Most facial consultations begin with the same small gesture. Someone lifts the skin at their cheeks in the mirror, watches the jawline snap into place, and says, “I just want this back.”
Underneath that gesture is almost always the same set of problems. Jowls. A heavy neck. A lower face that sags when they smile. And, increasingly, a face tired of being chased with filler.
Here is how I talk about the fix, candidly.
A Facelift You Cannot See the Scars From
For the right candidate, I use a facelift with no visible scars. The incisions hide in the hairline, which is why it is called a ponytail facelift, and a good portion of the lift is done endoscopically.
It brings the brow up just slightly and lifts the cheek, so that when you smile the lower face softens instead of dropping. You can still wear your hair up.
“Is This Just Pulling the Skin Tight?”
No, and that is the entire point. It is a deep plane facelift, which means I reposition the deeper tissues rather than pulling on skin. That is what makes it look natural and last. You do not end up looking pulled or windswept, because the tension lives in the deep layer, not in your skin.
What the Neck Actually Needs
For the neck, I place a small incision under the chin and behind the ear. Through that I can remove a little of the gland and the deeper fat and build a tight, youthful jawline.
Taking out the deeper fat matters for the long run. Even if your weight changes later, the result will not blur as much, because the fat that tends to come back is more superficial.
And no, most people do not need a chin implant. If you already have a strong chin, the neck lift alone makes it look more pronounced and sharper, because right now it is getting lost.
My Strong Opinion on Old Filler
This is where I will not hedge. Chasing facial aging with more and more filler eventually stops helping and starts distorting, especially stacked over high cheekbones. Old filler often does not fully dissolve. It migrates.
So during the facelift, I can place medication to dissolve some of that old filler, which leaves us working with your own tissues instead of building on top of someone else’s product. I would rather reposition your own anatomy than keep adding to it.
The Add-Ons That Travel With a Facelift
| Concern | What I Often Add |
|---|---|
| High forehead, hairline sits high | Hairline-lowering incision to move the scalp forward, hair transplant later |
| Hollow folds, tired upper-eye shadow | A little fat grafting, often sparing you an upper eyelid surgery |
| Old filler over the cheeks | Medication to dissolve it during surgery |
| Slow bruising and swelling | ElixirMD LED therapy starting day seven |
On the forehead, the rule of thirds says it should measure about the same as the length of your nose. If your hairline sits high, I can make an incision at the hairline and move the scalp forward to close that distance, with a tiny scar in front, and refine it later with a hair transplant. It can be done at the same sitting as the facelift.
For the eyes, I almost always add a little fat to the folds and sometimes the upper eyelid hollows. The fat is permanent and very natural. It is alive, so it shifts a touch with weight, but it erases the tired shadow so you look awake, and it often keeps you away from a separate upper eyelid surgery.
What Recovery Is Really Like
The good news about facial surgery is that it does not really hurt. The pain level is close to zero. What you deal with is swelling and bruising.
Plan on a couple of weeks before you are comfortable being seen, and about six weeks to be ready for a special event. Most people return to work after two weeks, sometimes with a little makeup. We also offer an LED therapy called ElixirMD starting seven days after surgery that roughly doubles the speed of recovery, and Morpheus8 microneedling can refine skin quality later.
Who I Think Is a Candidate
I am candid in the room about who this is for. The ponytail deep plane facelift is for the patient who has real structural change, jowls, a softening jawline, a lower face that drops with a smile, not for someone whose only complaint is fine surface lines that a good skincare plan and a laser would handle. It is ideal for a patient who wants to keep wearing their hair up and who refuses the visible incisions in front of the ears. Healthy patients who do not smoke heal the cleanest, and I will tell a smoker to stop well before I will operate.
The other thing I look for is the neck. So often the neck is the tell, and a beautiful cheek lift over an untreated neck looks unfinished. When I assess a face, I plan the cheek, the jawline, and the neck as one unit, because that is how they age and that is how they should be corrected.
Why I Chose This Approach
I completed my plastic surgery fellowship at the Mayo Clinic and I teach facial surgery as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I trained for the deep plane and ponytail technique at the Ponytail Academy in Pittsburgh and Santa Monica. I chose this approach because it lasts and because it looks like you, not like surgery.
See the Patient-Facing Versions
For the patient-facing walkthrough, see the companion post on agulloplasticsurgery.com. For the treatment menu, see the version on swplasticsurgery.com.
Ready to Talk?
If you are pulling your cheeks up in the mirror, that is your sign to come in.
Call the office at (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful.
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