This chapter represents the fifth or sixth major textbook chapter I have written on the subject of face and neck lift over the past 20 years. Although many of the techniques I use have remained, many have changed over the years. On that note, I have abandoned a given technique for another, then switched back to the original way I did it. This is not uncommon for seasoned surgeons and for that matter, this type of “learning” happens with many facets of our lives.
I personally believe there are two types of surgeons. One type of surgeon learns techniques in residency and fellowship and rarely deviates from this dogma throughout their entire career. The other type of surgeon, building on learned techniques, is on a continual search for improvement of patient safety and predictable outcomes. This type of surgeon is not satisfied with the status quo and in the bounds of ethics is continually thinking, “How can I make this better? How can I do this with fewer complications? How can I make this result better? How can I make this result last longer?” I confess that I am this type of surgeon. This drive for improvement is not purely subjective or intuitive but is based on decades of surgical experience, thousands of hours of continuing education, surgical journals, and videos and collegial interaction. Interacting with experienced colleagues has been one of the most powerful means of learning in my career. Having five high-volume surgical friends with progressive thinking and regularly interacting with this group by sharing victories and defeats knowledge is of extreme value.
At the time of this publication I have performed over 1000 facelifts with the following statistics:
27% had simultaneous full face CO 2 laser skin resurfacing
The scientific literature is replete with descriptions of early facelift techniques from the early 20th century that primarily detailed skin tightening via excision. In 1973, Skoog presented a technique of elevating the platysma muscle without detaching the skin. In 1976, Mitz and Peyronie described the superficial musculoaponeurotic system (SMAS), and later other authors described techniques of SMAS plication and imbrication. By the late 1970s and mid-1980s, a combination of complete platysma muscle transection, plication of medial borders, and pulling laterally was presented as the way to get the “best result.” Patient complaints, complications, and over operated necks occurred, and many of these techniques were abandoned. Deep-plane and subperiosteal techniques have been described by multiple authors, as have endoscopic approaches.
Face and Neck Lift Operative Technique
A surgical marker is then used to mark the following structures:
Preauricular and postauricular incisions
Inferior border of mandible if laser is performed
Outline of jowls to be liposuctioned
Outline of submental area to be liposuctioned
Submental crease for platysmaplasty incision
Ancillary markings if blepharoplasty, browlift or other procedures are planned.
There are many ways to make incisions and various surgeons have various approaches in females and males. I have tried virtually all of these approaches and from experience, I have settled on the described techniques because they have produced the best aesthetics on over 1000 facelifts. Female and male incision designs have nuances that relate to hair coverage, existing wrinkles, and bearded skin. To appreciate these nuances, the incision planning will be discussed from top to bottom and front to back. Some operations have incision markings that are approximate or can be estimated whereas other operations such as blepharoplasty and facelift require very precise and exact markings because the actual incision placement is critical to the success of the procedure. In the subsequent section, the markings are essentially described as incisions because they will be one in the same. A lot of description is put into each segment of the marking because each segment will also be an incision. The nuances of various incision placement are discussed to educate the reader on what type of marking and incisions are used and preferred. Complications of poor incision placement are also discussed.
The sideburn incision is extremely important to preserve the temporal hair tuft in a natural position. As simple as this sounds, it is not uncommon to see patients who are literally “scalped” and missing their sideburn. Unfortunately, numerous plastic surgery texts show this incision with a straight-line component that extends above the ear into the temporal hairline. Because the average vectors of pull in most facelifts are superior and lateral a combination of skin excision and elevation can produce a total loss of the temporal tuft ( Fig. 6.2 ).
To prevent temporal tuft elevation, many surgeons make a curvilinear incision at the junction of the natural sideburn and skin. Although this incision site will preserve the temporal tuft, it can be problematic if it scars or hypopigments ( Fig. 6.3 ). The most appropriate position for the sideburn incision is within the actual sideburn. It is best to make the incision in a curvilinear fashion so that there will be hair present above and below the incision ( Fig. 6.4 ). In this manner, not only is the temporal tuft not elevated but the incision is hidden within the hair. It is also of extreme importance to use a transfollicular (trichophytic) hyperbevelled incision in the sideburn (and all hair-bearing incisions). By holding the scalpel at an angle to create a thin bevel that transects 4 to 5 mm of hair follicles, the transected hair bulbs will regrow through the scar with superior aesthetic results in all hair bearing regions ( Fig. 6.5 ).
The male sideburn is somewhat less critical in patients with normal bearded skin because males can adjust the height of their sideburns by how they shave. The normal sideburn is approximately at the level of the lateral canthus; therefore this can be a starting point for male incision placement. Fig. 6.6 shows a before-and-after image of sideburn placement following this guideline.
The next leg of the incision is the superior portion of the helical attachment to the cheek. This is a critical marking because the skin of the ear and the skin of the cheek are very different in color and texture and the dividing line must be precisely placed. If this incision is placed too far anteriorly or posteriorly, the natural transition is lost and the skin color and texture can appear unnatural ( Fig. 6.7 ). There are two simple ways to properly position this junction ( Fig. 6.8 ). The first is to push the helical rim gently posteriorly. This creates a crease perfectly between the ear and the cheek and this junction is then marked. Another means of creating accuracy in this region is to simply push down harder on the marking pen. This pressure causes the tip of the pen to automatically fall in this junction. This incision is always placed the same regardless of gender.
