertical vector over time. The SOOF and malar fat pad drop. The endoscopic approach lets me elevate these compartments back toward their native position without a coronal incision and without the scalp numbness and prolonged recovery that comes with it. The result is cheek projection and infraorbital fullness that reads as structural rather than injected. When you combine this with the temple lift, you restore the lateral brow position and the orbital framing simultaneously.

The lower face and jawline were addressed by re-supporting the deep tissues along their native vectors through the deep plane dissection. The face wasn't pulled. The tissues were lifted back toward where they originated. Skin doesn't hold a facelift result. Structure does.

The neck required more than surface work. She had true glandular fullness contributing to the deep neck contour, not just skin laxity or subplatysmal fat. I removed a portion of the submandibular glands to sculpt the deep cervical line. This is a technically demanding step that most surgeons don't perform, and it's why the neck holds under downward gaze rather than bunching. The surface result is a direct reflection of what was done underneath.

Fat transfer and nanofat addressed the global volume deficit and skin quality simultaneously. Nanofat processed through fine emulsification carries a biologic payload it improves collagen architecture and vascularity in the subdermal plane in a way that structural fat alone doesn't replicate. CO2 laser resurfacing was layered on top to address texture and contractility. She is genetically prone to scarring, and at three months the incisions are already blending. That comes from tension-free closure and not asking the skin to do structural work it was never designed to do.

A few things I want to address directly because they come up every time.

On the 70% rule: during surgery I reposition tissues. Once the last stitch is placed, biology takes over. Healing, inflammation, tissue quality, and genetics determine the remainder. A 70% correction is an excellent outcome. An 80% result is uncommon. A 90% result is rare. Anyone promising perfection is either lying or has never followed their patients long enough to know what actually happened.

On the smiling after photo: I use it because it's the hardest test. A smile is the most mechanically demanding expression the face makes. If the result holds through a genuine smile with no distortion, no bunching, and no asymmetry, that tells you more about the surgical architecture than any neutral photograph does. Neutral is easy to fake. Motion is not.

I’m going to say something a lot of surgeons won’t agree with.

Most lower blepharoplasties still look operated because they’re built on a subtraction model. Fat equals bag, so remove it. That framework is outdated, and the results show it.

When you remove fat from the lower eyelid, you’re not just taking away fullness. You’re often creating a hollow directly adjacent to where the bulge was. So instead of solving the problem, you trade a convexity for a skeletonized contour that reads as aged, not rested.

You see the downstream effects constantly. Flat lower lids. Sharp tear troughs. That slightly done look patients can’t quite name but immediately recognize when they see their own photos.

The issue was never the fat. It’s the relationship between the fat compartment and the hollow beneath it, the lid-cheek junction. That’s the actual anatomy you’re treating.

In this patient, fat was repositioned, not excised. Volume was restored to the deficient zone below it. The skin envelope was treated with CO2 laser to improve quality and contractility.

The result looks natural because nothing was subtracted. No hollowing. No change in aperture. No tension pulling the lid. Just a smooth transition from eyelid to cheek that looks the way it did fifteen years ago.

This is the structural shift that’s been happening in periorbital surgery. Not removal but restoration. Not skin tension but vector alignment at the level of the deep tissue.

Skin doesn’t hold the result. Structure does.

If you’re looking at lower bleph outcomes and something feels off, this is almost always why.​​​​​​​​​​​​​​​​

Learn more by listening to this podcast

https://open.spotify.com/episode/1jpsl5z6cUhnBLmhLCmyZn?si=DAk93NkpRQCPb3N0WpPyDA

I am posting this case differently than most of what appears in this community. Rather than standardized clinical photographs at a single settled timepoint, this is a recovery sequence documented by the patient herself in selfies taken at home, under inconsistent lighting, without a clinical camera or controlled conditions. That is the point.

The sequence runs from approximately two weeks postoperative through six weeks and then just under three months. The early photographs are uncomfortable to look at. They are supposed to be. If your expectation of facelift recovery is that you will look improved immediately, this post will correct that expectation more effectively than anything I could write.

On early intervention at 40 and why the timing was appropriate

This patient is 40 years old. This will generate the predictable comment that she did not need surgery or should have waited. I want to address the clinical reasoning directly before that thread develops.

The decision to intervene early was anatomical, not cosmetic. She presented with structural changes that were already creating functional aging in her appearance, specifically lower lid descent and hollowing producing a chronic tired appearance, early jowling beginning to blunt the mandibular border, and submandibular fullness affecting the cervicomental angle in profile. These are structural problems. They do not reverse with time. They progress.

The clinical argument for early deep plane intervention before significant skin laxity has developed is straightforward. When the retaining ligaments are addressed before the skin envelope has been substantially stretched by years of unresisted descent, the composite flap repositions with less tension, the skin redrape requires less redistribution, the closure is more naturally tension-free, and the result ages forward from a better structural baseline. Operating at 40 in appropriate anatomy is not vanity. It is treating a structural problem at the point where it is most correctable with the least surgical complexity.

Nobody needs this surgery. But nobody needs to accept progressive structural changes that are correctable either.

What was performed

The operative plan addressed every structural layer contributing to her presentation. The deep plane facelift included complete release of the osseocutaneous retaining ligaments including the zygomatic, masseteric cutaneous, and mandibular ligaments, allowing the SMAS-platysma composite flap to mobilize freely as a single anatomic unit rather than as a skin-only or superficial SMAS flap. Complete ligamentous release is what allows true structural repositioning rather than skin redistribution. The difference is visible in the oblique and lateral views: the jawline is not tightened, it is rebuilt. The mandibular border is sharp because the tissue that had descended below it has been returned to its correct anatomic position above it, not pulled back along the skin surface.

