12 Secondary deformities and the secondary facelift

Synopsis

Although many aspects of planning and performing secondary facelift surgery are similar to those of the primary procedure, one must identify and treat not only new problems that are the product of age, but those that have resulted from any prior procedure as well. Often it is these secondary deformities that present the biggest challenge in terms of creativity, planning, preparation, and technique.

Recognizing the problems in the secondary facelift patient and appreciating their underlying anatomical abnormalities is fundamental to planning and performance of any repair. Although not all problems can always be completely corrected, any surgeon able to recognize their anatomic basis can, through the application of logic and careful planning, select techniques that are safe, effective, and rational.

Secondary deformities are worth every surgeon’s consideration, even if he or she performs only the occasional secondary procedure, as they exist as compelling reminders of mistakes to avoid in the planning and performance of any primary procedure.

The placement of an incision and thus of the resultant scar along a hairline at secondary surgery represents a choice between two imperfect alternatives but the best overall artistic and aesthetic compromise in many patients.

Using the SMAS to lift sagging facial tissues and restore facial contour circumvents the problems associated with skin-only facelifts, as it is an inelastic structural layer capable of providing meaningful and sustained support. Although skin must be excised in SMAS procedures, only redundant tissue is sacrificed and closure can be made under normal skin tension.

“Lamellar” dissections, in which the skin and SMAS are dissected as two separate layers, offer the important advantage that skin and SMAS can be advanced different amounts, along separate vectors, and suspended under differential tension. This allows each layer to be addressed individually as indicated and, in turn, results in a more comprehensive and natural appearing improvement.

It is not enough in most secondary facelift procedures to limit treatment of the neck to pre-platysmal lipectomy and post-auricular skin excision in secondary facelift patients. For many patients, subplatysmal fat accumulation, submandibular salivary gland “ptosis”, and digastric muscle hypertrophy will contribute significantly to their neck deformity and necessitate additional treatment.

As experience is gained in evaluation of patients presenting for secondary surgery, prominent submandibular glands will increasingly be recognized as a frequent part of the secondary neck deformity and the underlying cause of objectionable residual bulges in the lateral triangle of the lateral submental region. In most instances, the secondary facelift will provide an opportunity for proper diagnosis and appropriate treatment, when present.

The secondary facelift will generally require a comparatively small resection of skin and an increased focus on correcting deep layer problems and secondary deformities, depending upon the skill of the surgeon performing the primary procedure and the type of technique used.

Secondary facelifts are often time consuming and technically demanding when compared to primary procedures and are likely to test the patience and composure of most surgeons.

Many patients requesting secondary facelifts are chronologically elderly, but deceptively young in appearance. A careful medical history must be taken because they often have medical problems consistent for their age group.

The opportunity to perform a facelift is a unique artistic privilege granted to us by our patients that carries a significant responsibility. It deserves nothing less than our best effort, and a few extra hours of our time in the operating room benefits them for the rest of their lives.

Performing a secondary facelift if frequently a considerable undertaking and its difficulty should not be underestimated. The procedure must be carefully planned, meticulously carried out, and the patient’s safety and wellbeing unfailingly insured.

Performance of the procedure itself only fulfills part of our obligation to the patient and the care they receive perioperatively is arguably as important as the surgery itself. Diligent perioperative care will ensure the best result and reduce the likelihood that problems and complications will occur.

Introduction

The increased number of patients seeking facelifts at a younger age, coupled with the continued good health of an older group of patients who have already undergone one or more procedures, has resulted in a significant increase in requests for secondary and tertiary procedures. Although many aspects of planning and performing secondary surgery are similar to those of the primary procedure, additional considerations must be taken into account in the evaluation and treatment of the patient presenting for secondary facelift, as one must identify and treat not only new problems that are the product of age, but those that have resulted from any prior procedure as well. Often, it is these secondary deformities that present the biggest challenge to the surgeon in terms of creativity, planning, preparation, and technique.

