Male facelift - Clinical Tree

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Introduction

Over the past few decades increased numbers of men have sought facial rejuvenation as prevailing attitudes regarding aging and appearance have shifted. During this time plastic surgeons have recognized that a diminished margin for error arguably exists in male patients due to the fact that men have fewer options to conceal their scars or a mediocre result. Plastic surgeons have also come to recognize that in most cultures male facial aesthetics differ from those thought desirable in females and attractive masculinity is not as closely equated with youth and beauty as is femininity. Men generally seek a somewhat different outcome from facial rejuvenation surgery, and this has led to a rethinking of techniques that have evolved mainly to treat facial aging in women. New approaches, modified techniques, and aesthetic goals have subsequently emerged that allow attractive rejuvenation of the male face while preserving a natural, masculine, unoperated appearance.

Aging of the male face and male facial aesthetics

Treatment strategies in men will be different from those in women and it is not appropriate to arbitrarily apply concepts and techniques that evolved largely for treating the female face to that of a man. The male face is arguably more nuanced than that of a woman, whom we have come to accept as having a more contrived and made-up appearance, and certain aspects of male facial aging are often regarded as signs of experience, wisdom, and power that many men wish not to lose. In these and other ways men often have different goals than women when seeking rejuvenation of their faces, with the man arguably more concerned about a natural appearance free of signs that a surgical procedure has been performed. If we see a woman whose face looks younger that the rest of her body, or if her face has visible signs that a facelift might have been performed, we smile and tell ourselves “she might have had something done”. If we see a man with an overdone or unnatural appearance, or tell-tale signs that surgery has been performed, however, we are often more judgmental and disapproving. Women, who typically wear longer hairstyles and make-up, also have more ways to hide signs that surgery has been performed than a man. In this sense, there is perhaps less room for error, both technically and artistically, when a male facelift is performed.

In the time since history has been recorded female beauty has been closely associated with smooth skin, the absence of wrinkles, and youth – whereas male attractiveness often encompasses a certain weathered ruggedness, and even a certain disdain for an overly perfected appearance. These conventions and attitudes are indeed changing, but nonetheless are a consideration when performing male facelift procedures.

In our current cultural climate, female attractiveness is seen as correlated with smooth skin, a wrinkleless forehead, an arched eyebrow, a stylized eye appearance, a high cheek profile, a tight jawline, and overall inverted oval facial shape. Male attractiveness, on the other hand, rests more in a bottom-heavy rectangular facial shape, a heavier and bolder jawline, a strong athletic neckline, a lower and more horizontal eyebrow, a flatter cheek profile, and less meticulously maintained skin. When these differences are considered it can be seen that a different endpoint is typically sought by men seeking facelift surgery, and the goals of the procedure and accompanying technique must be modified accordingly.

Men typically seek and desire a bold, athletic neck and jawline, and more subtle and less dramatic changes in other areas of the face. All things considered, a surgeon who can deliver a good result in the neck and jawline, provide well-concealed scars, and exercise restraint when operating on the forehead, eyes and mouth is likely to be successful when treating male patients. In contrast, surgeons who over-treat the orbital area, do not provide well-concealed scars, and do not deliver a good result in the neck are likely to have more unhappy patients.

Recognizing the components of the aging deformity of the face

Recognizing the components of the aging deformity of the face and appreciating the underlying anatomical abnormalities is essential to properly advising patients and fundamental to the planning of any surgical procedure. Careful analysis will reveal that most patient problems will fall into three broad categories: (1) aging and breakdown of the skin surface; (2) facial sagging, skin redundancy, and loss of youthful facial contour; and (3) facial hollowing, atrophy and/or age-related lipodystrophy. Proper treatment will depend upon the types of problems present, the patient’s priorities, and the time, trouble and expense he is willing to endure to obtain the desired improvement.

Male patients primarily concerned with surface aging of their face do not require formal surgical procedures and may achieve the type of improvement they desire through dermatologic surface treatments of the skin. These treatments include skin peels, skin resurfacing, chemodenervation (neuromodulator injections), and other treatments designed to remove or reduce age-related skin surface imperfections. In our experience, few men have this as a primary concern.