The operative plan was organized within the Vectara framework, my system for individualized three-dimensional vector identification and architectural restoration in deep plane surgery. Vectara treats the correct angle of SMAS suspension as an intraoperative measurement rather than a preoperative assumption borrowed from population averages. Following complete deep plane release of the retaining ligaments, the freed SMAS-platysma composite flap is moved to identify the direction of greatest distraction without pleating or bunching at the suspension point. That direction directly opposes the vector of greatest descent in that specific patient at that anatomical level. It is not calculated before surgery. It is found during surgery. The tissue tells you where it needs to go when the release has been complete enough to let it move freely.

This matters practically because facial aging does not follow a uniform vector. Different anatomical regions descend along different angles, and the left and right hemifaces of the same patient age asymmetrically. Our published vectorial analysis of 71 patients across 142 hemifaces documented that the correct SMAS suspension vector averages approximately 70.8 degrees but varies significantly between individuals and between hemifaces, with intersuture variability in secondary cases nearly four times that of primary cases (Talei, Gould, Ziai. Aesthetic Surgery Journal 2024). Applying a standard vector to an individual face is a generalization. Vectara replaces the generalization with a measurement.

For this patient at 40 with relatively early-stage anatomy, the Vectara planning produced conservative suspension vectors that repositioned the composite flap without overcorrection. The goal in an early intervention case is not maximum measurable change but optimal structural repositioning that will hold and age well over the following decade and beyond.

The endoscopic temple and midface lift was performed with a strictly vertical suspension vector rather than the oblique or lateral vectors that produce the swept or widened midface seen in traditional facelift techniques. Vertical vector midface elevation restores the anterior malar projection that characterizes a young face. The cheek sits forward, not lateral. In the frontal and oblique views the malar eminence has returned to a position of anterior support. The temple fixation used bone tunnel anchoring for long-term stability, offloading upper facial tension from the lateral canthal area without visible incisions and without the medial brow elevation that can feminize or alter the brow architecture.

Structural fat grafting was performed to all major facial compartments including the temporal, malar, submalar, nasolabial, perioral, and mandibular regions to restore volumetric architecture that pure lifting cannot address. Fat grafting provides structural restoration that injectables cannot replicate. The transferred fat integrates with native tissue, establishes a living graft with its own vascular supply, and continues to mature over the following twelve months. Nanofat transfer, prepared by mechanical emulsification of the same harvest, was layered into the superficial dermis and periorbital compartments specifically to deliver the stromal vascular fraction including adipose-derived stem cells for regenerative skin quality improvement at the cellular level. The surface quality visible in the later selfies reflects both the CO2 laser protocol and the regenerative effect of nanofat in the dermis working over time.

Upper and lower blepharoplasty were performed with fat repositioning rather than excision. The before images show the characteristic shadow of periorbital hollowing. The tear trough descends into the lower lid, the inferior orbital rim is skeletonized, and the lower lid rests below the limbus with visible scleral show, most apparent on the right side in the frontal preoperative photographs. Fat repositioning takes the herniated orbital fat that creates lower lid fullness and advances it over the orbital rim to fill the tear trough and infraorbital hollow rather than discarding it. The after images show the lower lid now resting at the limbus with the tear trough shadow eliminated and the periorbital frame supported rather than hollowed.

The deep neck lift was planned around the specific anatomy contributing to her cervicomental fullness. Partial submandibular gland resection was performed to address the deep neck volume that no amount of surface tightening can correct. The gland itself is a structural contributor to submandibular fullness in many patients and is not responsive to SMAS manipulation or skin tightening alone. The mastoid crevasse technique provided posterior-superior fixation using the gonial angle as a mechanical fulcrum to vertically support the submandibular triangle and submental contents, producing measurable gonial angle depth improvement beyond what standard mastoid periosteal fixation achieves. The lateral selfies document the result without clinical lighting. The cervicomental angle is clean, the neck-chin transition is sharp, and the submental contents are supported rather than prolapsing. That result in a car selfie, without controlled lighting or a clinical camera, is what structural deep neck surgery produces that surface tightening alone cannot.

On the recovery sequence and what the photographs actually show

The two-week photographs show what patients frequently describe as the uncomfortable phase. The face is swollen, asymmetrically so in most cases, and the features look distorted relative to their preoperative baseline. Nothing about this appearance represents the final result. Nothing about it indicates something went wrong. It indicates that surgery was performed two weeks ago and that healing is proceeding normally.

The six-week photographs show the early stabilization phase. Primary swelling has largely resolved. The structural changes are becoming visible for the first time. The face looks recognizably improved but the result is still not settled. Fat grafting in particular continues maturing for months beyond this point and the malar and periorbital regions hold swelling longer than other areas.

The three-month photographs show an early settled result. This is the timepoint at which most standardized clinical photography is taken and most result series are documented. The structural architecture is visible. The swelling is substantially resolved. The fat grafting is beginning to integrate. The scars are in early maturation. This is a representative early result but not a final one. Full maturation including complete fat integration, final scar remodeling, and complete skin quality improvement from the CO2 laser protocol continues for twelve to eighteen months.

Looking across all eight collages, the structural changes that were planned anatomically are visible even in uncontrolled selfie conditions. The mandibular border is definable in the oblique views. The cervicomental angle holds its definition in the lateral views across multiple lighting conditions and head positions. The malar eminence sits anteriorly rather than laterally in the frontal views. The periorbital frame shows lower lid support without hollowing. The neck is smooth in profile without banding or residual submandibular convexity. None of these findings are artifacts of lighting or posing. They are structural findings present because the anatomy was addressed at the correct layer.