Consideration must also be given to possible underlying anatomical damage that may have resulted from previous procedures but is not evident as a visible deformity. This includes possible damage to skin, fat, SMAS and deeper layer structures. Injury to these tissues at the time of the primary procedure can preclude certain maneuvers and limit the overall amount of improvement possible at the time secondary surgery is performed. “Red flag” procedures in this regard include radiofrequency and ultrasonic “skin tightening” treatments, prior “suture lifts”, and prolonged large volume use of facial fillers (“filler fibrosis”).

As in primary procedures, recognizing the problems in the secondary facelift patient and appreciating their underlying anatomical abnormalities is fundamental to planning and performance of any repair. Although not all problems can always be completely corrected, any surgeon able to recognize their anatomic basis can, through the application of logic and careful planning, select techniques that are safe, effective and rational.

Identification and analysis of secondary aging deformity

Surgery does not halt the aging process and patients requesting secondary or tertiary facelifts usually present with many of the same problems seen when they presented for their primary procedures. This is particularly true if the primary facelift was limited and consisted of skin excision and skin tightening only. In such instances, a tight or pulled appearance will typically be present, but problems of deep layer origin will still be evident and will likely have worsened over time. These include nasolabial folds, labiomental folds, cheek ptosis, infraorbital hollowing, malar flattening, jowl laxity, subplatysmal fat accumulation, submandibular gland hypertrophy, and cervical band formation (Fig. 12.1).

Fig. 12.1 Identification of secondary aging deformities. Surgery does not arrest the aging process, and patients requesting secondary facelifts usually present with many of the same problems seen when they presented for their primary procedures. This is particularly true if the primary facelift was limited and consisted of skin excision and skin tightening only, as with this patient. Problems typically seen include nasolabial folds, labiomental folds, cheek ptosis, infraorbital hollowing, malar flattening, jowl laxity, submental fat accumulation, and platysma band formation. Note that although some wrinkling and atrophy are present, the patient’s predominant problem is deep layer tissue ptosis. Additional skin excision and tightening under these circumstances will be of little benefit to the patient.

(Previous procedure performed by an unknown surgeon.)

Regrettably, many surgeons have been traditionally taught to perform a limited “tuck” or “touch-up” in secondary procedures consisting of additional skin excision and skin tightening. This does not address the true underlying problems however, and compounds the secondary deformities present in many patients.

Identification and analysis of secondary surgical deformities

The number and degree of secondary deformities present will determine the difficulty of any additional surgery and the overall potential for improvement possible. Typical problems seen in the patient presenting for secondary facelift include hairline displacement, hair loss, poorly situated scars, thick scars, wide scars, scleral show, eyelid dysfunction, tragal distortion, earlobe distortion, over-excision of cervicofacial fat, distortion and abnormal appearances due to inappropriate tissue shifts, and abnormal appearance when emoting. Less commonly, problems related to nerve injury, skin slough, or other surgical complications may be present. These problems are worth every surgeon’s consideration, even if he or she performs only the occasional secondary procedure, as they exist as compelling reminders of mistakes to avoid in the planning and performance of any primary procedure.

Hairline displacement and disruption

Hairline displacement and disruption remain predictable outcomes of many currently used facelift plans and are a source of disappointment and frustration for patients and surgeons alike. These problems are the result of poor analysis and planning at the time of the primary procedure and failure to use an incision along the hairline when indicated. Although hairline displacement may be acceptable after some primary facelifts in which incisions were made in the traditional location within hair bearing scalp, it will almost always be intolerable after a secondary facelift if such an incision plan is used again. For this reason, thoughtful planning of secondary and tertiary facelifts frequently requires the use of incisions placed along hairlines, rather than behind them.

The placement of an incision and thus of resultant scar along a hairline at secondary surgery represents a choice between two imperfect alternatives but the best overall artistic and aesthetic compromise in many patients. Although incisions upon the scalp produce concealed scars within the hair, they will result in tell-tale and objectionable hairline displacement in many patients that is usually readily apparent upon casual glance and at some distance. These deformities are often not subtle and frequently result in an unnatural or even grotesque appearance (Fig. 12.2). In addition, they are uniformly difficult for the patient to disguise and a challenge for the surgeon to correct.

