Home > Techniques For Creating Inconspicuous Facelift Incisions:
Avoiding Visible Incisions And Loss Of Temporal Hair
Russell W.H. Kridel, MD1
Edmund S. Liu, MD2
Please send all correspondences to:
Russell W.H. Kridel, MD
Facial Plastic Surgery Associates
6655 Travis Street, Suite 900
Houston, TX 77030
(713) 526-5665 tel
(713) 526-5160 fax
rkridel@todaysface.com
1 Associate Clinical Professor, Division of Facial Plastic Surgery, Dept. Otolaryngology – Head and Neck Surgery, University of Texas Medical School at Houston
2 Fellow, Division of Facial Plastic Surgery, Dept. Otolaryngology – Head and Neck Surgery, University of Texas Medical School at Houston
First Presented at the Aging Face Course, Indianapolis, IN, October 16-19, 1997
ABSTRACT
Patients seeking rhytidectomy desire an improved neckline, jawline, and mid-face, but rarely at the expense of visible incisions that clearly show that a facelift has been performed. We describe our technique for facelift incisional planning and the rationale behind specific surgical maneuvers for preventing unwanted sequelae. These telltale signs of poor incisions include temporal hair loss, conspicuous scars, an unnatural appearance to the tragus, and the presence of a posterior hairline step-off. Special considerations are given to the male patient and for salvage of readily visible incisions from previous surgery.
INTRODUCTION
Much of the recent literature on rhytidectomy describes techniques for improving the quality of the facelift, whether it is improvement in the neckline, decreased jowling, or a longer lasting lift. Many papers focus on newer techniques for improving mid-face results. However, what is patently missing from these papers is attention to actual incision placement so as to avoid visible incisions. Patients want an improved neckline, jawline, and mid-face, but rarely at the expense of visible incisions that show obvious signs of a facelift. Most before and after pictures in facelift papers show the neck and the jawline, but rarely do they show closer views of the hairline. To the contrary, in most pictures, the hair is covering the areas of the incisions. In our practice, patients are routinely shown close-up photographs of the post-operative incisions. In fact, patients should be weary of surgeons who fail to show their results with patients wearing their hair up.
Review of patients in our private practice office who have had facelifts elsewhere show, in general, a large patient non-acceptance of the incisional results from other facelift surgeons. One of the most difficult problems we encounter is the loss of the temporal tuft or sideburn hair. Once lost, no salvage facelift procedure can be done to improve upon this complication, and improvement necessitates either hair flaps or hair transplantation via follicular units. Most other scars can be improved with a secondary facelift, but in some instances, these scars remain for life. We would like to coin the phrase “facelift cripple“ or “hairline cripple” for the individual who has had a facelift and now can no longer wear her hair up, but must always wear it down to hide conspicuous incisions.
This paper outlines a safe method for making facelift incisions that preserves the hair tufts, makes well concealed incisions, and allows patients to wear their hair in any style after a facelift, without compromising the results of the lift itself. In addition to temporal hair loss, other telltale signs of a poor facelift result include visible pre-auricular incisions, an unnatural appearance to the tragus, loss of earlobe definition with a pixie-ear configuration, migrating postauricular incisions, postauricular webbing or hypertrophy, a posterior hairline step-off, and visible posterior hairline incisions. We will examine reasons why unacceptable facelift incisions occur and show examples of descriptions from the classic texts showing how almost all of these older techniques lead to incisional problems. Careful attention to preoperative incisional planning, meticulous intraoperative technique and suturing, and lastly timely and detailed post-operative care are essential to the success of inconspicuous incisions. This paper initially focuses on the female patient. Techniques specifically designed for the male patient are described at the end along with techniques for salvaging incisions from a previous facelift.
OUR TECHNIQUE
The patient is first marked in the pre-operative area in a sitting position, which provides a more accurate determination of the gravitational forces of aging. Once in the operating room after general anesthesia is achieved, the patient’s hair is trimmed with scissors and clippers around the incisions. It is important to be liberal with this step, as hair is easily trapped in the suture lines when closing which may pose problems later. Hair detangler is sprayed and rubber bands are placed to pull the hair away from the incisions. Clear sticky drapes are then placed to further keep the hair out of the surgical field.
