One Stitch Facelift: Modern Endoscopic Approach

By Dr Scott J Turner, Specialist Plastic Surgeon | Sydney & Brisbane

Dr Scott J Turner is a Specialist Plastic Surgeon (FRACS) with over a decade of experience specialising in facial aesthetic surgery. At FacePlus Aesthetics, Dr Turner provides comprehensive education about various facelift techniques, helping patients understand what different procedures involve and whether they might be suitable for their individual concerns.

The term “one stitch facelift” appears frequently in cosmetic surgery marketing, yet its meaning varies considerably depending on context. This blog examines the differences between marketing terminology and surgical reality, explores the anatomical principles underlying endoscopic midface lifting, and clarifies what patients should understand when researching these procedures.

What is a One Stitch Facelift?

The phrase “one stitch facelift” has become a source of considerable confusion within cosmetic surgery. This terminology is used to describe vastly different procedures—from non-surgical clinic-based treatments to sophisticated surgical operations requiring general anaesthesia and extensive anatomical dissection.

Understanding these distinctions proves essential for patients researching their options and seeking appropriate care for their facial concerns.

The Marketing Definition

In cosmetic clinics, the “one stitch facelift” typically describes procedures marketed for convenience and reduced recovery time. These involve small incisions near the ear where a single suture is placed into the SMAS layer, performed under local anaesthesia in less than one hour, with recovery periods of several days rather than weeks.

These simplified approaches frequently deliver disappointing outcomes. Without releasing the underlying ligaments that anchor facial tissues to bone, a single suture cannot effectively reposition the cheek tissue. The tissue inevitably relaxes around the tension point—a phenomenon known as “cheese-wiring”—as the suture gradually cuts through soft fat. Results typically fade within 6 to 12 months, and for patients with anything beyond minimal facial changes, such procedures rarely justify the cost or deliver meaningful, enduring correction.

The Surgical Reality: Endoscopic Deep Plane Lifting

In the hands of experienced facial plastic surgeons, “one stitch” terminology describes something fundamentally different—the specific method of tissue fixation following extensive surgical dissection.

The endoscopic deep plane midface lift represents a sophisticated procedure involving:

• Complete release of the zygomatic and masseteric ligaments
• Wide undermining of the deep plane facial tissue 
• Repositioning of the malar fat pad and deeper facial structures
• Secure fixation to the deep temporal fascia using long-lasting sutures

The “single suture” in this context refers only to the final suspension step. The actual procedure involves three to four hours of meticulous surgical work under general anaesthesia.

Endoscopic Midface Lift: The Surgical Procedure

The endoscopic midface lift utilises small incisions concealed within the temporal hairline to access and reposition deeper facial structures. Here, we outline the key surgical stages.

Access and Initial Dissection

The procedure commences with infiltration of dilute local anaesthetic containing dilute adrenaline to reduce bleeding, which is critical when operating with endoscopic visualisation, where even minor haemorrhage obscures the surgical view.

A small incision (2-4 centimetres) is made within the temporal scalp, approximately 2 centimetres behind the hairline. This placement ensures the scar remains entirely within hair-bearing tissue.

Dissection proceeds through the superficial temporal fascia until the deep temporal fascia is identified. This forms the “floor” of the dissection.

Navigating Critical Anatomy

As dissection approaches the zygomatic arch, the surgeon encounters the inferior temporal septum, where superficial and deep layers merge.

A perforating vein (the “sentinel vein”) typically marks this area, serving as a landmark. The frontal branch of the facial nerve usually lies within 10 millimetres of this vessel. Under endoscopic magnification, meticulous care protects this nerve while the dissection transitions over the arch into the midface.

Ligament Release

Entering the midface, the surgeon works in the deep plane, overlying the zygomaticus major muscles.

The zygomatic ligaments appear as firm white bands originating from the malar eminence and inserting into the overlying cheek fat. Using sharp dissection or electrocautery, these ligaments undergo complete division. An immediate “release” or give in the tissue confirms adequate mobilisation, allowing the cheek to move as a single cohesive unit.

