# How is a facelift performed? From planning to discharge: anesthesia, the deep plane, fat grafting and combined procedures, which depend on your assessment. [Dr. Walter Zamarian Jr.](https://www.walterzamarianjr.com/us/walter-zamarian/) · CRM-PR 17.388 · RQE 15.688 Published October 29, 2026 Topics: [Facelift](https://www.walterzamarianjr.com/us/blog/category/facelift/) [Read the article ↓](#leitura) ## At a glance: how is a facelift performed? I start by planning treatment for the face and neck. During surgery, under total intravenous anesthesia, I reposition the deep tissues beneath the SMAS (deep plane), redrape the skin and, when volume has been lost, add fat grafting. The neck, eyelids and other procedures are included only when they have their own indication; when they are, I always follow the same order. - Planning: an area-by-area exam, your health and your expectations come before the technique. - Anesthesia: total intravenous anesthesia (TIVA), as in almost all of my surgeries. - Duration: about 3 hours for the facelift; fat grafting adds about 2 hours and a deep neck lift about 50 minutes. - Incisions: along the ears (pretragal) and the hairline; the neck may need one beneath the chin. - Bleeding: a hemostatic net in every facelift, with no drains. - Hospital stay: discharge the next morning, after I examine you. My [regenerative deep plane facelift](https://www.walterzamarianjr.com/us/face/facelift/) page covers candidacy, recovery and risks. Here, I walk you through the operation itself, from planning to discharge. ## What I assess before choosing the technique At the consultation, I examine the forehead, temples, brows, eyelids, cheeks, folds, lips, chin, jawline and neck, and I ask what bothers you and what you want to keep. I distinguish between tissue descent, volume loss and skin changes, because each calls for a different treatment. Examining an area does not mean recommending surgery for it: sun spots and fine wrinkles, for example, may need dermatologic care instead. Before surgery, every patient has lab tests and a surgical risk assessment that includes an electrocardiogram (ECG). Medications, previous surgeries and habits such as smoking are part of that assessment. ## Anesthesia and the start of surgery I operate at Hospital do Coração Bela Suíça in Londrina. You arrive two hours beforehand, and I mark your face and, when fat grafting is planned, the donor area. I use total intravenous anesthesia (TIVA) with propofol and remifentanil, given by the anesthesiologist, as in almost all of my surgeries. Combined procedures are decided at the consultation, not in the operating room. I don’t add a different operation just because you are already under anesthesia. ## The order of the steps When the plan includes every step, I follow this order: harvesting the fat, the eyelids and brows, fat grafting to the face, the neck and, last, the deep plane. The facelift itself takes about 3 hours; fat grafting adds about 2 hours and a deep neck lift about 50 minutes. A step that is not indicated is simply left out, and the others keep the same order. ## The deep plane: repositioning rather than pulling the skin The SMAS is the supporting layer of the face, connected to the muscles of facial expression. In a deep plane facelift, I work beneath it and move the skin, the fat under it and the SMAS together, instead of relying on tension in the skin. To do this, I release the retaining ligaments included in the plan. Jacono and Bryant describe, in the extended deep plane facelift, the release of the zygomatic, masseteric, mandibular and cervical ligaments [2]. The tissues are repositioned in a predominantly vertical direction. Once they are in place, I redrape the skin and remove the excess along the ears and the hairline. The incision in front of the ear is pretragal, in both men and women. The goal is to address how the cheeks, jawline and neck relate to one another without unnecessary tension on the skin. That does not eliminate scars or risks, and it does not allow me to promise a set number of years of rejuvenation. ## Fat grafting When volume has been lost, I add [facial fat grafting](https://www.walterzamarianjr.com/us/face/fat-grafting/), usually with fat taken from the lower abdomen or the inner thighs. Fat restores volume; repositioning addresses support. They are complementary goals, as Marten and Elyassnia discuss [1]. A face with enough volume does not need fat in every area. ## The neck and the eyelids A less defined jawline can involve both descent of the facial tissues and changes in the neck, so I assess the two together. When structures beneath the platysma muscle, such as fat, the digastric muscles or the submandibular glands, add to the fullness, we discuss a [deep neck lift](https://www.walterzamarianjr.com/us/face/neck-lift/) and its specific risks. I don’t remove muscle or gland tissue as a routine step. When indicated, [blepharoplasty](https://www.walterzamarianjr.com/us/face/blepharoplasty/) can be done together with the facelift without increasing the surgical fee. Each eyelid may be treated differently, because the anatomy of the two sides can differ. ## Procedures not everyone needs A [lip lift](https://www.walterzamarianjr.com/us/face/lip-lift/), a [chin implant](https://www.walterzamarianjr.com/us/face/chin-implant/) and [buccal fat removal](https://www.walterzamarianjr.com/us/face/buccal-fat-removal/) each have their own indication and are not a package. I perform a lip lift only together with a facelift, and buccal fat removal only combined with another facial surgery, when a localized excess justifies it. A solid silicone chin implant addresses a lack of projection that repositioning the tissues cannot create; added to a facelift, it adds only the cost of the implant to the quote. ## The end of surgery and the first night I use a hemostatic net in every facelift: temporary stitches that hold the skin against the treated tissues to reduce spaces where blood could collect. I don’t use drains. The net does not eliminate the risk of hematoma; my [hemostatic net](https://www.walterzamarianjr.com/us/face/hemostatic-net/) page explains the technique. After about two hours in the post-anesthesia recovery unit, you return to your room. I come back to see you that night, and discharge usually takes place the next morning, after I examine you. The net is removed at my office the day after discharge. ## What we discuss before you decide I explain the expected benefits and the limits: scars, asymmetry, bleeding, changes in sensation and possible nerve injury, which can be temporary or permanent. The ASPS also breaks the operation down into steps: anesthesia, the incision and closure [3]. Knowing how the operation is done helps you ask why each procedure was recommended and what was left out. ## Questions Is a facelift just pulling the skin tighter? No. In a deep plane facelift, I reposition the deep tissues first and only then redrape the skin. Removing more skin does not replace support. Does every facelift include fat grafting? No. I add fat grafting when volume has been lost; when it hasn’t, the facelift can be done without it. Will I have drains? I don’t use drains. I use the hemostatic net in every facelift, and it is removed at my office the day after discharge. How long will I stay in the hospital? One night. Discharge usually takes place the next morning, after I examine you. ## Let’s talk about your plan To find out which steps make sense for your face, [write to us on WhatsApp](https://www.walterzamarianjr.com/us/contact/): Bruna, my AI assistant, handles the first contact and then puts you in touch with Isanna to arrange a consultation with me, including from abroad. I’ll explain what I propose, what I don’t recommend and why. ## References - Marten TJ, Elyassnia D. [Fat grafting in facial rejuvenation](https://pubmed.ncbi.nlm.nih.gov/25827566/). Clin Plast Surg. 2015;42(2):219–252. - Jacono A, Bryant LM. [Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation](https://pubmed.ncbi.nlm.nih.gov/30268241/). Clin Plast Surg. 2018;45(4):527–554. - American Society of Plastic Surgeons. [Facelift Procedure Steps](https://www.plasticsurgery.org/cosmetic-procedures/facelift/procedure). ## About the author I am Dr. Walter Zamarian Jr., a plastic surgeon in Londrina, Brazil. My practice focuses on deep plane facelift surgery with fat grafting. Here I explain my approach, the available evidence, and the limits of each treatment. CRM-PR 17.388 · RQE 15.688 [Read about my training and practice →](https://www.walterzamarianjr.com/us/walter-zamarian/) This article provides general information and does not replace an individual medical consultation. 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