Many of the classically described facelifts describe a vertical, pre-auricular incision that enters the temporal scalp posterior to the sideburn hair and then angles forward in a curvilinear fashion (Figure 1A). The direction of the redraping and/or pull of the anterior facial skin is in a posterosuperior direction, which then advances the lower cheek skin into the area of the temporal sideburn causing an area of hair loss. The textbook examples show the pre-operative planned incisions, but do not show the typical post-operative appearance (Figure 1B). Most females do not have long sideburn hair, and subsequently, posterior-superior advancement of the non hair-bearing cheek skin causes an area of temporal alopecia.1 If a large amount of facial skin laxity is present, then a large amount of facial skin will be removed with a concomitant greater loss of temporal hair. The possible advantage of extending the vertical incision superiorly into the hairline is to most likely achieve a greater pull in the temporal area without doing a forehead lift. However, any advantage of this approach is nullified by the loss of the temporal hair tuft.
We advocate a lower incision that goes horizontally across the hairline tuft no higher than the level of the supra-auricular crease (see Figure 1C, segment cd). This incision then, as it extends horizontally, does have a vertical limb (segment bc) and then an anterior inferior limb (segment ab) in order to accommodate any excessive skin reduction and prevent tissue coning. To avoid visibility of this incision, the angle of the first horizontal portion closest to the ear is designed to cut across the hair follicles so that if there is no hair below this line, the hair follicles above will grow through the advanced lower facial skin flap so as to minimize the scar. In other words, this portion of the incision (segment cd) would be beveled across the hair follicles. Conversely, if there may be some hair still remaining inferior to the incision that would abut against this area, the incision is made parallel to the hair follicles (Figure 2). This latter circumstance is rare because of the usual shortness of the hair sideburn tuft in females. The more anterior vertical tuft (segment bc) and then horizontal limb (segment ab) are carried out parallel to the hair follicles so no alopecia results. These exact length and placement of these temporal incisions may vary slightly depending upon the preoperative height and width of the sideburn and temporal tuft hair in this area.2
The next problematic area is the pre-auricular incision. When placed anteriorly to the tragus, a long visible vertical line is noticeable. One of the underlying rationales for scar revision surgery is to break up a straight line, so that the eye cannot follow it. A totally pre-auricular facelift incision extends for at least 3 cm in most individuals which makes it quite noticeable. Our method attempts to camouflage this pre-auricular incision first by creating a curved incision superiorly mimicking the natural curve of the helix in the superior segment as opposed to making this vertical. This curve enters back into a V-shape that we make in the supra-auricular crease where a ¼ inch Penrose drain is placed (Figure 3). The curving of this incision maintains a more natural as opposed to vertical appearance. Then we make a retrotragal incision that is at least 4-5 mm deep into the external auditory meatus from the edge of the tragus. This incision often becomes more visible if made more anteriorly or closer to the edge of the tragus. When raising the skin flap over the tragus, the perichondrium is left intact over the cartilage to both preserve the blood supply to the cartilage and maintain the natural shape of the cartilage.
 If redraping the skin over the tragus is performed with any excessive tension, the redraped skin will tend to pull the tragus forward creating an abnormally open external auditory meatus. It is paramount not to place any tension here, and this accounts for why some retrotragal incisions have an operated appearance. In fact, we provide extra skin in this area and would rather have the skin bunch up at the incision site at the time of surgery, rather than be short of skin. The redundant skin usually evens out and appears quite natural. Excess subcutaneous tissue or fat is debulked if necessary from the undersurface of the tragal skin flap. Next, a 5-0 polydioxanone (PDS) deep suture is placed through the subcutaneous tissue and deep dermis of the pre-tragal skin approximately three to four millimeters anterior to the tragus and secured down to the underlying subcutaneous tissue prior to closure (Figure 4A). This stitch accomplishes two things. First, it counteracts any pull that could occur on the tragus in an anterior direction, and second, re-creates the natural pre-tragal sulcus. A noticeable preauricular dimple lasts for about a month and then evens out into a normal appearing pre-tragal sulcus, which is a quite normal anatomic finding (Figure 4B). Additionally, in order to take tension off of the incision, two stay sutures of 5-0 polypropylene (Prolene) are first placed at the superior and inferior limits of the tragus prior to cutting the tragal skin. It is also very important that the principle of redraping of skin in a facelift be utilized rather than that of placing tension on the skin. We prefer that the tension of any facelift be placed on the deeper layers rather than on the skin itself, whether or not the method is a deep plane facelift or any of the various SMAS techniques. In our repertoire, skin-only facelifts have no place without re-suspending the SMAS layers and can only lead to widened and visible scars and non-lasting results.
