Facelift, Neck Lift, and MACS Lift
Schedule a Consultation
Dr. Horton
Emily Sespaniak, MSN, FNP-C
Danielle Bautista, MSN, ANP
Understanding Facial Aging
What Is a Facelift?
Neck Lift: Addressing the Lower Face and Neck
The MACS Lift: Dr. Horton’s Preferred Technique
Benefits of Facelift Surgery
Who Is a Good Candidate?
Preparing for Surgery
What Happens on the Day of Surgery
Recovery
Combining Procedures: Enhancing Your Results
Before and After Photos
FAQs
As we age, the lower face and neck are often among the first places to show visible signs of time. Jowling along the jawline, loose skin beneath the chin, sagging in the midface, deep creases from the nose to the corners of the mouth, and a softening or blunting of the neck contour can all contribute to an appearance that feels older or more tired than you feel on the inside. These changes are natural, are often genetically based, and for many people, they become a source of genuine concern.
Facelift surgery is one of the most transformative and lasting procedures in cosmetic Plastic Surgery. At her San Francisco practice, Board-Certified Plastic Surgeon Dr. Karen Horton specializes in facelift surgery, including neck lift and MACS (Minimal Access Cranial Suspension) lift techniques, helping patients achieve a refreshed, natural appearance that reflects the energy and vitality they carry within. Dr. Horton’s approach is always individualized, always precise, and always focused on results that look like the best version of you, never “done.”
Understanding Facial Aging
To understand what facelift surgery accomplishes, it helps to understand what aging does to the face. Youthful faces are fuller, more lifted, and better defined. Look at a photograph of yourself from ten years ago and you may notice fuller cheeks, a smoother jawline, and more volume beneath the eyes and in the temples.
With time, several things happen simultaneously. The skin loses elasticity and begins to sag downward. Volume, the fat that gives the face its youthful roundness and structure, is lost in the cheeks, temples, and under-eye area. The deeper soft tissues of the face, collectively known as the SMAS (submusculoaponeurotic system), the network of muscles of facial expression and surrounding fibrofatty tissue, descend predictably downward with gravity. This descent creates jowling along the jawline, deepening of the nasolabial folds (from the nose to the corners of the mouth), marionette lines, and the characteristic “turkey neck” that results when platysmal bands in the neck relax and loose neck skin migrates downward.
These changes are universal. The question is not whether they will occur, but how and when to address them in a way that is safe, effective, and suited to your individual anatomy.
What is a Facelift?
A facelift, or rhytidectomy, is a surgical procedure designed to reverse the visible effects of aging on the face and neck. By carefully lifting and repositioning the underlying facial soft tissue structures, removing excess skin, and redressing the remaining skin without unnatural tension, a facelift restores a smoother, firmer appearance to the face and jawline.
Facelifts are not one-size-fits-all procedures. Techniques vary widely in scope and approach. Some are subcutaneous, addressing only the skin. Many involve manipulation of the SMAS. Others pursue a “deep plane” approach that dissects beneath the SMAS, placing the facial nerve, the motor nerve responsible for facial movement and expression, at greater risk. There are also minimally invasive approaches using threads or energy-based devices that claim to lift or tighten the skin without surgery. These methods have been available for decades, and there is a reason most Board-Certified Plastic Surgeons do not rely on them as their primary facial rejuvenation technique: they do not produce lasting, meaningful results. When it comes to your face, if something sounds too good to be true, it usually is.
Most patients who seek facelift surgery present with jowling, loss of jawline definition, fat accumulation under the chin and in the neck, and a “turkey neck” appearance caused by sagging skin and relaxed platysmal bands. For these concerns, Dr. Horton focuses on the lower face and neck, the area that benefits most from surgical intervention and where the MACS lift excels.
Neck Lift: Addressing the Lower Face and Neck
A neck lift, also called a lower facelift, is the component of facelift surgery specifically designed to address signs of aging in the neck and lower face. It targets loose, crepey neck skin, submental fat, vertical platysmal bands, jowling, and loss of jawline definition. The result is a smoother, more youthful neckline and a cleaner, better-defined jawline that harmonizes with the rest of the face.
During a neck lift, excess skin is removed, the platysma muscle and underlying SMAS are tightened and repositioned, and the neck contour is refined for lasting improvement. Neck and chin liposuction is frequently incorporated to remove excess fat in the submental region for the most complete aesthetic outcome.
A neck lift does not address the upper face, brow, or eyelids. It is most often performed as part of a comprehensive facelift plan, and frequently alongside blepharoplasty (eyelid surgery), to achieve full facial rejuvenation in a single procedure.