The next marking is the tragus, and this is extremely important because poor tragal scars are one of the major stigmata of ill-planned incisions. Failure to properly address the tragus can create a blunted tragus or an unnatural pretragal scar. In general, a patient will not be aware of a blunted tragus, but when this occurs, other surgeons, patients, hair dressers, etc., look at it as a lack of finesse on the part of the surgeon. There are basically two means of addressing the tragal incision and that is a retrotragal incision (also called endaural) or a pretragal incision ( Fig. 6.9 ). There are advantages and disadvantages of both. In males, a pretragal (also called preauricular) incision is often chosen for numerous reasons. The first reason is that most males of facelift age have a natural preauricular crease which is convenient for incision. Also thicker bearded skin heals with less scaring, so placing the incision in the preauricular crease heals nicely in men. Another reason to choose the preauricular or pretragal incision in men is to avoid pulling bearded skin onto the tragus. This can occur when a retrotragal incision is made and when reconstructing the tragus, the bearded cheek skin is pulled over the tragus (see Fig. 6.9 ). This can look unnatural as well as being a difficult region to shave. With the advent of laser hair removal, this is less of a problem. Finally, it is less time consuming to avoid incising and reconstructing the tragus. Simply making an incision in front of the tragus is advantageous in men for all of the above reasons and is my go-to placement for male facelift. Men can also be treated with a retrotragal incision, and I have done this many times. A pretragal incision can be used in men who have a hairless region in front of the ear. In this situation, pulling bearded skin is less of a problem. It is important to discuss these finite details with the surgeon and/or patient ( Figs. 6.10 and 6.11 ).
Female facelift incisions can be made in the same manner as males ( Fig. 6.12 ).
Some surgeons advocate pretragal incisions in females and perhaps most of the time their patients heal with acceptable scars. I have, however, seen too many female pretragal incisions performed by other surgeons who left truly unacceptable scars ( Fig. 6.13 ). The main reason for poor pretragal scars is improper preauricular incision placement. Figs. 6.14 to 6.16 show several patients with optimal healing after facelift incision with the pretragal and retrotragal approaches performed by the author. Paratragal incision placement in females is also the decision of the surgeon and patient and is imperative to discuss preoperatively. The best incision to use is the one that works best in the hands of the given surgeon. In the first edition of my textbook, I advocated pretragal female incisions and used them on many hundreds of patients with good results; but encountered the occasional blunted tragus. Because of this, I began working with preauricular incisions on females and perfected them by using a triarcuate (three arcs) approach (see Fig. 6.14 ). This includes gentle curves at the helical attachment, the pretragal area, and the lobe. By incising at the natural junction of these arcs, an extremely aesthetic incision is produced and has become my preferred approach on both genders. There are few straight lines on the head and neck, and a straight line pretragal incision is not preferable in my opinion (see Fig. 6.13 ). Gentle curves in the correct junction of ear and cheek skin is the key to acceptable incision scars in both males and females.
A distinct tragus is essential for a natural appearing facelift and a blunted tragus accentuates the external auditory canal ( Fig. 6.17 ). A retrotragal incision is preferable as long as the surgeon has mastered tragal flap contouring and reconstruction of the natural appearing tragus. If a surgeon cannot craft a natural tragus or repeatedly experiences tragal blunting, they are better off performing a preauricular incision. As stated, when a pretragal incision is used, it should never be a straight line, but rather consist of three distinct crescents: one crescent around the helical attachment, one around the tragus, and one at the lobe border. These crescents serve to break up the scar.
After the tragal portion, the incision continues inferiorly traversing the incisura to the lobe. Some surgeons make a right-angle incision at the incisura whereas I prefer to cross the incisura junction with a gentle curve ( Fig. 6.18 ). The specific approach should be determined by the best scar in the hands of the surgeon.
Every single millimeter of incision is critical for a natural result. The earlobe is very important and is frequently very mismanaged by surgeons. I prefer to simply outline the natural junction between the lobe and cheek with a gentle curve (arc) because this has provided the best aesthetics in my hands.
There are numerous ways to mark and incise the postauricular incision. Some surgeons advocate making the incision several millimeters superior to the postauricular crease which places it higher than the crease. The thought is that during healing, the skin will contract, and the actual incision will be hidden in the postauricular sulcus. One limitation of this approach in males is the possibility of pulling bearded skin onto the posterior ear. The other means of placing this incision is to simply place it in the base of the postauricular sulcus. I personally use this approach, and it had provided superior aesthetics in my hands ( Fig. 6.19 ). This incision should meet the hairline incise at a 90-degree angle (see Fig. 6.19 ). Using a 4-0 gut running mattress suture with slightly everted edges has proven to be the most aesthetic closure of this area ( Fig. 6.20 ).
The final leg of the incision marking is also one of importance, varied use, and opinion. True facelifts have posterior auricular incisions. Many short cut facelifts omit the posterior auricular incision and for this reason are limited in dissection and management of excess neck skin. The sideburn and postauricular incisions should be perpendicular to the vector of pull to be most effective in lifting the jowls and neck. Because the general aging vectors are inferior and anterior, the rejuvenative vectors should be posterior and superior. The most natural vectors are superolateral if the patient were in the upright position, which would approximately be the 10 o’clock position on the right side and 2 o’clock position on the left side ( Fig. 6.21 ). This makes it obvious why facelift procedures that do not have a posterior incision cannot provide as much skin pull in the proper vector as traditional facelift procedures that always include a posterior incision.
