Chapter-44-Lamellar High SMAS Face-Lift

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Part 1 Facial Aesthetic

T E C H N I Q U E S

B

A

C

D

TECH FIG 5  • A. The face-lift marker. The use of a flap marker provides a reliable means for appropriate excisions of skin to be made. The pin on the lower jaw of the marker is placed near the edge of the incision. The skin flap is then draped over the lower jaw of the instrument, and the instrument is closed. On closing, the upper jaw of the instrument marks the precise position of the edge of the scalp flap beneath it. B. Incorrect trimming of postauricular skin flap. It is an error to excise any skin over (superior to) the apex of the occipitomastoid incision and shorten the post- auricular flap along the long axis of the sternocleidomastoid muscle. There is no true excess of skin along this vector nor any aesthetic benefit from shifting skin in this direction. C,D. Proper insetting of the earlobe. In the artistically ideal “nonsurgical” appearing ear, the long axis of the earlobe ( dotted line ) sits approximately 15 degrees posterior to the long axis of the ear itself ( solid line ) in the lateral view (C) . As this angle is reduced, or the axis of the lobule shifted anterior to the long axis of the ear, an old, unnatural, and “face-lift look” is produced (D) .

correctly, often skin redundancy will be present on the posterior surface of the ear. This can be easily treated by excising a triangle of skin in this area. ■■ If the temporal portion of the face-lift incision has been made on the temporal scalp, the incision is closed in one layer without excision of any hair-bearing temporal tis- sue. A small amount of cheek skin and scalp only will be excised immediately above the ear. If the temporal incision has been made along the hairline, skin only will be conservatively trimmed and closure performed in one layer without any skin tension using a combination of half-buried vertical mattress 4-0 nylon sutures and sim- ple interrupted 6-0 nylon sutures. ■■ After all planned procedures have been completed, the patient’s hair is shampooed, rinsed, and detangled, and no dressings are required or applied.

■■ There is nothing as telltale as an abnormal position of the earlobe, and for this reason, the lobule should be inset as the last step in the preauricular closure. The cheek flap should be trimmed and the earlobe inset so that the lob- ule ends up situated in a posterior and somewhat supe- rior position even if it was in a more anterior and inferior position before surgery. This is because the long axis of a natural appearing earlobe ideally sits approximately 15 degrees posterior to the long axis of the ear itself ( TECH FIG 5C,D ). As this shifts anteriorly or too far inferiorly, an unnatural “face-lift look” is produced. Insetting the lobule in the proper position often requires the lobule be released from tethering tissue. It is then secured in two layers to protect the incision in the first few weeks from disruption when patients pull clothing, jewelry, and other items off over their heads. If the lobule is inset