Men primarily concerned with facial sagging, skin excess and loss of facial contour will achieve minimal ultimate improvement, however, if surface treatments only are employed, and will require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is excised if these problems are to be properly corrected and an attractive and natural-appearing improvement is to be obtained. Most men’s concerns fall solidly in this category. The misapplication of surface treatments of the skin to the sagging face with excess tissue will produce little more than a smooth, saggy face with no improvement in contour. This sort of “smooth-saggy look”, typically seen in older patients who have undergone laser resurfacing or deep skin peels, is inconsistent with a natural appearance as patients with loss of facial contour generally also have concomitant skin surface aging. It is arguably more masculine and natural-appearing to have youthful facial shape with a few wrinkles and surface imperfections, than a smooth but saggy face.

Many, if not most, of the changes associated with loss of facial contour in men represent primarily "deep layer" problems that will be inadequately corrected if traditional “skin-only” techniques are used. Regrettably, many surgeons unfamiliar with deep layer techniques, and other physicians insufficiently trained to perform then, often employ a variety of conceptually flawed procedures including skin-only “mini-lifts”, “suture lifts”, “thread lifts”, and “short scar” lifts and resort to other misguided and misapplied ancillary procedures to overcome the shortcomings of these methods in men. These procedures include facial liposuction, buccal fat extraction, malarplasty, submalarplasty, and PTFE (“Gortex”) implantation. Although some of these ancillary procedures are at times indicated in male patients, they will be unnecessary in the majority of cases if a superficial musculo-aponeurotic system (SMAS) facelift and deep layer rejuvenation is performed ( Fig. 9.11.1 ).

Figure 9.11.1, High SMAS facelift and related procedures in a male patient. (A) Before surgery view of patient, age 59. He can be seen to have combined surface aging of his skin, tissue sagging and redundancy, and facial atrophy. Note heavily wrinkled forehead, hollow cheeks and midface, deep cheek folds and sagging facial tissues. (B) Same patient, 1 year and 6 months after facelift, necklift, forehead lift, upper blepharoplasty with levator reinsertion, lower blepharoplasty, and partial facial fat grafting. Note improvement in forehead wrinkling, brow position, eye appearance, lower eyelid fullness, posture of perioral tissues, and overall facial sagging. Increased facial fullness following fat grafting is also evident particularly in the midface. The patient has a more rested, youthful, healthy, virile, and masculine appearance without a tight, pulled, or “facelifted” look. All surgical procedures performed by Timothy Marten, MD, FACS.

Male patients with significant facial atrophy and age-related facial hollowing will generally achieve suboptimal improvement from both surface treatments of facial skin and surgical lifts. Smoothing skin will not hide a drawn appearance due to loss of facial volume, and it is difficult to create natural and healthy masculine contours by lifting and repositioning tissues that have abnormally thinned and deflated with age. Restoring lost facial volume with autologous fat grafting is a powerful technique that has gained widespread acceptance in treating the aging face. Properly performed, the addition of fat to areas of the male face that have atrophied due to age or disease can produce a significant and sustained improvement in appearance unobtainable by other means (see Figs. 9.11.1, 9.11.37 & 9.11.39 ). In addition, autologous fat grafting may represent the first true anti-aging therapy plastic surgeons have to offer our patients in that there is a growing body of evidence that adult stem cells transferred with fat exert a rejuvenating effect on tissues in areas adjacent to areas where fat is injected.

Figure 9.11.37, Patient Example 1. (A) Front view; before surgery view of patient, age 42. The patient has full upper eyelids, ptotic, hollow upper cheeks, cheek ptosis, and a weak appearing jawline. (B) Front view; same patient, 2 years and 3 months after facelift, necklift , small incision forehead lift, upper and lower eye lifts, fat grafting, and chin implant. Note corrections of hooded eyelids, improved cheek contour, and creation of a youthful and masculine facial shape without a tight or pulled appearance. (C) Oblique view; before surgery view of patient, age 42. Note hooded upper eyelid, sagging cheek, hollow lower orbit, and loss of youthful neck and jawline contour. (D) Oblique view; same patient, 2 years and 3 months after facelift, necklift , closed forehead lift, upper and lower eye lifts, fat grafting, and chin implant. Note softer appearance to eyes, improved cheek contours, masculine jawline, and improved neck contour. The chin contour is also improved and the patient has a rested, fit, athletic, decisive, and masculine appearance. (E) Lateral view; before surgery view of patient, age 42. Note lower eyelid fullness, infra-orbital atrophy, poor transition from the lower eyelid to the cheek, poor jawline, weak chin, and full neck. (F) Lateral view; same patient, 2 years and 3 months after facelift, necklift , closed forehead lift, upper and lower eye lifts, fat grafting, and chin implant. The transition from the lower eyelid to the cheek is improved, the cheek position has been improved, chin contour is improved and a fit, athletic, masculine-appearing jawline and neckline can be seen. The face has a natural appearance and all scars are well concealed. All surgical procedures performed by Timothy Marten, MD, FACS.