Descending down inferiorly towards the ear lobule, the incision is carried out around the lobule in female patients and then extends parallel to the post-auricular sulcus several millimeters onto the posterior concha itself (Figure 3). With time, the scar tends to migrate posteriorly into the sulcus. If the initial incision is made in the sulcus itself, the scar becomes much more visible. Perkins agrees and also makes this incision above the sulcus to avoid settling of the scar onto the visible mastoid area.3 This incision then extends superiorly to a level usually approximating the uppermost portion of the external auditory canal. Before entering on to the postauricular skin itself, it is most important to look at the natural pre-operative oblique continuity of the postauricular hairline. We vary the height of the postauricular incision, Figure 1C, segment hi, based upon the shape of the helical rim and posterior hairline. Ideally the height of this segment hi should be placed so that it traverses as little as possible visible skin. If the ear is shaped so that there is more helical prominence superiorly, the incision is carried a little bit more superiorly onto the concha. It is quite often that the distance between the hairline and the ear is variable, not only from patient to patient, but from right to left in the same patient. The incision then travels posteriorly from the ear extending straight back into the hair for five centimeters and then obliquely in a posterior-inferior direction for another one centimeter (Figure 3). This last turn helps to avoid any tissue coning. The horizontal portion of this incision within the hairline is beveled parallel to the hair follicles to prevent alopecia.
The postauricular incision tends to migrate posteriorly with time. Most papers describe the closure of the post-auricular incisions as just a simple skin-only closure. Typically some tension exists posteriorly on the flap that causes this incision to migrate away from the sulcus and be visible. Additionally, the postauricular area is a common site for hematomas because of the dead space in the retro-auricular area. Our method utilizes deep interrupted 5-0 polydioxanone sutures that not only approximate the skin edges subcutaneously, but which also suture the overlying skin and dermis to the underlying soft tissue exactly in the postauricular sulcus (Figure 3B). This accomplishes both obliteration of any dead space and prevention of possible migration of the incision posteriorly to a more visible location. Total closure of this area is later accomplished with additional 5-0 plain gut skin sutures.
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Another common problem that occurs in classic facelifts quite often is when the post-auricular skin is also pulled in a posterior-superior direction similar to the preauricular skin. Again, hair is lost and a step-off is quite common postauricularly where normal non hair-bearing skin replaces the scalp hair. The most probable explanation lies in the direction of the redraping of the skin in the posterior direction. Some individuals will try to avoid this postauricular step off by making an incision right along the postauricular hairline edge itself. The problem with this incision is that it certainly can become hypertrophic or stretched and is definitely visible when a patient wears her hair up. Therefore, we do not advocate an incision that follows the hairline because of its visibility. Rather, we advocate an incision that goes into the hair-bearing portion of the postauricular scalp as noted in the previous paragraph to avoid visibility. Most importantly, we advocate an anterior or purely superiorly oriented redraping rather than a posterior vector in order to recreate the natural, normal, pre-operative hairline. This horizontal, posterior incision into the hair-bearing scalp is done at a high enough level so that there is sufficient amount of hair below the incision so that when some of the skin and scalp with hair is removed that there is still enough hair inferiorly to camouflage the incision.
