Patients undergo facelifts to improve their neck and jawline but would ot consider visible or poor scarring a good trade-off in most cases. While many plastic surgeons can demonstrate how good their postoperative jawline, neck, and midface results are, it is equally important to have little to none of the telltale signs of having had a facelift such as being pulled too tight or poor incisions resulting in conspicuous scars, loss of the sideburn and a hairline moved too high up into the temporal area, and an evident step-off behind the ear in the occipital hairline.
Proper incision placement is the most important aspect of a facelift in my opinion. With good incision placement, most of the aforementioned problems can be avoided. The loss of the preauricular tuft of hair in the sideburn area in women is common. This comes from the often-used vertical incision that comes up from the ear superiorly into the temporal hairline. As loose facial skin is pulled up from the cheek area, the preauricular hairline has no choice but to go up resulting in loss of the sideburn and a high temporal hairline. Such hairline loss may result in the female patient being unable to wear their hair pulled back due to this unnatural appearance. I prefer to make a horizontal cut at and into the preauricular tuft of hair subsequently resulting in keeping its position intact, regardless of how much skin is pulled up and removed.
The incision around the earlobe is another potential visible area. While the incision must be made at the junction of the earlobe and facial skin, the earlobe needs to be ‘cradled’ after to keep this incision away from being ultimately seen. This technique will almost always result in a more detached or separated earlobe from the side of the head which must be closed with a few small sutures but the facelift incision will sit up high under the earlobe. Even if it decends a little bit with time, it will still not ever be seen and the dreaded ‘pixie-ear’ deformity will not develop.
Another frequent problem is a step-off in the occipital hairline behind the ear when non-hair bearing skin is redraped into where scalp hair used to be. This is a reflection of neck skin that is redraped back too far in the wrong orientation. While I use an incision whcih extends from the fold of the ear back into the scalp hair, I pull the skin up directly superiorly and anteriorly, rather than in a posterior and superior direction. This allows enough scalp hair to remain after trimming to put back a well-aligned occipital hairline.
While there are some other fine details that do make a postoperative incision difference in a facelift, I find that these three areas (sideburn, earlobe, and occipital hairline) make the biggest differences in avoiding poor facelift outcomes in the female patient.
Dr. Barry Eppley
Indianapolis, Indiana