Figure 9.11.39, Patient example 3. (A) Front view; before surgery view of patient, age 68. The patient has eyebrow ptosis, full upper eyelids, sagging cheeks, deep cheek folds, and jowls. Loss of youthful facial contour can be seen in the cheek and jowl areas. (B) Front view; same patient, 1 year and 9 months after facelift, necklift , small incision forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note improved eyebrow position and configuration, corrections of hooded eyelids, diminished cheek folds, elimination of jowls, and restoration of youthful and masculine facial shape without a tight or pulled appearance. (C) Front smiling view; before surgery view of patient, age 68. Note suboptimal upper dental show and tired and disinterested appearance despite broad smile. (D) Front smiling view; same patient, 1 year and 9 months after facelift, necklift , small incision forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note alert and composed appearance and fit, masculine-appearing jawline. A more natural smile with improved dental show is also seen. (E) Oblique view; before surgery view of patient, age 68. Note drooping eyebrow, hooded upper eyelid, sagging cheek and overall loss of youthful facial contour. There is little if any transition from the lower cheek to the neck, and a poor jawline is present. (F) Oblique view; same patient, 1 year and 9 months after facelift, necklift , closed forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note eyebrow position and configuration, restoration of cheek fullness, diminished cheek (nasolabial) fold, bold masculine jawline, and improved neck contour. The patient has a rested, fit, decisive, virile and masculine appearance. An improved transition from the lower cheek to the neck is evident. (G) Lateral view; before surgery view of patient, age 68. Note lower eyelid fullness, sagging cheek, poor jawline, heavy jowl, and neck laxity. (H) Lateral view; same patient, 1 year and 9 months after facelift, necklift , closed forehead lift, upper and lower eye lifts, partial facial fat grafting, and earlobe reduction. An improved transition from the lower eyelid to the upper cheek can be seen, the cheek position has been improved, and a fit, masculine-appearing jawline and neckline is evident. The face has a natural appearance and all scars are well concealed. Note also that the earlobe has been subtly reduced, adding to an overall more youthful appearance. (I) Lateral view, looking down; before surgery view of patient, age 68. Note poor neckline when looking down. (J) Lateral view, looking down; same patient, 1 year and 9 months after facelift, necklift , closed forehead lift, upper and lower eye lifts, minor partial facial fat transfer, and earlobe reduction. Note improved neck contour in the flexed position. The face has a natural appearance and all scars are well concealed. All surgical procedures performed by Timothy Marten, MD, FACS.

Age-related facial atrophy rarely exists as an isolated event in the healthy patient, however, and thus male patients troubled by it are not always logically or appropriately treated by fat grafting alone. Isolated fat grafting is also arguably of questionable benefit to the patient troubled by significant facial sagging and skin redundancy. Although aggressive filling of the sagging face with fat can produce improved contour and a smoother appearance, it generally results in an unusually large, overfilled face that appears unnatural. Such an overfilled face can be hard to correct in an attractive manner at a later date, and it is both more logical and practical to perform fat grafting in conjunction with formal surgical lifts if needed, or sometime after ptotic tissue has been repositioned and redundant tissue has been removed. When a SMAS facelift technique is used in conjunction with fat grafting, both loss of facial contour and facial atrophy can be corrected and optimal improvement in the patient’s appearance can be obtained.

Treatment strategies in the male patient

There are a number of situations one encounters in treating men in which a somewhat different strategy than one would use in women can be employed.

The bald man and the man with short hair

The bald man or the man with short hair, while often regarded by some as a significant challenge above and beyond that of the typical patient, can in reality be treated largely in the same way as a man or woman with abundant hair. Even sparse, short hair provides good cover for the temple and occipital incisions if properly planned as the short hair worn by most men falls over them and conceals them. This is the case even in the man who wears a “military-style” haircut. In these patients the basic facelift incision plan need not be specifically modified ( Fig. 9.11.2 ; see also Fig. 9.11.39 ).

