EBM SPECIAL TOPIC

A Systematic Review of Comparison of

Efficacy and Complication Rates among
Face-Lift Techniques
Suzie Chang, M.D.
Andrea Pusic, M.D., M.H.S.
Rod J. Rohrich, M.D.
Dallas Texas; and New York N.Y.

Background: The ideal face lift has the longest efficacy, the fewest complications, and ultimately, the highest patient satisfaction. With so many different
techniques, there exists a need to make this comparison and to establish which
approaches may work best in various groups. To date, there has been no
systematic review to study the efficacy and complication rates among different
face-lift techniques. This study aims to make this comparison.
Methods: A systematic search of the English language literature listed in the
MEDLINE (Ovid MEDLINE 1950 to November of 2009 with Daily Update),
PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL)
databases yielded trials on comparison of different face-lift techniques in their
efficacy and complication rates. All relevant articles reference sections were
studied for additional relevant publications.
Results: The keyword search yielded 39 articles. Eighteen more articles were
retrieved from reference sections of relevant articles. Only 10 articles made a
direct comparison of efficacy between face-lift techniques, and only five articles
made a direct comparison of complications between face-lift techniques.
Conclusions: Although this systematic review revealed a lack of quality data in
comparing the efficacy and safety among different face-lift techniques, it is
important to review and pool the existing studies to improve patient outcomes.
This analysis has also shown the need for better studies, especially randomized,
prospective, controlled studies, and a need for a standardized method of efficacy
analysis and patient-reported outcomes measures to allow objective comparison
of face-lift techniques. (Plast. Reconstr. Surg. 127: 423, 2011.)

ince the first described modern face lift in

1910 by German surgeons, there have been
many published variations and techniques in
the face-lift procedure. The modern day face lift is an
evolution and combination of the various techniques such as: direct rhytidectomy, skin-only face
lift, superficial musculoaponeurotic system (SMAS)
plication, SMASectomy, SMAS imbrications, SMASplatysma flap face lift, composite face lift, deep-plane
face lift, subperiosteal face lift, endoscopic, suturesuspension face lift, and the short-scar/limited scar
face lift. With so many variations, the question of
which type to perform arises.
From the Department of Plastic Surgery, University of Texas
Southwestern Medical Center, and the Department of Plastic
and Reconstructive Surgical Services, Memorial Sloan-Kettering Cancer Center.
Received for publication March 10, 2010; accepted July 14,
2010.
Copyright 2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181f95c08

The ideal face lift would be one with the longest efficacy, the fewest complications, and ultimately, the highest patient satisfaction. With so
many different techniques, there exists a need to
make this comparison. To date, there has been no
systematic review to study the efficacy and complication rates among different face-lift techniques.
This study aims to make this comparison.

WHY A SYSTEMATIC REVIEW?

A systematic review is considered one of the
highest levels of evidence, ranked higher than
even randomized controlled trials. This is because
it is a review designed to be reproducible, with
predetermined inclusion and exclusion criteria.
This method of analysis summarizes existing data

Disclosure: The authors have no financial interests regarding the content of this article.

www.PRSJournal.com

423

Plastic and Reconstructive Surgery January 2011

Fig. 1. Study algorithm.

and provides analysis on the quality and validity of

the reviewed studies. This systematic review can
aid the plastic surgeon and the patient in making
an informed decision on the safest and most efficacious face-lift technique, if such exists.1

METHODS
The systematic search was started with a thorough English-language literature search of the
Medline (Ovid MEDLINE 1950 to November 2009
with Daily Update), PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) da-

424

tabases. This search used the keyword search

terms in combination as follows: facelift, face
lift, rhytidectomy, comparison, study, and
complication. This was designed to be broad and
inclusive to yield published trials on comparison
of different face-lift techniques regarding their
efficacy and complication rates.2 61 The retrieved
articles were read in their entirety and their bibliographies were studied for additional relevant
publications. Articles were then eliminated based
on the inclusion and exclusion criteria (Fig. 1 and
Table 1). Each qualifying article was examined by

Volume 127, Number 1 Comparison of Face-Lift Techniques

Table 1. Inclusion and Exclusion Criteria
Inclusion criteria
Articles
Original studies
Human studies
Exclusion criteria
Brow lifts
Midface lifts
Books
Non-English
Keyword search terms
Facelift, face lift
Rhytidectomy
Comparison
Complication
Study

two reviewers (S.C. and R.J.R.); disagreements

were settled by consensus.

