Facial plastic surgery reshapes the face by lifting, removing, or repositioning tissue beneath the skin. The specific steps depend on the procedure, but nearly all facial surgeries share a common logic: incisions are placed where they’ll be hidden, deeper tissue layers are restructured for lasting results, and the skin is redraped over the new contour. Here’s how the most common procedures actually work, from the first cut to the final stitch.
How Facelifts Restructure Deeper Tissue
A facelift isn’t just about pulling skin tighter. The real work happens in a layer called the SMAS, a sheet of connective tissue and muscle that sits between the skin and the deeper structures of the face. This layer runs continuously from the forehead down to the neck, taking different names in different regions. When it loosens with age, the visible result is sagging cheeks, jowls, and a slack jawline.
To lift the face in a way that lasts, the surgeon separates the SMAS from the skin above it and the bone below it. This requires releasing a series of ligaments, fibrous anchors that hold the soft tissue to the skull at specific points along the cheekbone, jaw, and around the ear. Once these ligaments are cut, the entire tissue layer becomes mobile. The surgeon then repositions this deeper layer upward and backward, securing it with sutures to the firm tissue near the ear and behind it. The skin is then redraped over the newly tightened foundation, and any excess is trimmed away.
In a deep plane facelift, the surgeon goes one step further. Instead of lifting the SMAS and skin as separate layers, the cheek fat, muscle, and SMAS are moved together as a single unit. This requires releasing all the retaining ligaments in the cheek and neck so the entire composite block of tissue can shift freely. Releasing the zygomatic ligament complex along the cheekbone is considered the most technically challenging step. Once fully mobilized, the tissue is repositioned and fixed in place, which smooths the nasolabial folds and jawline without creating a “pulled” look.
Where Incisions Are Placed
Surgeons hide facelift incisions in the natural creases and contours of the ear. In women, the cut typically runs along the tragus (the small flap in front of the ear canal), continues behind the ear, and extends into or along the hairline. In men, the incision follows a slightly different path, tracing the beard line in front of the ear to avoid placing hair-bearing skin in an unnatural location. In both cases, the scars settle into areas that are easily concealed by hair or the ear itself.
Other facial procedures use their own hiding spots. Eyelid surgery incisions follow the natural crease of the upper lid or sit just below the lash line on the lower lid. Some lower eyelid procedures are done entirely from inside the eyelid, leaving no visible scar at all. Brow lifts use incisions within the hairline or at the temples.
How Rhinoplasty Reshapes the Nose
Nose surgery takes one of two approaches. In an open rhinoplasty, the surgeon makes a small incision across the columella, the strip of tissue between the nostrils. The skin of the nose is then lifted upward like a hood, fully exposing the bone and cartilage framework underneath. This gives the surgeon a direct view of every structure and allows for precise, detailed reshaping.
In a closed rhinoplasty, all incisions are made inside the nostrils. There’s no external scar, and the skin stays mostly in place while the surgeon works underneath it. The tradeoff is limited visibility. Closed rhinoplasty works well for smaller changes, but complex reshaping or revision surgeries typically require the open approach.
Once the framework is exposed, the surgeon sculpts the nose by shaving down bone, trimming or rearranging cartilage, or adding grafts taken from the patient’s own septum, ear, or rib cartilage. If the nose needs to be narrowed, the bones on either side are carefully fractured and repositioned inward. After the structural work is complete, the skin is redraped over the new shape and the incisions are closed.
What Happens During Eyelid Surgery
Eyelid surgery, or blepharoplasty, addresses puffy bags, drooping lids, and excess skin around the eyes. The upper and lower eyelids involve different techniques.
For the upper eyelid, the surgeon marks and removes a crescent of excess skin along the natural eyelid crease. If the underlying muscle has stretched, a strip of that may be removed as well. The incision is closed with fine sutures and heals into the existing crease, making the scar nearly invisible once mature.
Lower eyelid surgery is more complex because the puffiness comes from fat pads that have pushed forward over time. The surgeon evaluates three separate fat pads beneath each eye. Some fat may be trimmed conservatively, particularly the outermost pad, which tends to be the most prominent. But modern techniques often reposition this fat rather than removing it. The surgeon releases the fat from its attachments, slides it downward over the orbital rim into the upper cheek, and secures it with a small suture. This fills the hollow “tear trough” groove while reducing the bag above it, creating a smoother transition from the lower eyelid to the cheek.