The posterior auricular incision is placed at various levels by different surgeons, but clearly there is a right and wrong position. Some surgeons make this incision low in the mastoid region. The only (and) minimal advantage for this would be that the flap dissection is shorter and therefore less surgery and less skin trimming. The problem is that in the mastoid region, the incision is very visible because there is more exposed skin from the helical rim to the posterior hairline ( Fig. 6.22 ). A visible low mastoid incision is an additional stigma of poor incision planning.
The most aesthetic posterior incision is one that occupies the smallest area of visible skin on the posterior auricular region. The optimal place for a hidden incision is at or slightly above the greatest width of the pinna. This is the widest portion of the ear which means that it has the smallest amount of exposed skin from the helical rim to the posterior hairline ( Fig. 6.23 ).
Students of facelift surgery will notice that some surgeons advocate a right angle where the vertical sulcular incision meets the horizontal hairline incision whereas other surgeons recommend a curved junction instead of a right angle. Having done this both ways many times I still find the right-angle incision to be easier to trim and is my choice (shown in Fig. 6.19 ). The abrupt angle of this type of incision and flap would lead some to believe that flap viability would be a problem but breakdown at this right-angle junction has not been problematic. Regardless of the angle, breakdown can occur at this junction but is usually limited and rarely is significant scarring a problem.
The posterior hairline incision is equally controversial and has numerous descriptions of various techniques. The entire thought process of skin incision design basically surrounds an aesthetic hidden scar with a natural hairline that allows adequate access and is optimally positioned to assist proper skin pull vectors. Most facelift surgeons use either a transverse tapering incision hidden in the hairline (dashed yellow line in Fig. 6.24 ), a similar tapering incision that is lower in the hairline (solid white line in Fig. 6.24 ) that follows the occipital hairline, or a lower tapering incision at the junction of the follicles and skin (dashed blue line Fig. 6.24 ).
I have used all of these incisions and I prefer the mid-hairline incision (solid white line) because with careful placement, the skin excess can be trimmed and allow the scar to be hidden totally within the hair (middle and right image in Fig. 6.24 ).
If the occipital hairline incision is used, the incision should be beveled from the hair to the neck skin (see Fig. 6.5 ). This allows some hair follicles to regrow through the suture line. Beginning surgeons often ask how long the occipital hairline incision should extend. It is generally the amount of neck skin excess that determines this. Patients with significant neck skin excess (turkey gobbler) require larger lifts and hence larger posterior hairline incisions. The key is to have sufficient dissection to address the neck skin excess without a dog ear at the hair line terminus. Significant neck skin excess requires larger soft tissue dissection on the flaps and hence a longer posterior incision. Smaller lifts have a smaller length hairline incision. If a dog ear is present after extending the incision, it must be eliminated to a passive tension closure.
All of these incisions should be made in a transfollicular manner to allow hair regrowth through the scar. I used the incision that extended into the hairline (white hashed line in Fig. 6.19 , yellow hashed line in Fig. 6.24 ) with hundreds of lifts and generally had invisible incisions without significant hairline changes. Scar contraction and healing can produce small notching in the hairline and this can be disconcerting for patients who wear their hair up. Even with the best planned incision and surgical technique, small notching can occur. This is more of a problem with larger lifts that have longer posterior flaps. For this reason, I switched to (and currently use) the mid-occipital hairline (solid yellow line) incision but with several requisites. First and foremost, the incision has to be transfollicular (trichophytic) with extreme bevels and transecting hair follicles as shown in Fig. 6.25 . Second, it is important to place the incision within the hairline enough to have hair on the superior and inferior portions of the incision, which will further hide the scar ( Figs. 6.26 and 6.27 ).
With careful analysis of 1000 facelifts, I initially used the more superior horizontal hairline incision. I have, however, switched to a hyperbevelled occipital hairline incision which produces the most consistent results of aesthetic scars. This is not true if the incision is not transfollicular (trichophytic) and a right-angle scalpel incision in this area can lead to noticeable scars. There are steps that need to be taken to avoid a stepped hairline or damage to hair follicles with all posterior hairline approaches, and this will be described in the complication section of this chapter.
Most patients will never see this postauricular scar, but other doctors and hairdressers surely will. A great facelift with poor scars is no longer a great facelift and a surgeon’s reputation can be enhanced or detracted by scar quality. The main problem with this incision is that if and when it does not heal properly, it is extremely obvious and can preclude patients from ever wearing their hair up. Transecting 4 to 5 mm of hair follicles with a steep bevel is the best means of a predictable occipital hairline incision. I try not to place the occipital incision at the skin/hair junction. Many times, placing the incision here will heal well, but an ungracefully healed incision can be very noticeable ( Fig. 6.28 ).