RESULTS
Comparison of Efficacy among
Face-Lift Techniques
There were 10 studies that fit the qualifying
criteria in comparing the efficacy of face-lift techniques (Table 2).
Tipton, 1974
In 1974, Tipton published a prospective randomized trial of 33 patients who underwent mixed
face-lift procedures: one side of face was a skinonly face lift and the other side of the face was a
SMAS-plication face lift. Evaluation of photographs
taken at 2 years postoperatively was performed to
detect any difference in sides. No differences were
seen between the plicated and nonplicated sides.53
This study did not describe the method of analysis to
objectively measure efficacy of the face-lift techniques; there is a lack of standardized objective measurement analysis for efficacy, again exposing itself
to error of subjectivity.
Rees and Aston, 1977
In 1977, Rees and Aston published a prospective trial of 25 randomized patients who underwent mixed face-lift procedures: one side of the
face underwent a skin-only face lift, and the other
side of the face underwent SMAS-platysma flap
elevation. Patients were evaluated at 1 year or
longer postoperatively by two experienced plastic
surgery nurses and by one of the authors. Only one
patient had a noticeable difference between sides
by all three observers consistently.50
This study is limited by observer bias, as one of
the evaluators was one of the performing surgeons. Also, it did not elucidate how many oper-

ating surgeons participated. There is also a lack of

standardized objective measurement analysis for
efficacy (therefore exposing itself to error of subjectivity). It is, however, the only published prospective, randomized, self-controlled study comparing skin-only face lift to the SMAS-platysma flap
face-lift technique.
Webster et al., 1982
In 1982, Webster et al. published a prospective
mixed cadaveric/living human study that compared the SMAS-plication face lift versus SMAS
imbrications face-lift techniques. This comparison
was made by means of measurements of facial
features intraoperatively (or during dissection for
the cadavers) of five cadavers and 15 patients. By
measuring the displacement of certain aesthetically important anatomical landmarks (e.g., cervicomental angle, submental mark, lateral and
posterior displacement of the vermilion at the
commissure, the buccolabial groove from the
space between the central maxillary incisor teeth),
the two face-lift techniques were compared. This
study concluded that there was no significant difference between the two methods in the measurements taken and thus disproved the theory that
undermining and imbricating the SMAS would
provide greater displacement of aesthetically important landmarks than SMAS-plication alone
without undermining.54
This studys main limitations are its use of
cadavers, the small number of participants, the
lack of measuring long-term efficacy because of
no follow-up evaluation, the lack of randomization, and the lack of blinding. It is the only study
that compared different face-lift techniques on
the same side of the same patient (by intraoperative measurements).
Ivy et al., 1996
In 1996, Ivy et al. published a prospective randomized study comparing the efficacy of the lateral and standard SMAS face lift against the extended SMAS and composite face-lift technique.
The procedures were performed by two surgeons.
Twenty-one patients underwent conventional or
limited SMAS on one side and extended SMAS or
composite SMAS surgery on the other side. Evaluation of midface and nasolabial folds was performed on the operative table and at 24 hours, 6
months, and 1 year postoperatively by means of
photographs. Three independent surgeons and
three surgeons involved in the study compared
sides to observe any discernible difference in ef-

425

426

Conventional SMAS vs.

deep-plane

SMAS plication vs.

SMAS underminingimbrication

Kamer and
Frankel17

Webster
et al.54

Hemiskin only vs.

hemiSMAS plication
Minimal incision with
SMAS elevation vs.
standard incision
SMAS flap elevation
Photographic analysis,
t test

Photographic analysis

ASAPS, American Society for Aesthetic Plastic Surgery.

