Facial ageing and preoperative assessment — What falls, what deflates and who to operate
The four changes of cervicofacial ageing, what separates a good candidate from one who needs a different operation, midface classification, neck examination and the risk factors to detect before operating.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Ageing is not only sagging: it is the sum of ptosis, volume loss, loss of elasticity and bone resorption. Treating only one of the four gives an incomplete result.
- The good candidate has a precise definition: adequate bony base and medialisation of the cutaneous-fatty tissue that is not due to lack of skeletal support, but to the laxity of ageing itself.
- A poor facelift candidate is not a patient who cannot be helped: it is a patient who needs something else first — genioplasty, malar volume or skin treatment.
- The negative vector is checked with a line perpendicular to the Frankfort plane from the glabella: if the most anterior midface point lies behind it, projection is deficient and lifting will not correct it.
- The neck has objective criteria and an examination of its own: pinching and asking the patient to swallow distinguishes whether the excess is skin, fat or muscle, and that distinction changes the technique.
- Five history items must be sought actively: smoking, haemostatic disorders, antiplatelet or anticoagulant drugs, diabetes and a tendency to hypertrophic scarring.
Ageing is a multifactorial process
Facial ageing combines changes in soft tissue and in the bony structure, and from that combination come laxity, wrinkles and volume loss. It is worth keeping in mind because it defines the goal of surgery: a facelift is not only about tightening but about repositioning tissue and restoring lost volume while preserving expression. A procedure that only pulls corrects one of the four things that have changed, hence that tight but still aged look recognisable from a distance.
The four changes in the cervicofacial structure
- Loss of bony support. It is the base everything else rests on, and its resorption withdraws support from the orbital rim, the malar eminence and the mandibular border.
- Muscle atrophy, with a nuance that explains many wrinkles: the muscle loses mass but increases its tone to maintain function. Less muscle working harder creases the skin more.
- Fat hypertrophy and medialisation from hyperlaxity of the ligaments that contain it. It is not merely that fat descends: the ligaments that compartmentalised it stop doing so, and that is where the grooves appear.
- Loss of skin elasticity with static wrinkles: those already present at rest, which no traction will erase.
What happens to each layer
| Layer | Change | How it shows |
|---|---|---|
| Skin | Collagen and elastin degradation from ultraviolet radiation and genetics, with elastic fibre fragmentation | Elastosis, loss of tone and fine wrinkles. It is what limits achievable redraping |
| Subcutaneous fat | Atrophy and migration of the fat compartments | Malar hollowing and loss of the jawline |
| SMAS | Loss of its supporting function against gravity; the fixed segment atrophies and the mobile one slides | Ptosis of the whole soft tissue block and appearance of the grooves |
| Musculature | Loss of mass with compensatory increase in tone; in the neck, platysmal laxity | Dynamic wrinkles turning static, loss of the cervicomental angle and platysmal bands |
| Skeleton | Bone resorption reducing the support on which everything else rests | Loss of malar projection and definition of the orbital and mandibular rims |
Good and poor candidates
| What is seen | Why | |
|---|---|---|
| Good candidate | Strong bony structure — prominent chin and malar eminence — with nasolabial and nasojugal grooves not too marked, and skin in good condition, without major photoageing or static wrinkles | The problem is purely positional, which is exactly what a facelift corrects |
| Retruded chin | Obtuse cervicomental angle and a very marked melolabial groove | Skeletal support is lacking: consider genioplasty or orthognathic surgery before or alongside the facelift |
| Hypoplastic malar eminences | Very marked nasolabial groove with a flat midface | Volume is lacking: consider malar filling with hyaluronic acid or hydroxyapatite, or fat grafting |
| Very poor skin quality | Intense photoageing and deep static wrinkles | A facelift repositions, it does not change skin quality: a resurfacing treatment — peel or laser — is needed alongside or beforehand |
The working definition of a good candidate
In one sentence: a patient with adequate bony base whose medialisation of the cutaneous-fatty tissue is not due to lack of skeletal support but to the laxity of ageing itself. That distinction prevents most disappointments. When tissue is medialised because there is no bone beneath to hold it, any traction reproduces the same problem within months; when it is medialised because the ligaments have given way, well-executed traction resolves it. The consultation should not end without having answered which of the two we face.
The midface: four variables that order the decision
The midface is the hardest area to rejuvenate, not for lack of techniques but the opposite: there are so many — transtemporal lift, transblepharoplasty, rhytidectomy with malar repositioning, fat grafting, implants, fillers — that without a classification criterion the choice becomes arbitrary. A useful system assesses four variables through examination and preoperative photography: volume loss, midface ptosis, loss of elasticity and presence or absence of a negative vector or hypoplastic malar eminence. The advantage of the scheme is that each variable points to a different kind of manoeuvre, and their combination defines the plan.
How the negative vector is measured
It is the most objectifiable variable and the one that most changes the plan. With the patient in the Frankfort plane, a perpendicular line is dropped from the glabella. If the most anterior point of the midface lies clearly behind that line, there is a projection deficit — the same negative vector concept used in periorbital surgery. A practical detail: in men with a very prominent frontal bar the nasion is used instead of the glabella, since the glabella falsifies the measurement. Finding a negative vector changes the indication: pulling over a deficient skeleton does not project, volume or support must be added.