Further dissection along the masseter releases the masseteric ligaments, mobilising the lateral cheek and pre-auricular tissues.

The Suspension

With the midface fully mobile, repositioning begins. A heavy-gauge suture is introduced through the temporal access point.

Using a specialised suture passer, this captures the malar fat pad and sub-orbicularis oculi fat. The suture is pulled superolaterally toward the temporal incision along a carefully planned vector—typically around 60 degrees—to restore a heart-shaped facial contour.

The suture anchors under tension to the deep temporal fascia, providing stable fixation against which healing occurs.

Skin Management

Unlike traditional facelifts, no skin is excised from the cheek area. Excess skin created by lifting redistributes superiorly into the temporal region. A small amount of skin may be removed at the temporal incision site, with the hairline advanced or preserved depending on individual anatomy.

In younger patients with good skin elasticity, the cheek skin contracts over the new contour without requiring excision. The concealed incision placement within the hairline results in minimal visible scarring.

Combining Procedures for Comprehensive Outcomes

The endoscopic midface lift is frequently performed alongside complementary procedures to address multiple facial zones simultaneously.

Endoscopic Brow Lift

The temporal incision used for midface lifting also provides access for lateral brow elevation. By extending dissection medially across the orbital rim and releasing the arcus marginalis, Dr Turner can lift the brow and cheek as a single unit.

This combination addresses lateral hooding of the upper eyelid whilst preventing the “crowding” that might occur if only the cheek were elevated against a heavy, static brow.

Facial Fat Transfer

While lifting repositions existing tissue, it cannot replace volume lost to atrophy. Ageing involves deflation of deep fat compartments—particularly in the temples and deep medial cheek.

During the same anaesthetic, fat can be harvested (typically from the abdomen or thighs), processed, and injected into depleted areas. Facial fat grafting acts as a volumetric strut, helping maintain the projection of the lifted cheek whilst improving skin quality through cellular effects.

Upper Lip Lift

Midface lifting elevates the cheek but can occasionally leave the upper lip appearing relatively long by comparison. A sub-nasal or “bullhorn” lip lift removes a strip of skin beneath the nose, shortening philtral length and enhancing tooth show—restoring proportional relationships between facial zones.

Blepharoplasty

Endoscopic midface lifting often reduces the need for traditional lower blepharoplasty because elevating the cheek covers the “bags” created by prolapsing orbital fat. However, transconjunctival fat removal or repositioning may still be performed simultaneously to refine periorbital contours.

Suitable Candidates for Endoscopic Midface Lifting

Patient selection proves crucial for successful outcomes with this technique. The endoscopic midface lift is best suited to younger patients—typically in their late twenties to late thirties—who demonstrate early signs of facial ageing such as mild midface descent, early nasolabial fold deepening, and subtle cheek flattening. Good skin elasticity is essential, as this technique relies on the skin’s ability to contract and adapt following structural repositioning.

Patients with more advanced facial ageing are not suitable candidates for this approach. Those presenting with significant jowling, neck laxity, platysmal banding, substantial skin excess, or marked loss of skin elasticity require more comprehensive surgical techniques. The deep plane facelift addresses these concerns through extended access that permits skin excision and comprehensive lower face and neck correction—outcomes that endoscopic approaches cannot achieve.

Potential Risks and Complications

All surgical procedures carry inherent risks. Specific considerations for endoscopic midface lifting include:

Nerve Injury: The frontal branch of the facial nerve lies within the operative field. Temporary weakness (neuropraxia) occurs in 1-5% of cases, usually resolving within 3 to 6 months. Permanent injury remains rare (<1%) with experienced surgeons.

Temporal Hollowing: Aggressive dissection or cautery can atrophy the temporal fat pad, creating a hollow appearance.

Alopecia: Incisions within the hairline can cause temporary or, rarely, permanent hair loss.

Asymmetry: Minor differences in suspension tension can produce visible asymmetry in cheek height.

Unnatural Appearance: Excessive lateral vectoring can distort the eye position, creating an unnatural slant.