Zager and
Dyer39

Tipton53

Rees and
Aston50

Antell and
Orseck2

Photographic analysis
of two sets of
monozygotic twins by
the four surgeons that
operated and panel
discussion at ASAPS
1996, 2001, and 2005
Skin-only vs.
Photographic analysis
conventional SMAS vs.
of eight sets of
SMASectomy vs. SMAS
monozygotic twins by
plication
four plastic surgeons
Hemi-skin only vs.
Live evaluation by two
hemiSMAS-platysma
nurses and one
elevation
surgeon

Alpert et al.40 Lateral SMASectomy vs.

composite; SMASplatysma bidirectional
(extended) vs.
subperiosteal

Prado et al.48

Hemi-SMAS and hemi

extended SMAS/
composite

Ivy et al.12

Photographic evaluation
of jowl, cheek, and
melolabial fold by
means of exact 2
statistical analysis
Photographic
comparison of each
side (no statistical
analysis)
Determination of
revisionary tuck rate
(Fishers exact test)

Efficacy Outcome
Measurement

Facial feature
measurements
(intraoperative or
intradissection)
Short-scar lateral
Photographic analysis by
SMASectomy vs. shortmeans of Strasser
scar minimal access
method of evaluation;
cranial suspension
revisionary tuck rate

Deep-plane or SMAS
plication

Face-Lift Types

Becker and
Bassichis41

Authors

Table 2. Efficacy Comparison Chart

5c, 15p

634

1 yr

2 yr

1 yr

1360
mo

1, 6, and
10 yr

70

33

25

16

1 mo and 82 (41 and

2 yr
41)

None

NA

21

40

6 mo and
1 yr

No.

Follow-Up
618 mo

No

Yes

Yes

No

Yes

No

Yes

No

Yes

No

Prospective

No

Yes

Yes

No

No

No

No

No

Yes

Yes

Randomize

Control

Blinded

No

No

More Effective

No statistical
difference in the
cosmetic result
by means of
STRASSER, 50%
tuck rate in both
techniques
NA

Higher tuck rate in

conventional
(11.4%) vs. deepplane (3.3%)
No statistical
difference between
the two techniques

Younger patients did

better with SMAS,
older patients did
better with deepplane
No discernible
difference noted

Statistically significant
improvement in
cervicomental
angle, jowl region
(p 0.0001)

No difference in
cosmetic outcome
among the four
procedures
No
Only one patient
had noticeable
difference between
sides by all
observers
consistently
Unknown No difference

No

No

No

Yes (35 Yes

vs. 35)

Yes

No

Yes

No

Yes

Yes
No
(itself)

No

Yes

Yes (20 Yes

vs. 20)

Plastic and Reconstructive Surgery January 2011

Volume 127, Number 1 Comparison of Face-Lift Techniques

fect. They concluded that all procedures were
lacking in improvement of midface ptosis and the
nasolabial folds.12
This studys main limitations are a lack of description on how efficacy comparisons were made
between photographs, lack of standardized objective measurement analysis for efficacy, lack of statistical analysis, a small number of participants,
inability to eliminate bias created by concomitant
aesthetic procedures, and lack of blinding in observers. This studys main strength lies in it being
a prospective, randomized study.
Kamer and Frankel, 1998
In 1998, Kamer and Frankel published a retrospective chart review of conventional SMAS flap
versus deep-plane face lift performed by a single
surgeon. Of 634 face-lift operations within the
specified time period, revisionary tuck procedures
were studied to see which type of face lift resulted
in a higher tuck ratea marker of a less efficacious,
less than optimal face lift. The tuck procedure was
defined as a secondary procedure within 18 months
after the first face lift to tighten an unwanted redundancy excision of the skin and subcutaneous
tissue with very minimal or no undermining. The
tuck rate was found to be 11.4 percent in conventional SMAS procedure and 3.3 percent in the deepplane face lift. Of the tuck procedures, 13.6 percent
followed a complication (83 percent were SMAS procedures and 17 percent were deep-plane procedures). This study concluded that the deep-plane
technique was more effective (p 0.0001, Fishers
exact test, two-tail).17
This studys main limitations are that it is an
indirect comparison using a secondary measure as
a marker of inefficacy. Its main strengths are the
large number of participants, elimination of operator bias (single surgeon), elimination of subjectivity bias by using a calculated secondary measure, and use of statistical analysis.
Becker and Bassichis, 2004
In 2004, Becker and Bassichis made a comparison between SMAS plication face lift technique and the deep-plane face-lift technique. This
study is a retrospective chart review of 20 SMAS
plication face lifts compared with 20 deep-plane
face lifts performed by a single surgeon. Four sets
of photographs obtained preoperatively and at 6
to 18 months postoperatively were evaluated of
each patient. A panel of four blinded board-certified facial plastic surgeons reviewed (1) melolabial fold, (2) jowl, and (3) cheek areas. Evaluators