The MACS Lift: Dr. Horton’s Preferred Technique
The MACS (Minimal Access Cranial Suspension) lift is the most commonly performed facelift technique in Dr. Horton’s practice and her approach of choice for the majority of patients seeking lower face and neck rejuvenation. Developed in Europe and first published in 2003, the MACS lift is grounded in a thorough, scientifically accurate understanding of the anatomical changes that drive facial aging. It is safer and more effective than traditional facelift techniques, produces shorter, better-concealed scars, and is associated with lower complication rates and less downtime.
Why the Lower Face Sags: The Anatomy Behind the MACS Lift
As both women and men age, volume is lost throughout the face, creating hollows and allowing the deeper soft tissues to shift downward. The SMAS, the connective tissue network comprising the muscles of facial expression and surrounding fatty tissue, descends in a predictable downward vector with gravity. This produces the jowling, marionette lines, and neck laxity that characterize an aged face. Much of the lost volume can be addressed with injectable fillers, but surgical correction and SMAS repositioning is necessary to restore the structural foundation of the lower face and neck.
The logic of the MACS lift is straightforward: if the soft tissues of the lower face have descended downward, the most effective correction is to lift them back upward, where they belong.
What Does MACS Stand For?
MA: Minimal Access This refers to the short scar. The incision begins at the earlobe, travels upward in front of the ear to the base of the sideburn, and then zig-zags forward approximately one inch into the hairline. The zig-zag lies hidden beneath the sideburn, and the incision in front of the ear rests in the natural crease between the ear and the cheek. With proper healing, this scar is typically imperceptible within two to three months.
Unlike traditional facelifts, which extend long incisions into the hairline in front of the ear and sweep behind the ear into the scalp, the MACS lift requires no such extensions. Longer incisions are nice for the surgeon as they expose a large surface area, but they put the face and neck skin at risk of losing blood supply, they increase bleeding risk and they are simply unnecessary to achieve meaningful, lasting correction of the lower face and neck.
CS: Cranial Suspension This describes how the deep tissues are repositioned. Once the skin flap is elevated, two purse-string sutures are placed along the surface of the SMAS, lifting the deep soft tissues in two distinct vectors: one directly upward to correct jowling, and one obliquely upward from the corner of the mouth to lift and restore the lower face. These sutures are anchored to the deep temporal fascia, a strong, stable point higher on the cranium (the head). This is what distinguishes the MACS lift from older techniques that simply pull the skin tighter without addressing the underlying structures.
The suspension sutures dissolve gradually over approximately 18 months, during which time the tissues heal in their newly elevated position. By the time the sutures are fully dissolved, the lower face and neck deep tissues have been permanently repositioned.
Why the MACS Lift Is Safer
Because the dissection during a MACS lift remains superficial to the SMAS rather than beneath it, the facial nerve, the motor nerve responsible for the movement of all facial muscles, is not placed at risk. Deep plane facelifts, which dissect beneath the SMAS, carry a higher risk of facial nerve injury, with potential consequences including partial or permanent facial weakness or paralysis. The MACS lift achieves superior correction of jowling and neck laxity without this elevated risk, making it a kinder, safer approach to the delicate structures of the lower face.
How Long Does Facelift Surgery Take?
The MACS lift is performed under general anesthesia as an outpatient procedure at Dr. Horton’s Quad-A certified San Francisco Plastic Surgery center. Surgery takes approximately three to four hours. The total operative time includes anesthesia induction, preparation, the procedure itself, the application of postoperative dressings, and transport to the recovery room.
Benefits of Facelift Surgery
Facelift surgery with Dr. Horton offers meaningful, lasting improvements to both appearance and confidence. Specific benefits include:
- Elimination or significant reduction of jowling for a cleaner, more defined jawline
- Correction of sagging neck skin and “turkey neck” appearance
- Smoothing of deep creases and nasolabial folds
- Restoration of volume and structure to the midface and cheeks
- Improved neck contour and definition beneath the chin
- Shorter, better-concealed scars with the MACS technique compared to traditional facelift approaches
- Natural-looking results that enhance, rather than alter, your appearance
- Long-lasting improvement that continues to look natural as you age
Many patients describe a profound boost in confidence and a renewed sense of vitality following surgery, reflecting on the outside how they have always felt on the inside.
Who is a Good Candidate for a Facelift?
Good candidates for facelift surgery are generally healthy individuals who are at or near their ideal body weight, including those who have achieved stable weight following significant weight loss. Candidates should have realistic expectations and a clear understanding of both the benefits and the limitations of the procedure.
