Face-Lifting, What Not to Do

C^hapter 65

65

look. If this technique is not performed, an unnatural look of the pretragal area will result, taking away the advantages of the postauricular tragal scar.

65.1    The Incisions

Do not make an incision behind the sideburns and elevate the skin flap since it will elevate the sideburns to too high a position leaving a bald spot in front of the ear pinna.

Unless the elevation is minimal it should not be done. To achieve proper excision of thick skin after undermining, a counterincision below the sideburns is necessary. The excess skin is then not removed at the expense of hairy skin and it is only done in remov- ing bald skin and elevating the lower incision edge to the actual sideburn area (Figs. 65.1, 65.2).

Often also in men this approach is necessary and it could prevent a thinning of the sideburns in front of the ear if the beard happens to develop low in front of the ear. If the hairy cheek occupies a large zone, its elevation will prevent a thinning of the width of the sideburn and will be adequate. A curved incision at the sideburn is less visible than a horizontal incision (Figs. 65.1, 65.2).

65.1.2    The Tragal Area

The placement of the face-lift incision behind the tra- gus reduces the appearance of the preauricular scars;

however, a few important points must be kept in mind. Avoiding tension on the skin flap will prevent the distortion of the tragus, which is pulled forward and leaves the ear canal open. Although it might be necessary to defat the flap going over the tragal carti- lage, excessive defatting will lead to skin necrosis:

thus the maneuver should be done with care. Before suturing the skin flap, which should be rounded or rectangular, it is a good technique to defat the anteri- or portion in front of the tragus and in front of the auricular canal in an attempt to allow a depression to be created in front of the tragus, keeping a natural

Face-Lifting, What Not to Do

Adrien E. Aiache

Fig. 65.1. Excess skin should not be removed at the expense of hairy skin in the sideburn area for fear of ending-up with a bald spot

Fig. 65.2. At the sideburn a curved incision is less visible than a horizontal incision

65.1.3    The Earlobe

Rounding the skin excision around the earlobe pre- vents the straight effect of the skin flap distorting the shape of the ear–cheek junction (Fig. 65.3). The poste- rior skin incision should not include some conchal skin since this would obliterate the postauricular sul- cus and tether the ear cartilage to the mastoid, mak- ing the postauricular area unsightly and the sulcus more shallow than it is normally. This maneuver should be done with care in attempting to leave the postauricular scar exactly in the postauricular sulcus and then more posteriorly over the mastoid. In an at- tempt to limit the visibility of the scar in the mastoid, a zigzag fashion might be a good idea and, in addi- tion, will make the hair implantation more natural- looking than if the incision is straight (Fig. 65.4).

65.1.4    Facial Incisions

Pretragal versus retrotragal incisions are always dis- cussed. Incisions in front of the pinna can be either vertical or oblique; however, if they are oblique and support the facial skin with a large amount of tension, they can become hypertrophic. A perilobular incision is lifted or pulled in the retroauricular area. The retro- auricular incision should be in the sulcus but not situ- ated on the ear since it could obliterate the postauricu- lar fold. The mastoid incisions could be either hori- zontal or oblique, lying high or low. If they are oblique and there is a fair amount of tension on the skin, they could be hypertrophied, especially in younger pa- tients. If they are horizontal, they might need to be placed very high, thus allowing a bald area to be situ- ated behind the ear, which is not a pleasant situation.

If the mastoid incision is performed in the hair scalp junction, the best technique is then to perform a W- plasty which will hide the visibility of the scar and give a better appearance to the hair implantation.

The retrotragal incision, which is useful in hiding the pretragal scar should be done carefully. A rectan- gular portion of the flap should be left on the skin to allow coverage of the tragus without an unnatural look since a straighter or less-rounded or squared flap could make the appearance of the tragus unnatural.

This flap can be defatted, however carefully, and in addition, in men the hair can be plucked. Careful dis- section should be performed to avoid sloughing of the skin in that area. The perilobular excision should not leave a low scar which could cause an unnatural look.