Figure 9.11.2, (A,B) Occipital hairline scar in men with short hair. The bald man or the man with short hair, while often regarded by some as a significant challenge above and beyond that of the typical patient, can be treated in the same way as a man or woman with abundant hair. Even sparse, short hair provides good cover for the temple and occipital scars if properly planned as the short hair worn by most men falls over the scars and conceals them. This is the case even in the man who wears a “military-style” haircut. All surgical procedures performed by Timothy Marten, MD, FACS.

Small incision and endoscopic foreheadplasty (see Fig. 9.11.26 ) is also usually possible in these patients if indicated as incisions can be sited on the temple scalp and at the superior-most spot that hair is present (see Fig. 9.11.39 ). Alternatively, a forehead lift can be performed by excising forehead skin along a transverse forehead crease (see Fig. 9.11.28 ), or by using a supraciliary incision (see Fig. 9.11.29 ). Both these strategies result in inconspicuous scars and represent a worthwhile trade-off in most men in the facelift age group.

Figure 9.11.26, “Small incision” temple and forehead lift. Most men need conservative treatment of their forehead and brow and are well served with a “sort scar” small incision plan as shown. The incision on the temporal scalp is used to make a subgaleal dissection and the incision on the parietal scalp is used to make a subperiosteal dissection. A lateral forehead flap can be mobilized and elevated by subsequently releasing the temporal line of adherence between the two planes and dividing the periosteum under the lateral aspect of the eyebrow. An endoscope is not required and the latter maneuvers can be accomplished under direct vision through the incision on the temporal scalp.

Figure 9.11.28, Forehead crease temple-forehead lift incision plan. Bald or balding men, men who wear very short hairstyles, men who have previously had hair transplants and fear disruption of their hairline, and men with shaved heads can be effectively treated using an incision in a horizontal forehead crease. Skin only is excised and minimum undermining only is usually required. The scar once healed is often less conspicuous than the forehead crease it was planned around if meticulously closed under no tension. Unlike a “superciliary” “direct” eyebrow lift (see Fig. 9.11.29 ) this plan allows lifting of the temporal face as well as the eyebrow, and reduction of temporal redundancy that is sometimes generated by a facelift procedure.

Figure 9.11.29, Superciliary “direct” eyebrow lift incision plan. Bald or balding men, men who wear very short hairstyles, men who have previously had hair transplants and fear disruption of their hairline, and men with shaved heads can be effectively treated using and incision along the upper margin of the eyebrow. Skin only is excised and minimum undermining only is usually required. The scar once healed is typically inconspicuous, especially in men in the facelift age group. This plan does not allow lifting of the temporal face as and is not helpful in reducing temporal redundancy that is sometimes generated by a facelift procedure.

Man with shaved head

Although once uncommonly seen, the shaved head has gradually become a near cultural norm and an increasingly common fashion statement, and this has resulted in plastic surgeons encountering a growing number of these men seeking facelifts and related procedures. Although these patients may initially present a quandary and are often mistakenly turned away by some surgeons, they are very good candidates for “facelift” surgery if a thoughtful surgical plan is employed.

In treating the man with the shaved head one can exploit the fact that a key and quintessential feature of an attractive, athletic appearing man is a good neckline. Unlike women – for whom optimal appearances are more closely tied to youth, an inverted oval facial shape, high cheek contour, and a tight jawline – the male face is more tolerant of a rectangular shape, a lower cheek profile, and a lax jawline. As such, a short scar necklift performed in conjunction with ancillary procedures such as fat grafting, superciliary eyebrow lift, nasolabial fold excision, and conservative eyelid surgery, can result in quite satisfactory improvement without the need for a full facelift and periauricular scars ( Fig. 9.11.3 ) .

Figure 9.11.3, Facial rejuvenation strategy in the man with the shaved head. In treating the man with the shaved head one can exploit the fact that a quintessential feature of an attractive, athletic appearing man is a good neckline. As such, a short scar necklift performed in conjunction with ancillary procedures, as indicated, such as facial fat grafting, superciliary eyebrow lift, nasolabial fold excision, and conservative eyelid surgery, can result in quite satisfactory improvement without the need for a full facelift and periauricular scars. (A,C) Male patient with shaved head seen preoperatively. On casual consideration it seems treating him would be difficult. (B,D,E) Same patient following short scar necklift (note: no scar is present around the ear), facial fat grafting, and conservative eyelid surgery. The patient appears remarkably rejuvenated even though a periauricular incision was not used and no periauricular scar is present (see also Fig. 9.11.4 ). All surgical procedures performed by Timothy Marten, MD, FACS.