Therefore, the secret to making a post-auricular incision inconspicuous is in the redraping of the postauricular skin after any of the various SMAS techniques have been utilized. Again, the skin is redraped in a superior and anterior direction, not in a superior and posterior direction. The hairline on the flap skin is then aligned and reapproximated with the superior hairline in the postauricular area (Figure 5). Any excess skin is removed by directing the flap skin superiorly and then excising the excess both on the superior portion of the postauricular flap as well as in the postauricular sulcus. The majority of this incision is in the hair bearing area, and the only portion of the incision that shows is that between the postauricular hairline and the conchal sulcus which is minimized by the technique described.
The next major area that is a telltale sign of a facelift is distortion of the earlobe. If too much skin is excised at the earlobe or if there is excessive tension on it, the earlobe no longer retains its own definition and appears attached to the face in what has been described as a pixie ear or satyr ear configuration (Figure 6A). One method to reduce any tension on the ear lobule is to incise the flap prior to performing any SMAS dissection of placing suspension sutures. At this step it is not difficult to estimate the distance of the insertion of the lobule onto the face. One then generally makes an effort not to excise any more skin in this area after the suspension is accomplished unless there is gross excess. A further addition in preventing tethering of the lobule is the use of a mattress suture at the cut edge of the ear lobule secured to the underlying tissue (Figure 6B), which was described by Clyde Litton (personal communication, Washington DC, 1986) 4 . This mattress suture helps to pull the ear lobule onto itself and is left in place for approximately 14 days after the facelift to allow some fixation of the ear lobule before releasing the suture. A further permanent tacking suture is placed at the insertion of the earlobe into the face at the skin surface that is likewise left in place for the same amount of time.
Excessive tension placed on any incision causes widened and hypertrophic scarring. This is quite prominent in the postauricular area where some surgeons believe that more tension can be placed since this usually is not that visible an area. We would again encourage minimal tension postauricularly because such incisions closed with tension will show, especially with migration of the incision posteriorly. Furthermore, incisions also show when sutures are left in place for too long of a period and tissue tracking occurs where epithelium travels down along the circumference of the suture (Figure 5E). Railroad tracking is common with sutures left over 5-6 days. Skin staples have been utilized to avoid tissue tracking, but skin staples will not avoid making permanent marks if left in place for too long or if used to hold skin together that is under tension.
In addition to the aforementioned polypropylene tacking sutures, the entire incision is closed in several segments utilizing running locking 5-0 plain gut sutures. An exception to this includes the V-shaped excision in the supra-auricular crease, which is closed with a running locking 5-0 polypropylene suture to enable placement of the Penrose drain. (We also use a 15 French Blake drain on each side through a separate stab incision. The Penrose drain enables an additional site where any fluid accumulated under the flaps can be expressed out, decreasing bruising and edema. This site provides drainage for the temporal and superior preauricular areas that are not directly accessible by the Blake drain which serves the more inferior portions of the flap. All drains are removed the first postoperative day.) We find that 5-0 plain gut sutures have some inflammatory tissue response that results in less suture tracking while also providing sufficient tensile strength. A running locking suture provides hemostasis and an airtight flap closure that allows the suction drains to function more effectively. It also allows loosening of the suture prior to complete removal a few days later. Staples are placed in the postauricular segment and occasionally in the temporal area if the hair is not too thin.
Timely removal of sutures under the microscope is imperative for inconspicuous incisions. Because the pre-auricular area is the most noticeable, we loosen our superior pre-auricular incision at about 3-4 days and then remove all of the plain gut sutures by the 5th day at the latest. The individual polypropylene tacking sutures remain in place usually for up to a week at the superior helix, one above the tragus, one below the tragus, and one at the ear lobule so as to maintain good approximation. What we want to avoid here is railroad tracking in the preauricular area. Sutures around the lobule are removed usually about the 5th postoperative day. The retrotragal incision into the ear canal rarely has its sutures removed since ointment is used over this area, and usually these will dissolve on their own prior to needing removal. This incision is hidden and therefore does not require early removal. The same is for any other incisions that area within the hair since tissue tracking would not be noticeable. The postauricular sutures and any staples that are in the non-hair bearing areas are removed by the 5th post-operative day. Those within the scalp are sometimes left for 7-14 days. With the use of plain sutures, especially in fair-haired individuals, it is often hard to see these sutures, and therefore, removal under microscopic visualization is often necessary. There is a necessity to follow the patients post-operatively for ingrown hairs where we have approximated hair to non -hair bearing areas or hair-to-hair areas. Ingrown hairs may serve as a nidus for infection, inflammation, and potentially thickened scars.