were told to ignore the areas of adjuvant operations. Each patient was given a rating of good,
average, acceptable, or poor. By means of an exact
chi-square statistical analysis, they concluded that
younger patients scored higher after SMAS-plication than those who underwent deep-plane face
lifts, and that older patients scored higher after
deep-plane procedures than after SMAS-plication
face lifts.41
This studys main limitations are that it is a
retrospective review, has a small number of participants, lacks a standardized objective measurement analysis for efficacy, and lacks the ability to
eliminate bias created by patients undergoing concomitant ancillary aesthetic procedures. It is the
only study found in the literature that directly
compares the SMAS-plication technique with the
deep-plane technique.
Zager and Dyer, 2005
In 2005, Zager and Dyer published a study on
a retrospective chart analysis of 35 consecutive
minimal incision face lifts (with SMAS flap elevation, submentoplasty, and Tisseel) versus 35 consecutive SMAS flap elevation face lifts (minimal
incision plus incision into hair-bearing areas), and
reported aesthetic result and complication rates.
The t test was used in statistical analysis (p 0.05).
One-year postoperative photographs were viewed
by a blinded observer. Grades of 0 (no improvement) to 4 (dramatic improvement) were given.
The aesthetic result showed cervicomental angle
ratings of 2.5 with the traditional and 3.6 with the
minimal incision technique (p 0.0001) and jowl
region ratings of 2.8 with the traditional and 3.5
with the minimal incision technique (p 0.0001),
showing that the minimal incision technique provided a better result.39
As with many of the studies described in our
systematic review, there is a lack of standardized
objective measurement analysis for efficacy. This
study, however, made the use of consecutive face
lifts, statistical analysis, and blinded evaluators.
Prado et al., 2006
In 2006, Prado et al. published a retrospective
photographic analysis of 82 patients undergoing
short-scar face lifts: 41 minimal access cranial suspension and 41 lateral SMASectomy procedures.
Photographs were analyzed preoperatively and 1
and 24 months postoperatively by two blinded
plastic surgeons using the Strasser method of evaluation. This analysis was based on malposition,
distortion, asymmetry, contour deformity, and scar.

427

Plastic and Reconstructive Surgery January 2011

Statistical analysis was performed using the Wilcoxon signed rank test for continuous and ordinal
variables and the Fishers exact test for binary data.
They concluded by means of Strasser evaluation at
1 and 24 months postoperatively that there was no
statistically significant difference in the cosmetic result between the two techniques. However, more
than 50 percent of the cases needed a revisionary
tuck procedure (in both technique groups).48
This studys main limitations are its small number of participants and unknown number of operating surgeons. This studys main strength is that
it is the only study that used a standardized objective measurement analysis for efficacy with its
use of the Strasser method of evaluation (a previously published objective grading system of aesthetic improvement), statistical analysis, and a secondary measure of efficacy by calculating the tuck
procedure rate.
Antell and Orseck, 2007
In 2007, Antell and Orseck published a retrospective photographic analysis of eight sets of
monozygotic twins at 13 to 60 months postoperatively that were evaluated by four blinded
plastic surgeons after undergoing four different
face-lift techniques. All face-lift operations were
performed by a single surgeon. The four different
techniques used were (1) skin only, (2) conventional SMAS flap (dissection just anterior to the
parotid gland), (3) SMASectomy, and (4) SMAS
plication with or without adjunctive ancillary aesthetic procedures. The face was divided into three
regions for evaluation: the cervicomental angle,
the jawline, and the nasolabial fold. Each region
was given a rating (1 no improvement to 5
perfect result). They concluded that no one facelift technique produced a superior result.
Although this study used identical monozygotic twins confirmed by genetic tests, thus eliminating any genetic differences, it provided no
randomization to one technique or the other (the
senior author carefully chose one to best fit the
needs of the individual patient). Therefore, a selection bias exists. There was no statistical analysis
performed because of small sample size; thus, a
type II error, not having the ability to detect a
difference when one exists, would be likely given
a small number of patients.2
Alpert et al., 2009
In 2009, Alpert et al. published a prospective
analysis of four different methods of face lifts performed on two sets of twins by four different sur-