On the eyes specifically

The preoperative periorbital anatomy shows three findings that together created the chronic tired appearance. The lower lid rests below the iris with inferior scleral show, most apparent on the right side in the frontal photographs. A tear trough shadow transitions continuously into lower lid hollowing, creating a skeletonized orbital rim appearance. The lower lid-cheek junction shows loss of anterior malar support producing downward traction on the entire periorbital complex. These are not surface findings. They reflect descent of the deep fat compartments, orbital fat herniation through a lax orbital septum, and loss of the ligamentous support that normally holds the lower lid-cheek complex in its youthful position. The postoperative images show the lower lid now resting at the limbus with the scleral show resolved, the tear trough shadow eliminated by fat repositioning over the orbital rim, and the lower lid-cheek junction restored to a smooth continuous contour supported by the repositioned malar fat. The eye aperture reads as slightly different because the lower lid is in a more anatomically correct position. The structural anatomy of what changed is visible in the photographs even under inconsistent selfie lighting, which is precisely the point of documenting results this way.

On the selfie documentation format

Clinical photographs with standardized lighting, matched expressions, controlled hair position, and consistent camera distance are more immediately comparable than patient selfies. I agree with that. I also chose to post this recovery sequence in selfie format specifically because standardized clinical photographs at three months under controlled lighting do not communicate what facelift recovery actually feels like from the inside. The inconsistent lighting, the changing backgrounds, the varying expressions and makeup across timepoints are realistic representations of how patients experience and document their own recovery. They are a more honest window into the recovery arc than a clinical comparison panel would be, even if they are methodologically less rigorous.

The standardized clinical photography for this case is available in the gallery on my website and on Instagram. This post is not a substitute for that documentation. It is a complement to it.

See her results in motion and hear from her directly

The result holds in motion the same way it holds in the selfies. Watch the architecture across head positions and lighting changes before forming an opinion from still photographs: https://www.instagram.com/dr.gouldplasticsurgery/reel/DWAL-BDEtH7/

She documented her own experience and outcome in her words, not mine: https://www.instagram.com/dr.gouldplasticsurgery/reel/DUtDW75ASoN/

Her full testimonial on YouTube: https://youtu.be/YZt7jN42esU?si=YuOCMRD94Q1_Vy5f

An extended look at the case on TikTok: https://www.tiktok.com/@doctorgould/video/7559297855614160159

One more note on the documentation. After this case was posted, a clinic based in China lifted the photographs and used them in their own marketing to attract patients. I documented that here: https://www.instagram.com/dr.gouldplasticsurgery/reel/DUZfa_xD5k6/

The theft is worth mentioning not as a complaint but as context. When results get stolen for use in someone else's marketing, it is usually because they are difficult to replicate or dismiss. A clinic that cannot produce comparable outcomes finds it easier to borrow the photographs than to develop the technique. The fact that these particular selfies, taken by the patient at home under bar lighting and in a car, were considered worth stealing tells you something about what the result actually looks like when you strip away the clinical photography setup.On the comment about tension creating asymmetry

One comment in the thread suggested tension was visible creating asymmetry. I want to address this directly: tension is not measurable from a photograph. What is visible in a photograph is the current anatomical state of the tissues at a specific healing timepoint. Asymmetry at three months is normal and expected because the two hemifaces do not swell identically, do not heal at identical rates, and did not descend symmetrically to begin with. Asymmetry in a healing result is not evidence of asymmetric tension. It is evidence that two sides of a human face are two sides of a human face.

References

Talei B, Gould DJ, Ziai H. Vectorial Analysis of Deep Plane Face and Neck Lift. Aesthetic Surgery Journal. 2024;44(10):1015-1022.

Talei B, Shauly O, Marxen T, Menon A, Gould DJ. The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting. Aesthetic Surgery Journal. 2024;44(2):NP132-NP148.

Shauly O, Gould DJ. Structural Fat Grafting as a Mechanical Fulcrum in Deep Plane Facelift and Neck Lift. In preparation.

Happy to answer technical questions on early intervention candidacy, the Vectara vector planning approach, the periorbital fat repositioning rationale, the recovery timeline, or any component of the operative plan in this case.

I want to use this case to address something that does not get enough honest clinical attention in facelift discussions: what a realistic excellent outcome actually looks like across time, why the difference between a three month result and a fourteen month result matters clinically, and why the post-weight-loss neck is one of the most technically demanding presentations in lower face and neck rejuvenation.

Most surgeons post results at one timepoint and let the community assume that represents the settled outcome. This case has two documented timepoints and I am posting both deliberately, because the maturation between three months and fourteen months is itself a clinical argument about what kind of surgery was performed.

The clinical context

This patient had a genuinely heavy neck preoperatively. Some of that was constitutional anatomy. Some of it was genetics. A meaningful component was post-weight-loss skin laxity following significant intentional weight reduction. She came to me at her goal weight having done everything right metabolically, and the face and neck had not responded the way she hoped they would.

This is an extremely common presentation and it deserves a more precise clinical framing than it usually receives. Weight loss produces two simultaneous changes in the face and neck. It removes the volume that was stretching the skin envelope from within, which unmasks laxity that the volume was partially concealing. And it removes structural fat from compartments that contribute to facial support, producing deflation that compounds the descent problem that aging was already producing. The result is a face and neck that looks heavier and more aged than the patient's new body composition would suggest, because the skin and soft tissue envelope has been stretched and deflated simultaneously and has not remodeled back to a tighter geometry.

Non-surgical treatments do not solve this problem. Skin tightening devices improve surface texture but do not address the platysmal anatomy, the cervicomental angle definition, or the submandibular architecture that determines neck contour in profile and in the chin-down position. Waiting longer does not improve the situation. The skin that has been stretched by excess weight and then deflated by weight loss does not spontaneously contract to a geometry that matches the new body.