MALE FACELIFT CONSIDERATIONS
Male facelift incisions deserve special considerations and need to be modified to accommodate the male beard and also the male sideburn which usually has an infinite inferior extent because of the beard itself. Rarely is loss of the temporal tuft a problem because of this inferior beard. Therefore, a curving vertical incision into the post-tuft scalp is permissible in most males (Figure 7). However, if one can estimate that a large amount of skin is going to be removed, then the most anterior extent of the beard especially in the temporal area may be pulled back significantly so that the sideburn is noticeably narrowed or even non-existent. In such cases, a horizontal sideburn incision might also be considered.
When one makes a post-tragal incision, the beard may be pulled onto the tragus and oppose the anterior lobule and the region just anterior to the root of the helix. Because most men do not wish to shave this area on the tragus and because a clear non-hair bearing preauricular space is more normally evident, most surgeons will make a vertical preauricular incision in front of the tragus and preoperatively tell the patient that the vertical limb will be visible (Figure 7). However, in our practice, we have noted an increasing number of male patients who would much rather have a retrotragal incision, shave this hair and have a less noticeable incision. In those patients on whom we do perform a post-tragal incision, we do attempt to inactivate the hair follicles that would abut against the tragus or the immediate pre-auricular area by directly cutting the follicles from the undersurface of the flap with fine scissors prior to suturing and/or by using the cautery unit on the hair follicle bulbs. If needed, electrolysis can be later utilized for persistent hairs.
The incision around the lobule in the male is also usually not made exactly in the sulcus, but slightly more anteriorly to leave a tuft of non-hair bearing skin so that the hair-bearing skin is not pulled into the lobule sulcus. Again, rather than having this incision, one can make an incision in the sulcus and attempt to destroy the hair follicles.
Most candidates for male facelift are in the aging population and have already noted an increase of tragal and ear canal hair. These individuals often state that they wind up having to trim that hair on an almost daily basis anyway and do not object to trimming any further hair that grows from the post-tragal incision. We carry out a very thorough discussion with males on this subject so that they can decide which incision they would prefer and allow them to actively participate in the decision making process. All males, no matter what incision is used, must be warned that the neck beard will be pulled postauricularly to a certain extent when skin is removed and will need to shave this area posteriorly. Obviously, the more skin that is removed, the more posterior and superior the beard will be redraped.
SALVAGE FOR POOR FACELIFT INCISIONS
Unfortunately, some of the visible incisions due to too much tension cannot be immediately repaired or camouflaged. These require the facial skin to loosen to allow for redundant skin that can be excised with the old scar under minimal tension. When another facelift can be accomplished and there is enough laxity, care should be taken to place the new incision so that the scar itself will be excised with the excess skin. For instance, in the preauricular area, one should place the new incision posterior to the scar. With posterior (and superior) advancement of the skin flap, the scar is removed along with the redundant skin.
Loss of hair, however, can be remedied soon after an unsuccessful facelift. Usually, after three to four months the surgeon can be more assured that a telogen phenomenon is not occurring where the hair follicles are in a state of shock from tension from the previous facelift. At this point, reimplantation techniques are employed. Micro-follicular unit hair transplantation is utilized, and several hundred plugs can be placed just in one temporal sideburn tuft alone (Figure 8). Usually, two sessions are necessary to get adequate coverage since one is attempting to give full natural density and thickness in this area. The grafts are placed to orient the hair shafts in the naturally occurring direction. Hair transplantation can also be utilized for those post-auricular incisions that are placed right along the hairline. Alopecia that occurs within the hair bearing areas of the scalp, again usually secondary to excess tension, whether in the posterior scalp or in the temporal area, can usually be excised with incisions that parallel the hair follicles and then reapproximated. Usually, one would wait until enough skin laxity has returned to avoid cicatricial alopecia.