In a short scar necklift a submental incision only is used and improved neck contour is obtained by modification of deep layer neck structures and not the excision of neck skin. These modifications include subplatysmal lipectomy, submandibular gland reduction, partial digastric myectomy, and platysmaplasty. Skin is then allowed to redrape over the deeper and geometrically longer concave surface created and this, in effect, “takes up” “loose” neck skin. Short scar necklift can be productive in men well into their 60 s in most cases ( Fig. 9.11.4 ).

Figure 9.11.4, Short scar necklift. (A) patient before surgery. (B) Same patient after short scar necklift. A submental incision only is used and improved neck contour is obtained by modification of deep layer neck structures and not the excision of neck skin. Skin is then allowed to redrape and redistribute itself over the deeper and geometrically longer concave surface created and this takes up “loose” neck skin. No scar is present around or behind the ear. All surgical procedures performed by Timothy Marten, MD, FACS.

If a man with a shaved head feels excess skin is present that needs to be removed an “extended necklift” incision plan can be used (typical periauricular facelift incision with no temporal portion Fig. 9.11.5 ) modified by shortening or eliminating the occipital portion of the incision. Typically men needing and requesting this are older (in their 60 s or 70 s) and the scar is less of an issue and better concealed on their more aged skin than in the typical “short scar” candidate (40s–60 s).

Figure 9.11.5, Extended necklift incision plan. The incision plan for an “extended necklift” is similar to the typical periauricular facelift incision plan without the temporal portion of the incision. This incision plan allows some lower facial skin to be excised and a “low” superficial musculo-aponeurotic system (SMAS) flap to be elevated and advanced (or low SMAS plication or SMAS stacking to be performed) that provides improvement in the lower face and along the jawline that would not otherwise be obtained if an isolated necklift (short scar necklift) only was performed.

The “facelift” phobic man

Many men are simply put off by the word “facelift” and even when their typical fears of “looking different”, “having a pulled or tight appearance”, or “having obvious scars” are countered with explanations as to how those occurrences can be avoided, it can be difficult to convince them to undergo the procedure. Often it seems that they want the improvement afforded by the facelift but just cannot get past the name of the procedure. In such cases an accord can usually be struck by simply calling the procedure an “extended necklift” and modifying the facelift incision plan slightly accordingly.

In the extended necklift, a typical periauricular facelift incision is employed but no temporal portion of the incision is made (see Fig. 9.11.5 ). Such a plan places the incision and resulting scar in a well-concealed location but negates the possibility of a poorly concealed scar in the temporal (around the sideburn) area. This incision plan will allow a limited low cheek SMAS flap to be elevated (or a low cheek SMAS plication to be performed) as part of the procedure that provides improvement in the lower face and along the jawline that would not otherwise be obtained if an isolated necklift (short scar necklift) only was performed. In addition, it allows the excision of a significant amount of skin from the lower face, jawline, and neck that would not otherwise be removed. It should be noted that the extended necklift encompasses certain compromises however, including the fact that no upper cheek or midface improvement is obtained. While this is often an unacceptable compromise when operating on the female face, it can be a very acceptable trade-off in the male patient.

The extended necklift can be combined with fat grafting to offset some of its limitations and to obtain improvement on the upper face. Conservatively performed forehead and eyelid surgery, as discussed above and in following sections, can further enhance the outcome.

Short scar facelifts in men

A traditional short scar incision plan offers little benefit for most men and can in reality be problematic in many cases. The basic premise of shifting facial skin strongly in a vertical direction is conceptually flawed and typically results in the need for aggressive temple or forehead lifts and tedious gathering of redundancy along a temporal hairline incision that might not otherwise be required. Gathering of tissue, and the often resulting puckering and bunching of skin along incisions in the temple and post-lobular areas that typically occurs when short scar incision plans are used, can be concealed to some extent by women who typically wear longer hairstyles, but can be a significant source of embarrassment to men ( Fig. 9.11.6 ). Vertical skin shifts can also move deep cervical wrinkles up onto the lower face, a problem not encountered when a postauricular incision is used and a proper more posteriorly directed vector for skin shift is employed. And because neck improvement is of paramount importance in men, it could be argued that shortening the scar in the postauricular area where it should be well concealed (see Figs. 9.11.2–9.11.5 and Fig. 9.11.17A ), even in a man with short hair and compromising overall result in the cervicosubmental region, is of dubious value.