Factors that may affect candidacy include active smoking, unmanaged medical conditions, or being emotionally unprepared for surgery. All patients must discontinue smoking and all forms of nicotine at least six weeks before surgery to support safe healing and reduce the risk of complications.
Emotional readiness matters as much as physical health. The best outcomes come when a patient pursues surgery at the right time, for the right reasons, with the support of family and close friends and with a thorough education about the procedure and recovery ahead. Dr. Horton takes the time during your consultation to understand your goals, assess your anatomy, and determine whether surgery is the right choice for you now.
Important Note on GLP-1 Medications GLP-1 receptor agonist medications, such as semaglutide and tirzepatide should be discontinued at least one month before any procedure involving general anesthesia. These medications carry specific anesthetic and surgical risks that must be managed carefully before proceeding. For detailed information on managing diabetes or weight loss medications safely before your procedure, read our full blog post.
Preparing for Surgery
The journey to a successful facelift begins before you ever enter the operating room. During your consultation, Dr. Horton will review your complete medical and surgical history, evaluate your facial bone structure, skin quality, elasticity, and the specific features of aging you wish to address. She will answer all of your questions openly and thoroughly, and together you will build a customized surgical plan that reflects your goals.
Once your surgery is scheduled, you will receive detailed preoperative instructions tailored to your individual needs. These will cover medications to avoid, dietary guidance, and everything you need to know to prepare your body and your home for a smooth recovery.
What Happens On the Day of Surgery
Facelift surgery is performed as an outpatient procedure at Dr. Horton’s Quad-A certified San Francisco Plastic Surgery center. General anesthesia with a Board-Certified Anesthesiologist is used to ensure your complete comfort and absolute safety throughout.
On the day of surgery, the skin of the face and neck is gently elevated to access the underlying SMAS. Local anesthetic with epinephrine is injected to constrict small blood vessels and minimize intraoperative bleeding and bruising. If submental fat is present, liposuction of the chin and neck is performed first to refine the jawline and neck contour.
Using the MACS technique, the deep soft tissues are then lifted and resuspended upward in two distinct vectors via purse-string sutures placed at the surface of the SMAS and anchored to the deep temporal fascia. A minimal amount of excess skin is carefully trimmed, and the remaining skin is redraped naturally in an upward direction, without artificial tension. Dissolving sutures are used throughout. Small drains are placed to remove excess fluid and are removed comfortably at your first postoperative visit, the morning after surgery.
Following surgery, soft absorbent pads are applied over the incisions, and a compressive chin strap is placed. Postoperative discomfort is typically minimal and well-managed with prescribed medications.
Recovery After Facelift Surgery
Recovery from facelift surgery follows a predictable progression. Swelling and bruising are a normal and expected part of healing. Some initial asymmetry or uneven skin appearance may be noticeable in the early weeks due to differential swelling, and this resolves as healing advances. Most patients see noticeable resolution of puffiness and discoloration within two to four weeks.
What to Expect During Recovery:
Sleeping with your head elevated on extra pillows for the first several days helps reduce swelling. Neither heat nor ice should be applied to the face or neck, as numb skin is at risk for thermal injury, and normal circulation is essential to uneventful healing.
Exercise and any activity that elevates your heart rate or blood pressure should be avoided for a full month following surgery. Plan for approximately one month of social downtime before returning to public-facing activities.
Protecting your skin from the sun is critical during recovery and as a lifelong habit to preserve your results. Use a broad-spectrum SPF 30 or higher sunscreen every day on any bruised areas and avoid direct sun exposure. Makeup may be applied over sunscreen approximately one week after surgery. Our office carries medical-grade skincare products selected specifically to protect and support healing skin during your recovery.
If you have short hair, growing it slightly longer before surgery can help conceal healing incisions. Avoid chemical hair treatments, such as coloring or perming, for at least one month post-surgery. A salon appointment before surgery is a wonderful way to feel prepared and pampered.
Facelift scars are permanent but are skillfully placed within natural skin creases, in front of the ear, and at the hairline, where they are well-concealed and typically imperceptible with time.
Scar Therapy: Dr. Horton provides individualized scar therapy guidance as part of every patient’s recovery plan. Learn more about scar therapy here.