Keloid scarring can be a problem in the keloid prone patient after a facelift. Careful questioning of the patient pre-operatively should be able to ascertain whether keloids have been a problem for that patient. Because of the rather large incisional area that is made, keloids could present an unacceptable cosmetic complication after facelift. Hypertrophic scars may occur in the post-auricular incisions either in the sulcus, in a non hair-bearing area, or at the lobule. These incisions, if they do occur, can be injected with triamcinolone acetonide (Kenalog) beginning at a 10 mg/cc concentration advancing up to 40 mg/cc depending upon the response to the Kenalog and the thickness of the hypertrophic scar. If steroid injections are ineffective after repeated injections, usually spaced out six weeks apart, then one can consider re-excision.
DISCUSSION
This technique has been used successfully in over five hundred consecutive facelifts. Most other papers concentrate on one area whether it be the preauricular regions, prevention of temporal alopecia, or the postauricular hairline. We have attempted to address and integrate all of these into a single all encompassing method.
Regarding the placement of the preauricular incision, Becker agrees that the post-tragal incision yields improved cosmesis.5 In his study, four surgeons compared postoperative close-up photos of 18 female patients receiving pretragal incisions to 18 with posterior tragal edge incisions, all at least six months from surgery. Three specific properties of a natural appearing tragus, all of which are achieved by our technique, were common in the incisions that were rated to have a superior result - the presence of a pretragal sulcus, maintenance of a gentle posterior curve in the center, and prevention of lateral and anterior deflection.
Other techniques have been described to prevent temporal alopecia. Brennan et al. categorizes the preauricular hair tuft into three types according to the level of the hair tuft in the vertical dimension.6 In type 1, the tuft is located superiorly at the supra-auricular crease, and a pretrichial temporal incision is made with a V-Y advancement of hair bearing skin into the incision. In type 2, the tuft is in an intermediate position and a horizontal incision only is made at the inferior edge of the tuft. In type 3, a low positioned tuft, the incision is made within the hair. These authors also describe a novel anteriorly based transposition flap of hair bearing skin with primary closure of the donor site to correct iatrogenic temporal alopecia. We agree with the ensuing discussion by Dr. Barrera that micrografts allow for more exact replication of the natural hairline and better control of the natural inferior direction of hair growth.7
Knize outlined a similar wedge-like excision of nonhair-bearing skin between the temporal hairline and the superior pole of the ear.8 This skin removal allows transposition of the temporal hairline down to the level of the superior pole of the ear and prevents temporal hairline migration superiorly. To address specifically the posterior scar, Little advocates what he terms the “omega incision” to conceal the scar and maintain the natural posterior hairline.9 However, drawbacks include significant dissection of the posterior scalp, additional operative time with increased expense to the patient, increased risk of hematoma formation, and increased risk of sensory nerve damage of the posterior scalp. Our technique avoids these disadvantages but still achieves the same goals.
Camirand and Doucet compared the invisibility, nonlinearity, absence of hypopigmentation, and amount of hair at the incision between incisions made parallel versus perpendicular to the hair shafts.10 They concluded that in 95% of patients (thirty total), the perpendicular incision healed better by subjective evaluation. In the temporal area, they perform micro W incisions inside the hairline with linear excision of excess skin from the distal flap. In our experience, beveling the incision depends upon the location of the incision with respect to how the surgeon anticipates if hair-bearing skin will be on both sides of the incision. Thus, in our practice there are indications for both.
Regarding male facelifts, some authors prefer routinely using only pretragal incisions or solely retrotragal incisions. Cremone et al favor retrotragal incisions and in 1982 described their technique for cauterization and removal of hair shafts from the immediate preauricular skin to maintain an area of non-hair bearing skin.11 This technique is similar to the one described here; however, we have found that despite these efforts, sometimes the hair is not permanently removed. Botta describes a continuous incision in the male temporal incision and a lower blepharoplasty incision.12 He claims this provides an advantage in rotation, leaves the preauricular nonhair-bearing skin undisturbed, and does not elevate the temporal hairline (he makes a pre-tragal incision usually at the hairline). The tradeoff is a visible scar in the temporal area which he believes heals exceptionally well.