The submental incision is frequently described as being made “in the submental crease”. In some people with a normal crease, this may be appropriate but there are some caveats and exceptions. The first consideration is the location of the submental crease. If it is very superior and would be visible, making the incision several millimeters inferior to the crease is preferable. I prefer making the incision about 3 to 5 mm below the actual submental crease. If a moderate to large chin implant is planned with a facelift procedure, this added horizontal projection can displace the submental crease anteriorly to a more visible position, and hence the incision should be made more inferiorly to compensate for this. Another situation that calls for lowering the submental incision is the patient with chin ptosis. The aging chin will frequently gain fat and lose bone support and become ptotic (witches’ chin deformity). Part of this deformity is caused by the deepened submental crease that separates the chin from the neck. If the incision is made in this crease, it can actually worsen the deformity. These patients are also treated with a submental incision inferior to the actual submental crease ( Fig. 6.29 ).
Using a straight edge to mark the patient’s midline and horizontal axis through the planned incision will assist in correct positioning of the submental incision. It is not uncommon to see crooked or skewed submandibular incisions. This can occur because of the patient position on the operating room (OR) table or from marking after anesthesia has been injected. A crooked incision can be very noticeable and proper marking of the X and Y axis with the patient awake in the upright position enables accuracy ( Fig. 6.30 ).
Again, this section on a relatively simple step of “marking the patient” has turned into a very detailed description. As stated, the reason for this level of detail is the fact that these simple pen markings will turn into the actual facelift incisions, which will turn into scars, and how and where these incisions are placed will critically impact the incision aesthetics of the lift or the lack thereof. Remember, the only part of the surgery that the patient and others see is the incision.
Like any surgery, the very first step of facelift surgery is to make sure the correct patient is getting the correct operation on the correct area. Surgical timeout has become a mandatory standard of care and should be performed on all procedures. Facelift surgery frequently involves numerous simultaneous cosmetic procedures and often involves older patients with medical issues and allergies. All of the planned procedures and medical caveats need to be recited out loud in front of the entire OR staff before any surgery is performed ( Fig. 6.31 ).
The main goal of cosmetic anesthesia is to provide a safe procedure that renders the patient relaxed and insensate with stable vital signs. This includes a rapid emergence, no postoperative nausea and vomiting, adequate pain control, and reasonable discharge time. Because hypertension will increase bleeding, it is important to maintain a normotensive anesthetic, especially toward the end of the procedure. It is not uncommon to maintain low blood pressure during surgery and have a hemostatic surgical field, only to bleed as the patient emerges. This can contribute to postoperative hematoma. Some surgeons prefer hypotensive anesthesia, and in this situation, it is important to slowly increase the blood pressure to a normal range before closing the wounds to make sure that new bleeding does not occur. This will be discussed at a greater level in the complications section of this chapter. Hypertensive patients may be treated with 0.1 to 0.2 mg of oral clonidine the day of surgery and for the next several days. Some surgeons advocate a clonidine patch placed the night before surgery.
Anesthetic techniques vary from total, local, and tumescent and oral sedation to TIVA (total intravenous anesthesia which is deep sedation) to intubated general anesthesia. Propofol and ketamine anesthesia with BIS (bispectoral index monitoring system). All of these techniques have positive and negative consequences. Early in my career, I performed most facelifts with intravenous (IV) anesthesia and tumescent local. My personal preference for the past decade has been intubated general anesthesia because it provides a totally protected airway and does not use nausea causing opiates. Modern anesthetic gasses allow for fast induction and recovery and work well in the accredited office ambulatory surgery center with professional anesthesiologists or certified registered nurse anesthetists. Patients can be intubated with laryngeal mask airways or endotracheal tubes depending on the preference of the surgeon and anesthesia personnel. I am steadfast that the experience for both surgeon and patient is better with an unconscious patient. A surgeon can perform more precise surgery on a patient who is not moving and talking, and a patient will be more comfortable when unaware of surgery. Having said this, the best technique is the one that is safe and effective and produces happy patients.
Because my original training was oral and maxillofacial surgery, I am trained and licensed to perform IV sedation and general anesthesia. Early in my career, I performed many facelifts while doing my own anesthesia and surgery (with the assistance of trained staff) because this is safe in the head/neck region. I still perform surgery/anesthesia from time to time on smaller cases to maintain my skills. As my facelift practice progressed, I began seeing many more patients, and many of these patients were older with significant medical comorbidities, who required a higher level of anesthetic care. In general, I think it is more efficient and safer to have trained anesthesia personnel during surgery, which includes physician anesthesiologist and certified registered nurse anesthetists. This basically represents the standard of care in cosmetic facial surgery for ambulatory outpatient office anesthesia. There are a number of surgeons from various specialties who do perform their own anesthesia, which would include oral sedation, conscious sedation, and tumescent anesthesia with IV sedation, etc.
Surgical Preparation and Draping
After the IV is started and the patient is induced and intubated, the staff performs a “pre prep”, which is disinfecting the regions of the face and neck that will be injected with local and or tumescent anesthesia. This is performed in a clean but not sterile manner. Also, at this point, a felt tipped surgical marker is used to mark the cricothyroid ligament on each patient. Although I have never had to establish an emergency airway, this would be more difficult after tumescent injection, so preemptive marking is performed. The carotid pulse is also marked on the neck in the event of emergency because it can be difficult to locate on some patients. Thinking ahead is the essence of surgery.
Some surgeons perform facelift surgery in a “surgically clean” environment, although all facelifts in my accredited office surgery center are performed under full sterile technique as if done in a hospital. Although infections are rare in the head and neck, I believe it is the standard of care to use sterile techniques. In addition, especially when performing simultaneous browlift and other procedures, facelift surgery can be bloody. Using sterile techniques, completely gloved and gowned, and fully draping the patient’s entire body protects not only the patient but also the surgeon and staff.