Your Follow-Up Schedule:
- Day 1 after surgery: First postoperative visit; drain removal and dressing check
- Weeks 1 to 2: Healing check with Dr. Horton; removal of any non-dissolving sutures or staples (if used in the hair-baring scalp region)
- Weeks 4 to 6: Scar therapy education begins once all scabbing has resolved
- Month 3: Follow-up photographs documenting your results
- Month 12: Final follow-up photographs; results are fully mature
Postoperative Instructions Special Instructions for Facial Surgery
Combining Procedures: Enhancing Your Facelift Results
Facelift surgery, including the MACS lift, focuses on the lower face and neck. For patients who also wish to address the eyes, brow, or upper face, or who want to enhance and prolong their results with non-surgical treatments, Dr. Horton offers a full range of complementary procedures that can be performed at the same time as or alongside facelift surgery.
A thorough facial evaluation during your consultation will identify the combination of procedures best suited to your anatomy, the specific features of aging you wish to address, and your overall aesthetic goals.
Complementary Surgical Procedures
Eyelid Lift (Blepharoplasty)
Blepharoplasty removes excess, heavy eyelid skin and reduces puffiness in the upper and lower lids, refreshing and rejuvenating the eye area. It is one of the most frequently combined procedures with facelift surgery, as the eyes and lower face age together and respond beautifully to simultaneous treatment.
Brow Lift (Forehead Lift)
A brow lift gently elevates a descended or heavy brow, restoring a more open, youthful appearance to the eyes and upper face. Combined with a facelift, it provides the most comprehensive facial rejuvenation possible in a single surgical setting.
Neck and Chin Liposuction
Liposuction of the submental region removes excess fat from beneath the chin and in the neck, enhancing jawline definition and complementing the lifting effects of facelift surgery. It may also be performed as a standalone procedure in patients with good skin elasticity who are not yet candidates for surgical lifting.
Earlobe Repair or Reduction
Aging and the prolonged wearing of heavy earrings can stretch, elongate, or split the earlobes over time. Earlobe repair restores a more youthful, proportionate earlobe and brings meaningful balance and harmony to the overall facial appearance. It is easily and comfortably performed at the same time as facelift surgery.
Non-Surgical Enhancements
Non-surgical treatments are a natural and effective complement to facelift surgery, both in the weeks leading up to a procedure and as part of a long-term maintenance plan. Preparing the skin with physician-directed skincare before surgery supports optimal healing, while ongoing non-surgical treatments help prolong surgical results over time.
BOTOX® and Dysport
Neuromodulators relax the dynamic muscles responsible for forehead lines, crow’s feet, and other expression-related wrinkles that facelift surgery does not address. They are among the most effective tools for maintaining a refreshed, rested appearance between and after surgical procedures. cx
Dermal Fillers and Lip Fillers
Injectable fillers restore volume lost to aging in the cheeks, temples, under-eye area, and lips. While facelift surgery lifts and tightens, fillers replenish the volumetric foundation of a youthful face. Together, they are a powerful combination.
Laser Treatments (IPL, Clear + Brilliant)
Laser and light-based treatments address skin tone, texture, sun damage, and discoloration, refinements that surgery alone does not target. IPL (Intense Pulsed Light) and Clear + Brilliant treatments are well-suited to the recovery period and long-term maintenance plan following facelift surgery.
Medical-Grade Skin Care
A physician-recommended medical-grade skincare regimen is one of the most important investments you can make before, during, and after facelift surgery. Properly selected skincare prepares the skin for surgery, actively supports healing during recovery, and helps preserve and extend your surgical results for years to come. Our office offers medical-grade skincare products curated by Dr. Horton specifically for patients undergoing facial rejuvenation.
Before and After Photos
One of the most meaningful steps in considering facelift surgery is seeing what is achievable. Dr. Horton’s patient gallery features real results from real patients, representing a range of ages, anatomies, and surgical plans. Each result reflects her commitment to outcomes that look natural, refreshed, and uniquely suited to the individual.
You will also have the opportunity to review additional results privately and in greater detail during your personal consultation with Dr. Horton.
Before & After
Frequently Asked Questions About Facelift Surgery
Facelift results are long-lasting. While the natural aging process continues after surgery, you will consistently maintain a more youthful appearance than you would have without the procedure. Modern techniques, including the MACS lift, are designed to produce results that age gracefully over time, never appearing tight or overdone. Maintaining excellent skincare habits, protecting your skin from the sun, and incorporating non-surgical maintenance treatments can extend the longevity of your results considerably. Some patients choose a secondary facelift procedure many years later to refresh their outcome; this requires careful judgment and the expertise of an experienced Board-Certified Plastic Surgeon.
A facelift is a broad term for surgical procedures that address aging of the face and neck. A neck lift is the component of facelift surgery that specifically targets the neck and lower face. The MACS lift is a specific facelift technique that Dr. Horton performs most frequently because of its superior safety profile, shorter scar, meaningful results, and lower complication risk compared to traditional approaches. In practice, most patients seeking lower face and neck rejuvenation are best served by the MACS lift, as it addresses exactly the anatomy responsible for jowling and neck sagging while leaving the upper face open for complementary procedures as needed.