CONCLUSION
In summary, we believe that the facelift surgeon must pay careful attention not only to the technique of the facelift for achieving neck, jaw, and cheek lines, but also must take extreme care to ensure that facelift incisions are as least visible as possible and that no natural hairlines are significantly altered so that loss of hair is apparent. We have noted patients who have had previous facelifts with loss of hair who have avoided having any future facelifts for fear that they would lose even more hair - the “facelift cripples.” Patients should be weary of surgeons who do not show them close-up photographs of their post-operative incisions with the hair worn up. It seems incongruous that a surgeon would attempt a rejuvenation procedure to make a person appear younger and more well rested to his or her friends while at the same time leave visible incisions that tell everyone the patient has had surgery, thus negating any benefits from the lift.
REFERENCES 1. Kridel RWH, Covello LV. The aging face (rhytidectomy). Editor Byron Bailey. Head and Neck Surgery-Otolaryngology, 2nd Ed.. Philadelphia, Lippincott-Raven Publishers, 1998. 2693-2716.
2. Kridel WH, Aguilar EA, Wright WK. Complications of rhytidectomy. Ear, Nose, and Throat Journal. 1985; 64: 44-56.
3. Perkins SW. Achieving the “natural look” in rhytidectomy. Facial Plastic Surgery. 2000; 16: 269-82.
4. Litton C. Personal communication, Washington DC, 1986.
5. Becker FF. The preauricular portion of the rhytidectomy incision. Arch Otolaryngol Head and Neck Surg. 1994; 120: 166-171.
6. Brennan HG, Toft KM, Dunham BP, Goode RL, Koch RJ. Prevention and correction of temporal hair loss in rhytidectomy. Plast Reconstr Surg. 1999; 104: 2219-25.
7. Barrera A. Comment on Prevention and correction of temporal hair loss in rhytidectomy. Plast Reconstr Surg. 1999; 104: 2226-8.
8. Knize DM. Periauricular face lift incisions and the auricular anchor. Plast Reconstr Surg. 1999; 104: 1508-1520.
9. Little JW. Hiding the posterior scar in rhytidectomy: the omega incision. Plast Reconstr Surg. 1999; 104: 259-272.
10. Camirand AC , Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when performing a facelift. Plast Reconstr Surg. 1997; 99: 10-15.
11. Cremone J, Courtiss, Baker JL. Male rhytidectomy incisions. Plast Reconstr Surg. 1983; 71: 423-5.
12. Botta SA. Face lifts in male patients. Facial Plastic Surgery. 1992; 8: 72-8.
FIGURES (Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Schematic of a typical female facelift incision that has been performed elsewhere. The temporal portion of this incision should be avoided in females at all costs. Skin excision after a superior and posterior pull inevitably leads to loss of the temporal hair tuft by advancing non hair-bearing skin into the temporal region.
B. Temporal hair loss and readily visible preauricular incision secondary to poor placement of incisions. This “facelift cripple” patient is unlikely to be able to wear her hair up.
C. Schematic of our incision with various segments labeled. The incision begins in the temporal region and is designed to preserve the temporal hair tuft. A retrotragal incision is made. The posterior portion does not extend along the hairline but rather extends straight posteriorly to properly realign the hairline.
D. Postoperative result of a typical patient with our incision. There is no temporal tuft hair loss. The preauricular incision is well concealed partially behind the tragus, which has a natural contour with a pretragal sulcus. The postauricular incision is not readily visible and there is a natural hairline with no step-off.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. One of the options in the temporal incision is to bevel the knife blade perpendicular to the hair shafts to allow the hair to grow through the advanced skin flap as depicted here in the schematic. The other option is to bevel the blade parallel to the hair shafts (usually if the surgeon expects to have a sufficient sideburn tuft inferior to the incision even after excision of excess skin). Both techniques may be used in different segments of the temporal incision. Beveling parallel to the follicles is always done in the occipital incision.
B. Intraoperative view of incision parallel to hair shafts to preserve the hair follicles. There will be some hair remaining on the inferior skin flap even after excision of excess skin.
