Ask any Instagram baddie: In this economy, staying snatched is a full-time job. Perhaps that's why, 20 years into the dermal filler boom, a controversial new-wave facelift is gaining traction with people who’ve grown weary of endless “tweakments.” Trademarked by Chia Chi Kao, MD, the ponytail lift is an endoscopic plastic surgery procedure designed to beautify faces of all ages with minimal downtime and no visible scarring. Unlike traditional facelifts, which can leave behind telltale plastic surgery scars in front of the ears and require serious recovery time, the ponytail lift hides a handful of tiny incisions behind the ears and hairline. Once healed, they more or less vanish, allowing the majority of clients to emerge “restaurant-ready” in less than a month.
The procedure is a hat trick of surgical adjustments that enable Dr. Kao to vertically reposition the face from top to bottom using a fiber-optic endoscope: a miniature camera attached to the tip of a long, thin tube. By inserting this tube through a small opening in the skin, the surgeon can use it like a pair of binoculars to peer inside the body without having to open it up with longer incisions. Through two half-centimeter cuts behind the hairline, he can sweep the eyes, brows, and cheeks into Bella Hadid–worthy angles. Add a half incision in the crease behind each earlobe and he can sculpt the jawline and neck too. And by tucking one more incision under the chin, Dr. Kao can tighten the neck all the way down to the décolleté. Top it off with a round of fat transfer across the midplane and superficial dermis, and there you have it: the ponytail lift.
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For decades, the facelift was a skin-only operation until it became clear that aging affects the underlying musculature as well. Now facelift techniques can be roughly divided into two camps: the SMAS (superficial musculo-aponeurotic system) lift and the deep plane lift. The SMAS lift is a two-step process that moves the skin and fat as separate layers by picking up the SMAS from above. But cutting the skin away from the fat can disrupt the network of blood vessels that keep those layers healthy, potentially causing them to thin, sag, and sweep over time. SMAS lift patients will look good immediately after the procedure, Dr. Kao hedges, but less so as the postoperative swelling goes down.
“At eight months, a year, two years, tops, you'll start seeing the changes in the skin and the fat,” Dr. Kao cautions. “A traditional facelift just does not age well, because the fat is devascularized, the skin is devascularized.
A deep plane lift, on the other hand, works below the SMAS—meaning the skin and fat can remain connected and vascularized. SMAS lifts are generally considered less invasive and more customizable to the patient's facial anatomy than deep plane lifts, but they aren't as transformative or effective for patients with advanced signs of aging. And that small but meaningful distinction is what makes the ponytail lift so alluring: It’s a deep plane lift without the inconveniences traditionally associated with extensive facelifting.
According to Dr. Kao, this makes it suitable for facial beautification in patients as young as 17 years old. Only in cases where an older patient’s skin laxity has progressed to the point of becoming “very stretchy, like bubblegum” is Dr. Kao sometimes forced to make an incision in front of the ear to flatten any gathered skin.
Dr. Kao has been perfecting his technique since 2000. But the Instagramification of beauty has created a new market for the ponytail lift: hyper-aesthetic young people stuck in a holding pattern of overinjecting. Typically, it begins with lip filler in their 20s before maybe graduating to the cheeks, nasolabial folds, undereyes, and jawline.
It’s a progression Dr. Kao calls “filler burnout,” the point at which injectables begin to mask and distort, rather than enhance, a person’s appearance. And in the next five years, he expects it to emerge as a “serious problem.” Contrary to popular belief, filler doesn’t dissolve very well, even with the help of hyaluronidase, the injectable enzyme meant to reverse hyaluronic acid filler almost immediately.
Instead, it lingers for what could be 15 to 20 years, gradually changing the face by stretching the skin, compressing the fat, and creating deeper folds by congesting the soft tissue with stagnant lymphatic fluid. That’s how, in the span of a decade, one or two syringes of filler injected once or twice per year may add up to 20 or 30 “lifetime syringes” and heavy “masculine” features that blur into one another.
Last year Dr. Kao performed a ponytail lift and upper lip lift with an internal corner lift on a 36-year-old patient who’d been getting injections since the age of 27. “I didn't even know that fillers migrated,” she says. “I started to put the pieces of the puzzle together. I'm like, ‘Hang on a second. I'm getting fillers done and spending all this money, [for what?]’ It looks great when you first do fillers, but unfortunately, it doesn't stay that way.”
As certain areas started to droop, the cost of keeping up her filler regimen stopped making sense. “I felt like [the ponytail lift] was a permanent solution that wouldn't end up changing the look of my face in a negative way over time,” she adds. “With Dr. Kao, you look like that now for 10, 15 years.”
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Dr. Kao is on the precipice of publishing a “landmark paper” documenting his 21 years of experience performing the ponytail lift technique on more than 600 patients. But it’s worth noting that traditional facelifts can be done endoscopically too. In fact, the majority of the facelifts New York plastic surgeon Konstantin Vasyukevich, MD, performs are endoscopic-assisted, whether they're SMAS or deep plane lifts. In certain procedures, operating with an endoscope can minimize scarring, bruising, and swelling for quicker recovery times. That said, it's not always necessary. And for Dr. Vasyukevich, the tool “doesn't change in principle” of what he does.