If the scar is too high, it could pull the ear up, also leaving an unnatural look. It should be performed carefully and with checking that the right amount of skin is removed. It is a good idea to have it rounded around the earlobe and to leave a scar on the skin it- self with a very thin amount of skin on the earlobe.

This allows a more natural appearance of the earlobe.

Fig. 65.4. A zig-zag incision makes hair implantation more natural-looking than a straight incision

518

Scalp incisions should be closed with relatively small tension. A careful galea approximation might release some of the tension from the skin itself but not totally; a second subcuticular level closure should be absolutely tension-free. Muscle excision should be limited to the corrugator and possibly the external su- perior portion of the orbicularis oculi muscle.

Frontalis muscle excision leaves a thin atrophic ex- pressionless forehead. Extreme tension on the tempo- ral area could result in hair loss of the whole temple and even skin slough.

65.2    The Neck

Extreme platysmal work or bleeding in the neck re- sults in scarring with induration and distortion which can be treated later by steroids, massages and ultra- sound.

Fat suction should stop at the level of the mandible or 1 cm below it since the skin is elevated, thus expos- ing the defatted neck over the border of the mandible, ending-up in an unsightly appearance of the man- dibular border. It is better to have a little more fat be- low the mandible than having a very thinned-out mandibular border. The skin might look fat if it has not been suctioned; however, in banding the neck, ugly wrinkling can result after vigorous suction and can be avoidable unless the neck is not defatted at all (Fig. 65.5).

Extreme defatting of the neck results in a vertical wrinkling of the skin over the hyoid and thyroid car- tilage, making it look older and unnatural. Careful defatting in that area is advisable.

Do not sever completely the platysma since it could give a really acute angle to the submandibular area, distracting from the beauty of the neck. Do not suc- tion vigorously the chin area at the level of the man- dibular border. The skin elevation of the face-lift might end up placing the suctioned area over the mandibular edge, ending in an unsightly appearance at this level. In suctioning when the platysma’s bands are objectionable, only an elongation of the bands can be useful by performing limited myotomies which can help the elongation of the muscle. The corset pli- cation may result in a tight middle band looking quite unsightly.

65.3    Over the Mastoid

The posterior incisions should be designed to accom- modate the skin elevation obtained in some cases where the neck skin is not in excess. The scar can re- main behind the ear sulcus and not enter the mastoid area, which is then a very good advantage.

A low placement of the scar in the mastoid will help in lifting the neck skin; however, in young per- sons keloids can develop if the scar is low and oblique.

The scar should be made at the limit of the scalp and be in a zigzag fashion to prevent keloid formation. A high incision may be the cause of postauricular bald area and should be avoided; a very large flap excision is necessary when a large amount of excess tissue is present. One should be extremely careful in these cases not to raise the hairline too high in the posterior auricular mastoid area (Fig. 65.6).

Fig. 65.5. Bad wrinkling can result after vigorous suction in the neck and can be avoided.

65.4   

The Brow and the Forehead

Do not excise the frontalis muscle. That could result in skin adhesion to the calvarium and an unnatural appearance of a frozen forehead without expression.

In elevation of the forehead, the scar should be in W shape to avoid a visible track. Even sometimes it will be necessary to implant hair plugs to minimize that scar.

Do not remove the retro-orbicularis oculi fat un- der the brow since it could result in brow adhesion to the orbit and prevent its movement.

Do not fix the brow to the orbit by suturing it to the periosteum since it will immobilize it.

Do not excise the corrugator completely since it will eliminate the frown and its attendant lines; how- ever, it will create a depression which is unsightly and difficult to correct.

Check the height of the brows before deciding to raise them. They are often higher than you think and any elevation will result in an exaggerated look (Fig. 65.7).

The shape of the brow is distorted when:

1. An aggressive corrugator procerus removal (even with endoscopy only) is performed on a medial brow that is already positioned too high. The re- sulting “surprised look” is then difficult to cor- rect.

2. The medial part of the brow is elevated in addition to the lateral and central brow when it is detached from his periosteal attachment.

3. The lateral brow can less often be too high except in cases where it is already highly positioned, oth- erwise a pleasant lateral elevation is not a prob- lem.