428

geons. The face-lift techniques used were (1) lateral

SMASectomy with extensive skin undermining, (2)
composite rhytidectomy, (3) SMAS-platysma flap
with bidirectional lift, and (4) endoscopic midface
lift with open anterior platysmaplasty. This study
made a comparison between lateral SMASectomy
versus composite face lift technique in one twin set
and between the SMAS-platysma bidirectional (extended SMAS) face lift versus subperiosteal (endoscopic midface lift with platysmaplasty) face-lift technique in another twin set. Photographic analysis by
independent surgeons at 1, 6, and 10 years postoperatively was performed and presented for panel
discussion at the American Society for Aesthetic
Plastic Surgery meetings in 1996, 2001, and 2005.40
Although this study compared four different face-lift
techniques on monozygotic twins, which is arguably
the best way to compare two different face-lift techniques and their final outcome by eliminating any
genetic differences, it is essentially a case report
with discussion.
Comparisons of Complications among
Face-Lift Techniques
In our systematic review, there were five studies that performed a comparison of complication
rates between one face-lift technique and another
(Table 3).
Rees et al., 1994
In 1994, Rees et al. published a retrospective
chart review of 1236 consecutive face lifts performed by 50 different surgeons at one institution
to evaluate the determinants of the incidence of
hematoma. The overall incidence of hematoma
was reported at 1.86 percent. For those surgeons
that performed more than 50 face lifts, the incidence was 3.83 percent. Multivariant analysis was
performed for the following variables: age, preoperative tests, medical history, sex, perioperative
medications, type of anesthesia, number and combination of procedures, and treatment of the
SMAS. Most of these factors did not show a statistically significant difference. However, SMASplication had a higher hematoma rate than moderate or extensive SMAS dissection (p 0.002).
SMAS-plication had 3.67 percent hematoma rate,
moderate SMAS elevation had a 3.41 percent hematoma rate, extensive SMAS elevation had a 1.03
percent hematoma rate, and no SMAS had a 0
percent hematoma rate. This is especially perplexing as, in this institution, the dissection of both the
SMAS and non-SMAS face lifts involves the same
extent of skin flap dissection. However, this vari-

Prado
et al.48

All face-lift techniques

included

Leroy
et al.58

ESP, extended supraplatysmal plane.

SMAS plication vs.

modified SMAS vs.
extended SMAS

Rees et al.,
199451

Chart review

Chart review with

multivariate
analysis

Chart review, t test

Short-scar lateral
SMASectomy vs.
short-scar minimal
access cranial
suspension
Minimal SMAS
elevation vs.
traditional SMAS
elevation

Grover
et al.10

Zager and
Dyer39

Method of Analysis
Multivariate analysis

Face-Lift Types

Extended SMAS,
SMASectomy, ESP,
skin-only

Authors

Table 3. Complications Comparison Chart

1 yr

1 mo and
2 yr

Follow-Up

No.

6166

1236

70

82 (41 and
41)

1078

No

No

No

No

No

Prospective

No

No

No

No

No

Randomized

No

No

Yes

Yes

No

Blinded

Complications
No statistical
difference in
hematoma rates
among the
different
techniques

Yes (35 vs. 35) Less ecchymosis,

edema,
hematoma, and
seroma rates in
the minimal
technique
(p 0.05)
No
SMAS plication
had a higher
hematoma rate
(p 0.002)
than the
moderate or
extensive
No
0.18% incidence
of infection (11
patients: 2 were
skin-only, 9 were
SMAS elevation)

No

No

Controlled

Volume 127, Number 1 Comparison of Face-Lift Techniques

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Plastic and Reconstructive Surgery January 2011