“What exactly [Dr. Kao] means by ‘ponytail lift’ is a bit of a mystery to me and I don't know him in person,” Dr. Vasyukevich says. “But when I look at his before-and-after pictures that he displays on his website and he calls them all ponytail lifts, they just look like not-so-good facelifts.”
“Nobody wants to give a patient a scar unless it's absolutely necessary,” Dr. Vasyukevich continues, but achieving the soundest long-term outcomes often means agreeing to some degree of semivisible scarring around the ears. Without that incision, the surgeon can’t remove the excess skin they’ve pulled up from the jaw and cheeks.
“Everybody tries to make incisions shorter, but at some point when you start making them too short, then shorter than necessary for this particular patient, you're going to start compromising results,” Dr. Vasyukevich concludes. “And there's absolutely nothing wrong with that as long as the patient understands that this is what's happening.”
New York plastic surgeon Steven Levine, MD, echoed Dr. Vasyukevich’s doubts about endoscopic facelifts. At least for now he has “zero interest in adding endoscopic facelifts to [his] repertoire.” “They were a thing in the ’70s and early ’80s,” Dr. Levine says. But today? Not so much. “What I would say about the endoscopic surgeons I'm familiar with and that I've seen, they're putting in a lot of volume to make up for the fact that it's hard to lift something without removing skin and without separating the skin,” he says.
By “volume,” Dr. Levine means purified fat that has been harvested from another area of the body, then injected into the face. Dr. Kao incorporates fat transfer in every ponytail lift he performs to plump up wrinkles and strategically add definition to areas like the cheeks, neck, jawline, and under the eyes. Today most surgeons are using fat to enhance their facelift results.
“I'm not against fill, I'm not against fat,” says Dr. Levine. “But the traditional patient who doesn't have a lot of volume loss and just has gravity and laxity working against them, if you really lifted well, you shouldn't need—maybe a little bit of fat, fine—but you shouldn't need to fill the cheeks.”
At his practice Dr. Levine performs a version of the facelift that works above and below the SMAS layer—a hybrid SMAS and deep plane lift, or “dual plane lift,” if you will. Well-done facelifts, in his opinion, go from the top of the cheek to the middle of the neck. He’s not a big fan of brow lifts (at least, not for his average patient) or lip lifts for that matter. (“Often they can look very pretty, but they almost always look different,” he quips.) But the biggest difference among surgeons isn’t technique or technical ability. “It's aesthetic judgment,” he says.
“I don't think you can get a long-lasting, nicely contoured result without removing some of the extra skin,” Dr. Levine elaborates. “If somebody's adding a lot of volume to a face while they're doing the surgery, just maybe ask yourself why they're doing that. I want to be clear, there are plenty of surgeons out there who know how to do things I don't know how to do. But I haven't yet been impressed with results I've seen from endoscopic lifts.”
Melinda Farina, a.k.a. the Beauty Broker, is a plastic surgery whisperer trusted by patients and doctors alike. As a consultant and patient advocate, Farina taps her closely vetted referral network of specialists to match clients with the best procedures and practitioners on the market. Dr. Kao, Farina says, has perfected the endoscopic brow lift with lasting results, but their views on facelifts differ. Like Dr. Levine, Farina believes a dual plane lift tailored to the patient’s unique facial anatomy is the best approach.
“As it pertains to a full endoscopic facelift, [Dr. Kao] and I, we have our arguments about certain things,” Farina says. “And I'm like, ‘Nope, skin needs to be cut off.’ And he's like, ‘No, it doesn't. You could do all the lifting from inside.’ So we definitely go back and forth…. He is really one of the only people doing a full endoscopic facelift.”
Dr. Kao prefers not to disclose pricing information for the ponytail lift without a proper consultation, but Farina said she’s seen estimates range from $30,000 to about $250,000 depending on the treatment and recovery plan. Levine’s fee for a face and neck lift starts somewhere between $55,000 and $60,000. A standard fee for facelift across the U.S. is about $40,000 to $45,000, Farina says, but the highest prices can always be found in California.
Aesthetics generally seem to be trending in the direction of less is more, if beauty bellwether Kim Kardashian’s recent comments about having “chilled” on Botox can be believed. Drs. Kao, Vasyukevich, and Levine, and Farina are split on the subject of whether a facelift could be considered a preventive measure. But they all agreed on this, if nothing else: The demographics for facelift patients are skewing younger. It’s not unthinkable to imagine a future where facelifts are no more controversial than scarless rhinoplasties.
“My philosophy about plastic surgery is when things start to fall or change, we rewind the clock and refresh that person's face or body,” Farina concludes. And sometimes “the best thing to do is wait, let things get a little bit worse” before taking action.
“But people are impatient,” she says. “We live in a very instant-gratification society.”
