The Facelift Has Gotten a Little Work Done

According to Dr. Talei, who does not perform endoscopic facelifts but is renowned for his deep plane expertise, older endoscopic techniques that tunneled down to bone caused tons of swelling and produced results that lasted, on most people, about a year and a half. But the more novel and “technically challenging” endoscopic deep plane facelifts can be “a really good option for select patients who don’t need a big lift,” he says. “They’re not just marketing.”

As this procedure’s approval rating grows so too does evidence supporting its efficacy. In 2023, Dr. Kao and Dr. Mani published separate peer-reviewed articles detailing their respective endoscopic approaches. Dr. Kao is hopeful that his paper, analyzing 600 consecutive ponytail cases over 22 years, will sway “naysayers who say it doesn’t work or is only for young people.”

Dr. Kao offers four distinct “ponytail” operations, each designed to tackle an increasing degree of laxity. While his youngest (and tautest) patients leave the OR with just four tiny slits hidden in their hair, those in their mid-40s, 50s, and 60s may have additional incisions behind (or, rarely, in front of) the ears to take out redundant skin from the face and neck.

With the least invasive of his procedures, Dr. Kao can tighten “all the way down to the angle of the jaw through incisions in the temple area,” a maneuver that “came to me maybe six years ago,” he says. For a long time, he couldn’t see how to do it safely without injuring a major facial nerve. Eventually, inspiration struck as it so often does: “I figured it out in the shower.”

Dr. Mani’s endoscopic technique mimics his conventional deep plane approach, save for the incisions, which he conceals in the hair of the temples and behind the ears (sparing the scar in front of the ears). Unlike Dr. Kao, who performs ponytail procedures exclusively, Dr. Mani operates endoscopically in 60% to 70% of patients. He’ll otherwise perform a regular deep plane facelift with traditional incisions.

Both doctors say the longevity of their endoscopic lifts rivals that of standard deep plane procedures and that complication rates and recovery periods are virtually identical. When speaking of safety, Dr. Mani tells me that the endoscope actually gives him an edge by making “the nerves look like giant snakes,” so he can avoid them more easily.

However, navigating an endoscope—a skill not every surgeon possesses—can prolong an already lengthy procedure. Dr. Kao’s most complex facelifts can take 10 to 12 hours, twice the time of a standard deep plane facelift. Some view this as a potential drawback, particularly for older patients who ultimately wind up needing incisions in front of the ears anyway, the very thing they’re aiming to avoid with an endoscopic lift. If there’s a possibility that those incisions will be necessary to remove excess skin, says Dr. Nayak, the patient may be better off with a regular deep plane lift that “gets them off the table three hours earlier.”

4. The deep structural neck lift

Lately, every time I open Instagram, I land on a lecture about submandibular glands and the importance of contouring them to take a neck lift to the next level. (I follow plastic surgeons the way normal people do celebrities.) Inevitably, digastric muscles and subplatysmal fat enter the chat. (Again, my echo chamber, er feed, may look a little different than yours.)

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