Figure 9.11.6, Flawed “short scar” facelift incision plans. (A,B) A short scar incision plan offers little benefit to most men and can be problematic in many cases. Gathering of tissue, and the often resulting puckering and bunching of skin along incisions in the temple and postauricular areas, that typically occurs when short scar incision plans are used can be concealed to some extent by women who typically wear longer hairstyles, but can be a significant source of embarrassment to men. Procedures performed by unknown surgeons.

Figure 9.11.17, Planning the position of the transmastoid part of the postauricular incision. Strategically placing the transmastoid part of the postauricular incision conceals it and allows optimal excision of skin from the anterior neck. If it is placed too low it is visible. If it is placed too high the defect created will force an overly vertical shift of the postauricular skin flap and compromise improvement in the neck. (A) The point of divergence of the anterior and superior crus of the helix provides a useful guide as to how high the transmastoid part of the postauricular incision should be placed (red dot). (B) At this horizontal level (red line) the rim of the helix will typically “touch” the occipital hairline in the lateral view. (C) A transmastoid scar placed at this level will cross over to the occipital scalp in a hidden location. Note that if the incision were placed lower the resulting scar would show. (D) Typical plan for the postauricular incision showing the transmastoid component (red line) to be concealed (gray dotted line shows location of the auriculomastoid component incision hidden behind the ear and white dotted line the occipital incision hidden along the occipital hairline). (Note: the male patient shown has undergone a previous facelift and it can be seen that his scars are well concealed despite his very short “military-style” haircut). (Procedure performed by Timothy Marten, MD, FACS.)

Shortening the occipital portion of the facelift incision somewhat may be useful in the man with the shaved head however (see previous discussion).

Preoperative planning in the male facelift patient

It is not possible to design or use a "universal" male facelift technique as each male patient will present with a unique set of problems that require precise anatomic diagnosis and an appropriately planned and individualized surgical repair. Committed study, careful planning, and avoiding the use of a “formula technique” will maximize improvement, limit complications, and minimize secondary deformities.

Planning incisions in the male facelift patient

Planning the temple incision

The temporal portion of the facelift incision has traditionally been placed within the temporal scalp in a well-intended, but all too frequently counterproductive attempt to hide the resulting scar. When cheek skin redundancy is small and abundant temple and sideburn hair is present, such a plan can be used without producing objectionable sideburn elevation and temporal hairline displacement ( Fig. 9.11.7 ).

Figure 9.11.7, Temple scalp temporal incision plan. When cheek skin redundancy is small and abundant temple and sideburn hair is present, an incision hidden in the temple scalp (red dotted line) can be used without producing objectionable sideburn and temporal hairline displacement. Note sideburn and bearded skin in front of the ear (area between black arrows) have been moved posteriorly closer to the ear but not objectionably so (retrotragal pre-auricular incision plan has been used; (see Fig. 9.11.12 ). Procedure performed by Timothy Marten, MD, FACS.

This, however, is often seldom the case for male patients, who typically present for facelifts at a later age. Patients best suited for this incision plan are usually young men and women who are troubled by mild to moderate cheek laxity only. In many men, however, skin shifts and the presence of sparse temple hair can result in unnatural, tell-tale, and effeminate-appearing displacement of the temporal hairline and sideburn if such a plan is used. Proper analysis, careful planning and the use of an incision along the hairline, when indicated, can avert this problem without compromising the overall outcome of the procedure ( Fig. 9.11.8 ).