For excess skin on the lower lid, the surgeon separates the skin from the muscle beneath it, redrapes it, and trims only what’s truly redundant. More skin is typically removed from the outer corner than the inner corner. Conservative trimming is critical here because removing too much can pull the lower lid downward.
How Fat Grafting Restores Volume
Aging doesn’t just cause sagging. It also causes volume loss in the cheeks, temples, and around the mouth. Fat grafting addresses this by transplanting a patient’s own fat from one area of the body to the face.
The process starts with harvesting. Fat is suctioned from a donor site, commonly the abdomen, hips, or lower back, using a thin cannula. The harvested fat is then processed to separate the usable fat cells from blood, oil, and fluid. The degree of processing determines the type of graft. Microfat is gently purified and used for volume restoration, filling hollowed cheeks or temples the way a dermal filler would, but with the patient’s own tissue. Nanofat is processed more aggressively, filtered through a fine mesh with 0.5-millimeter pores, breaking it down into particles too small to add volume. Instead, nanofat is injected into the skin itself with a very fine needle and works by improving skin quality, reducing fine lines, and helping with scarring.
Fat grafting is often performed alongside other procedures like facelifts or eyelid surgery. Not all transferred fat cells survive, so surgeons typically over-correct slightly, knowing some volume will be reabsorbed in the weeks following surgery.
Anesthesia and What You Feel
Most facial procedures use one of two anesthesia strategies. Office-based and less invasive procedures often rely on regional nerve blocks, where an anesthetic is injected near specific nerves to numb large sections of the face. The face has well-defined nerve pathways that supply sensation to predictable zones, so blocking a single nerve near the cheekbone, jaw, or forehead can eliminate feeling across a wide area. These blocks are sometimes combined with light sedation to keep you relaxed but not fully unconscious.
More extensive surgeries like full facelifts or complex rhinoplasties are typically performed under general anesthesia, where you’re completely asleep. The choice depends on the length and scope of the procedure, as well as patient preference. A facelift lasting several hours is more comfortably done under general anesthesia, while a minor eyelid procedure might only require local numbing and sedation.
How Sutures Hold Everything Together
Facial surgery uses two categories of sutures. Internal, absorbable sutures are placed in the deeper tissue layers to hold repositioned structures in place while they heal. These dissolve on their own over weeks to months and don’t need to be removed. They’re what anchors the SMAS layer after a facelift or secures a transposed fat pad after eyelid surgery.
External sutures close the skin. These are often non-absorbable materials like nylon or polypropylene, chosen for their strength and minimal tissue reaction. They’re removed within the first one to two weeks. Some surgeons use fast-absorbing external sutures instead, which dissolve on their own and spare you a removal visit. Both approaches produce comparable cosmetic results, though surgeon preference and incision location influence the choice.
Recovery and Healing Timeline
The first three days after facial surgery are the most swollen and uncomfortable. By days four through seven, the worst begins to subside and some sutures may be removed. By the end of the second week, most remaining sutures come out and the bruising, initially deep purple, has typically shifted to yellow-green as it fades. Significant bruising resolves within 10 to 14 days for most people, though residual discoloration can linger for about three weeks before it’s easily hidden with makeup.
Initial results become visible around weeks three to four, once the major swelling has settled. But the face continues to change for months afterward. Tissues gradually settle into their final position, internal scar tissue softens, and residual swelling slowly resolves. Most facial plastic surgeons consider the one-year mark the point where final results are fully apparent. This doesn’t mean you’ll look swollen for a year. The changes after the first month are subtle, often only noticeable to you and your surgeon.
Complication Rates
The most common surgical complication in facial procedures is hematoma, a collection of blood beneath the skin that may require drainage. An analysis of over 129,000 cosmetic surgery patients found a major hematoma rate of 0.7% for facial procedures, lower than the rate for breast or body surgeries. The risk increases slightly when multiple procedures are combined in a single session. Temporary nerve weakness, causing difficulty moving part of the face, occurs in a small percentage of facelift patients and typically resolves within weeks to months as the nerve recovers. Permanent nerve injury is rare. Infection rates are low in facial surgery because the face has an exceptionally rich blood supply, which helps tissue resist bacteria and heal quickly.