Fig. 12.2 (A,B) Displacement of the sideburn and temple hair due to poor incision planning. The temporal portion of the facelift incision was made in the temporal scalp in a well-intended effort to hide the resulting scar. Because cheek flap redundancy was large and skin elasticity poor, advancement of the cheek skin flap has resulted in objectionable hairline displacement. An incision along the hairline would have prevented this deformity.

(Procedures performed by an unknown surgeon.)

Placing the incision along a hairline, however, usually results in a fine scar only visible on close inspection when correctly planned and proper technique is used. And unlike displaced hair, a scar along the hairline can usually be easily concealed with make-up or tattooed if necessary, but generally go unnoticed in most social situations and casual encounters. Often, they are difficult to detect even on close inspection (see Fig. 12.5). Attempts to disguise displaced hair by combing adjacent hair over these areas is no more effective than the “comb-over” hairstyles worn by many balding men. Although this is perhaps preferable to the patient to having bald spots and missing hair showing, it is immediately evident that the problem is still present in most cases.

The temporal portion of the facelift incision traditionally placed within the temporal scalp will frequently result in a tell-tale and unnatural-appearing superior elevation and posterior displacement of the temporal hairline. Secondary or tertiary facelifts using the same incision plan will compound this problem and often result in a bizarre appearing and objectionable absence of temple hair (Fig. 12.3).

Fig. 12.3 Sideburn elevation and displacement of the temporal scalp after multiple facelifts. A secondary facelift using the same incision plan as at the primary procedure has resulted in the telltale displacement of temple hair and elevation of the sideburn (procedure performed by an unknown surgeon).

This can best be minimized or avoided at secondary facelift by the use of an incision along the hairline (Fig. 12.4).

Fig. 12.4 Plan for incision along the temporal hairline. An incision along the temporal hairline should be considered whenever objectionable displacement of the sideburn and temple hair is predicted. Although a fine scar is present in these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full, youthful appearing sideburn.

If it is appropriately planned and carefully executed, an acceptable scar will result that is artistically and aesthetically superior to additional hairline displacement (Fig. 12.5).

Fig. 12.5 (A,B) Healed incisions along the temporal hairline. The use of an incision along the hairline, when indicated, can prevent hairline and sideburn displacement without compromising the end result. Although a fine scar is present in these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full, youthful appearing sideburn (compare with Figs 12.2 and 12.3).

(Procedures performed by Timothy J Marten, MD, FACS.)

In choosing the location of the temporal portion of the facelift incision, it is important to note the degree of existing temple “skin show” (Fig. 12.6) and consider it in conjunction with skin redundancy present over the cheek (Fig. 12.7).

Fig. 12.6 Temporal skin show. The distance between the lateral orbit and the temple hairline and how it will change with flap shift must be considered when planning the temple portion of the facelift incision.

Fig. 12.7 (A,B) Estimating skin redundancy over the upper cheek. Gauging the skin redundancy over the cheek assists in predicting the degree of temporal hairline displacement that will occur when the facelift flap is shifted.

This allows an estimate to be made of the degree of elevation and/or displacement of the sideburn and temporal hair that will occur when facelift flaps are shifted, and thus facilitates rational planning of incision placement. In certain instances, a sub-sideburn incision used in conjunction with a traditional incision on the temporal scalp will be adequate in preventing objectionable sideburn elevation and/or hairline displacement. In other situations, however, the incision must extend more superiorly along the temple hairline. Such an incision will accommodate large posterior-superior skin shifts and prevents tell-tale hairline displacement.

The occipital portion of the facelift incision is traditionally placed high upon the occipital scalp, in a well intended, but almost always counter-productive effort to hide the resulting scar. Unfortunately, any such a plan embodies an inherent defect in design that will preclude optimal improvement in the neck and frequently result in a tell-tale and unnatural appearing displacement of the occipital hairline (Fig. 12.8).

