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Facelift Surgery (Cervicofacial Rhytidectomy)


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:

  • 97.5% female

  • 2.5% male

  • 7% smokers

  • 27% had simultaneous full face CO 2 laser skin resurfacing

I am proud of this number and I have meticulously documented this with charts, operation reports, and before-and-after pictures for every single patient. I say this because many cosmetic surgeons inflate their actual numbers or cannot substantiate their claim. Of these 1000 plus facelifts, 98% were traditional comprehensive facelifts with midline platysmaplasty and preauricular and postauricular flaps averaging 6 to 8 cm of circumferential dissection. In other words, large facelifts. Some 2% were short scar lifts. I have heard surgeons state that they have done 2000 or 3000 facelifts. Some of them worked for corporate facelift companies and performed numerous extremely small “lifts” each day. There is a big difference in performing 1000 of these very small lifts than doing 1000 traditional lifts. In addition, some surgeons have numerous interns, residents, and fellows who do a lot of the preparation work, tumescent injection, surgery, closing, and patient management. I have done every inch and every stich by myself. I am not saying this to brag, but rather to underline my journey with facelift surgery. I have attempted to analyze and reanalyze every step. I went from doing a facelift every several weeks, to doing about 80 a year. I think about facelift surgery when I am driving to work and when I drive home. I think about it before I fall asleep at night, and I think about it with my bow and arrow in my lap sitting in a tree stand. I can say that facelift surgery is a personal obsession. I love to do it, and I want to do each one better than the last one. In a single chapter, it is impossible to cover all areas of facelift surgery and that single topic could easily fill this entire text. My goal with this chapter is to convey the techniques that have proven to be safe and effective in over 1000 facelifts. This does not mean that “my way” is the only way to do it or that it cannot be done better. Arrogance does not work in cosmetic surgery because it only takes a single case to humble someone.

Facelift History

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

Incision Design

A surgical marker is then used to mark the following structures:

  • 1.

    Preauricular and postauricular incisions

  • 2.

    Inferior border of mandible if laser is performed

  • 4.

    Outline of jowls to be liposuctioned

  • 5.

    Outline of submental area to be liposuctioned

  • 7.

    Submental crease for platysmaplasty incision

  • 8.

    Ancillary markings if blepharoplasty, browlift or other procedures are planned.

It is important to make all markings with the patient in repose in an upright position. Some surgeons mark the patient after they are supine or after local anesthetic injection, both of which can lead to inaccuracy because of tumescence or gravity. Also important is to use a marking pen with ink that will stay remain visible during the preparation and entire surgical procedures. I have found the disposable marking pens by Viscot ( www.viscot.com ) to be excellent in precision and longevity ( Fig. 6.1 ). The surgical markings are the blueprint of the surgery and must remain visible for the procedure. Hours of surgery occur between incision and wound closure, but the only thing the patient (and everyone else) ever sees is the incision scars. For this reason, they must be designed with precision because they are the signature of the surgeon. A great facelift with bad scars is not a great facelift.

Fig. 6.1, A quality marking pen that will be resistant to wiping off with surgical prep is important to preserve important surgical markings.

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 ).

Fig. 6.2, The left image (A) shows a commonly described temporal incision. The use of this incision can elevate the hairline to a point of temporal baldness as shown in the right picture (B).

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 ).

Fig. 6.3, Although incisions at the sideburn will preserve the natural position, a visible scar can result.

Fig. 6.4, This image shows sideburn incision in a manner that will leave hair above and below the incision and cannot elevate the temporal tuft. The left image (A) shows the skin excess with this incision placement, and the right image (B) shows the incision and how the future scar will be hidden in the hair.

Fig. 6.5, All incisions in hair-bearing regions should be made in a transfollicular (trichophytic) fashion with an extreme bevel that allows hair to regrow through the scar.

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.

Fig. 6.6, Placing the sideburn incision approximately at the level of the lateral canthus makes a natural temporal tuft position. Males can adjust their sideburns with beard skin. The preoperative (A) image has more bearded sideburn than the postoperative (B) but can be simply adjusted by shaving or not shaving.

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.

Fig. 6.7, This example of poor incision planning shows not only an unnatural preauricular incision scar but also poor posterior incision planning and tensioned suture lines.

Fig. 6.8, Simple means of correctly marking the helical attachment incision is to move the superior portion of the ear forward to create a crease (A) or to simply place downward pressure on the marking pen which will allow the marker to sink into the skin to the correct junction (B).

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 ).

Fig. 6.9, This image illustrates pretragal bearded skin that can become part of the new tragus if improperly planned. This patient would benefit from a pretragal incision.

