Modified Facelift Procedures

Short Scar (Weekend) Facelift Surgical Procedure

In the previous chapters I discussed the pluses and minuses of small facelifts (short scar facelifts [SSFLs]). It is obvious that I feel that these types of facelifts are very limited for the average patient of facelift age, however they remain useful for younger patients with minor aging as well as a means of learning facelift surgery for the novice surgeon.

It has become very trendy to offer and promote these small facelifts. Many of these procedures omit the critical posterior auricular incision as well the submental incision and platysmaplasty. This type of approach may be acceptable for very small lifts on young patients but this group only makes up 2% of my over 1200 facelifts. I have shied away from this type of approach for the reasons already discussed. I feel it is simply a compromise to result and longevity. If and when I agree to perform a short scar lift, I have the patient sign a consent detailing what the surgery will and will not do. I also have the patient agree to allow me to convert the small lift into a traditional lift if I feel there is too much skin for the small lift to be effective. Although I think these lifts are a great way for novice surgeons to learn facelift surgery, I have time and again started a small lift only to convert it to a traditional lift.

Positive aspects of these conservative procedures are that they are simpler to learn and perform, can be done with local anesthesia, do not require bandages, have shorter recoveries, and are easier to market compared with larger procedures.

These procedures also have serious drawbacks. They do not and cannot address moderate and advanced aging to the level of larger lifts. Patients must be told that their result will not be as tight or last as long as conventional lifts. Also of significant importance is the fact that these procedures are designed for younger patients with minimal excess submental and neck skin. Performing an SSFL on the right 38-year-old to 42-year-old patient can be quite effective, whereas performing the same procedure on an older patient or one with advanced aging can be very disappointing for both surgeon and patient. Personally, I feel it is unethical to perform a small lift on a patient who needs a big lift. These conservative lifts involve a preauricular incision with some mastoid extension but generally do not include the posterior auricular incision. For any surgeon who truly understands the pathophysiology and vectors of aging and facelift surgery, the postauricular incision is a requirement to truly tighten the neck with a lasting result.

The SSFL, sometimes called weekend facelift (WEFL), is built around omitting the postauricular incision and traditional platysmaplasty and therefore has much less effect on significant jowl and neck aging. These “franchise” lifts go by many names and when performed correctly, they do offer a result, but they are not new miracle procedures, and cannot produce comparable results to more comprehensive facelifts. Frequently, the procedure sounds too good to be true: “local anesthesia, drive home from the office, no bandages, go back to work the next day” can be very inviting to a patient who does not fully understand other available options or the limitations of these lifts.

The main reason I am not a huge proponent of these conservative lifts is simply that the average patient who needs a facelift needs a conventional one. When I do treat patients with WEFL, I ask them to give me permission to add a full posterior auricular incision to obtain a better result if I feel intraoperatively that the small procedure will not address the aging changes. I have done this numerous times when my intraoperative observations show that these patients would ultimately be short changed with the single incision procedure. What continues to amaze me is the amount of excess skin these specific patients exhibit, even with minimal outward signs of aging. In short, although they may not have visible skin excess, most patients in their mid to late fourth decade are candidates for traditional-incision facelift. Fig. 6.188 shows two such patients.

Conservative lifts certainly have a place in the armamentarium of the cosmetic surgeon, but my personal requisites are illustrated by the fact that out of over 1000 facelifts, only 2% have been short scar. My personal indications for performing a short scar (limited incision) facelift are:

Young patients with minimal aging
Slightly older patients with minimal to moderate jowl and neck aging
Patients who have medical problems that preclude a larger facelift or anesthesia
Patients with budget or recovery limitations who cannot have a larger lift.

As stated very early in this chapter, if a small procedure is performed on a patient who needs a bigger procedure and although the patient may be happy, it is sometimes very obvious that the facelift is not all that it could be and the surgeon could actually get negative publicity as other observers see shortcomings of a small procedure and do not realize it was not a conventional facelift. Short cuts in any procedure can have negative marketing consequences. This type of facelift is a great way for the novice surgeon to learn facelift techniques and some surgeons only perform short-scar procedures. As long as the patient selection is appropriate and the patients are given full disclosure of the pluses and minuses, the procedure is appropriate.