able became nonsignificant when controlled by
the surgeon who performed the operation.51
This study compared all types of face-lift techniques. Its limitations include operator bias, and
its strength is its use of statistical analysis and a very
large sample size (n 1236).
Leroy et al., 1994
In 1994, Leroy et al. published a retrospective
study evaluating 6166 consecutive face lifts performed by 35 surgeons at one institution that revealed 11 infections requiring hospital readmission. There was no consistent finding regarding
medical history, use of perioperative antibiotics,
surgical equipment, complexity of the surgical dissection (all face-lift techniques included), drains,
or hematoma formation. The incidence rate was
0.18 percent (11 patients). Two patients underwent skin-only face lifts, and nine patients underwent SMAS elevation face-lift surgery.58
This studys limitations include operator bias
with multiple operating surgeons (11 with various
training levels). It included all face-lift techniques
and revealed infections in only two types: skin-only
and SMAS elevation techniques. Its great strength
is that it provided a very large sample size (n 6166),
which reduces the possibility of a type II error.
Grover et al., 2001
In 2001, Grover et al. published a retrospective
study of 1078 consecutive face lifts by two experienced surgeons to determine which parameters
were significantly associated with hematoma formation. Using multivariate statistical analysis, they
found that there was a 4.2 percent hematoma rate.
Statistically significant factors discovered were anterior platysmaplasty (p 0.04; relative risk, 4.3),
systolic pressure (p 0.02; relative risk, 3.6), sex
(p 0.03; relative risk, 2.8 for male patients),
acetylsalicylic acid/nonsteroidal antiinflammatory
drug use (p 0.04; relative risk, 2.3), and smoking
(p 0.049; relative risk, 2.1). Factors that were not
significant were type of face-lift technique (extended
SMAS, SMASectomy, extended supraplatysmal
plane, or cutaneous, with subperiosteal excluded, as
this is associated with a significantly lower risk) (p
0.097), or whether the face lift was primary or secondary (p 0.18), Tisseel (p 0.43), age (p 0.63),
surgeon (p 0.57), and cardiovascular/lung disease
(p 0.29).10 The study by Grover et al. had a large
number of participants and used statistical analysis to
calculate incidence and relative risk.

430

Zager and Dyer, 2005

In a 2005 efficacy comparison study previously
described above, Zager and Dyer also studied the
complication rates of the 35 consecutive minimal
incision face lifts (with SMAS flap elevation and
submentoplasty and Tisseel) and the 35 consecutive SMAS flap elevation face lifts (minimal incision plus incision into hair-bearing areas). This
was a retrospective chart analysis. Ratings were
given on a scale of 0 to 4 (where 0 no ecchymosis/
edema and 4 severe ecchymosis/edema). The t
test was used for statistical analysis (p 0.05). They
reported the following complications: the ecchymosis rating was 2.4 for the traditional incision
and 1.7 for the minimal incision at 1 week (p
0.003), and 1.4 for the traditional incision and 0.6
for the minimal incision at 2 weeks. The edema
rating was 2.5 for the traditional incision and 1.8
for the minimal incision at 1 week (p 0.0001),
and 1.5 for the traditional incision and 1.1 for the
minimal incision at 2 weeks (p 0.008). The hematoma rate was 8.6 percent for the traditional
incision and 0 percent for the minimal incision.
The seroma rate was 14.3 percent for the traditional incision and 8.6 percent for the minimal
incision (p 0.368).39
This studys limitations are the lack of standardized objective measurement analysis for the
amount of ecchymosis and edema, raising the risk
of the error of subjectivity. Its strengths are its use
of statistical analysis.
Prado et al., 2006
To complement the 2006 efficacy comparison
study described previously, Prado et al. also reported associated complications in the comparison of the 82 patients undergoing short-scar face
lifts: 41 underwent minimal access cranial suspension and 41 underwent lateral SMASectomy procedures. The complications reported included
two hematomas (one for each technique), hypertrophic/dog-ear scar formation requiring revision
(two dog-ears and one hypertrophic scar with minimal access cranial suspension and none with lateral SMAS), and postoperative pain (six with
lateral SMAS and four with minimal access cranial suspension). Statistical analysis was performed using the Wilcoxon signed rank test for
continuous and ordinal variables; for binary
data, the Fishers exact test was used.48
This studys main limitations are its small number of participants, unknown number of operators,
retrospective design, and the inability to eliminate
operator bias (unknown number of operating sur-

Volume 127, Number 1 Comparison of Face-Lift Techniques

geons). There is a lack of standardized objective
measurement analysis for the amount of edema
(therefore exposing itself to error of subjectivity). Its
strengths are its use of statistical analysis.