The face and hair are washed with a surgical preparation, and sterile towels and a split sheet are draped over the operating field. The surgeon and staff wear sterile gloves, mask, surgical cap, and eye protection, and all instruments are sterile. Because facelift with combined procedures can take hours, special considerations for the patient must be followed. I prefer a gel-filled head “doughnut” to cradle the patient’s head on the operating table and pressure points such as elbows and knees are cushioned with the same material to prevent nerve or tissue damage. All facelift patients are also prescribed compression hose to be worn for the procedure and the next 24 hours and sequential compression devices are used with general anesthesia. Being vigilant for infection, cross contamination, pulmonary emboli, and intraanesthetic problems is a constant challenge for all surgeons and staff and is part of the standard of care. For facelift surgery and anesthesia, intraoperative IV fluids are kept to a minimum. Most cosmetic facial patients do not experience significant blood loss, and administering excess fluid may necessitate a urinary catheter to prevent intraoperative micturition of bladder distention.
Females or patients with long hair present a relative problem for surgery in that the hair can continually be an obstacle during the procedure. After the full head and neck preparation with betadine, the hair is gathered in tufts and secured with orthodontic rubber bands so a part is made in the areas of hair bearing incision ( Fig. 6.32 ). Some surgeons shave some hair in the incision line, I have never done this. A 2-0 silk suture is threaded through the pinna to serve as an ear retractor throughout the case. This simple technique works well because it is effective, not bulky, and does not require continual passing of retractors ( Fig. 6.33 ).
Sterile cotton pledgets are placed in the external ear canal to prevent blood and surgical debris from entering the external auditory canal. Dried blood on the tympanic membrane can produce significant postoperative discomfort. It is imperative to remember to remove the cotton ball at the end of the surgery because it may get pushed into the ear canal and forgotten.
Protecting the eyes is also imperative because operations that last hours and involve numerous procedures can put the eyes or corneas at risk. If blepharoplasty is performed, this is done first and a tarsorrhaphy is performed using 6-0 gut suture. This is a simple mattress suture placed through the grey line on each lid and tied to safely secure the lids and left in place until the end of the procedure. If blepharoplasty is not performed, a transparent adhesive dressing is placed over the lids to keep them in the closed position during the case. Bandage contact lenses can also be used to protect the cornea, but the risk of inadvertently leaving them in is problematic, and a sign is put on the door of the operating suite to remind the team to remove them.
The video portion of this text includes several actual live surgery narrated facelifts presented in a step-by-step fashion. I believe the preferable learning technique is to read this chapter in its entirety and then view the video cases. Alternately, the reader could refer to the videos as they progress through the chapter. In the three video cases presented, they each show the same steps of operation on different patients. Because of this, the viewer will see anesthesia technique on three different patients, incision techniques on three different patients, etc. These techniques are repetitive but performed on different patients with different indications.
Local and Tumescent Anesthesia
Even when using general or IV anesthesia, local and tumescent anesthesia is used for all facelift surgery. This is invaluable for pain control, hemostasis, and tissue hydrodissection, and reduces the amount of IV or gas anesthetic agents required. All incision sites are injected with 2% lidocaine with 1: 100,000 epinephrine. The tragus and underside of the tragus is also injected with local anesthetic because it is innervated in part by Arnold’s nerve, which is a branch of the Vagus nerve and the underside of the tragus may otherwise remain sensate.
Tumescent solution (0.1% lidocaine with 1 : 1 million epinephrine) is injected into the submental area. This standard Klein’s solution is made by mixing 1 g of lidocaine (50 mL of 2% lidocaine or 100 mL of 1% lidocaine) with 1 L of normal saline and adding 1 mL of epinephrine 1 : 1000. Because an entire liter of solution is not generally required in facelift surgery, a smaller volume may be used by halving the components ( Fig. 6.34 ). Alternately, a more concentrated solution can be safely used and is the surgeon’s preference. A common formula for a more concentrated hemostatic effect is mixing 1.5 mL (1.5 ampules) of 1 : 1000 epinephrine and 50 mL of 1% lidocaine with 500 mL of normal saline. This produces 0.1 % lidocaine and 1 : 333,333 epinephrine.
There are numerous ways to inject tumescent solution including large hypodermic syringes, hand pumps, and peristaltic pumps (Klein pump). I use a Klein pump with an 18-gauge spinal needle ( Fig. 6.35 ). A smaller 22-gauge spinal needle or blunt injection cannula is recommended for novice surgeons, and regardless of the injection tip, the injector must remain vigilant of the significant vascular structures in the head and neck.
For facelift surgery, 500 mL of tumescent solution is generally adequate volume for all areas. Approximately 125 mL of the tumescent solution is injected in the preauricular and postauricular regions bilaterally and the same amount in the submental region Fig. 6.36 ). Basically, all undermined areas are injected ( Fig. 6.37 ). Unlike body liposuction that requires “rock hard” tumescence, the face and neck do not need this level of infiltration. All the areas are injected at the same time because the local anesthetic effect lasts for many hours.
No surgery is begun until the tumescent anesthesia has taken effect, which is evidenced by skin blanching in the injected areas ( Fig. 6.38 ).