When I do perform this procedure on a patient, they are required to sign an additional consent that details the limitations of this type of facelift. Although some surgeons perform these procedures with only local and tumescent anesthesia, I still use general anesthesia. The preauricular work with the SSFL is very similar to a conventional facelift but generally more conservative. The sideburn release incision is generally shorter, and the actual preauricular incision is identical. The main differences are seen when the incision turns the corner of the earlobe. Most of the conservative lifts use a postauricular incision that is made in the postauricular sulcus and extends 2 to 4 cm superiorly. Some surgeons advocate making a horizontal releasing incision across the mastoid region, which is a mistake because it will be very noticeable postoperatively. To pull the jowl and especially the ptotic neck skin and the antiaging vector without a traditional postauricular hairline horizontal releasing incision can result in skin bunching behind the ear. There is no way to prevent this without a longer postauricular hairline incision, and it will be commensurate with the amount of skin present in the neck and submental region. Fortunately, much of this bunching will dissipate with healing, but some will persist and can be noticeable with certain hairstyles. The tradeoff of an improved appearance versus some posterior skin bunching is usually not a problem as long as the patient has been made aware of this preoperatively. I personally had a case where the postauricular bunching took an entire year to dissipate (see Fig. 6.189).

In the minimally invasive procedures, I do not routinely perform midline platysmaplasty. If the patient has enough aging to warrant midline platysmaplasty, they need a conventional facelift. I do, however, perform submental liposuction if the patient has excess submental fat and this will usually cause some skin contraction.

The short scar or weekend incision for the preauricular region and temporal tuft is identical to a smaller conventional facelift ( Fig. 8.1 ). The short-flap subcutaneous dissection is smaller than conventional facelift and is generally 2 to 4 cm circumferential from the ear ( Figs. 8.2–8.5 ).

Fig. 8.1, Both of these patients requested a “weekend” (short scar) facelift. Observing these before picture (A, C) shows that both patients appeared to have only minor skin excess. The intraoperative pictures of both patients show the amount of skin excess that actually existed (B, D). This impressive amount of skin required conversion to a conventional facelift, otherwise the patient would have not had an optimum result and longevity.

Fig. 8.2, This patient insisted on a short scar facelift and because of the limited postauricular incision, sustained significant skin bunching. The bunching took almost one year to resolve and the bottom images show the patient 12 months later. Surgeons are to be careful about being talked into a deeper procedure than the patient actually need.

Fig. 8.3, This image shows the incision markings and actual incision in a short scar type facelift.

Fig. 8.4, This image shows the anterior, inferior, and posterior limits of a typical short scar (“weekend”) facelift dissection.

Fig. 8.5, This image shows the dissection completed on a typical short scar facelift. This particular case has a generous posterior auricular dissection because many short scar lifts have a posterior auricular incision, which terminates in the mastoid region as shown in Fig. 8.14 .

When addressing the superficial muscular aponeurotic system (SMAS) during SSFL surgery, SMAS plication is the most conservative means of SMAS management and probably produces less swelling and faster recovery ( Fig. 8.6 ).

Fig. 8.6, This image shows a superficial muscular aponeurotic system plication in a short scar facelift. The plication sutures are diagramed to show their placement, extension, and vectors.

In most cases, I prefer the same SMASectomy procedure as described earlier but on a smaller scale ( Fig. 8.7 ).

Fig. 8.7, Even though the shortscar facelift technique uses smaller dissection than conventional lift, a small superficial muscular aponeurotic system (SMAS)-ectomy is still an option. The left image (A) shows the SMAS strip being excised, the middle image (B)shows the SMAS strip overlying its approximate position, and the right image (C) shows the final SMASectomy sutures.

Although I always advocate using posterior platysma sutures to fashion the sling referred to numerous times in this chapter, it is not as applicable in the short scar lifts because of limited access. In general, there is enough room to place at least one posterior platysma suture below the angle of the mandible to assist in tightening the deeper layers of the neck ( Fig. 8.8 ).

Fig. 8.8, This image shows a solitary suture securing deep tissues in the area of the posterior platysma to the mastoid fascia.

