Facial aging has long been misunderstood by the general public as simply the loosening and sagging of skin. This misconception dates back to the early days of cosmetic surgery, when the primary method of facial rejuvenation involved excising and redraping the skin. While the skin is indeed part of the aging process, it represents only one component of a much more complex, multilayered transformation. True facial aging occurs at several anatomical levels—skin, fat, muscle, and bone—each undergoing changes such as shifting, volume loss, or structural weakening over time. Addressing only the superficial layer often results in outcomes that appear incomplete or unnatural.
Dr. David Webb is recognized for his deep understanding of these underlying anatomical dynamics and for his commitment to addressing facial aging at every level. As modern techniques have evolved, so too has the facelift—from a surface correction to a comprehensive, structural restoration
The Skin: A Surface Symptom, Not the Root Cause
Skin aging is the most visible and often the earliest sign of facial change. It thins, loses elasticity, and begins to fold and wrinkle due to intrinsic collagen breakdown and extrinsic damage like sun exposure. While this process certainly contributes to sagging, treating it in isolation is a mistake. Early facelift techniques relied heavily on simply pulling the skin tighter, sometimes resulting in a “windblown” or overly taut appearance. What we now know is that skin laxity reflects what’s happening beneath it. It is the visible effect of structural changes, not the primary cause of them. Modern surgical techniques acknowledge this by using the skin as a redraping envelope—something to contour and smooth, but never to rely on for long-term support. A proper facelift must address the deeper anatomy to create a foundation that the skin can drape over naturally.
Fat Pads and Volume Loss
The next layer of concern lies within the facial fat pads. These distinct compartments—spread across the cheeks, jawline, temples, and periorbital regions—undergo redistribution and atrophy with age. Some fat pads descend due to gravity and ligament laxity, while others deflate entirely. This contributes to a gaunt or hollow appearance, especially in the midface and under-eye area. In the past, patients often sought to “lift” their features back into place when what they truly needed was volume. Modern facelifts take a far more nuanced approach, often incorporating fat grafting to areas where fullness has been lost. This restores the natural contour of the face, improves skin quality over time due to stem cell benefits, and supports the overlying tissues. For example, a cheek that has both descended and flattened cannot simply be lifted—it must also be refilled. Recognizing this has led to a dramatic shift in facelift planning, with volume restoration being just as important as repositioning.
Muscle and SMAS: The True Lifting Plane
Below the fat lies the SMAS—the superficial muscular aponeurotic system. This fibromuscular layer connects the facial muscles to the skin and provides a structural framework that can be repositioned to support long-term results. Lifting this layer, rather than just the skin, is now the gold standard in facelift surgery. The SMAS can be approached in several ways: it can be plicated (folded), imbricated (overlapped), or elevated entirely in a deep-plane technique. Each method has its indications, and the choice often depends on the degree of ptosis, the patient’s anatomy, and the desired longevity of the result. Importantly, lifting the SMAS restores the natural position of the facial tissues without over-tightening the skin. It allows for vertical or superolateral repositioning that mimics youthful anatomy, especially in the midface, jawline, and neck.
Bone Resorption and Skeletal Support
Perhaps the most underappreciated aspect of facial aging is bone resorption. As we age, we lose volume in the facial skeleton—particularly in the maxilla (upper jaw), mandible (lower jaw), and periorbital rim. This loss of bony support causes the overlying soft tissues to collapse inward and downward, creating shadows, flattening contours, and reducing facial projection. In younger patients, the cheekbones and jawline serve as scaffolding for the skin and fat. When this support shrinks, everything above it appears more deflated or saggy. Traditional facelifts did not take this into account, often tightening tissues over a diminishing framework. Today, a growing number of facial surgeons factor in skeletal changes when planning rejuvenation. While we cannot surgically restore bone through a facelift, we can augment areas with fat grafting or implants to restore projection. Some patients benefit from chin augmentation, premaxillary fillers, or even structural fat grafting to the orbit to restore a youthful convexity. In this way, the facelift becomes part of a broader architectural rebuild.
A Holistic, Customized Approach
The most important evolution in facelift surgery is not just technical—it is conceptual. Every face ages differently, and every facelift must be planned around a patient’s unique anatomic changes. A thirty-five-year-old with early jowling and minimal volume loss will not need the same approach as a sixty-year-old with extensive deflation, platysmal banding, and skeletal recession. The one-size-fits-all philosophy of the past is obsolete. Today, surgical plans are modular and layered. They combine SMAS elevation, skin redraping, fat restoration, and sometimes adjunctive procedures like brow lifts or neck lifts. In many cases, nonsurgical therapies such as resurfacing or neuromodulators are incorporated into the overall plan for texture improvement and maintenance. Patient education is also critical. Most are surprised to learn how much of their “sagging” is really due to volume loss or changes in bone structure. Understanding the three-dimensional nature of aging helps them see why a modern facelift looks more natural—it doesn’t just tighten, it restores.
The Future of Facial Rejuvenation
As imaging technology, regenerative medicine, and surgical tools continue to advance, our ability to understand and address aging at its root cause will only improve. Techniques like high-resolution ultrasound and 3D photography now allow us to map volume loss and soft tissue descent with greater accuracy. Biologic therapies, such as PRP or stem cell-enhanced fat grafting, offer promise in not only replacing lost tissue but rejuvenating the skin and subcutaneous matrix. What remains constant, however, is the surgeon’s role in interpreting this information and translating it into an individualized plan. Ultimately, modern facelift surgery is not about reversing time, but about harmonizing a person’s outer appearance with their inner vitality. By treating facial aging as a complex, layered process—one involving skin, fat, muscle, and bone—we honor both the science and the art behind the work. And it is that layered understanding that continues to move facial rejuvenation forward.