The risk of complications reduces significantly when surgery is performed by a qualified Specialist Plastic Surgeon (FRACS) with specific experience in endoscopic facial procedures.

The Role of Deep Plane Techniques in Modern Facial Surgery

The evolution of facelift surgery over recent decades reflects a fundamental shift in understanding how faces age and how surgical correction should address these changes.

Beyond Skin Tightening

Earlier facelift approaches focused primarily on skin excision and tension-based correction. While effective for addressing laxity, these techniques frequently failed to correct—and occasionally worsened—the underlying volumetric deflation and structural descent characterising facial ageing.

The deep plane concept emerged from recognition that meaningful, lasting correction requires addressing tissues at the level where ageing actually occurs: the fascial layer, retaining ligaments, and deep fat compartments.

Ligamentous Release as the Foundation

Whether performed through traditional extended incisions or endoscopic temporal access, deep plane techniques share a common foundation: complete release of retaining ligaments that tether descended facial tissues to fixed skeletal points.

Only after these anchoring structures are divided can the facial soft tissue envelope be meaningfully repositioned. Attempting to lift against intact ligaments creates unnatural tension, distorts tissues, and produces the characteristic “operated” appearance that both surgeons and patients seek to avoid.

Structural Repositioning Versus Superficial Tension

Deep plane approaches move tissue as coherent units—the malar fat pad, sub-orbicularis fat, and overlying skin move together as a composite flap rather than being separated and manipulated independently.

This preservation of tissue relationships produces more natural outcomes and avoids the hollowed, skeletonised appearance that can result from aggressive dissection separating anatomical layers.

The Importance of Surgeon Selection

The technical demands of endoscopic facial surgery require specific training and experience distinct from traditional facelift techniques.

Endoscopic Expertise

Operating through small access points with camera-assisted visualisation demands different skills than direct-vision surgery. Surgeons must navigate complex three-dimensional anatomy using two-dimensional monitor displays, maintain meticulous haemostasis to preserve visibility, and execute precise tissue manipulation with elongated instruments.

Learning curves for endoscopic facial procedures are well-documented in surgical literature, with outcomes improving substantially as surgeons accumulate experience.

Anatomical Knowledge

The facial nerve and its branches traverse the operative field during endoscopic midface and brow procedures. The frontal branch, responsible for forehead movement, lies in close proximity to typical dissection planes.

Surgeons performing these procedures must possess intimate knowledge of nerve anatomy, fascial relationships, and the variations that exist between patients. This understanding allows safe navigation through danger zones while achieving effective tissue mobilisation.

Honest Assessment

Perhaps most importantly, surgeons should demonstrate willingness to recommend against procedures when alternative approaches would better serve patient interests. The most technically elegant endoscopic midface lift cannot adequately address advanced neck ageing or significant skin excess—honest acknowledgment of these limitations reflects surgical integrity.

Choosing the Right Approach

The appropriate technique depends entirely on individual anatomy, degree of facial change, and treatment goals.

Patients experiencing early midface descent without significant skin excess may benefit from endoscopic approaches. Those with more advanced ageing, substantial jowling, or neck concerns typically require more comprehensive traditional facelift techniques.

During consultation at Dr Turner’s Sydney or Brisbane clinics, your facial anatomy, skin quality, and specific concerns undergo a thorough assessment. Dr Turner provides honest guidance about which techniques are likely to address your concerns effectively—and equally importantly, which procedures may not be appropriate for your situation.

Book a Consultation in Sydney or Brisbane

If you are considering endoscopic facelift surgery, Dr Scott J Turner offers comprehensive assessments at his Sydney and Brisbane clinics. As a Specialist Plastic Surgeon specialising in facial aesthetic surgery, Dr Turner can evaluate your individual concerns and recommend the most appropriate surgical approach. Consultations are available at convenient clinic locations in Sydney and Brisbane.

To arrange your consultation, please contact us or telephone 1300 437 758.

Learn more about Dr Turner’s ponytail facelift.