Figure 9.11.8, (A,B) Temporal hairline incision in the male patient. In many male patients skin shifts and the presence of sparse temple hair can result in unnatural, tell-tale, and effeminate-appearing displacement of the temporal hairline and sideburn if such a plan is used. Placing the incision along the hairline prevents this problem and results in a well-concealed scar if the incision is closed properly. (A) Plan for temple hairline incision in the male patient. Note that unlike the incision plan in a female patient that is made as a soft curve, the incision in men should be planned in a more angular fashion, echoing the shape of the male sideburn. (B) Close-up of healed incision. Hairline displacement has been avoided and the scar is well concealed. The sideburn has an angular masculine shape and has not been retrodisplaced or diminished in size (note slight shift of bearded skin below the sideburn can be seen). Surgical procedures performed by Timothy Marten, MD, FACS.

This incision will accommodate large posterior-superior skin flap shifts and allows maximum improvement in the upper lateral face to be made. If it is made with care and closed under no tension, the resulting scar is usually inconspicuous and will be far less troublesome for the patient than a displaced hairline. This is particularly true for men whose temple hair is generally kept cut short and usually falls forward and over the scar, as opposed to women who typically wear their hair long and tuck it up over their ear, exposing the scar. The length (extent superiorly) of the temple-sideburn incision can be varied depending on the amount of redundant skin in the upper lateral cheek, and the amount of midface improvement obtained ( Fig. 9.11.9 ).

Figure 9.11.9, (A–C) Length of the temple hairline incision. The superior extent of the temporal hairline incision will vary depending upon the amount of cheek skin shift predicted (and whether a forehead lift is to be concomitantly performed) if puckering and gathering is to be avoided in this area. (A) Superior extent of temple hairline incision when modest cheek skin displacement is predicted (white dotted line). (B) Superior extent of temple hairline incision when moderate cheek skin displacement is predicted (white dotted line). The incision must be made higher to accommodate the cheek skin shift, but still is situated in a well-concealed location. (C) Superior extent of temple hairline incision when large cheek skin displacement is predicted (white dotted line). This incision should be made no higher than the junction of the temporal hairline with the frontotemporal hairline, however (point shown by white arrow). If it is carried more superiorly along the frontotemporal hairline (area designated by red X) the resulting scar will usually be visible as hair tends to grow posteriorly in that area. Procedure performed by Timothy Marten, MD, FACS.

Planning the pre-auricular incision

Open to inspection, the pre-auricular region exists as a frequent point of reference for those seeking to identify a facelift patient. Traditionally, incisions in this area in men are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus in a “pretragal” location ( Fig. 9.11.10 ).

Figure 9.11.10, Traditional location of the pre-auricular incision. This places the scar in most men in an area open to inspection by others and “brands” the male patient as having had facelift surgery. Gradients of color and texture between smooth, pale auricular skin and coarse, red cheek skin draw additional attention to the scar (see Figs. 9.11.11A–C ).

This plan, however, works well only for the unusual male patient with cheek and tragal skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most male patients have a marked gradient of color, texture, and surface irregularities over these areas and a tell-tale mismatch will be evident, even in the presence of an inconspicuous scar ( Fig. 9.11.11 ).

Figure 9.11.11, Typical irregularities seen when a pretragal incision is used in male patients. (A) An unknown surgeon has mistakenly tried to “hide” the pre-auricular incision along the posterior border of bearded skin. The scar is easily seen in the exposed location. A gradient of color and texture on each side of it draws additional attention to it, and the patient’s attempt to hide it by growing a long sideburn has failed. Retro-displacement of bearded skin against the scar has resulted in a thin, spindly, unnatural, and unmasculine-appearing sideburn. (B,C) An unknown surgeon failed to recognize the difference in color and texture of the ear (tragal) and cheek skin and the use of a pretragal incision has resulted in an obvious irregularity even though the scar itself is well healed. The difference in color and texture on each side of the scar would be better concealed along anatomic interfaces if a retrotragal (see Figs. 9.11.10–9.11.14 ) incision plan had been used. Procedures performed by unknown surgeons.

For these reasons, and in all but the unusual case, the pre-auricular portion of the facelift incision in men is usually best placed along the posterior margin of the tragus, rather than in the pretragal sulcus ( Fig. 9.11.12 ).

Figure 9.11.12, “Retrotragal” plan for the pre-auricular portion of the facelift incision. (A,B) Placing the incision along natural anatomic contours conceals the scar and disguises differences in color and skin texture on each side of it (see also Figs. 9.11.13 & 9.11.14 ).

In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a tragal highlight ( Fig. 9.11.13 ).