Fig. 6.10, Most males have naturally occurring preauricular creases that are suitable to contain a preauricular incision (A). Although retrotragal incisions can be used on males (B) the preauricular incision (C) is advantageous for reasons mentioned.

Fig. 6.11, This image shows male patients after facelift. Note the excellent scar and healing from a retrotragal approach (A, B) and a preauricular approach (C, D).

Female facelift incisions can be made in the same manner as males ( Fig. 6.12 ).

Fig. 6.12, This image demonstrates retrotragal approach for female incision (A), and the pretragal approach (B).

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.

Fig. 6.13, These images show unaesthetic scars from preauricular incision approaches performed by other surgeons (A, B, C).

Fig. 6.14, This image illustrates the author's common approach to facelift incision for scar aesthetics (A, B).

Fig. 6.15, This image shows excellent healing from a pretragal incision (A, B).

Fig. 6.16, This image shows excellent healing from a retrotragal incision (A, B).

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.

Fig. 6.17, Although the best facelift surgeons will experience tragal blunting on occasion, it should be an exception. If a surgeon cannot control tragal blunting, then they are better off using a preauricular incision. This image shows obvious tragal blunting after facelift.

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.

Fig. 6.18, This image shows two popular means of transitioning the preauricular facelift incision from the tragus to the earlobe. The left image (A, arrow ) shows a right-angle transition and the right picture (B, arrow ) shows a gradual curve following the normal anatomy.

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.

Postauricular Incision

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 ).

Fig. 6.19, This image illustrates an incision in the center of the postauricular sulcus which has provided excellent aesthetic results in over 1000 facelifts. Note that the posterior auricular incision meets the hairline incision at a 90-degree angle.

Fig. 6.20, These images show the positive aesthetic scar result with optimum healing in patients treated with the postauricular incision placed directly in the sulcus and closed with a running mattress suture (A, B, C, D).

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.

Fig. 6.21, The natural vectors to correct ptotic jowl and excess neck skin are superolateral or approximately the 10 o'clock and 2 o'clock if the patient were upright.

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.

Fig. 6.22, A low mastoid incision is undesirable because there is more visible scar in that region when compared with a more superior incision (A, B).

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 ).

Fig. 6.23, Making the postauricular at or above the greatest width of the pinna (1) will produce the shortest visible scar. The lower the scar is placed (2) the more it will be visible because less is hidden behind the ear.

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 ).

Fig. 6.24, This image shows three common posterior hairline approaches for comprehensive facelift surgery (A, B, C). I prefer the solid white line placement, especially for larger lifts.

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 ).

Fig. 6.25, A transfollicular incision will transect the hair follicles. The thin, beveled skin flap margins allow hair regrowth to hide the scar. This image shows visible transected hair follicles.

Fig. 6.26, This image shows how well the transfollicular posterior occipital hairline incision can be hidden. The left image (A) shows the occipital hairline incision at 24 hours and the right image (B) shows the healing at 8 weeks. Notice the shorter hairs are regrowing through the scar.

Fig. 6.27, These images (A, B), taken 3 months after face and neck lift with occipital hairline incision within the hairline and using a transfollicular incision, show the excellent healing that can occur with a properly crafted hairline incision.

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 ).

Fig. 6.28, Placing any incision at a hairline/skin junction is an acceptable approach if it heals well. This incision placement, however, is extremely problematic if healing is not normal. These pictures are from patients operated on by other surgeons who presented to my office requesting scar revision.

Submental Incision

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 ).

Fig. 6.29, This image shows the actual submental crease and proposed lowering when dealing with chin ptosis and large chin implants. The author prefers to incise below the actual submental crease in most facelift patients.

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 ).

Fig. 6.30, This image show precision marking of the submental incision by marking the patients' midline and the horizontal axis. The incision is generally made below the actual submental crease and is placed 5 mm below the crease in a typical patient or 5 to 10 mm below if the patient has a ptotic chin with a deep crease or if a chin implant will be simultaneously placed.

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.

Facelift Procedure

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 ).

Fig. 6.31, A surgical “timeout” is performed before each and every case to confirm patient, surgery, operative site, comorbidities, allergies, etc. Posting a standardized form listing procedures, medical conditions and allergies on a widescreen TV in the operating room assists communication.

Anesthetic Considerations

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 ).

Fig. 6.32, After full surgical preparation, the hair is placed into tufts and secured with rubber bands to create a parting in the areas of the proposed incision.

Fig. 6.33, A 2-0 silk suture is threaded through the pinna to serve as a retractor throughout the case.

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.

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