What was performed

Deep plane face and neck lift with individualized vector planning using the Vectara framework, identifying the correct suspension angles intraoperatively through palpatory feedback following complete retaining ligament release rather than applying population-averaged vectors to her specific anatomy. The SMAS-platysma composite flap was mobilized and suspended tension-free along three-dimensional correction vectors individualized to her pattern of descent.

Deep neck dissection addressed the structural anatomy responsible for her cervicomental heaviness directly. The mastoid crevasse maneuver provided posterior-superior fixation with measurable gonial angle depth, using the gonial angle as a mechanical fulcrum to vertically suspend the submandibular triangle and submental contents. The near-vertical cervical platysmal suspension vector and three-dimensional crevasse inset are what produce the neck contour visible in the profile and chin-down views at both timepoints. This is not skin redistribution. It is structural repositioning anchored at a mechanically advantageous fixation point that holds because the forces are distributed through deep anatomy rather than concentrated at the skin closure.

An endoscopic temple lift offloaded lateral tension from the upper face and brow without producing visible incisions or altering the medial brow position. Structural fat grafting was performed to the lower eyelids, midface, nasolabial region, and perioral area before the facelift dissection began, following the fulcrum-first sequencing strategy that increases composite flap load-bearing capacity before mobilization. Skin resurfacing addressed the surface envelope quality independently of the structural work.

On the three month result

The three month photographs represent an early result in which the structural correction is present but the biological refinement is incomplete. Fat grafting swelling persists in the malar and periorbital regions at three months, which is expected and normal. The scar maturation process is active but not complete. The deep structural work is fully in place and visible in the neck contour, cervicomental angle, jawline definition, and chin-down positional views. But the face at three months still carries residual surgical edema that will continue resolving over the subsequent months.

Several things are already clear at three months that matter clinically. The lateral incisions are already faint and difficult to identify at three months despite this patient having a genetic predisposition toward more visible scarring. This early scar quality is a direct reflection of closure tension. A tension-free closure heals differently than a closure that is holding structural load, and the difference is visible within the first few months rather than requiring the full scar maturation period. The neck holds its architecture in the chin-down positional view at three months, confirming that the improvement is structural rather than positional or swelling-dependent.

These are the last photos in the queue.

On the fourteen month result and what the maturation demonstrates

These are the first photos in the series.

The fourteen month photographs show the settled result after the full biological refinement period has elapsed. The fat grafting has matured and integrated. The scar has completed its primary remodeling cycle. The structural edema has fully resolved. What remains is the architectural correction without any of the additive swelling that makes early results look potentially overcorrected or puffy.

Compare the two timepoints carefully, particularly in the profile and oblique views, because the maturation tells a specific story about the type of surgery that was performed. A result built on skin tension looks best at six to eight weeks, when the tension is still at its highest, and begins to soften progressively as the tissues relax under sustained mechanical load. Stress relaxation in a tension-based construct is not a complication. It is a predictable biomechanical outcome of asking suture lines and skin to hold structural forces they were not designed to maintain.

A result built on deep structural architecture with tension-free closure looks different at three months than at fourteen months not because it is failing but because it is maturing. The swelling resolves. The fat integrates. The tissues settle into their corrected position. The neck at fourteen months in this case is cleaner and more defined than at three months, not less. That trajectory is the opposite of what a tension-based result produces over the same period.

This is why long-term documentation matters and why I post it when I have it. A result that looks excellent at three months and holds or improves at fourteen months was built on structural architecture. A result that looks excellent at three months and has softened meaningfully by fourteen months was built on tension. You cannot distinguish between these two categories from a single early photograph, and most result series posted anywhere online do not give you the information you need to make that distinction.

On the result and what 70% correction means

This represents approximately 70% correction of the preoperative deformity, and that is an excellent result for this anatomy. I want to be precise about why the target was not 100% correction, because this is misunderstood frequently in discussions of post-weight-loss cases.

Complete correction of a constitutionally heavy neck with significant post-weight-loss skin laxity would require skin tension that produces an immediately recognizable surgical result and fails mechanically within the first year. The 70% structural correction achieved here is held by deep architecture rather than surface tension. It will age forward from a better structural baseline rather than relapsing toward the preoperative geometry on a timeline determined by how long the skin tension holds.

Overcorrection is a failure mode. The correct benchmark for a facelift outcome is not maximum measurable change from the preoperative photograph. It is whether the patient looks like themselves at their structural best, whether the result holds in motion and under positional stress across multiple timepoints, and whether it will age well forward from the corrected baseline. This result meets all three criteria at both documented timepoints.

On the lower eyelid treatment

Her preoperative lower lids showed early descent and hollowing that created a tired appearance. The correct treatment for this presentation is not lower lid excision. Removing skin and fat from an already-hollowed, already-lax lower lid produces a result that looks marginally tighter at six weeks and significantly worse at two years as the periorbital volume depletion continues. The correct treatment is structural support restoration: lifting the midface to give the lower lid a foundation, and restoring volume to the periorbital compartments with fat grafting so the lid is supported from underneath rather than tightened from above. The lower lid result visible at fourteen months is the product of midface elevation and fat grafting. There was no lower lid skin excision. The improvement held at fourteen months because it is supported by restored anatomy.

On the chin-down positional documentation at both timepoints

The chin-down view is the most demanding functional test of a neck lift outcome and I include it at both timepoints deliberately. At three months the neck holds its architecture under positional load with no bunching or banding, confirming the structural basis of the correction. At fourteen months the same positional test shows the same structural integrity in the settled result after all surgical swelling has resolved. The consistency of the chin-down result across both timepoints is the biomechanical argument for deep structural correction over surface tension techniques. Surface tension fails this test progressively over time. Deep structural architecture holds it.