Fig. 12.8 Displacement of occipital scalp due to poor incision planning. The occipital portion of the facelift incision was made high within the occipital scalp in a well-intended effort to hide the resulting scar. Because cervical redundancy was large and skin elasticity poor, advancement of the neck skin flap has resulted in objectionable hairline displacement. An incision along the hairline would have prevented this deformity (procedure performed by an unknown surgeon).

A high transverse post-auricular incision plan presumes that the resultant vector of skin redundancy is directed mostly superiorly and that the majority of skin redundancy is present over the lateral neck. Both careful consideration and direct observation will reveal the proper direction of post auricular flap shift to be in a mostly posterior, slightly superior direction that roughly parallels the mandibular border if an optimal result is to be achieved in the cervicosubmental area. This is because it is along this vector that the majority of neck skin redundancy is present. As the flap is shifted along a more superiorly directed vector, as it must be with any high transverse occipital incision plan, tension will rise across the cervicomental angle, but a diminished effect will be seen over the anterior neck and submental regions. In addition, transverse cervical rhytides, if present, will be unnaturally shifted superiorly over the upper lateral neck and sometimes onto the pre-lobular and post auricular area. It must also be kept in mind that neck contour should be the result of deep layer repair, and not skin tightening. Thus, neck skin should be shifted and excised along a vector that allows maximum elimination of redundancy, and not one that appears to produce the most neck tightness.

Although occipital hairline displacement may sometimes be acceptable to patients after their primary procedure, secondary or tertiary facelifts using the same incision will compound this problem and usually result in an unnatural and intolerable absence of occipital hair and notching of the occipital hairline (Fig. 12.9).

Fig. 12.9 Elevation and displacement of the occipital scalp after multiple facelifts. A secondary facelift using the same incision plan as at the primary procedure has resulted in the objectionable displacement of the hairline (procedure performed by an unknown surgeon).

If an attempt is made to reconstitute the hairline by superior shifting of the post- auricular flap, a wide scar will usually result as the tissue discarded in any such maneuver is necessary for side-to-side head tilt and shoulder drop when the patient is in an upright position. These problems can best be minimized at the time of secondary facelift by the use of an incision along the occipital hairline (Fig. 12.10).

Fig. 12.10 Plan for incision along the occipital hairline. An incision along the occipital hairline should be considered whenever objectionable displacement of the occipital hairline is predicted. This incision plan protects the hairline and prevents hairline displacement.

If the incision is appropriately planned and carefully executed, an acceptable scar will result that is artistically and aesthetically superior to additional hairline displacement. In addition, this plan will sometimes allow scalp displaced at the primary procedure to be partially advanced back towards its proper position (Fig. 12.11).

Fig. 12.11 Healed incision along the occipital hairline. The use of an incision along the occipital hairline will prevent hairline displacement without compromising the end result. Although a fine scar is present in these patients, it is not evident upon casual inspection and they are free to wear their hair up off their neck in any manner they choose.

(Procedures performed by Timothy J Marten, MD, FACS.)

When and incision is used along the occipital hairline it should be planned in such a way that the inferior portion of the incision and thus the resulting scar is turned back into the scalp and at the junction of thick and fine hair on the nape of the neck (see Figs 12.10, 12.11). It should not be carried more inferiorly because it will be incompletely concealed and is likely to be visible to others (Fig. 12.12).

Fig. 12.12 Improper design of an incision along the occipital hairline. The incision has been made too low and carried too far inferiorly in front of the fine hair on the nape of the neck. It would have been better concealed if it had been made more superiorly and turned posteriorly into scalp hair more superiorly.

(Procedure performed by an unknown surgeon.)

Fundamental to obtaining an inconspicuous, well-healed scar when incisions are placed along the temporal or occipital hairline is the diversion of tension to deeper tissue layers and precise flap trimming so that wound edges abut each another under little if any tension before sutures are placed. The incision is then closed using a combination of half buried vertical mattress sutures of 4-0 nylon with the knots tied on the scalp side and multiple simple interrupted sutures of 6-0 nylon. The 6-0 sutures provide precise wound alignment and are removed in 5 days. The half buried vertical mattress sutures of 4-0 nylon provide wound support, while simultaneously avoiding cross-hatched marks. These sutures are removed 7–10 days after surgery.