4. On patients who have a tall forehead, it is prefera- ble to place a pretrichial incision. However, de- pending on the direction of hair growth and the patient’s hair style, a straight scar can be visible and it should be avoided by making a “W” incision.

Hair transplants on the scar help in attenuating scar visibility.

5. Problems arising from that pretricheal scar include the fact that the continuation of this incision in the scalp might leave a thin, hairless zone, thus giving patients dissatisfaction because of the visibility of that hairless area.

Do not pull undermined skin in only one direction since it will end up giving a “wind-tunnel” appear- ance to the face. Levels of elevation and tension have to be at different angles up to 90° of divergence.

65.5   

The Skin Flap and Its Thickness

Elevation of the skin flap can vary according to the needs of the area. Patients who have had multiple facial injections including fat, Restylane, Perlane and so on may have a scarred cheek area between the skin and the superficial musculo-aponeurotic system (SMAS), leading to potential problems.

The decision of undermining thickness can trigger problems. Undermining of a skin flap could end up with devascularization of the cheek, leading to skin necrosis. Do not undermine superficially close. If the surgeon decides to make the flap thicker, he/she could inadvertently end up elevating the SMAS with the skin flap, resulting in multiple problems.

Beware of motor nerve injuries in elevating a sec- ondary skin flap, especially when dissecting anterior

Fig. 65.6. One should be careful not to raise the hairline too

high in the posterior auricular mastoid area Fig. 65.7. Undermined skin should not be pulled in only one direction since it could give the “wind-tunnel” effect. Levels of elevation and tension have to be at different angles

520

to the parotid since it could lead to nerve injury and localized paresis. Deep secondary elevation of the skin flap can enter the superficial parotid, resulting in a parotid cyst or fistula (Fig. 65.8).

65.6    SMAS Elevation

The SMAS should be freed from below in two crucial areas. The parotid ligaments should be released as well as the malar ligaments. During surgery the re- peated elevation of the SMAS will eventually deter- mine the ideal point of release and exhibits an in- creased lower face elevation which will indicate the complete freeing of these ligaments.

The suturing of the SMAS on the arch should be carefully performed in order to avoid injuries to the motor branch of the facial nerve. The SMAS should be elevated vertically to prevent an oblique cutting ef- fect on the facial tissues and laterally it should be su- tured in front of the ear canal and the earlobe in order to prevent compression of the SMAS edge on the pa- rotid and facial nerve element, possibly ending in temporary facial paralysis (Fig. 65.9).

Do not suspend the relatively heavy malar mounds to the eyelid zone that could be dragged down by their weight, giving an ectropion or a lower-lid malposi- tion.

65.7    Hypertension 

Hypertensive patients should be avoided, otherwise they should be controlled by treatment designed to lead them through surgery. An internist in charge of their problems is often useful.

Postoperative nausea and vomiting should be tightly controlled to avoid the mechanical conse- quences of retching and vomiting leading to venous congestion in the face. Clonidine, Phenergan, Zofran are all used for that purpose.

65.8   

Evaluation of Patients 

– Hypertension: Do, if mild and under control. Do not do, if severe, not controlled, or associated with cardiovascular problems.

– Bleeding problems: Do, if mild and controlled. Do not do in patients with von Willebrand’s disease, with heavy doses of anticoagulants or supplements, and in patients with easy bruising which is uncon- trolled.

– Psychological problems. No.

– Unattractive old patients who have hope of becom- ing younger and more attractive: An ugly young girl will become an ugly old one, no matter how her skin is tightened. No.

– The patient who saves her last cent and expects to regain youth and beauty in one shot. No.

– The patient who asks multiple questions for an ex- tended consultation, requires many photographs, visualizations, criticizes some of your best results and criticizes other physicians that she has seen previously, and then negotiates your fee to the low- est possible range. No.

– The 73-year-old woman who comes in with a pic- ture of herself when she was 20 years old, or even sometimes, when she was a baby. She has saved all her money for that. No.

Fig. 65.8. Deep secondary elevation of a skin flap could end-up in a parotid cyst or fistula