If you spend enough time looking at facelift surgery online, you will eventually see a patient covered in purple lines. Sometimes there are so many markings that the patient looks closer to an Andy Warhol painting than someone getting ready for surgery.
But more purple ink does not mean more surgery, and it does not tell you whether the surgery is more sophisticated.
For me, the markings are the visible end of a planning process that started well before the morning of surgery. I have already examined the patient, listened to what bothers them, reviewed their medical history, studied their photographs and thought through what I intend to do.
The purple ink is not the plan. It is where the plan becomes visible.
My Facelift Plan Starts Long Before I Pick Up the Marker
When I meet someone considering a facelift, I start with what they are trying to change. Then I look at the anatomy responsible for what they are seeing.
Between that consultation and surgery, I do my homework.
I review the medical history and medications. I take another set of photographs at the preoperative visit. Then I sit down with those photographs and think through how I want the surgery to happen.
If the plan includes a facelift, neck lift, brow lift and fat transfer, for example, I need to decide more than which procedures I am performing. I need to think about the order. I need to think about the direction of the brow lift, where volume should be added, how the face and neck relate to each other and whether there is asymmetry I need to account for.
Sometimes I draw directly on the photographs. For cases where I want to work through particularly fine details, I may even use tracing paper over the photograph.
INSIGHTS FROM DR. ATHRÉ
What All the Purple Ink Actually Means
I explain how I move from consultation and preoperative photographs to a written and visual surgical plan, and why the markings on the patient are another opportunity to think through that plan before surgery begins.
The Morning of Surgery Is a Second Planning Session
When I mark the patient immediately before surgery, I am transferring the plan I have already created onto a three-dimensional person. That is important because a photograph and a patient standing in front of me are not exactly the same thing.
I can look again at the jawline, neck, facial volume, asymmetry and the relationships between different areas. I can confirm the incisions I intend to use. I can mark boundaries for dissection and areas where I need to be particularly aware of the underlying anatomy.
If I am performing facial fat transfer, I can use different markings to remind myself not only where I intend to add volume, but how I intend to treat different areas.
And sometimes I change something.
That is not a failure of the original plan. It is one of the reasons I mark the patient in the first place. I would rather look at the face again, question a decision and modify the plan before making an incision.
The value is not in how many lines I draw. It is in whether every line represents a decision I have already thought through.
Not Every Facelift Marking Means the Same Thing
One reason surgical markings can look confusing is that different lines may be telling me completely different things.
Some markings identify an incision. Some define an anatomical landmark or the boundary of a planned dissection. Some identify areas where nerves or other important structures require particular attention. Others map areas where I intend to add or redistribute volume.
So when you see a patient with purple lines across the face and neck, you should not assume every line represents somewhere I am going to cut.
INSIGHTS FROM DR. ATHRÉ
Three Facelift Markings and What They Tell Me
Here I show three specific examples from an actual surgical plan: the submental incision beneath the chin, the border of the mandible and the areas I am evaluating for facial fat transfer.
Why I Changed Where I Place the Incision Beneath the Chin
The submental incision is a good example of how my own planning has changed with experience. Ten or twelve years ago, I commonly put this incision directly into the natural crease beneath the chin. It seems logical. There is already a crease, so why not hide the incision there?
Today, I often move it slightly lower.
One reason is access. The mandible creates a three-dimensional boundary above the neck. If I place the incision very high beneath the chin, I have a smaller opening and a longer working vector toward some of the deeper structures I may need to address.
Moving the incision slightly lower can give me a somewhat larger opening and a shorter, more direct path into the deep neck. That can be particularly useful in selected patients when I am addressing structures such as the submandibular glands during a deep neck lift.
There is also a contour reason.
If I put an incision directly into an existing deep crease, healing can sometimes make that crease more noticeable. In someone who already has a full neck, I do not want to create the appearance of a second ravine beneath the chin.
I am thinking about the entire transition from the chin through the submental area and into the neck, not simply where I can hide a line.
Why I Draw a Line Along the Mandible
The line I draw along the jaw is not an incision. I mark the border of the mandible toward the angle because it gives me an anatomical reference and helps define the lower aspect of the facial dissection I am planning.
During a deep plane facelift, I am working through anatomical layers where the relationships between the SMAS, retaining ligaments, facial spaces and facial nerve matter. Surface markings do not replace my knowledge of that three-dimensional anatomy. They help orient the plan I have already made.
This is also why I am careful when I talk about marking nerve areas. Facial nerve branches do not follow one simple surface drawing that is identical in every patient. I may mark areas where I know I need particular caution, but the surgery still depends on understanding the tissue plane and anatomy underneath the marker.
Why I Mark Facial Fat Transfer With the Patient Upright
Facial rejuvenation is not always only a lifting problem.
Aging can involve tissue descent and changes in facial volume at the same time. That is why facial fat transfer may be part of a larger rejuvenation plan, including the approach I use in selected 4D Facelift™ patients.
When I am deciding where I want to add volume, I prefer to evaluate and mark the patient relatively upright. Once someone lies flat, gravity changes the way the soft tissues sit. Some of the hollows, transitions and asymmetries I was evaluating can become less obvious. So I mark what I see before positioning changes it.
The markings can also remind me that not every area is being treated in exactly the same way. Depending on the plan, I may use different fat preparations or parcel sizes for different purposes and different parts of the face.