Although incisions placed along the frontal, temporal, and occipital hairlines will prevent additional hairline displacement at a secondary procedure, they do not provide for correction of large and severe problems sometime seen (see Figs 12.2, 12.3, 12.8, 12.9). In these situations, consideration must be given to the use of hair flaps, hair transplantation, and scalp expansion.

Hair loss

Hair loss is an all too common and avoidable stigmata of facelift surgery seen in many patients presenting for secondary procedures. Hair loss is generally the result of technical errors, including improperly made incisions that damage hair follicles, placement of overly tight sutures, or the closure of inadequately mobilized scalp flaps under too much tension. It may occur, however, in smokers, certain individuals with scalp disease (alopecia areata), eating disorders, or patients with a variety of systemic illness in the absence of any wrong doing on the part of the surgeon. Consideration should be given to an origin of this sort before hair loss experienced by the patient at the primary procedure is attributed to technical error. Hair loss is also frequently the result of the ill-conceived shifting of scalp flaps along the wrong vector. This is commonly seen on the temporal scalp after erroneous attempts to smooth the forehead and glabella by applying lateral traction on the forehead flap (Fig. 12.13).

Fig. 12.13 Temporal hair loss. Hair loss is frequently the result of improper shifting of scalp flaps along the wrong vector. This is commonly seen on the temporal scalp after well intended but misguided attempts to smooth the forehead and glabella by excising temporal scalp and applying lateral traction on the forehead flap (procedure performed by an unknown surgeon).

The use of cautery near or within the plane of hair follicles can also result in hair loss, as can rough flap handling and pinching or prolonged folding of scalp flaps beneath retractors.

Small areas of hair loss resulting from tight suture placement or attempts at spot suspension of the scalp can often be corrected at the time of secondary facelift by direct excision after adequate mobilization of surrounding tissue or by incorporation of the hairless area into a more comprehensive incision plan (Fig. 12.14).

Fig. 12.14 Hair loss resulting from tight suture placement or attempts at spot suspension of the scalp. These problems can often be corrected at the time of secondary facelift by direct excision after adequate mobilization of surrounding tissue or by incorporation of the hairless area into a more comprehensive incision plan (procedure performed by an unknown surgeon).

Larger areas of hair loss resulting from excessive flap tension, an overly tight closure or ill-conceived scalp flap shifting are usually much more difficult to correct, especially if scalp excision was aggressive at the primary procedure and little residual redundancy is present (Fig. 12.15). In such instances, the patient and surgeon must accept that complete correction may not be possible at the time of secondary facelift and that hair transplantation, scalp flaps and even scalp expansion may be necessary at a later date. The goal at any secondary procedures in these patients is to select a surgical plan that does not further compound the problem.

Fig. 12.15 Large areas of hair loss. Large areas of hair loss are usually difficult to correct, especially if scalp excision was aggressive at the primary procedure and little residual redundancy is present. In such cases, complete correction may not be possible at the time of secondary facelift and that hair transplantation, scalp flaps and scalp expansion may be required (procedure performed by an unknown surgeon).

Poorly situated scars

Poorly situated scars are a common problem after primary facelift and the result of artistic insensitivity, poor planning, and tension-based surgical techniques. In many patients, secondary facelift will provide the opportunity to relocate these to a more appropriate, less conspicuous location, but in others it must be recognized and accepted that complete correction is not possible if additional problems are to be avoided.

Poorly situated scars are typically seen in the pre-auricular, peri-lobular, and post-auricular areas. They can also be found in the submental region in many patients. Proper placement of incisions is important, particularly in the pre-auricular area, because even a thin, well-healed scar will ultimately be visible and noticed by others in most cases as a result of the gradient of skin color and texture typically present on each side of it. Although differences in skin color can sometimes be concealed with make-up, differences in texture usually cannot. Scars placed along natural anatomic interfaces tend to be overlooked by the eye however, where a gradient of color and texture is expected to be seen and where the scar appears to be a natural crease on the face. Make-up becomes less necessary as the scar is lost in shadow, appears to be a natural part of the face, or is mistaken to be a reflected highlight (Fig. 12.16).

