Unfortunately, the word facelift may conjure unflattering images of aging actresses with unnatural expressions - the skin pulled tight and the corner of the mouth pulled toward the ears. This is not a desirable appearance. No one wants to look artificial or freakish. In fact, most people prefer to look like themselves, just without the superimposed effects of aging, which makes them look less like themselves. Family members may respond negatively to mom wanting a facelift. Spouses, nervous about the idea, tell them they love them the way they are. Patients deal with guilty feelings, as if this were a frivolous self-indulgence.

This bias is not undeserved. Those who have had facelifts in the past, or second and third facelifts, with excessive skin tightening, often do have an unnatural look. Not a younger look, just a lifted look. Fortunately, this is not a necessary consequence of a facelift itself, but a consequence of facelifts that stretch the skin tight, instead of repositioning the foundation layer below it.

The pioneers in plastic surgery were well aware that skin lost elasticity with age and tended to sag with gravity. It was understandable that they would seek to restore a youthful appearance by tightening the skin of the face. The first facelift was performed in 1901. The original, antiquated term was rhytidectomy, which means to literally cut out the wrinkles. The procedure was particularly effective for the neckline but did little to correct the nasolabial creases- the parentheses creases caused by sagging cheek tissue. The appearance of the jawline and neck was improved, but patients still looked older in the mid-face. After surgery, rather than looking like a fifty-something, they often looked like a fifty-something who had a facelift, rather than the desired forty-something. Treatment of the mid-face became the challenge for plastic surgeons.