The Invisible Scar: Energy-based Facial Tightening Through the Lens of the Deep-layer Facelift Surgeon

Energy-based devices are widely used for facial rejuvenation; as a result, an increasing proportion of patients presenting for facelift or necklift surgery have a history of prior treatment with ultrasound- or radiofrequency-based technologies. While the efficacy and safety of these devices are well-established, their cumulative effects on facial soft tissues critical to deep-layer facelift surgery remain under-recognized. This article examines three commonly used energy-based facial tightening modalities - microfocused ultrasound, high-frequency parallel beam ultrasound, and fractional radiofrequency microneedling - from the perspective of the facelift surgeon. Device-specific mechanisms of action and tissue-level effects are reviewed, followed by discussion of their potential operative implications and the senior author's experience-informed strategies for managing these patients. Recognition of these effects is essential for patient counseling, operative planning, and preservation of long-lasting surgical outcomes.