Midface: lift, fill, or both?
Does the most anterior midface point lie behind the perpendicular from the glabella?
Does tissue descent or compartment deflation predominate?
Facial analysis: thirds and proportions
Assessment starts globally: symmetry, height-to-width proportion, and profile. On frontal view the face divides into thirds: upper from the hairline to the lower brow border, middle to the nasal base, and lower to the chin border. All three should measure the same. Within the lower third there is a second useful proportion: one third from nasal base to oral commissure and two thirds from commissure to chin. And a note on canons: they are not fixed, they have shifted across eras and today a biprotrusive profile is favoured, so they serve to detect deviations, not to impose a template.
The four patient factors that change the approach
- Skin type: thin or thick, with or without actinic damage. It decides how much redraping is possible and how it will heal.
- Soft tissue laxity: how much can be repositioned and along which vector.
- Amount of adipose tissue: excess, deficit, or maldistribution. A patient needing removal is not the same as one needing replacement.
- Bony support: what holds everything else up. It decides whether the approach must include volume or skeletal surgery.
What a youthful neck is: the five criteria
- A well-defined mandibular border, uninterrupted along its course.
- A visible subhyoid depression.
- A defined thyroid cartilage.
- A visible anterior border of sternocleidomastoid.
- A cervicomental angle of 110 to 120 degrees. It is the most cited and the one most used to explain the goal to the patient.
Examining the neck
- Pinch and swallowPinch the submental tissue and ask the patient to swallow. If what is held is skin with subcutaneous fat, the fat is superficial; if it slips away on swallowing, it is lax muscle or deep fat
- Measure the foldLiposuction makes sense when the pinched fold exceeds 3 cm; below that, the excess is probably not supraplatysmal fat
- Platysmal bandsDistinguish dynamic bands — appearing on contraction — from adynamic ones, present at rest. It changes the solution: muscular transection versus corset suture
- Submandibular glandsPalpate for glandular ptosis: it conditions the repositioning vector and the platysmaplasty design
- Hyoid positionA low, anterior hyoid limits the cervicomental angle achievable, however good the technique. Better to tell the patient beforehand, not afterwards
Five history items to seek actively
They do not surface unless asked about, and each compromises the result differently. Smoking: the factor that most increases flap necrosis. Haemostatic disorders and antiplatelet or anticoagulant medication: they lead straight to haematoma, the commonest complication. Diabetes mellitus: healing and infection. And a tendency to hypertrophic scars or keloids, decisive in a surgery whose result depends on hidden scars. Detecting them beforehand allows optimising, postponing or declining; detecting them afterwards only allows regret.
Expectations: the conversation that prevents dissatisfaction
Managing expectations is crucial to the success of the procedure, and not rhetorically: postoperative dissatisfaction in aesthetic surgery correlates more with the gap between expected and obtained than with the technical quality of the result. The conversation must cover three things: possible results, limits and complications. The aim is not to persuade but to ensure mutual understanding of realistic goals. One question orders the consultation: whether the patient wants to “look like someone else” or “look the same but rested”, because those are two different conversations and two different operations.
The complete photographic record
- Overall viewsFrontal, both profiles, both three-quarter, basal and superior
- StateAt rest and in motion: smile, forced closure, expression. Motion reveals what rest conceals
- DetailsSpecific views of orbit, nose, mouth and lips and any area to be operated
- AfterwardsRepeat the same views after surgery. Without identical position and lighting, the comparison is worthless
- And besidesIt serves as a reference in case of dispute: almost every late asymmetry complaint refers to something already present
What should be written down before operating
- Pre-existing asymmetries, pointed out and discussed with the patient in front of a mirror. Almost every late complaint refers to something pre-existing that nobody named.
- What will not change: skin quality, deep static wrinkles and the cervicomental angle if the hyoid is low.
- Which adjunctive procedures were proposed and why: fat grafting, genioplasty, resurfacing. If they were offered and declined, it must be recorded.
The conclusion that orders the indication
The whole analysis yields one operative question: what proportion of the problem is descent and what proportion is deflation. If descent dominates, the answer is repositioning; if deflation dominates, volume replacement; and in most patients over fifty, both in the same procedure. This is why a technically impeccable facelift can leave a patient dissatisfied: the ptosis was corrected but the atrophy ignored, and the result is a tight, empty face. The therapeutic approach can be entirely different in each patient and frequently requires combining techniques.
References
- 1.Vaquero Martínez P. Cirugía de lifting. En: Manual de la Sociedad Española de Cirugía Oral y Maxilofacial y de Cabeza y Cuello. SECOM CyC; 2025.
- 2.Jacono AA, Rousso JJ. An algorithmic approach to multimodality midfacial rejuvenation using a new classification system for midfacial aging. Clin Plast Surg. 2015;42(1):17-32.
- 3.Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-2227.
- 4.Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753-760.
- 5.Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6):826-837.
Related specialty: Facial Lifting & Rejuvenation