The Surgical Procedure
When performing multiple procedures, it is important to stage the procedures in a manner to facilitate patient safety and surgical team comfort and ergonomics. Facelifts are usually not a single procedure; many patients also have upper and midface procedures as well as skin resurfacing. The surgeon and surgical team should stage the procedures to optimize the anesthesia, keep bleeding to a minimum, and keep the work flow efficient. There is generally no right or wrong way to stage procedures, and much of it depends on the surgeon’s preference. I personally like to do the procedures that demand the most precision first; after 3 to 4 hours of surgery, fatigue can make delicate and precise surgery more difficult. For this reason, I perform blepharoplasty and browlift first and wear loupes (for the blepharoplasty) and a headlight. After the eyelid surgery, I remove the loupes and retain the headlight for the remainder of the procedure. It is also important to be able to stage the instrumentation so various procedure trays can be removed from the field increasing efficiency. I perform the blepharoplasty and browlift first and hand off those trays, which makes the main instrument table less cluttered and easier for the surgical assistants to find and pass instruments. Keeping things simple greatly facilitates the harmony of surgery. Like any art, the process of surgery is beautiful when it flows correctly. An experienced surgeon with experienced staff literally glides through the procedure like ballet. When I say that I have performed over 1000 facelifts, it means my surgical nurse and assistants have done the same. They can anticipate and read my body language and know the procedure so the correct instrument is placed in my hand almost subconsciously. They know when to retract, when to pull, when to cut, and improve my work and accuracy. They excel at what they do to the point that I ask and appreciate their input during surgery. A good assistant is a copilot, navigator, and caddie and is simply invaluable. Any surgeon who has to rotate assistants at the hospital or has frequent office staff turnover can attest to the inefficiency this can bring. It is also beneficial to have a team break every hour and have a reward (sugar-free mints), stretch, and wipe blood from gloves and patient. This adds a little fresh start and breaks up the case and the stress.
The first incision in facelift surgery varies by surgeon preference. In my experience, most surgeons begin with the submental incision and platysmaplasty, then move on to one side of the facelift for dissection, SMAS treatment, and skin closure and end by performing the same steps on the contralateral side, which completes the lift. Right-handed surgeons tend to approach the patient’s right side first and left-handed surgeons usually approach the left side first, although it does not make a clinical difference.
The Balanced Facelift Technique
I also perform what I refer to as “the balanced facelift technique”. This involves making all incisions, dissections, suspensions, and excisions at the same time. In other words, I do the platysmaplasty dissection, open the left side and perform that dissection, then move to the right side and perform that dissection. This is the “dissection phase”. Next, I perform all suspensions. I do the midline platysma plication and SMASectomy on both either the right and left side. This is the “suspension phase”. Finally, I perform the “excision and closure phase”. This involves performing the key sutures and skin excision on both sides and final closure. My reason for performing this technique is to “balance” the various factors that can contribute to a substandard result. I believe there are numerous factors that “build in” laxity during the facelift procedure; for instance, pulling a dissected side against a tumesced side. The dissected side is free but the tumesced contralateral side is inflated and rigid, and I believe that freeing both sides before retracting the excess skin makes a tighter result. Having all flaps open also allows the surgeon to monitor bleeding in all areas throughout the case. Finally, having all the skin dissected at once and having all the “plication” performed at once may provide a more balanced draping and traction when compared with the more common technique of doing one side from start to finish, then moving to the second side. My tendency is to use this technique on larger cases involving patients with high body mass index or exceptional skin excess. This particular technique also may equalize the amount of skin removed from one side or the other. Classically, more skin is removed from the first side of a facelift as the surgeon is pulling across the midline. On smaller lifts this is less of a problem, but on very large lifts, having a lot of skin removed on the first side and less removed on the second side could lead to unwanted hairline changes of the first side. Although I perform this “balanced” technique on some patients, I have no evidence-based data proving it superior.
Figs. 6.39 to 6.41 demonstrate the surgical sequence in the balanced technique.
Step-by-Step Facelift Technique
(This section will parallel the videos for this text)
In the discussion of facelift surgery there are so many techniques that can be confusing. To simplify this, I am going to begin discussion by describing my main technique for comprehensive facelift. This is more of a discussion of “How I do it”, and not a comprehensive analysis of all available techniques, which is beyond the scope of this book. During this section, I will also discuss such common techniques as deep plane facelift and also short scar facelifts. Although it may seem rational to discuss small techniques first, my goal is to discuss the comprehensive techniques so the reader can understand the process of a comprehensive facelift. Before understanding the “tricks of the trade” you must first understand the trade.
The first incision is begun in the submental region at or below the submental crease as described earlier. A crooked incision in the area is very noticeable so care should go into a straight and level marking. An adjunct to making a straight incision in this area is to use the index and second finger in an inverted “V” position (like the peace sign) to stretch the skin in opposite directions while making the incision. This places the skin on stretch and enables a straighter line as compared with dragging the scalpel through loose skin ( Fig. 6.42 ). The incision can be slightly curvilinear with slight upturn of the edges in some patients with full necks. The length of the submental incision can affect final aesthetics, and the shorter the better. The average width of the submental incision is 3 to 4 centimeters. Some surgeons also make a small ellipse instead of a straight line to remove a small amount of skin in this region. An incision that is too small limits access for platysma treatment and an incision that is too long can be aesthetically problematic because “dog ears” can develop laterally in this region during closure ( Fig. 6.43 ).
