CHAPTER 14 The male facelift

History

Facial rejuvenation in the male patient can be particularly challenging for a variety of plainly apparent reasons: men don’t wear makeup, they eschew any possibility of an over-operated appearance, and the hairline and beard cause many differences in terms of operative strategies (see Table 14.1). In a world that equates youthful appearance with fresh, new ideas, the patient population now encompasses men who want to stay busy in a very competitive environment rather than for vanity. They may be in business, acting, television, even politics. Growing social acceptability of aesthetic techniques has added to this demand.

Table 14.1 Special challenges of male facial rejuvenation

The technical and aesthetic goals of the male facelift (Tables 14.2A and 14.2B) share similar principles as for the female: dissection in skin and sub-SMAS layers, repositioning of the SMAS and supra-SMAS fat to restore volume in a vertical vector, avoiding a lateral pull, and redraping of the skin in a natural way. It is, however, absolutely essential that the surgeon understands important differences between the male and female patient and also has a commanding knowledge of the male anatomy and techniques to achieve these goals in a naturally appearing way.

Table 14.2A General aesthetic goals for male facial rejuvenation

Most men are concerned with the “turkey neck”

Restore volume

Eliminate the jowling to create a streamlined jawline

Create an acute cervicomental angle

Table 14.2B Immediate surgical goals for male facial rejuvenation

A naturally appearing earlobe which lies correctly

Unaltered hairline

Natural sideburn length and shape

Avoiding a hair-bearing tragus

Avoiding a hematoma

Avoiding surgical alopecia

The process of facial aging represents a combination of gravitational effects, atrophy, and sun damage yielding the characteristic changes shown in Figs 14.1 and 14.2. This chapter will review the process of facial aging, the relevant surgical anatomy, and the common male facelift techniques.

Fig. 14.1 The preoperative evaluation of the aging male face.

Fig. 14.2 The anatomic basis of the aging male face.

Physical evaluation

Preoperative counseling

The main goals include attempting to ascertain the patient’s desires and expectations while incorporating reasonable aesthetic goals. Using computer photo imaging programs can help accomplish this.

Informed consent must contain risk of hematoma, infection, sloughing, nerve damage, hypertrophic scarring, hyperpigmentation, asymmetries, and a need for revisions. The male patient must be educated about the unattractive appearance of an over-operated look which can appear unnatural, feminizing, and alien. The emphasis should be on retaining a natural masculine, relaxed look where one or two character lines may remain, rather than a “pulled” unnatural result.

The classic “SIMON” patient described in the plastic surgery literature (see Table 14.3) should be avoided as well as patients with body dysmorphic disorder. These patients can be easily recognized, screened and referred for psychiatric evaluation.

Table 14.3 SIMON patient

As male patients generally refrain from wearing makeup, it is especially important to take this into account in terms of incision placement. The use of the short-scar technique remains extremely useful in terms of minimizing scar length behind the ear and avoiding extension into the retroauricular scalp or temporal region.

The male hairline

It is imperative to counsel the patient about possible surgical alopecia. Generally, as long as he is warned of the possibility and told of options for treatment postoperatively, the patient understands and is very accepting of the prospect. Also the patient must be made aware of scars becoming visible in areas of continued natural hair loss. Men may begin male pattern baldness as early as their twenties which can become increasingly prominent involving the temporocoronal area. This special consideration must be emphasized to keep the superior extension of the preauricular incision as short as possible, taking into account, the presumptive continued thinning in the temporal region. Fortuitously, for the great majority of men, this hair-bearing region, otherwise known as the “Friar’s patch”, remains remarkably well-preserved in later years.

This thinking extends to the post-auricular incision, where using the short-scar incision which doesn’t extend into the occipital hairline is always a preferred approach in men, particularly those who desire retaining a tightly-cropped hairstyle or those with extensive balding in this area.

The beard

The surgeon must have thorough preoperative conversation about pros and cons of the various incisions. Generally there is a periauricular pattern of non-hair bearing skin. Conversion of the hair bearing region to non-hairbearing can be achieved by cauterization of the hair follicles intraoperatively or by laser postoperatively in a staged manner in patients with thin skin or history of recent smoking. This should be carried out judiciously so as not to sacrifice the vascularity of the flap or create thermal injury to the dermis. If the patient has dark hair which is amenable to laser removal or electrolysis for permanent removal, he may opt for a retrotragal approach. In a fair-skinned, light-haired man, in whom laser is not a good option and the patient doesn’t want to be bothered with shaving this area, a pretragal incision is strongly recommended. Generally, the author prefers a pre-tragal incision for the following reasons: (1) it prevents bringing thicker, hairbearing male skin onto the tragus; (2) it prevents the potential for blunting the tragus, and (3) most men already have a preauricular crease that can masquerade this incision acceptably.

Patients should be encouraged to grow out their sideburns to the level of the tragus. This will allow rotation and insetting of the skin flap in an appropriate manner while avoiding an obvious, unnaturally appearing elevated sideburn in the early postoperative period.

Technical steps

Preoperative management

0.1–0.2 mg of clonidine is administered to the hypertensive patient at least 45 minutes prior to the procedure. Ten minutes before, the patient is also infused with local tumescent fluid (0.5% lidocaine, 1 : 200,000 epinephrine) bilaterally. These two steps will help blood pressure control intra- and postoperatively. It is especially important to maintain a dry intra-operative field as the hypervascularity of the male follicular skin contributes to the increased incidence of hematoma formation.

The incision options for the male facelift are illustrated in Fig. 14.3. The preauricular hairline incision chosen depends on the amount of skin laxity, skin quality, and previous incisions. The incision is initiated a short distance anterior and superior to the root of the helix in the temporal scalp, may extend transversely into the sideburn, and if necessary, sparingly follows the anterior temporal hairline (see Fig. 14.4). As discussed previously, the preauricular incision then proceeds caudally in the pre-tragal region if there is a natural skin crease and very little sun damage. The scalpel should bevel in line with the hair shaft. Alternatively, a post-tragal incision with defatting and follicular cauterization is performed. For the short-scar facelift, the incision passes beneath the earlobe and extends into the retroauricular sulcus staying 2 mm on the concha, so any scar migration that may occur will pull the scar no farther than into the sulcus. If there is severe laxity of the neck skin, the incision then traverses the hairless skin in the retroauricular region for 3–5 mm at a point which is superior enough in this region to be hidden if the patient opts for short hair. The final result should not be compromised simply to rigidly commit to a shorter retroauricular incision. If there is too much cervical laxity, the surgeon must extend the incision into the hair. Going into the retroauricular scalp with a sigmoid curve, instead of the occipital hairline incision, is preferred as men tend to retain their hair growth in this region and it allows the patient to have closely cropped hair without a visible incision.