After the SMAS is dealt with by the surgeon's preferred method, the skin must be properly placed on traction. The vector of pull may be somewhat different in the short scar lifts. Although there is no “guaranteed” correct vector and every patient is different, a more vertical vector (as opposed to posterolateral) may be required to tighten the jawline and jowls without bunching the posterior auricular region ( Fig. 8.9 ). This does not always apply and sometimes the posterolateral vector is preferable. All vectors of pull should be tried to see what direction provides the best result with the least amount of posterior skin bunching. When using vertical elevation of the preauricular flap, the surgeon needs to make sure enough skin exists to cover the tragus. Never make skin cutbacks or trim skin until coverage is verified.

Fig. 8.9, Some short scar lifts require a more vertical vector of skin pull and the surgeon should try various vectors to see which produces the best result with the least amount of posterior auricular skin bunching.

Once the proper vector is achieved, an anterior skin cutback and key suture are placed in a similar manner as conventional facelift ( Figs. 8.10 and 8.11 ).

Fig. 8.10, The left image (A) shows typical anterior skin excess on a short scar lift. The center image (B) shows the skin cutback, and the right image (C) shows the key suture placed. Note the blue ink on the skin that was formerly the tragus. This shows how much skin is displaced, even in a small facelift.

Fig. 8.11, The left image (A) shows a skin cutback in a short scar facelift and the right image (B) shows the flap suspended. Note the typical posterior auricular skin bunching seen with these procedures ( white arrow ).

Once the skin is suspended, the excess skin is trimmed and the lobe delivered in the same fashion as conventional facelift ( Figs. 8.12 and 8.13 ).

Fig. 8.12, The left image (A) shows the outline of the excess skin to be trimmed, the center image (B) shows the preauricular skin being excised, and the right image (C) shows the temporal skin excision.

Fig. 8.13, The lobe is delivered with a very conservative cut back. In many cases, no cutback is required and the lobe can simply be pulled out.

One of the biggest drawbacks of SSFLs is postauricular skin bunching. This occurs because, unlike conventional facelift, there is no postauricular flap to release and pull the skin. In small lifts this is not problematic and a simple triangle skin flap can remove the dog ear ( Fig. 8.14 ). Larger short scar lifts produce significant bunching and can be more challenging as shown in Fig. 8.2 . There comes a point when excessive posterior auricular skin signals the need for a conventional lift with postauricular excision. Sometimes less is not more!

Fig. 8.14, The left image (A) shows skin bunching on a very conservative short scar facelift. The skin hook retracts the excess and a geometric triangle reduction is performed to remove the pleat (B). It is imperative to keep this extension short and behind the ear to remain hidden.

One common mistake is instead of performing a conventional facelift, surgeons attempt to deal with the excess posterior auricular by large and low excision extension. Although extending the excision over the mastoid region may release the bunching, it also can produce an unsightly scar that is impossible to hide ( Fig. 8.15 ). Again, trying heroic measures to deal with skin excess can easily be avoided by performing a conventional lift, when needed, in the first place.

Fig. 8.15, This image shows a long excision release over the mastoid region to deal with posterior skin bunching on a short scar lift. This level of extension will produce a scar that is not hidden by the ear and is a handicap in terms of aesthetics. A more cephalad posterior auricular would provide better incision and scar management as opposed to the one used in this case as shown in Fig. 8.17 .

The tragal and earlobe is addressed in the same manner as conventional facelift ( Fig. 8.16 ); the anterior incisions are closed with 5-0 gut suture, and the posterior incision is closed with 4-0 gut suture ( Fig. 8.17 ).

Fig. 8.16, This image shows all the skin cutbacks and trimming completed and the sculpted tragus ready for suturing.

Fig. 8.17, The anterior incisions are closed with 5-0 gut suture (A) and the posterior incision is closed with 4-0 gut suture (B).

Bcause the short flap procedure does not have significant dead space, I do not use postoperative dressings or drains. Hematoma, tissue necrosis, and other complications are uncommon because of the small nature of the procedure ( Figs. 8.18–8.22 ). Healing is usually much faster and less complicated than bigger procedures.