DISCUSSION
Systematic reviews can help physicians keep
abreast of the medical literature by summarizing
large bodies of evidence and helping to explain
differences among studies on the same question.
A systematic review involves the application of scientific strategies in ways that limit bias, to assemble, appraise, and synthesize all relevant studies
that address a specific clinical question. In this
systematic review, we sought to synthesize our existing knowledge of face lift surgery regarding efficacy and complication rates. Our study is not a
meta-analysis and thus no attempt is made to pool
the data.
Although the identified studies were few and
lacking in quality evidence, this systematic review
can be applicable both to the practicing plastic
surgeon and to the general public. For surgeons,
this systematic review has revealed that there exist
no quality data that have shown better efficacy of
one face-lift technique over another. There also
exist no quality data proving one face-lift technique
to be safer than another. For the general public
desiring surgical facial rejuvenation, there remains a
lack of data showing high patient satisfaction of one
face-lift technique over another as well.
This systematic review reveals a need for future
research that can show a better comparison
among the different face-lift techniques, preferably through randomized controlled trials. In addition to these needed randomized controlled trials on efficacy and complication rates, there also
exists a need to evaluate patient satisfaction
among the different face-lift techniques.
The ideal face-lift procedure should also, most
importantly, derive the highest patient satisfaction
from the patient. Kosowski et al. performed a systematic review of published patient-reported outcome measures on facial cosmetic surgery that
revealed a lack of such reliable instruments.19 Recently, Friel et al. published the Owsley Facelift
Satisfaction Survey that reported long-term follow-up in a questionnaire format that showed the
level of patient satisfaction in the SMAS-platysma
face lift. Although this is an ad hoc questionnaire
and not a formally developed and validated patient-reported outcome measure, it does provide
some type of patient opinion derived data on satisfaction after a SMAS-platysma face lift.59 Currently,
Klassen et al. are in the process of creating a new

patient-reported outcome measure called the FACE-Q

that aims to provide a means of evaluating patient
satisfaction that can be used to make comparisons
between different face-lift techniques. The FACE-Q
includes five core scales on (1) satisfaction with facial
appearance overall, (2) satisfaction with outcome,
(3) psychological well-being, (4) social well-being,
and (5) satisfaction with consultation and treatment
experience.60
Limitations of This Systematic Review
This systematic review was comprehensive,
with very few exclusion criteria so that all possible
relevant published studies could be gathered. The
key search terms and search engines were predetermined, and data extraction can be performed reproducibly. To decrease database bias, references of
qualifying articles were evaluated and any pertinent
articles were included as well. Its limitations are that
there is an inherent bias attributable to exclusion of
non-English studies, and there is a publication bias,
as only published studies were evaluated.
However, the quality of the studies discovered
by the systematic review is not ideal. There were
only two identified prospective, randomized, controlled studies, and both were not blinded and had
very small sample sizes.
In the efficacy comparison studies, none of
these studies are systematic review or meta-analyses of randomized controlled trials. One had cadaveric subjects included. Three were randomized
controlled trials and five studies attempted statistical analysis. In the complications comparison
studies, none of these studies are systematic review
or meta-analyses of randomized controlled trials.
All studies used statistical analysis. No study was a
prospective, randomized, controlled trial.
The studies examined by our systematic review
almost uniformly lacked a standardized objective
means of analysis of face-lift efficacy. Only one used
an actual measurement instrument.48 Although
there have been some attempts at computerized systems of analysis,61 more research is needed to develop better standardized instruments with which to
analyze the efficacy of face-lift procedures.

CONCLUSIONS
Surgical success in rhytidectomy may be defined by high patient satisfaction and the absence
of complications. Although this systematic review
revealed a lack of quality data in comparing the
efficacy and safety among different face-lift techniques, it is important to review and pool the existing studies to define our current evidence base

431

Plastic and Reconstructive Surgery January 2011

and to establish a path forward for future research.
Ultimately, we seek to determine what works better and in which patients. Rigorous evaluation of
face-lift outcomes will inform patient selection,
optimize surgical techniques, and guide future
innovation. To acquire this knowledge, we require
higher quality studies, especially randomized controlled trials and prospective studies with suitable
controls. There also exists a need for standardized
methods of objective analysis and well-developed
and validated patient-reported outcome measures.
Rod J. Rohrich, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
1801 Inwood Road
Dallas, Texas 75390-9132
rjreditor_prs@plasticsurgery.org

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