Lifting what actually fell.

The facial muscles coalesce into a single fibrous layer — the SMAS. Beneath it sits the deep plane, and running through that plane are the retaining ligaments that anchor the face to the structures underneath.

Aging is largely those ligaments allowing descent. So the question a facelift has to answer is simple: are you going to release what is holding the tissue down and move it back, or are you going to tighten over the top of it and take out skin?

I work under the ligamentous layer, so the tissues that actually fell with age are the tissues that get lifted.

When the lift comes from repositioned deep tissue, the skin is not the thing under tension. It is simply redraped over a structure that has been put back where it was. That is the mechanical reason a deep plane result generally reads as more natural, and why it tends to be more durable than a technique that relies on pulling skin.

It also changes the risk profile of the operation. Tension on skin is what widens and migrates scars over time. And because the deep plane is largely avascular, dissecting in it is associated with less bleeding. That matters, because hematoma is the most common early complication in facelift surgery.

The branches of the facial nerve that move your face run in the deep plane. Operating in that plane means operating where those nerves are, and protecting them is the technical core of the procedure.

This is the argument for choosing a surgeon by anatomy. I’m dual board-certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology — Head and Neck Surgery. That second one is the specialty of the head and neck itself: the nerves, the planes, and what to do when anatomy is not textbook.

Two different things happen to a face over time, and they need different answers. Tissue descends. That is a lifting problem. Tissue deflates, which is a volume problem, and lifting will not fix it. Fat transfer addresses the second.

Most faces are a mix, in a proportion specific to that face. Working out which of your concerns is descent and which is deflation is what determines whether this is the right operation for you.

There is a shortcut, and most patients arrive already performing it. At the mirror you put your fingers along the cheek or the jaw and lift — upward, or upward and back — and you like what you see. Or you take hold of the loose skin under the chin and show me what you would want gone.

That gesture is diagnostic. It tells me what bothers you and the direction of pull that fixes it, in one motion.

What the gesture demonstrates is descent, because a lift is the only thing a pair of fingers can simulate. Deflation stays exactly where it is. So when I put your hands down and my hands on your face, I am largely sorting the part of your concern that moved from the part that emptied.

What tends to point here

• A fold forming just outside the nasolabial fold, sometimes with a slight hollow between it and the cheek
• Loss of definition along the jawline
• Loose skin under the chin, vertical banding of the platysma, or fullness in the neck
• A face in the mirror that looks older than you feel

None of that is an age question. Two people the same age can need entirely different operations, which is why this is settled with hands on tissue rather than from a photograph or a phone call.

Three, each placed in anatomy that hides it.

Under the chin

A submental incision, three centimeters or less, in the natural crease most people already have. Through it I lift the skin off the muscle and assess the fat and muscle layers directly. In most cases I trim the platysma and suture the edges into a sling, anchored laterally to the mastoid bone. That sling is what gives the neck its durability. Where there is fat beneath the muscle, it is addressed through the same opening.

Around and behind the ear

The incision comes up along the earlobe, passes behind the tragus, follows the auricular attachment, and continues into the hairline. Behind the ear it hides in the sulcus with a short limb, a centimeter or less, into the hair.

I deliberately avoid an incision running down the hairline. In patients with a lot of loose skin that choice can leave slight bunching behind the ear, visible only on close inspection and usually settling with time. I consider that a fair trade for not leaving a visible line along the hair.

The exact technique is decided during surgery, not before it. I have a very good idea from the examination of what I am likely to do. I do not know for certain until I can see the layers.

No presentation, no room full of coordinators. A conversation, an examination, and a plan you watch being made in a handheld mirror.

Your procedure is done in our own procedure suite with a CRNA who has been with this practice for years and is very good at keeping people comfortable.

We use IV sedation, typically midazolam and propofol. No general anesthetic, no endotracheal tube, no inhalational gases. If you have had a colonoscopy, it is the same class of anesthesia, and most people find that comparison settles the question faster than anything else I can say.

In my experience that approach means less nausea afterward and fewer swings in blood pressure during the case. The second one matters more than it sounds: blood pressure spikes are tied directly to the complication I worry about most.

People ask whether they will wake up during surgery. You will not. The anesthesia is not turned off until the operation is finished.

Afterward we watch you for an hour or two, give you something to eat, and empty the drain so we have an accurate count of its output. You are wrapped firmly for the first night and you go home the same day.

This is my actual post-operative protocol, day by day, including the parts nobody enjoys reading. Recovery is easier when you know in advance what is supposed to happen. The single most common call we get is from a patient on day three who thinks something has gone wrong.

You will look in the mirror in the first day or two and ask what on earth you did to yourself. So you are allowed to be furious with me. Just not until two weeks have passed.

By two weeks almost everyone has come round. What felt alarmingly tight on day three reads as normal, and patients tell me they realize it was not too tight after all — it was where it needed to be. Two weeks is also when most people are what we call restaurant ready: out to dinner, nobody asking what you have had done.

There is usually little real pain. Some people read the tightness as soreness, so you go home with the option of a narcotic, but a great many patients manage on Tylenol. A short course of steroids helps with the bruising and swelling.

Between visits we are reachable by phone, email or text. If something worries you, send a photograph. I would much rather look at something at nine in the evening than have you spend the night wondering.

This is surgery and surgery carries risk. These are manageable risks, but you should hear them plainly while you are deciding, not on a consent form the morning of your procedure.

In your fifties, a deep plane face and neck lift generally gives a good seven to ten years, sometimes longer. In your sixties, closer to five to seven. Beyond that I am reluctant to promise a figure, though the same five-to-seven range is reasonable.

Those numbers move with how you age, and aging is not evenly distributed. Sun exposure, smoking, weight fluctuation and general health all change how the tissues behave, which means a real part of how long your result lasts is in your hands as much as mine.

What the operation does not do is stop the clock. It resets your starting point. You go on aging from there, just from a better place than you would have.

If you would be happy with eighty percent improvement, you are going to be very happy. I would far rather set that number and beat it than promise perfection and spend a year explaining myself.