Another consideration is the patient with a ptotic (witches’) chin and a deep submental fold. These patients already have a deformity with a very deep submental crease that delineates the chin and neck. If the submental incision is made in this deep crease, it can worsen the situation. In these situations, the incision should be made 5 to 10 mm inferior to the submental crease, and the subcutaneous dissection should undermine the deep crease, which will release it and improve the cervicomental region. Some patients with ptotic chins are also good candidates for a silicone chin implant that supplies a supporting scaffold for the floppy chin and supports it for a more natural appearance ( Fig. 6.44 ).
Once the dissection begins, the surgeon can dissect superiorly to free the tethered submental crease which helps relax the witches’ chin deformity ( Fig. 6.45 ). Not all patients require dissection superiorly and it is mostly used in older patients with ptotic chins. This superior dissection also produces bleeding in this vascular area.
After the submental incision is made the surgeon’s preference dictates how the cervicofacial liposuction will be done. Some surgeons prefer to perform neck liposuction first using a small stab incision in the submental region and perform “closed” liposuction under a vacuum. I prefer to dissect the neck flap with scissors first and perform “open” (direct vision) liposuction to remove the subcutaneous fat with direct vision. When using scissors to dissect the anterior neck flap there are several factors that greatly facilitate this step. First, I prefer to use blunt-tipped, angled, facelift scissors for this region because they are more ergonomic and I believe gentler on the flap ( Fig. 6.46 ). Second, I use a Cottle double-hooked ring retractor to place tension on the flap that I dissect ( Fig. 6.47A ). This tension facilitates the actual dissection by keeping the tissues taught and the scissors in the correct plane and not “bumping” into lose tissue and folds. As the dissection proceeds distally, the ring retractor is placed deeper on the underside of the flap to maintain even tension. Finally, the surgical assistants stretch the flap vertically and horizontally ( Fig. 6.47B ). This also places tension on the lose skin and facilitates gliding through the tissue.
The initial anterior neck dissection proceeds commensurate to the amount of skin excess. Younger patients may only require dissection to the level of the hyoid bone or thyroid cartilage whereas older patients with advanced aging may require undermining to the level of the sternal notch and clavicles ( Fig. 6.48 ).
The average facelift patient has an adequate amount of subcutaneous fat and the depth of the initial neck dissection is important. Although fat is oftentimes perceived as the enemy, it is very important to “cushion” the skin after dissection as well as to produce a natural textural result. It is imperative to have this cushioning interface between the platysma and the dermis. Excessive cervical fat removal that allows the dermis to scar to the platysma can produce an unnatural result that can be difficult if not impossible to correct ( Fig. 6.49 ).
The astute surgeon will always control the submental flap thickness to allow sufficient fat on the dermal side of the flap to produce a natural texture and contour. As the scissors are inserted into the submental flap at the proper depth, inferior dissection proceeds by gently cutting and spreading of the scissors. Most facelift scissors will cut on the inside and outside edges, so motions of clipping, advancing, and spreading will be used ( Fig. 6.50 ).
Some patients have very fibrous tissues and offer resistance to dissection, whereas others have more delicate architecture, and in these patients the scissors can be spread open and simply and easily advanced to perform dissection without any “clipping” of the scissor tips. Some surgeons prefer dissecting with the curved scissor tips pointing up at the dermis whereas others prefer the opposite. As long as the dermis and underlying vessels are protected, the position is personal preference.
Although the subcutaneous plane is generally safe for dissection, significant neurovascular structures exist in this area. The anterior jugular veins are often encountered in the midline and the internal jugular vein may be encountered in the lateral neck ( Fig. 6.51 ). Because of this significant anatomy, dissecting with the scissor tips facing the dermis in this area may be preferable.
After the inferior scissor dissection is performed, the area is checked for bleeding and a bipolar forceps is used for hemostasis ( Fig. 6.52 ). Absolute hemostasis is an essential part of facelift surgery, and this is addressed continually throughout every phase of the case.
At this point the cervical fat will be addressed and it is very useful to have a lighted retractor, which greatly facilitates both retraction and vision ( Fig. 6.53 ) for undermined flaps.
Cervicofacial fat deposition is variable and although some patients have little or no excess fat, others have extensive deposits ( Fig. 6.54 ).
Liposuction is the act of removing fat, and liposculpture implies that we are sculpting the fat. This is a more accurate term because removing fat is not necessarily the definitive procedure. Liposculpture is an important part of facelift surgery. In some areas, significant fat may need to be removed or reduced whereas in other areas only a small amount will be reduced, and some patients require no removal. In addition, some areas of fat are “sculpted” where the surgeon reduces the fat in a manner to terrace the anatomy in to a more normal shape. Understanding the submental anatomy is paramount to effective liposculpture. Most patients (except very thin people) have an adequate layer of subcutaneous fat ( Fig. 6.55A ). This fat lies between the dermis and platysma and a generous layer should be left on the dermis when dissecting. Not leaving adequate dermal fat can produce a very irregular and tethered result. Deep to the platysma, lying between the anterior bellies of the digastric muscles is a deeper fat accumulation that in some patients may be excessive and contribute to bulge in the submental region ( Fig. 6.55B ).
