Facelift Revision and Facial Weakness After a Facelift

Most facelifts heal well. When a result is not what a patient expected, or when part of the face does not move normally after surgery, the next step depends on an accurate diagnosis. Dr. Panossian evaluates both aesthetic concerns after a facelift and facial nerve problems, which are a core part of his reconstructive practice.

• Recurrent laxity: loosening of the jawline or neck as tissues continue to age, or when the deeper layers were not repositioned.
• A pulled or windswept appearance: tension carried by the skin rather than the deeper tissues.
• Earlobe distortion: an earlobe pulled downward and attached to the cheek.
• Scars: incisions that widened, became visible, or were placed outside natural contours. See managing scarring after a facelift.
• Hairline or sideburn shift: displacement of the temporal hairline or sideburn after skin was removed.

Not every asymmetry after a facelift is a nerve injury. In the first hours after surgery, the local anesthetic used during the operation can weaken facial movement until it wears off. In the first days and weeks, swelling, bruising, or a collection of blood or fluid can distort the face or limit movement. Muscle spasticity can also occur, creating a temporary stiffness of the face. Uneven tightening of the deeper layers can change the shape of the smile or jawline with no nerve involvement at all. Separating these causes is the first step, because each is treated differently.

Numbness is different from weakness. A facelift divides small sensory nerves in the skin of the cheek and in front of the ear, so some numbness is expected after any facelift. Sensation usually returns gradually over 6 to 12 months, usually starting in the central face and progressing gradually toward the incision line near the ear.

In addition, the great auricular nerve supplies sensation to the earlobe and lower ear. It crosses the neck close to where the neck portion of a facelift is performed and is one of the nerves most often injured during the operation. Injury can cause lasting numbness of the earlobe or, less commonly, a painful neuroma, which is a sensitive knot of scar and nerve fibers that forms at an injured nerve end. A neuroma may need to be removed surgically.

The facial nerve branches lie close to the layers a facelift repositions. Weakness after surgery usually results from stretching, swelling, or bruising of a nerve branch rather than a cut. In most cases movement returns over weeks to months.

The effect depends on which branch is involved. Weakness of the frontal branch affects the brow and forehead. Weakness of the marginal mandibular branch affects the lower lip. Weakness of the zygomatic and buccal branches affects eye closure and the smile. The buccal branch has many cross-connections, so partial injuries there often recover without noticeable change.

Dr. Panossian examines each branch of the facial nerve separately. Forehead elevation, eye closure, smile, and lower lip movement are all documented. Standardized photos and video record a baseline, so each later visit is compared against a record rather than against memory. When the picture is unclear, electromyography (EMG) and nerve conduction studies (NCV) can show whether the nerve is still connected to the muscle and whether early signs of recovery are present. However, following a patient's progress over time is most often the best way to determine whether intervention is necessary.

The reinnervation window, the period during which facial muscles can still accept a new nerve supply, is roughly 12 to 18 months. A known injury, such as a nerve divided during surgery, needs a nerve procedure early, because waiting produces poor outcomes. Where recovery is possible, Dr. Panossian follows patients about every 3 months with standardized photos and video. If recovery has plateaued by month 9, treatment planning begins while observation continues toward 11 to 12 months.

Patients with weakness after a facelift should be evaluated early, even if their surgeon expects recovery. A baseline examination makes later decisions clearer.

Treatment is matched to the branch involved, the time since surgery, and how much function has returned.

• Botox for facial asymmetry: relaxing the stronger side to balance the face while the nerve recovers, or as a long-term option.
• Direct nerve repair: reconnecting a divided branch, most effective soon after injury.
• Nerve transfers and cross-face nerve grafting: bringing a new nerve supply to the affected muscles within the reinnervation window.
• Selective neurolysis: for tightness or unwanted movement that develops during recovery.
• Brow lift for facial paralysis: for a persistent brow droop.
• Lengthening temporalis myoplasty: for smile restoration when nerve repair is no longer possible.
• Facelift for facial paralysis: static repositioning of a drooping cheek, lip corner, and jawline when movement is not expected to return.

When a facial nerve branch recovers, the regrowing nerve fibers do not always return to the muscles they originally supplied. The result can be synkinesis, involuntary movement that occurs together with intended movement, such as the eye narrowing during a smile, or persistent tightness in the cheek and neck. Synkinesis is treated with targeted Botox, facial retraining therapy, and, in some patients, selective neurolysis or selective neurectomy. Synkinesis care is a large part of Dr. Panossian's facial paralysis practice. In Dr. Panossian's experience, synkinesis after facial nerve injury is more common than is often reported.

A revision facelift is performed through tissue that has already been operated on. Scar tissue, prior incisions, and skin that was already removed all shape what can be done. Many revisions address a layer the first operation did not treat. For example, when an earlier lift relied on skin tension, repositioning the deeper tissues with a deep plane approach can correct a pulled appearance and restore the jawline. The deep plane, known as the sub-SMAS layer, is often the target for a revision facelift, since it can bypass potential skin circulation problems from a prior facelift and create a much more natural-appearing lift. Incisions usually re-use the prior scars, and a poorly positioned scar can often be revised at the same time.

Cosmetic revision of a facelift is not covered by insurance. Treatment of a facial nerve injury can be different, because nerve repair and facial reanimation are reconstructive procedures. Dr. Panossian is an out-of-network provider and works with commercial insurance plans on a case-by-case basis when a facial nerve injury is present.

Dr. Panossian focuses his practice on facial reanimation and nerve reconstruction and also performs deep plane facelifts. He trained in facial reanimation under Dr. Ronald Zuker at the Hospital for Sick Children in Toronto and founded the Facial Paralysis Center at Children's Hospital Los Angeles. He sees patients from Pasadena, Glendale, and the San Gabriel Valley, as well as patients who travel from out of state. Virtual consultations are available.

Bring your operative report from the original surgery, photos from before the facelift, and photos or video taken since. Note the date you first noticed any weakness and whether it has changed. This lets Dr. Panossian separate an aesthetic concern from a nerve problem and judge where you are in the recovery window.