As with any surgical procedure, facelift surgery carries potential risks. While serious complications are uncommon when surgery is performed by a Board-Certified Plastic Surgeon, possible risks include bleeding (hematoma), infection, nerve injury causing temporary or permanent facial weakness, fluid accumulation (seroma), skin discoloration, numbness, unfavorable scarring, poor wound healing, hair loss near incision sites, and asymmetry. More serious but rare complications include deep vein thrombosis, cardiac or pulmonary events, and anesthesia-related risks.
Dr. Horton will review all potential risks in detail during your consultation and provide comprehensive preoperative and postoperative care instructions to support a safe, successful recovery.
Yes. Many patients combine facelift surgery with blepharoplasty (eyelid surgery), a brow lift, earlobe repair, or neck and chin liposuction to achieve more comprehensive facial rejuvenation in a single recovery period. Dr. Horton will conduct a thorough facial evaluation during your consultation to determine which combination of procedures best addresses your individual features and goals.
Non-surgical treatments are a meaningful complement to facelift surgery, not a replacement for it. Treatments such as BOTOX, dermal fillers, laser resurfacing, and medical-grade skincare work synergistically with surgery to optimize results, support recovery, and extend the longevity of your outcome. Dr. Horton will discuss a complete, individualized treatment plan during your consultation.
As with any surgical procedure, facelift surgery carries potential risks. While serious complications are uncommon when surgery is performed by a skilled, experienced Board-Certified Plastic Surgeon, possible risks include bleeding (hematoma), infection, nerve injury causing temporary or permanent facial weakness, fluid accumulation (seroma), skin discoloration, changes in sensation such as numbness, unfavorable scarring, poor wound healing, hair loss near incision sites, or asymmetry. More serious but rare complications include deep vein thrombosis, cardiac or pulmonary events, or anesthesia-related risks. Dr. Horton will review all potential risks in detail during your consultation and provide thorough post-surgical care instructions to support your recovery and minimize risk.
Yes, all surgical procedures involving incisions result in permanent scars. Dr. Horton places facelift incisions in discreet locations within the natural skin crease in front of the ear, at the earlobe, and briefly into the hairline at the sideburn, where they are well-concealed and typically imperceptible with proper healing. The MACS lift requires a shorter incision than traditional facelift techniques, which is one of its meaningful advantages. Dr. Horton provides individualized scar therapy guidance beginning approximately six weeks after surgery. Learn more about scar therapy here.
Thread lifts and energy-based devices marketed as non-surgical alternatives to a facelift have been available for decades. While they are frequently promoted as minimally invasive solutions for sagging skin and jowling, most Board-Certified Plastic Surgeons do not rely on these techniques for one reason: they do not produce lasting, meaningful results comparable to surgery. The correction is minimal, the results are temporary, and many patients who pursue these approaches ultimately proceed to facelift surgery. If a treatment sounds too good to be true, it usually is. Dr. Horton is happy to discuss all available options and help you make a fully informed decision during your consultation.
GLP-1 receptor agonist medications such as semaglutide and tirzepatide are increasingly common and require special consideration before any procedure involving general anesthesia. These medications should be discontinued at least one month before surgery to reduce specific anesthetic and surgical risks. For full guidance on managing diabetes or weight loss medications before your procedure, read our blog post.
The cost of facelift surgery in San Francisco varies based on the surgeon’s experience, the specific technique and scope of the procedure, the facility, anesthesia, and the patient’s unique treatment plan. Following your consultation with Dr. Horton, you will receive a detailed, fully itemized cost breakdown for your individualized procedure.
The best way to know is to schedule a consultation. Dr. Horton takes the time to understand each patient personally, review their medical history thoroughly, evaluate their facial anatomy in detail, and explore their motivations for seeking surgery. She designs each surgical plan around the individual patient’s features, goals, and the specific changes they wish to address, and she will ensure you have a complete and honest understanding of what facelift surgery can and cannot achieve before any decision is made.
Schedule a Facelift Consultation in San Francisco
If you are considering facelift surgery to address visible signs of aging and restore a refreshed, natural appearance, the first step is a personal consultation with Board-Certified Plastic Surgeon Dr. Karen Horton. At her San Francisco practice, Dr. Horton will take the time to understand your goals, evaluate your individual anatomy, and design a customized surgical plan built around your needs.
To begin your facial rejuvenation journey, contact our office today.