C. Intraoperative view of incision beveled perpendicular to the hair follicles. Here the goal is for the hair of the superior skin to grow through the inferior non hair-bearing skin flap after redraping.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Posterior view of incision. Note the V-shaped wedge of tissue excised at the supra-auricular crease, which facilitates placement of a Penrose drain and pulls the hair-bearing skin inferiorly. This additional superior drainage site complements the suction drain, which only drains the lower portion of the dissection. The postauricular incision extends several millimeters onto the posterior conchal bowl itself (to account for the migration of the incision posteriorly with time) to about the level of the superior external auditory canal and then posteriorly for five centimeters and finally obliquely for one centimeter (to account for any tissue coning).
B. Intraoperative photograph of deep 5-0-polydioxanone (PDS) in the postauricular sulcus closure. Note that the stitch not only approximates the skin edges subcutaneously, but also secures the overlying skin and dermis to the underlying soft tissue exactly in the sulcus itself. This obliterates the dead space and also prevents possible migration of the incision posteriorly to a more visible location.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. A deep 5-0-polydioxanone (PDS) suture is placed through the deep dermis of the pre-tragal skin and secured to the underlying subcutaneous tissue prior to skin closure. This recreates the natural pre-tragal sulcus and also counteracts any anterior pull on the tragus.
B. Post operative appearance showing a natural appearing tragus. Note the preauricular sulcus, gentle posterior curve to the posterior edge, and no lateralization or anterior pull.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Correct orientation of pull on posterior skin flap in a superior and anterior direction. This properly realigns the posterior hairline. After redraping, some skin excision of the superior portion of the posterior skin flap as well as in the postauricular sulcus is necessary.
B. Intraoperative view of properly aligned posterior hairline on the right side. The surgical marking along the hairline is made before making any incisions and is used to realign the hairline after flap advancement and skin excision.
C. Postoperative view with properly aligned hairline.
D. Incorrect orientation of pull in a posterior and superior direction. This creates a step-off.
E. Postoperative view with a step-off. Also note the migrated postauricular scar and suture tracking.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Pixie ear or satyr ear deformity caused by excessive skin excision or tension at the earlobe. This can be avoided by incising the flap prior to SMAS dissection or placement or suspension sutures. At this step, the surgeon can easily estimate the distance of the insertion of the lobule onto the facial skin.
B. To further prevent tethering of the lobule, a mattress stitch with 5-0 polypropylene (Prolene) is placed at the free cut edge of the lobule and secured to the underlying tissues (personal communication with Clyde Litton, Washington, DC, 1986).
C. Photograph of a natural appearing earlobe.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Schematic of two possibilities for the male facelift incision. Note the temporal incision varies from the female incision. The male typically has an indefinite inferior extent to the sideburn, and thus temporal alopecia is not a concern. The incision may extend either in front (red line) or behind the tragus (purple line). If a retrotragal incision is performed, the hair follicle bulbs are excised from the undersurface of the skin flap in the pretragal region with fine scissors and/or cautery is used directly on the bulbs. This prevents hair from growing on the tragus once the skin flap is advanced, otherwise the patient may have to shave this area.
B. Schematic of the retrotragal male incision after skin excision and posterior-superior flap advancement. Note that the hair-bearing skin has been pulled onto the tragus. Two polypropylene (Prolene) stay sutures are placed at the superior and inferior margins of the tragus. Also, a cuff of non hair-bearing skin is left around the lobule and the postauricular incision is placed in the sulcus and not onto the posterior concha itself as in a female. These maneuvers are an attempt to prevent the male from having to shave in these areas.
C. Postoperative result of a male retrotragal incision. (The patient had just removed his eyeglasses which left an indentation. There is no hair loss in this area.)
(Courtesy of Russell W.H. Kridel, Houston, TX.)
- A. Preoperative photograph of a patient who has temporal alopecia secondary to scarring.
B. Postoperative result following tissue expansion, scalp advancement, excision of scars, and micro follicular hair transplantation. This photograph is seven months after receiving 160 micro grafts over one session to the right temporal scalp.
C. Postoperative result 17 months after a second session of 147 micro grafts.
(Courtesy of Russell W.H. Kridel, Houston, TX.)
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