On the scars across both timepoints

The scar maturation between three months and fourteen months is visible and represents normal healing progression in a tension-free closure. The three month scars are already faint despite the early stage of the maturation cycle and despite this patient's genetic predisposition toward more visible scarring. The fourteen month scars have completed primary remodeling and are well camouflaged in the natural postauricular anatomy. The trajectory from three months to fourteen months is the expected outcome of a closure that had no tension to concentrate at the incision line during healing.

On what this case represents clinically

Post-weight-loss facial anatomy is a specific and underserved clinical problem that requires a different surgical calculus than standard age-related facial descent. The correct framework is not how close can we get to a perfect neck, but rather what structural correction can we achieve and maintain over time while preserving the patient's identity and allowing the result to age well forward from a better baseline.

At three months this patient had an early structural result with residual surgical swelling. At fourteen months she has a settled architectural result that has matured toward greater definition rather than softened toward relapse. She looks like herself at a structurally more supported and appropriately youthful version of her current age. Her facial identity is intact. The correction is visible in every standardized view at both timepoints including the most demanding positional tests. And the improvement she describes in how she moves through the world is the part of this work that does not appear in any photograph at any timepoint.

Photographs at two timepoints are still photographs. For this case I also have video documentation showing the result in motion, which is the only format that honestly captures how the neck holds its architecture dynamically, how the face moves after deep structural restoration, and what a settled fourteen month result looks like when the patient is not posed for a clinical camera. Watch those before reading the rest of this post. They will make the static images more interpretable.

Procedures performed

Deep plane face and neck lift with Vectara vector planning. Mastoid crevasse neck lift. Endoscopic temple lift. Structural fat grafting to lower eyelids, midface, nasolabial region, and perioral area with fulcrum-first sequencing. Skin resurfacing. Results documented at three months and fourteen months postoperative.

See This Result in Motion Across Both Timepoints

Everything I have described in this post about structural architecture versus surface tension, about the chin-down test, about the difference between a three month result and a fourteen month result, is visible in these videos in a way that no standardized photograph can fully communicate.

Watch the neck move. Watch it hold its cervicomental definition when she turns her head and changes position. Watch what the jawline does under dynamic load rather than in a single frozen frame under controlled clinical lighting. This is the information that matters for evaluating whether a result is structural or photographic, and it is the information that is almost universally absent from facelift result documentation everywhere online.

The result in motion, showing neck architecture, jawline definition, and facial dynamics across multiple angles and lighting conditions:

Instagram: https://www.instagram.com/reel/DMQN3prRcZT/?utm_source=ig_web_copy_link&igsh=MzRlODBiNWFlZA==

TikTok: https://www.tiktok.com/@doctorgould/video/7528436770313096479

A few specific things to watch for in both videos that the still photographs do not capture adequately:

The chin-down position in motion. In the photographs I have described the chin-down view as the most demanding positional test of a neck lift outcome. In the video you can see the neck transition through that position dynamically rather than holding a single posed angle. The contour does not collapse. The platysmal architecture does not band. The cervicomental definition is present throughout the range of motion, not just at the one angle where it looks best.

The lateral neck profile under movement. The profile photographs show the cervicomental angle improvement clearly. The video shows that the improvement is present across a range of head positions rather than being dependent on a specific chin elevation that maximizes the apparent correction.

The skin surface quality in motion. Static photographs flatten the three-dimensional quality of the skin surface. The video shows how the skin moves over the restored structural layer, which is the most honest assessment of whether the result looks natural or operated on. Natural movement over restored architecture looks different from skin that is being held by tension. You can see the difference immediately in motion even when you cannot always articulate it from a still image.

The overall facial dynamics. Facelift surgery that was properly done should be undetectable in motion. The face should move freely, expressively, and without the resistance or distortion that skin tension produces when the structural layers beneath it have not been adequately released and repositioned. Watch the overall facial movement in both videos and form your own assessment of whether this reads as a structural result or a surface one.

I post video alongside every case I document here because the comment threads on static photograph posts consistently generate debates that resolve immediately when the result is evaluated in motion. A neck that holds in the chin-down position dynamically, at fourteen months, in video documentation that was not staged for a clinical camera, is a neck that was corrected structurally. There is no other explanation for that finding that holds up to scrutiny.

Video should be standard documentation in facelift surgery. The consistent absence of motion documentation from most surgeons posting results anywhere online is worth thinking about carefully when you are evaluating whose work you trust and why.

References

Talei B, Gould DJ, Ziai H. Vectorial Analysis of Deep Plane Face and Neck Lift. Aesthetic Surgery Journal. 2024;44(10):1015-1022.

Talei B, Shauly O, Marxen T, Menon A, Gould DJ. The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting. Aesthetic Surgery Journal. 2024;44(2):NP132-NP148.

Shauly O, Gould DJ. Structural Fat Grafting as a Mechanical Fulcrum in Deep Plane Facelift and Neck Lift. In preparation.

Happy to answer technical questions on post-weight-loss facial anatomy, the dual timepoint documentation, the periorbital treatment rationale, the chin-down documentation standard, or how I think about realistic outcome expectations in anatomically challenging cases.

I want to focus on something that gets less attention than lift vectors and neck anatomy in most deep plane facelift discussions: skin quality as a surgical outcome variable, not a skincare outcome variable. This case also documents what a tension-free deep plane closure looks like at the scar level, what a properly executed endoscopic upper face approach produces without visible incisions, and why the chin-down positional view is the most honest documentation test of any neck lift result.