Fig. 12.16 Retrotragal scar. (A) The scar resulting from a properly situated retrotragal incision will usually be inconspicuous, even if it is suboptimally healed, as the eye will mistake it for a reflected highlight. Note the well-concealed scar on this darkly complexioned patient. A scar of the same type would be more obvious if the incision had been placed in a pretragal position. (B) A healed retrotragal face lift incision in another patient with fair skin. Transitions of color and texture are hidden along natural interfaces. (C) A healed retrotragal incision in another patient. If the incision is closed carefully, a natural appearance without anatomic distortion should result.

The pre-auricular region is a common point of reference for those seeking to identify the facelift patient, and, as such, it is of concern to patients and worthy of careful consideration by the surgeon. The pre-helical portion of the pre-auricular scar is often situated too far anteriorly in the patient presenting for secondary surgery and the illusion of the scar as an anatomical feature is lost. Moving this scar so that it rests in the helical-facial sulcus will result in a less conspicuous scar and a more natural appearance. This is generally possible in most secondary and tertiary cases if skin resection has not been overly excessive at prior procedures (Fig. 12.17).

Fig. 12.17 Improper and proper placement of pre-helical scar. The pre-helical portion of the pre-auricular scar is often poorly situated (A,B) and the illusion of it as an anatomical feature is lost. (A) The pre-helical incision has been made too far anteriorly and the illusion of the scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (B) The pre-helical incision has been made too far posteriorly and has obliterated the helical facial sulcus and part of the helix itself. The illusion of the scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (C) A patient with a properly placed pre-helical incision. The scar has been placed directly in the helical facial sulcus. In this location a transition of color and texture is expected and the scar appears to be a natural anatomical feature.

(Procedure performed by Timothy J. Marten, MD, FACS.)

Although it is not possible to move a pre-tragal scar to a “retro-tragal” position along the margin of the tragus in every patient presenting for secondary surgery, this is preferred when possible, for the reasons outlined above (Fig. 12.18). The feasibility of relocating a pre-tragal scar to a retrotragal position will depend on the amount of cheek skin redundancy that remains after the primary procedure. Because preoperative assessment of residual cheek skin redundancy can be difficult and exceedingly deceptive at the tragus, it is sometimes best to make the initial incision along the existing pre-tragal scar, when present. The decision to sacrifice the remaining skin over the tragus and move the scar to the tragal margin can then be delayed until after cheek flaps have been mobilized, SMAS advanced, and the actual amount of cheek skin recruited through these maneuvers, if any, determined. Often, skin recruited is needed to recreate an absent pre-tragal sulcus and to correct a “buried tragus” deformity. In such instances, relocation of a pre-tragal scar to the margin of the tragus will not be possible and the existing pre-tragal location of the scar must be accepted. If the secondary facelift incision is initially made along the margin of the tragus when a pre-tragal scar is present but before intraoperative assessment of skin redundancy can be made, needed skin may be erroneously excised. This will force an inappropriately tight closure and result in tragal distortion, tragal retraction, and obliteration of the pre-tragal sulcus.

Fig. 12.18 Pre-tragal and retrotragal incisions compared. (A) Pre-tragal incision in a patient presenting for secondary facelift. The scar has healed satisfactorily but attention is drawn to it due to differences in color and texture on each side of it. (Procedure performed by an unknown surgeon.) (B) Same patient after secondary facelift in which incision was moved to a retrotragal position. Color and texture differences, and the scar itself, are hidden along natural anatomic interfaces.

(Procedure performed by Timothy J. Marten, MD, FACS.)

The peri-lobular area is a common location for poorly situated facelift scar in secondary and tertiary facelift patients. Typically, it is low lying due to poor planning and the skin settling that occurs after “skin only”, non-SMAS facelift techniques (Fig. 12.19).