Although I own an expensive liposuction machine, I do not use it anymore. Standard surgical wall suction connected to the plastic surgical bucket that collects suctioned blood is generally adequate for facial liposuction. Our liposuction cannulas have tips that fit into the standard suction tubing, and we take off the surgical suction and replace it with the liposuction cannulas during the liposuction procedure ( Fig. 6.56 ).
For the actual submental liposuction, a 4-mm or 6-mm spatula tip cannula is generally used first, and cannula size is commensurate to the amount of fat present. The liposuction is performed in long rapid reciprocal motions under direct vision with the aid of the lighted retractor ( Fig. 6.57 ). The endpoint is generally obvious as the surgeon is directly observing the fat removal or reduction. In addition, red aspirate instead of fat is another endpoint. The skin can be pinched with the thumb and index finger in the area treated to determine consistency of fat removal. It is important to always keep the orifice of the cannula facing the fat and not the dermis as permanent grooves can occur in the dermis. The general deposition of subcutaneous fat is from the mandibular border to the thyroid region between the sternocleidomastoid regions. In heaver patients, the fat can extend to the clavicles.
The 6-mm cannula is then rotated 90 degrees, and gentle and conservative liposuction is performed just under the mandibular border ( Fig. 6.58 ). This maneuver serves to reduce the fat to better outline the mandibular border and will also facilitate scissor dissection of this region that will be performed later in the operation. Because the marginal mandibular nerve branch can run superficially in some patients, caution is exercised in the area of the medial mandibular border. It is very important to understand that when mandibular border liposuction is performed, the target is the fat immediately under the jawline and not the fat over the jawline. By sculpting the fat inferior to the mandibular border, the border itself will be more defined, but removing fat over the mandibular border can reduce the definition. A general rule is whenever in doubt about fat removal with liposuction, error on leaving fat instead over overtreatment. More fat can always be removed later.
As stated earlier and to clarify semantics, if a small stab incision was made on the submental crease and the liposuction was performed through this incision, it would be termed “closed” liposuction because it is not performed under direct vision. Open liposuction occurs when the fat removal is performed with direct observation of the cannula and fat.
I do not remove the deeper subplatysmal fat on the average patient. Even if there is a slight convexity of submental fat, the midline platysmaplasty sutures will elevate it towards the floor of the mouth and reduce bulge. Some patients clearly have isolated deep midline fat that require reduction. If excessive deep subplatysmal fat is present, it is grasped with forceps, elevated and trimmed with scissors or bipolar forceps and an open lipectomy is performed ( Fig. 6.59 ).
Again, the surgeon needs to keep in mind that some deep neck soft tissue reduction will be accomplished by the midline sutures and be cognizant not to over resect this deep fat ( Fig. 6.60 ).
At this point, most surgeons proceed to the platysma plication. Many facelift patients can benefit from chin implants for further profile enhancement, which is especially true with patients who have microgenia, retrognathia, or obtuse submental anatomy as discussed earlier. I only use silicone implants and they are placed through the submental incision after the liposuction is completed. The superior part of the chin incision in retracted with a double pronged skin hook which stretches the underlying tissues. Using a radio wave surgery microneedle, Bovie tip, or scalpel, an incision is made in the midline to the level of the mandibular periosteum. The midline is a safe plane because there are no critical structures in this region. Once the mandible is encountered, the excision is widened to about 10 to 15 mm. At this point, a No. 9 periosteal elevator is inserted, and dissection is performed superiorly to the level of the mandibular vestibule (sulcus), which frees the mentalis muscles in the subperiosteal plane. The periosteal elevator is then turned parallel to the mandibular border and dissection is completed to the second molar region. Great care is used to avoid the mental nerve and vessels which exit the mental foramen about 15 mm superior to the mandibular border in the region of the second premolar. If the No. 9 periosteal elevator tip is kept at the level of the mandibular inferior border while dissecting laterally, the tip will remain inferior to the neurovascular bundle in the average patient with teeth. The nerve is not in normal position in many edentulous patients so greater caution must be used in this group. Once the subperiosteal implant pocket is developed bilaterally, the silicone implant is placed and properly aligned vertically and horizontally, and in the patient’s midline. Most implants lie just at the inferior border of the mandible and must also be placed without any pitch or yaw. Once the implant is properly positioned and midline verified, it is secured with a single titanium retention screw ( Fig. 6.61 ). This is most often adequate to stabilize the implant and prevent rotation. If the implant appears to be rotating, a second screw can be placed for antirotation.
Although some surgeons do not advocate platysmaplasty, I have previously underlined its importance. For midline platysmaplasty, I perform a simple corset or “shoe string” platysmaplasty where a portion of the medial portion of the platysmal bands in the midline are resected and the margins sewn together. Most text books refer to this as a “plication”. The root word of plication is plica which is Latin for “fold or ridge”, so technically the platysma is not plicated. A platysmorrhaphy (as in herniorrhaphy) would be a more accurate word because the suffix “orrhaphy” is Greek for “stitching or joining a seam”. Platysma suturing or apposition (positioning side by side) will be used in this text. Numerous ways to suture the medial platysma borders have been described. Some surgeons use a single running suture, some use simple interrupted sutures whereas others suture the midline, then bring the lateral portions together with an additional suture in the midline ( Fig. 6.62 ). Finally, some surgeons excise as much of the platysma as possible to eliminate it all together.