This post covers: deep plane facelift technique, Vectara vector planning framework, endoscopic temple lift, scarless endoscopic blepharoplasty, endoscopic vertical midface lift, mastoid crevasse neck lift, submandibular gland excision, structural fat grafting, nanofat stem cell transfer, two-stage CO2 laser resurfacing, RF microneedling, medical-grade topical skin protocol, tension-free closure and scar outcomes, and chin-down positional documentation.

What was performed

The structural foundation of this case was a comprehensive deep plane face and neck lift planned within the Vectara framework, a system for individualized vector elimination and architectural restoration in three dimensions. Deep plane release was complete. The SMAS-platysma composite flap was suspended along vectors identified intraoperatively through palpatory feedback following full retaining ligament release, not borrowed from population averages. The closure was tension-free throughout at every layer.

The neck required full architectural management that goes substantially beyond what standard deep plane neck dissection addresses. Deep neck dissection included direct submandibular gland excision and the mastoid crevasse maneuver, seating the lifted platysma-SMAS unit into a three-dimensional recess at the anterior mastoid wall. This provides a stable posterior-superior fixation endpoint with measurable gonial angle depth, uses the gonial angle as a mechanical fulcrum to vertically suspend the submandibular triangle and submental contents, and eliminates tension concentration at the postauricular incision. Published data across 79 patients demonstrates a mean gonial angle depth gain of 8.1mm beyond standard mastoid suspension using this technique, statistically significant at P less than 0.0001 (Talei, Shauly, Marxen, Menon, Gould. Aesthetic Surgery Journal 2024).

The cervicomental angle visible in the lateral and chin-down views is not a skin redistribution result. It is structural repositioning of deep cervical anatomy anchored at a mechanically advantageous fixation point.

Scarless upper face access: endoscopic temple lift, endoscopic blepharoplasty, endoscopic vertical midface lift

The entire upper face and midface in this case was accessed without a single preauricular or visible hairline incision. This is worth explaining in detail because the combination of procedures performed through hidden endoscopic access is not standard, and the results it produces are meaningfully different from what open approaches provide.

An endoscopic temple lift was performed rather than a traditional coronal or hairline brow lift. This offloads lateral tension from the upper face and lateral brow without elevating the medial brow and without producing the surprised or arched appearance that overaggressive brow elevation creates. The incisions are within the hairline and are not visible.

A scarless blepharoplasty was performed through the endoscopic approach, addressing the upper lids without a visible lid crease incision. For patients who do not want the faint but permanent scar of a traditional upper blepharoplasty, this approach provides meaningful upper lid improvement while preserving the natural lid crease architecture entirely.

An endoscopic midface lift provided vertical repositioning of the malar fat pad along a superior vector. This distinction is clinically significant and underappreciated in most facelift discussions. Standard midface techniques, including many marketed as deep plane midface approaches, produce primarily lateral vectors that flatten anterior facial projection and contribute to the swept appearance. A true vertical midface vector restores the anterior projection of the malar eminence, rebuilds the ogee curve that aging displaces inferiorly, and produces the three-dimensional midface restoration that a lateral pull cannot replicate regardless of how complete the deep plane release is below it.

Structural fat grafting, nanofat stem cell transfer, and regenerative sequencing

Structural fat grafting was performed in layered micro-aliquots to the tear troughs, lower lids, brows, temples, malar and submalar cheeks, nasolabial folds, pre-jowl sulcus, and chin using a blunt 18-gauge cannula. This was performed before the facelift dissection began, following the fulcrum-first sequencing strategy that increases the bulk and load-bearing capacity of the SMAS-platysma composite unit before it is mobilized, distributing traction forces across a larger cross-sectional area and reducing stress concentration at fixation points (Shauly, Gould. In preparation).

Nanofat was placed subdermally throughout using a processed emulsified fat preparation enriched with adipose-derived stem cells and growth factors. Structural fat and nanofat are not interchangeable treatments delivering the same biological signal through different volumes. Structural fat restores mechanical bulk and topographic convexity. Nanofat delivers regenerative cellular signals to the subdermal layer that improve tissue vitality, dermal thickness, vascular density, and skin quality over the months following placement. The skin quality improvement visible in these photographs is partly a function of what the laser did to the surface and partly a function of what the nanofat did to the biology underneath it.

Two-stage CO2 laser and RF microneedling protocol

CO2 laser resurfacing was performed at the conclusion of surgery at the time of maximum structural access. A second stage of CO2 laser combined with RF microneedling was performed at three months, timed to the resolution of primary structural swelling and the beginning of the final dermal remodeling phase.

This two-stage approach is deliberate and sequenced rather than additive. The first treatment addresses the skin surface at the moment the underlying scaffold has just been restored and the dermal blood supply is maximally active from the surgical dissection. The second treatment addresses the skin as an independent surface once the structural healing is sufficiently complete to tolerate aggressive resurfacing without competing inflammatory signals from the deeper layers. The combined effect on collagen remodeling, surface texture, pigmentation, and dermal thickness is substantially greater than either treatment produces alone.

Medical-grade topical prescription protocol

Every patient I operate on is placed on a prescription topical regimen as a standard component of postoperative management, not as an optional add-on. The protocol includes tretinoin, hyaluronic acid, vitamins D and E, niacinamide, resveratrol, and turmeric delivered in a ceramide base.

Tretinoin accelerates keratinocyte turnover, stimulates collagen synthesis, and normalizes melanocyte activity, producing measurable improvements in surface texture, fine lines, and pigmentation with consistent use. Niacinamide addresses barrier function, reduces inflammatory hyperpigmentation, and improves ceramide synthesis. Resveratrol and turmeric provide antioxidant and anti-inflammatory activity at the dermal level. The ceramide base restores and maintains barrier integrity throughout the resurfacing and remodeling period when the skin is most vulnerable to transepidermal water loss and environmental oxidative stress.

