Introduction

While injectable treatments and nonsurgical modalities are becoming increasingly popular today, the most comprehensive solution to facial aging requires surgery. Today, face-lift techniques have become advanced in terms of better understanding of anatomy and maneuvers that produce the longest-lasting results. What was once a skin-only procedure has evolved into surgery that addresses deeper tissues and skin independently, while still appreciating the importance of safety and a relatively short recovery period.

Patient Evaluation

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  All patients are encouraged to bring photographs from their youth. While patients are told they cannot be made to look exactly like they looked when younger, a similar shape and greatly improved appearance can be reliably obtained.

  
  
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  Care and attention is paid to preoperative evaluation. Almost always, the two sides of the face will be noticeably asymmetric. For instance, there will be a dominant chin, wider palpebral aperture, long and short side, asymmetric brows, etc. These patients should be noted preoperatively.

  
  
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  Skin quality, elasticity, the extent of soft tissue descent (i.e., jowling), and underlying bony support is evaluated, as these qualities will all influence the final result of surgery.

  
  
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  The neck is evaluated at rest and by having the patient tense the platysma muscle (i.e., grimace). Significant banding, an obtuse cervicomental angle, indistinct thyroid cartilage bulge, noticeable pre- and postplatysmal fat, and excess skin are all signs of neck aging.

  
  
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  If patients exhibit significant signs of deflation in addition to descent of facial soft tissues, then autologous fat grafting should be considered.

  
  
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  In males, there are several considerations regarding hair and incision placement. The sideburn in males tends to be lower than in females; patients should be informed that the position of their sideburns may shift. Also, patients should be warned that they may have to start shaving behind their ears following the procedure because of the effect of skin redraping.

  
  
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  Male patients should also be informed that there is a higher risk of hematoma formation postoperatively compared to female patients.

Steps for the Male Face-Lift

The patient is marked preliminarily in the preoperative holding area and then brought to the operating room. After administration of general anesthesia or intravenous sedation, a neurosurgical headrest is used to allow proper head position and the surgeon to operate closer to the patient. At this time, a solution consisting of 150 cc of normal saline, 50 cc of 1% lidocaine, and 1 ampule of epinephrine is injected into the neck and first side of the face. The patient is then prepped and draped in standard fashion.

If the neck is treated, in certain patients, closed liposuction can produce a dramatic result. More commonly, the neck is treated in an open fashion ( Fig. 8.1 ). A No. 10 blade is used to open the submental incision and undermine the flap for 1 or 2 cm. Face-lift scissors are then used to elevate the subcutaneous flap above the platysma muscle down to the level past the thyroid cartilage, commonly caudal to the first cervical crease. Next, a single-port liposuction cannula is used to remove fat from the medial borders of the left and right platysma muscle for better visualization. Interrupted 3–0 buried Mersilene sutures are placed to approximate the platysma in the midline (starting at the thyroid cartilage and working up), followed by a running layer on top of this repair (with 3–0 or 4–0 Mersilene). Commonly at this point, a several centimeter wedge of platysma is resected caudal to the repair if significant banding is present; this maneuver breaks the continuity of the band. Hemostasis is achieved and then a temporary gauze placed.

Attention is then turned to the cheek. A preauricular incision is frequently used in males, as most males usually have a prominent preauricular crease and to avoid redraping hair-bearing skin onto the tragus. With the exception of secondary cases, an incision hidden in the temporal hair is used. A full retroauricular incision is used in an S-shaped pattern, with the only portion of the incision not hidden in the hair or in the retroauricular sulcus is a small segment that is completely covered by the ear ( Fig. 8.2 ). On occasion in the bald male, a total circum–auricular pattern is used, though in males a full pattern is often needed to address excess cervical skin laxity.

After making two preauricular stab incisions, the cheek flap is preliminarily undermined with a 2.4-mm cannula off suction. The incisions are opened with a No. 10 blade and, using a thimble hook, undermined for several centimeters before switching to face-lift scissors. In the cheek, precise flap elevation is paramount to balance flap vascularity while leaving enough tissue on the SMAS. In the temporal region, the flap is raised in a consistent subcutaneous plane to allow greater versatility in flap redraping; at this time, a transverse cut is made at an acceptable location along the sideburn, and two staples are placed at the medial extent of this incision to avoid flap tearing ( Fig. 8.3 ). Retroauricular flaps are kept thick to avoid sloughs (“yellow up white down”), though great care is taken to avoid injury to the great auricular nerve, which can be identified 6.5 cm below the tragus.

Once significant flap elevation has been achieved, a lighted retractor is used. The subcutaneous flap is dissected caudally, releasing the mandibular ligament and is then connected to the submental incision. It is critical to keep the platysma muscle down in this region as injury to a cervicomandibular branch can occur if dissection is deep to the muscle. Hemostasis is achieved as necessary.

At the completion of subcutaneous flap undermining, where the end point is determined based on mobility and “feel,” the angle of the mandible is marked. Below this mark, the lateral border of the platysma is briefly suctioned with the single-port liposuction cannula and is then grasped with long forceps, lifted, and elevated bluntly with vertical scissor spreads. Great care is taken to stay on the immediate undersurface of the muscle to avoid a motor injury as well as injury to the external jugular vein. Blunt spreading can be used, and the platysma retaining ligaments are released ( Fig. 8.4 ).

At this point, a decision regarding SMAS treatment is made based on preoperative examination, photos from the patient’s youth, intraoperative assessment of platysma/SMAS mobility and SMAS quality, and overall clinical judgment. If an SMAS flap is selected, then the plane of the platysma flap is continued cranially, taking care to release the zygomatic and masseteric ligaments while avoiding zygomatic facial nerve branches. The SMAS flap superiorly can then be sutured with a high fixation or the excess trimmed, and then sutured into place with interrupted 3–0 PDS (polydioxanone) sutures. The platysma portion of the flap is secured to the mastoid fascia also with 3–0 PDS sutures, with care taken to span the great auricular nerve.

If SMAS plication is performed, the zygomatic arch is palpated and marked. Using a pair of forceps, the SMAS below the zygoma is grasped and elevated superiorly to assess the amount of SMAS that can be plicated. The goal is to build volume over the zygoma, restore malar deflation, and correct lower facial laxity. The SMAS is plicated medially starting at the level of the lateral canthus with interrupted 3–0 PDS sutures. The malar fat pad is anchored to fixed soft tissue, and care is taken to avoid deep bites medially as injury to a motor branch can occur. A second running 3–0 PDS layer is performed to smooth and even the plication. Then, the platysma flap is secured to the mastoid fascia with 3–0 PDS ( Fig. 8.5 ).

At this point, meticulous hemostasis is achieved, while removing any irregularities directly and dissecting any tethering points. The contralateral side can be injected with local at this time. The skin is redraped and a 3–0 Monocryl placed in the deep dermis at the retroauricular apices as well as in the cheek at the level of the root of the helix. Excess skin is trimmed conservatively with care not to create tension. All the incisions in the hair are stapled, while the preauricular skin is closed with 5–0 nylon. The retroauricular skin is closed with a running 4–0 plain suture. A drain is also placed in the retroauricular incision and secured with a plain suture on either side ( Fig. 8.6 ).

Attention is turned to the second side. The same SMAS procedure is performed, but if necessary, a different procedure can be performed if mandated by the patients’ preoperative examination and anatomy. At the conclusion of the second side, hemostasis is obtained in the neck, and the submental incision closed with a running 5–0 nylon suture.

The patient is placed in a multilayered head dressing, aroused from anesthesia, and taken to the recovery area.