Before the general anesthesia kicks in, before the first incision is made, and long before the swelling goes down to reveal a new jawline, the most important part of facelift surgery has already happened.
It happens with a surgical marker.
To the untrained eye, the purple lines drawn on a patient’s face might look like random topography. But to a facial plastic surgeon, this is the blueprint. It's one of the most crucial steps in modern facial rejuvenation: the transition of facial anatomy into a surgical plan.
In this educational video, I explain exactly how these markings guide my decision-making in the operating room. Whether I'm performing a deep plane facelift, a deep neck lift, or a comprehensive facial rejuvenation, the ink is a big dictator of the outcome.
Watch: Dr. Athre Explains Pre-Operative Markings
A facelift isn't a cookie-cutter operation. You can't simply apply a template to every face and expect natural contours. Your bone structure, your asymmetry, and the way your skin and muscles have aged are unique to you.
The markings serve as the roadmap. They identify:
If a surgeon skips detailed marking, they're operating reactively. I prefer to operate proactively. By defining the plan while you're awake and upright, we ensure that the surgery restores balance rather than creating tension.
One of the most specific markings I discuss in the video is the submental incision, the small cut made under the chin to access the neck.
In a traditional technique, surgeons tend to place this incision directly in the natural submental crease (the fold under your chin). It seems logical to hide it there. But in a deep neck lift, I place it slightly lower, just below the crease.
Why? It comes down to access and camouflage.
This slight adjustment allows for a safer neck dissection and a more comprehensive removal of the heavy structures that blur the jawline.
The deep plane facelift is superior to older methods because we're repositioning the superficial musculoaponeurotic system (SMAS) and the muscle layers, not just pulling your skin taut.
But the deep plane is also where the facial nerve lives.
Marking the border of the mandible (the jawbone) is critical. These markings act as guardrails. They tell me exactly where the facial nerve branches are likely to be crossing. By defining these boundaries before we start the deep plane dissection, we can move quickly and safely, releasing the ligaments that tether the face without putting the nerves at risk.
This precision is why deep plane facelift results look natural. We aren't pulling the skin tight to fake a lift; we're structurally elevating the loose muscles and facial tissue back to their youthful position. The skin just comes along for the ride, no tension required.
Have you ever noticed that you look better when you lie on your back? Gravity pulls the excess skin and fat back, smoothing out the nasolabial folds and jowls.
It's a dangerous illusion for a surgeon.
If I marked you while you were lying flat on the operating table, I would underestimate how much volume loss you have in the cheeks and overestimate how much skin tightening you need.
This is why fat grafting markings must be done while you are sitting upright. Gravity shows us the truth. It reveals the hollows under the eyes, the deflation in the midface, and the heaviness in the jowls. By marking these zones in a vertical position, we ensure that when we perform fat transfer, we are placing the volume exactly where it is needed to restore a soft, youthful reflection.
The difference between a pulled look and a natural result often comes down to the planning.
When a surgeon relies on skin tension to lift the face, the result looks tight. The corners of the mouth sweep back, and the ears look distorted. This happens when the surgical plan ignores the deeper anatomy.
By using precise surgical markings to guide a deep plane dissection and deep neck lift, we are addressing the root cause of aging. We are respecting the anatomy, not fighting it. The goal is not to change your face, but to clear away the interference—the sagging, the heaviness, the shadows—so that your actual structure can shine through again.
Markings ensure predictability. And when it comes to your face, predictability is everything.
Facelift markings are preoperative surgical guides that identify incision placement, dissection boundaries, and volume restoration zones before facelift surgery.
They help customize surgery to a patient’s anatomy, improve safety, guide deep plane facelift dissection, and contribute to natural facial rejuvenation results.
A deep plane facelift repositions facial tissues at a deeper anatomical level, restoring youthful structure rather than simply tightening skin.
A deep neck lift addresses deeper neck structures—such as muscle, fat, and glands—to improve jawline definition and neck contour.
Evaluating patients upright reveals natural volume loss that may be hidden when lying flat, allowing for more accurate and natural facial rejuvenation.
Khoury, S., Almubarak, Z., Khan, H. et al. The Deep Plane versus SMAS Facelift: A Systematic Review and Meta-Analysis. Aesth Plast Surg 49, 5895–5903 (2025). https://doi.org/10.1007/s00266-025-05118-x.
Submandibular Gland Reduction in the Modern Necklift Surgery: A Systematic Literature Review — Aesthetic Surgery Journal (Advance Article). https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjaf206/8287145