Fig. 12.19 Improper and proper placement of the peri-lobular incision. (A) The peri-lobular incision has been made too far inferiorly and is evident even on casual inspection. (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift. The peri-lobular scar has been placed more superiorly and in such a manner that it is hidden by the lobule itself. In this location it cannot be seen.

(Procedure performed by Timothy J. Marten, MD, FACS.)

Unlike the pre-helical and post-auricular portions of the facelift scar, however, which should be placed directly in their respective anatomic creases the peri-lobular scar should not lie directly in the lobular-facial crease because the crease itself constitutes a delicate, aesthetically significant anatomical subunit that cannot be reconstructed and should not be disrupted. Other factors being equal, a superior result will be obtained if the scar is situated a few millimeters inferior to this junction and an attempt is not made to join thin, soft earlobe skin directly with course, thick cheek skin. As is the situation with the relocation of other scars about the ear, relocation of the peri-lobular portion of the facelift scar at the time of secondary or tertiary facelift will depend on the amount of cheek skin that remains after the primary procedure. If cheek skin excision has been excessive at the primary procedure, or if a “pixy” earlobe is present, relocation may not be possible. For these patients, it must be accepted that only partial correction can be accomplished.

A poorly situated post-auricular scar, although not as readily apparent and easier to disguise in most social situations than a poorly situated scar in the pre-auricular region, is nonetheless an objectionable deformity that should be corrected when possible. Typically, the poorly situated post-auricular scar will be seen to lie outside the auriculo-mastoid sulcus, and too low over the mastoid to be concealed by the pinna. Such a deformity is the result of poor planning and inferior–posterior migration of the post-auricular flap due to excessive tension placed upon it at the primary procedure (Fig. 12.20).

Fig. 12.20 Improper and proper placement of the post-auricular incision. (A) The post-auricular incision has been made too far posteriorly. The scar lies outside the auriculomastoid sulcus and is evident if hair is worn short or up off the neck (Procedure performed by an unknown surgeon.) (B) A different patient seen after facelift. The post-auricular scar has been placed in the auriculomastoid sulcus. In this location it mimics a natural anatomic feature and is overlooked on even close inspection.

(Procedure performed by Timothy J Marten, MD, FACS.)

Moving the post-auricular scar so that it rests directly in the auriculo-mastoid sulcus is sometimes possible in secondary and tertiary patients, if tissue sacrifice has not been excessive or along an improper vector at the primary procedure. Moving the scar more superiorly, although seemingly straight forward, is often not possible because of the common practice of inappropriately excising tissue from the superior tip of the post-auricular flap at the primary procedure. Attempts to do so will often result in a forced closure under excessive tension and eventual inferior migration and widening of the scar due to inferior traction on the post-auricular flap. Although an apparent redundancy will be present in the supine patient on the operating table due to a high lying position of the shoulders, this will be seen to vanish in the upright position when the shoulders fall to a normal position. As a result, little if any redundant skin is available along the needed superior vector of shift.

The submental incision will frequently be seen to have been erroneously placed directly along the submental crease in a well-intended effort to hide the resulting scar (Fig. 12.21). Regrettably, this serves only to reinforce the submental retaining ligaments and accentuate a “double chin” or “witch’s chin” appearance. In such situations, consideration should be given to moving the submental incision 1–2 cm posterior to the crease so that the existing scar car be undermined and released. Although this results in a new scar, it will be inconspicuously hidden in the shadow of the mandible in all but the unusual case (Fig. 12.22). This is preferable and a worthwhile trade-off for correction of the more obvious and objectionable contour deformity that would result if the incision were made again in the same place upon the existing scar. If limited work in the neck only is needed and minimal or no double chin deformity is present, it may be possible and appropriate to use an existing scar in the submental crease as the site for secondary incision. If more extensive maneuvers are required and a marked double chin deformity is present however, a new more posteriorly situated submental incision is indicated (Fig. 12.23).