The point is not simply to add fat. It is to decide where volume belongs, where it does not and how that volume fits with everything else I am changing.
Markings Also Force Me to Look at Asymmetry
No face is perfectly symmetrical. That becomes especially important when I am planning volume restoration or combining several procedures. One side may need more volume than the other. One brow may require a different vector. One side of the jaw or neck may not behave exactly like the other.
If I identify an asymmetry before surgery, I can decide whether it is something I should address, something I should preserve or something surgery is unlikely to change.
This is one reason standardized preoperative photographs are so useful to me. I can study the face away from the consultation room, compare views and think through relationships that are easy to overlook when the conversation is moving quickly.
Then, when I see the patient again on the morning of surgery, I have another opportunity to compare that plan with the face in front of me.
A Good Plan Lets Me Concentrate on the Surgery
I do not want to begin a complex facial rejuvenation procedure and only then start deciding what order I am going to do things in.
By the time I start surgery, I want to know the sequence. I want to know where I expect to work, what structures I am planning to address, where I intend to add volume and where I need to be particularly careful.
That does not mean surgery becomes automatic. Anatomy can still look different from what I expected, particularly in revision surgery or in patients who have had previous procedures. A surgeon has to respond to what is actually there.
Planning simply gives me a framework.
I want to make the important decisions before surgery whenever I can, while still being willing to change the plan when the anatomy gives me a reason to.
The Markings Are Part of a Feedback Loop
One reason I document my plans is that surgery should teach me something. I can look at what I planned, what I actually did and how the patient healed. Then I can ask whether the decision produced what I expected.
The change in my submental incision is a good example. I did not change it because someone told me every facelift incision belongs in one exact location. I changed it because my experience changed the way I thought about access and contour.
That process should continue throughout a surgical career.
I have a chemical engineering background, and I still tend to think this way: plan, execute, observe, reassess and refine. I do not believe experience should make a surgeon more rigid. I think it should give you more information with which to question your own decisions.
If you want to understand more about how that background shaped the way I approach facial surgery, you can read more about my training and philosophy on my Dr. Raghu Athré page.
The Surgery Begins Before the Incision
When you see a facelift patient covered in purple ink, you are seeing only one moment in a much longer process.
The conversation with the patient has already happened. The examination has happened. The photographs have been taken. I have thought about the anatomy, the sequence of surgery, the incisions, the areas of dissection, the volume plan and the things I need to be particularly careful about.
Then I draw.
And while I am drawing, I think through the surgery again.
I do not care how impressive the markings look. I care whether I know why every one of them is there.
FREQUENTLY ASKED
Questions About Facelift Markings and Surgical Planning
These are some of the questions patients ask when they see preoperative facelift and neck lift markings.
Why are patients marked before facelift surgery?
Markings help transfer the preoperative plan onto the patient. They do not replace the examination or photographs. Standardized photography is itself considered an important tool for facial surgical planning and later analysis of results. I use the markings as the next step in that process.
Do more facelift markings mean a more extensive or better facelift?
No. The number of lines does not tell you the quality or extent of the surgery. Good facial rejuvenation begins with understanding the patient’s concerns, medical history, anatomy and photographs. Those are established components of preoperative facial rejuvenation assessment. The markings are simply one way I organize that plan.
Why is the mandible marked before a facelift?
I use the mandibular border as an anatomical reference and as part of orienting my planned dissection. Cadaveric research has used the mandibular border and gonial angle to map the relationship between lower-face ligaments and the marginal mandibular nerve, which illustrates why this region is an important surgical landmark.
Do facelift markings show exactly where the facial nerves are?
No. I may mark caution areas, but a surface line cannot tell me the exact location of every nerve branch. Facial nerve branching varies, and safe facelift dissection depends on understanding the three-dimensional tissue planes and facial nerve danger zones.
Why is there sometimes an incision beneath the chin during a neck lift?
A submental incision can provide direct access to structures beneath the chin and within the deeper neck. Published neck-lift techniques describe using a submental incision to address deep-layer structures. Whether I need that access depends on the patient’s anatomy and surgical plan.
Does every deep neck lift involve the submandibular glands?
No. Submandibular gland reduction is a selective maneuver, not something every patient needs. Deep neck fullness can come from several structures, and the examination determines what should be treated. Surgical literature describes the role of subplatysmal fat, digastric muscle and submandibular glands in neck contour.
Why are facial fat transfer areas marked separately from facelift areas?
Lifting and volume restoration solve different problems. Facial aging can involve both tissue descent and volume loss, so I evaluate them separately even when I treat them during the same surgery. Reviews of fat grafting performed with facelift surgery similarly describe volume restoration as a distinct component of facial rejuvenation.
Why might different types of fat be used in different areas of the face?
Different facial areas have different anatomical and treatment requirements. Some fat-grafting approaches use different parcel sizes for different tissue levels and purposes. Published techniques describe millifat, microfat and nanofat as distinct preparations. My markings help me keep track of the plan for each area.
Can the surgical plan change after the patient has been marked?
Yes. The markings are a planning tool, not a contract with the purple lines. Facelift surgery depends on three-dimensional anatomy, including the facial nerve, retaining ligaments, tissue planes and deep neck structures. Modern anatomical reviews emphasize the importance of understanding these deep-plane anatomical relationships. If the anatomy gives me a reason to modify the plan, I modify it.