The skin you see in these after photographs is the product of the surgical restoration, the laser protocol, the nanofat regenerative treatment, and six-plus months of consistent topical support. These are not independent variables producing independent effects. They are sequenced interventions working on the same biological system in a planned and coordinated way.

On the scars: why tension-free closure produces categorically different scar outcomes

The postauricular incisions in these photographs are present. They are not absolutely invisible. But they are as close to undetectable as this surgery allows, and understanding why requires understanding what determines facelift scar quality in the first place.

Scar quality in facelift surgery is determined primarily by closure tension, not by suturing technique. When skin is asked to hold structural load at the closure, the mechanical stress concentrates at the incision line. The scar widens. The earlobe displaces inferiorly, producing the pixie ear deformity that is one of the most recognizable signs of a tension-based facelift result. The postauricular skin bands visibly under load and the scar becomes progressively more visible as it matures under sustained tension.

When the deep structural work is complete and the skin is redraped over a restored architecture without tension, the incision heals as a fine line in the natural postauricular crease at the correct anatomical position. The earlobe sits naturally. The scar matures to near-invisibility because it is not being mechanically stressed during the healing process.

The scars in these photographs are the direct product of a tension-free closure. They are not the result of scar treatment or special suturing. They are the result of structural work that was complete enough that the skin had nothing to do but heal.

On the chin-down positional view as the definitive test of neck lift outcomes

Every photograph in a standard facelift result series is taken in a neutral forward-facing or slightly elevated chin position. This is the position in which every neck lift looks its best regardless of how it was performed. It is the position that most effectively conceals residual submental laxity, incomplete platysmal correction, and the soft tissue redundancy that persists when the deep neck anatomy was not fully addressed.

The chin-down position is the opposite. It places the cervicomental skin and underlying platysma under direct gravitational and mechanical load in the direction opposed to the surgical correction vector. A result built on skin tension fails this test immediately. The submental skin bunches. The platysmal bands reappear. The submandibular fullness that appeared corrected in the upright photograph reasserts itself under positional load.

In this patient the chin-down view shows a clean submental contour with maintained cervicomental definition and no bunching or banding under positional stress. This is a biomechanical outcome, not a photographic one. The structures responsible for maintaining this architecture under load are the deep neck anatomy addressed surgically, the near-vertical platysmal suspension anchored at the mastoid crevasse, and the gonial angle fulcrum that converts the posterior-superior fixation force into vertical submental support.

The chin-down position should be standard documentation in every neck lift result series published anywhere. Its consistent absence from facelift result photography is not an accident.

On skin quality as an integrated surgical outcome

When the deep structural layer is properly restored, the skin sitting over it changes in ways that topical treatment and laser resurfacing alone cannot produce. The mechanical relationships between the dermis, subdermal fat, and underlying SMAS-platysma layer are normalized. The tension vectors that aging distributes across the skin in unfavorable patterns are resolved. The dermal blood supply, maintained through the intact dermal plexus in a preservation-technique deep plane lift rather than disrupted through skin delamination, supports dermal healing and regenerative cellular activity throughout the recovery period.

The CO2 laser, nanofat, and topical protocol in this case are working on a skin envelope that has had its structural foundation restored. That is a categorically different substrate than treating skin that is still compensating for an unresolved structural problem underneath it. The regenerative treatments amplify a structural result. They cannot substitute for one.

Procedures performed in this case

Deep plane face and neck lift with Vectara vector planning framework. Mastoid crevasse neck lift with submandibular gland excision. Endoscopic temple lift. Scarless endoscopic upper blepharoplasty. Endoscopic vertical midface lift. Structural fat grafting with fulcrum-first sequencing. Nanofat stem cell and growth factor transfer. Intraoperative CO2 laser resurfacing. Second-stage CO2 laser and RF microneedling at three months. Medical-grade prescription topical protocol including tretinoin, hyaluronic acid, vitamins D and E, niacinamide, resveratrol, turmeric in ceramide base.

References

Talei B, Gould DJ, Ziai H. Vectorial Analysis of Deep Plane Face and Neck Lift. Aesthetic Surgery Journal. 2024;44(10):1015-1022.

Talei B, Shauly O, Marxen T, Menon A, Gould DJ. The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting. Aesthetic Surgery Journal. 2024;44(2):NP132-NP148.

Shauly O, Gould DJ. Structural Fat Grafting as a Mechanical Fulcrum in Deep Plane Facelift and Neck Lift. In preparation.

Tonnard P, et al. Nanofat Grafting: Basic Research and Clinical Applications. Plastic and Reconstructive Surgery. 2013.

Happy to answer technical questions on endoscopic upper face access, the two-stage laser protocol, the topical prescription regimen, chin-down positional documentation, or how I think about skin quality as an integrated rather than adjunctive component of the surgical plan.

See This Result in Motion — and Hear From the Patient Directly

Static photographs are the standard documentation format for surgical results and they are the least informative format available for evaluating a facelift outcome. A face lives in motion. The test of a structural result is not how it looks in a standardized forward-facing photograph taken under controlled lighting. It is how it moves, how it holds under positional stress, how it responds to expression, and how the patient experiences living in it every day.

For this case, all of that documentation exists and I want you to see it before forming an opinion from the stills alone.