Figure 9.11.13, Retrotragal incision plan of the pre-auricular incision and resulting scar. (A) “Retrotragal” plan for concealed pre-auricular incision. The incision is planned along natural anatomic interfaces to disguise gradients of color and texture typically seen between the ear and cheek. (B) Healed retrotragal scar in a male facelift patient. The scar is situated along anatomic interfaces concealing gradients of color and texture that would be obvious if a pretragal incision plan had been used. In this location the scar, if seen, fools the eye and appears to be a reflected highlight. Procedure performed by Timothy Marten, MD, FACS.

In addition, if properly planned and executed, an incision along the margin of the tragus will not produce tragal retraction or other anatomical irregularity ( Fig. 9.11.14A–C ).

Figure 9.11.14, Healed “retrotragal” facelift scars in male patients. A retrotragal placement of the pre-auricular portion of the facelift incision has resulted in inconspicuous and well-concealed scars. In the upper third, the scar sits in the interface between the helix and the cheek and the scar appears to be a reflected highlight of the anterior helical border. In the middle third, the scar sits along the poster margin of the tragus and cannot be seen. Some coarse and bearded skin has been shifted up against and onto the tragus in (B) and (C), but this is less obvious than the presence of a pretragal scar with a gradient of color and texture on each side of it (see Fig. 9.11.11 ). In the lower third, the scar sits in a well-concealed location 2–3 mm outside the lobular-facial sulcus but far enough away from it that shaving in that area is not difficult. Note that the patient seen in (C) has a shaved head. All surgical procedures performed by Timothy Marten, MD, FACS.

If tissue repositioning is achieved using SMAS advancement and not excessive skin tension, as it rightly should be, modest displacement of skin will occur in many male patients and no bearded skin will be advanced onto the tragus (see Fig. 9.11.14A ). In the male patient in whom large skin flap shifts occur, beard growth on the tragus can be reduced by intra-operative destruction of beard follicles from the underside of the tragal flap (see Fig. 9.11.35 ).

Figure 9.11.35, Epilation of beard follicles from tragal skin flap. In the older male patient in whom large skin flap shifts occur, beard growth on the tragus can be reduced by intra-operative destruction of beard follicles from the underside of the skin flap. (A) The facelift flap has been trimmed but has not been sutured. Beard hair has been shifted into a normally non-hair-bearing area (area posterior to purple dotted line). Note: patient has not shaved for 2 days preoperatively. (B) The pre-auricular skin flap is inverted over the surgeon’s fingertip using small skin hook retractors. Because the patient has not shaved for several days preoperatively, beard stubble pushes the beard follicles out of the plane of the skin on the underside of the flap. Excising subcutaneous fat as shown further exposes the unwanted beard follicles and results in the direct removal of some follicles. (C) Using loupe magnification and a needle-tipped cautery set on a very low setting, remaining follicles and residual follicle elements are epilated. Care must be taken to only cauterize follicles and not apply cautery current to the skin itself.

Because beard hair grows in three phases, “beard shift” encroachment on the tragus cannot usually be completely eliminated at the time of surgery. However, most mature men in the facelift age group have some stray hair growth on the tragal area naturally, and some visible hair growth on the tragus is not necessarily seen as a sign that a facelift has been performed in the eyes of most casual observers and in typical social situations (see Fig. 9.11.14B,C ; also Figs. 9.11.7, 9.11.8 & 9.11.13 ). To obtain the most natural appearance, some men may wish to undergo electrolysis following their surgery in the relatively rare case that bearded skin is advanced onto the tragus and intra-operative epilation is not adequate. In general, it is prudent to wait 4–6 months after surgery before that is done.

The superior portion of the pre-auricular incision should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-appearing "width" to the helix in keeping with the rest of the ear, and the resultant scar, if visible, will appear to be a helical highlight. As the tragus is approached, the mark for incision is carried into the depression superior to it and then continued along its posterior margin . In this location the scar, if visible, will appear to be a natural highlight (see Figs. 9.11.8, 9.11.12–9.11.14 ).

At the inferior portion of the tragus the incision must turn anteriorly and then again inferiorly, into the crease between anterior lobule and cheek. If a more relaxed “lazy S” plan is made, or if a straight line incision is used, skin settling and scar contraction will result in crowding of the incisura, obliteration of the inferior tragal border and a tell-tale elongated and "chopped off" tragal appearance.

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