Why Should the Skin Never Be Trusted in Facial Surgery?
The most important lesson I have learned over the years in plastic surgery particularly facial surgery is this:
In facial aesthetics, one should never rely solely on the skin.
At first glance, this statement may sound bold or provocative. However, when facial anatomy and the mechanisms of aging are examined in depth, it becomes clear why this approach is both scientifically and clinically indispensable.
What Does “Not Trusting the Skin” Really Mean?
Not trusting the skin does not mean ignoring or undervaluing it.
On the contrary, it means correctly understanding the true role of the skin in facial aesthetics.
The skin is like a stretch film. It takes the shape of the underlying structures, envelops them, and reflects them.
In other words:
The skin does not create shape;
It follows shape.
Therefore, procedures that target only the skin no matter how well performed can never guarantee a lasting form.
Shape Is Defined by Deep Structures, Not the Surface
The true architecture of the face is formed by:
- Bone structure
- Muscles
- SMAS (Superficial Musculoaponeurotic System)
- Deep connective tissues
- Protective fat compartments
Critical aesthetic elements such as cheek contour, jawline, midface projection, periorbital support, and the cervicomental angle are products of deep anatomical layers not the skin.
Thus, procedures that focus solely on the skin:
- Do not change the true facial structure
- Create only temporary, superficial effects
Why Do Skin-Only Procedures Relapse Over Time?
The skin is an elastic tissue.
When the underlying support system is not reconstructed, the skin:
- Gradually loosens
- Cannot maintain applied tension
- Attempts to return to its original state
During this regression process, one often observes:
- Widened and more visible scars
- Unnatural indentations
- Downward traction of surrounding tissues, including earlobe distortion (pixie ear)
This is particularly common in outdated facelift techniques based solely on skin tension or insufficient SMAS mobilization (skin-only facelift techniques).
What Defines True and Lasting Facial Surgery?
For natural, balanced, and durable facial rejuvenation, the target must not be the skin—but the deeper layers.
True facial surgery:
- Reshapes bone support
- Repositions and stabilizes the SMAS
- Addresses muscles and connective tissues within their correct anatomical planes
Modern techniques such as deep plane facelift and temporal (midface) lift treat the face as a unified structure from top to bottom, providing structural rejuvenation rather than surface tightening.
The True Role of the Skin: The Final Touch
The skin represents the final and most delicate stage of the procedure.
It should be gently draped like silk over properly reconstructed deep layers, without excess tension and within natural limits.
This approach ensures:
- Finer, better-concealed scars
- Preservation of facial expressions
- More natural and long-lasting results
- Absence of an “operated” appearance
Conclusion: Structure, Not Surface, Creates Change
Lasting success in facial aesthetics is achieved not by pulling harder, but by performing the right anatomical intervention at the right depth and location.
The skin is merely a reflection.
True transformation begins beneath the surface.