The patient's own account of her experience, in her words, without prompting or scripting: https://www.instagram.com/dr.gouldplasticsurgery/reel/DVMBSjhgRD0/

The result in full motion across multiple angles and lighting conditions, showing the neck, jawline, skin quality, and facial dynamics that photographs cannot capture: https://www.instagram.com/dr.gouldplasticsurgery/reel/DUqi8PfgXDd/

Extended video documentation including profile and oblique views in motion: https://youtube.com/shorts/CeoZN_OOLWs?si=wYv7cn5fdKzjUAsh

Additional still documentation across all standard views at this time point: https://www.instagram.com/dr.gouldplasticsurgery/p/DUJnQ5IErV1/

I post video alongside every case I document here for a specific reason. The comment threads on static photograph posts consistently produce debates about whether the result is real, whether the lighting is matched, whether the makeup is equivalent, and whether the change is meaningful. Almost every one of those debates resolves immediately when you watch the patient move. The neck holds its architecture when she turns her head. The skin moves naturally over the restored structural layer. The cervicomental angle is present and defined in every position, not just the one captured in the standardized lateral photograph.

Video should be standard documentation in facelift surgery. The consistent absence of motion documentation from most surgeons posting results anywhere online is not a coincidence. A result that holds in motion is a result built on structural architecture. A result that only holds in a photograph is a result built on surface tension. You can tell the difference in about thirty seconds of watching someone move their head.

Watch the videos. Then look at the photographs again. The stills will mean something different.

I want to walk through this case carefully because it illustrates something that comes up constantly in this community and rarely gets discussed with enough honesty.

The before photograph is not a pre-surgical photograph. This patient had already had a facelift when I first saw her. She was 18 months out from her primary surgery with a surgeon who had reasonable results and a reasonable reputation. By 18 months she had recurrent laxity in the neck and lower face, significant hollowing of the upper and lower eyelids, and a result that looked tired rather than restored. She came to me asking a question I hear often in this situation: what are you going to do differently.

The answer to that question is always anatomical. What was left undone the first time, and why.

What the primary surgery did not address

The original operation treated the skin. The neck was tightened at the surface level. The deep musculature was not managed. The submandibular anatomy was not addressed. The platysmal suspension was insufficient and had relaxed back toward its descended position, which is exactly what happens when suspension is asked to do work that deep plane release should have done. The laxity that returned within 18 months was not a failure of healing. It was a predictable consequence of a structurally incomplete operation.

The eyelid hollowing was a separate problem with a separate cause. The primary surgeon removed fat from the upper and lower lids during blepharoplasty. Fat removal from the periorbital region is now understood to produce hollowing that worsens over time as the surrounding compartments continue to lose volume with normal aging. The deficit compounds. The correction requires volume restoration, not further excision.

What the revision required

The deep neck was reoperated. I returned to the subplatysmal space and addressed the underlying anatomical causes of heaviness directly, including the glands and deep musculature that had not been touched in the primary case. The platysma was re-elevated and re-suspended. The mastoid crevasse technique was used to establish a stable posterior-superior fixation endpoint with measurable gonial angle depth, using the gonial angle as a mechanical fulcrum to vertically reposition the submandibular triangle and submental contents. This is the geometric advantage that standard mastoid suture fixation does not provide.

Fat was grafted structurally throughout the face in layered micro-aliquots to the nasolabial folds, pre-jowl sulcus, chin, cheeks, temples, brows, and earlobes. Fat was also placed directly into the upper and lower eyelids to reverse the hollowing from the primary blepharoplasty. Nanofat was placed subdermally including in the lips, where it improves the perioral blood supply and tissue quality in a way that structural fat alone does not accomplish. The lower lip cracking visible in the before photographs improved as a consequence of that treatment.

A lateral temporal lift was performed to offload tension from the lateral brow and the side of the face. I want to be precise about what this is and is not. It is not an aggressive brow elevation. It does not produce the arched or surprised appearance that results from over-elevating the medial brow. What it does is release tension from the lateral face that, when left in place, contributes to a heavy or punched appearance following lower face lifting. The brow position changes subtly. The overall facial balance changes more substantially.

The scars from the primary surgery are visible in the before photographs. They were pulled inferiorly, which is a characteristic sign of a closure that was under tension. I did not excise significant additional skin in the revision because very little of what determines the outcome of this type of surgery is determined by skin removal. The improvement visible in the after photographs is the result of structural work in the deep plane, not skin redistribution.

On revision surgery generally

Revision cases are more difficult than primary cases and the results are less predictable. The anatomy has been altered. The tissue planes have scar. The glide surfaces are less reliable. I charge more for revision surgery than primary surgery because it takes longer, carries more intraoperative uncertainty, and requires more conservative decision-making throughout. This is not gouging. It is an accurate reflection of what the case costs to do well.

The more relevant point for anyone reading this who is currently evaluating surgeons for a primary facelift is this: the cost of getting it wrong the first time is not just financial. It is anatomical. The face you bring to a revision surgeon is harder to restore than the face you would have brought to the right surgeon initially. The deep plane anatomy that should be a reliable glide surface has been disturbed. The volume that should have been preserved has been removed. The tissue that should have been repositioned has been tightened and released and scarred. None of that is impossible to work with. But none of it is as good as untouched anatomy.

This is your face. The decision about who operates on it first is the most important surgical decision you will make.

See her in motion here — movement is the only honest documentation of a facelift result:

In motion: https://www.instagram.com/reel/DEiK1HSy9K4/?igsh=NTc4MTIwNjQ2YQ==

Patient testimonial: https://www.instagram.com/reel/C38EXKPxzJj/?igsh=NTc4MTIwNjQ2YQ==

Additional video: https://www.instagram.com/reel/C3QV8R_xmRR/?igsh=NTc4MTIwNjQ2YQ==

Happy to answer technical questions on any component of this case including the revision sequencing, the periorbital fat restoration, or how I think about the deep neck in a previously operated field.