Facelift Series #10: Incision Decisions

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Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue Plastic Surgeon, educator and technology innovator. Today's episode is Incision Decisions, part of our Facelift series. What are we talking about in this episode, Dr. Bass?

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We're starting a few episodes that dive into what is done in the facelift surgery itself, technically. The first step in any surgery is the incision. In this episode, we're going to present what incisions are used in various facelift procedures. We'll also discuss some of the variations on the basic incisions and provide our opinions about the advantages and disadvantages of each and when they are best used. Subsequent episodes will look at options for what we do under the skin and how that helps us achieve the rejuvenating effect of the facelift.

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To get started on the topic of incisions, can you tell us basically where the facelift incisions are? Yes, there is an incision along or within the anterior hairline, which then extends down along the front of the ear and sometimes to an extent within the ear before it goes around the earlobe, along the back of the ear, and then extending into the posterior hairline in some aspect. Okay, so can we look at mini facelift, mid facelift, and neck lift and split out which of those incisions are typically used? Yes,

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this is very confusing,

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but for me at least, for a mini facelift,

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the incision location really depends on where you're focusing your lift on. So if you're focusing your lift mostly on the midface, as we do with a midface lift, then your incision is really going to be mostly along the hairline, in front of the ear, and then maybe to the back of the ear at some extent. But if you're focusing your lift mostly on the jawline or the neck, the lower part of the face, then the incision is going to be focused primarily behind the ear into the hairline, and then extending up onto the front of the ear as needed to kind of re-drape the skin even out, any pleating, things like that. So you're either focusing it in front for the midface and chasing it out as you need behind or focusing it in the back for the neck and the jawline and then chasing it out in front as needed, if that made any sense at all.

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You're absolutely right, Dr. Edinger. It is very confusing. And the reason is because a lot of the facelift terminology, again, is marketing terminology. It's not technical. But to surgeons, based on the areas they're trying to focus their lift, they're going to need access to redrape that skin, to tailor out excess skin, and to do the deeper work of the facelift on the connective tissue and muscle layers to reposition and shape those tissues as well. So I think you explained it very well. It will vary depending what technique is being used, depending on where the lifting is needed and it mostly parses into that binary either upper half, lower half, or both. But there are a lot of variations depending on how each individual has aged and every facelift is going to be customized both in terms of the incisions and in terms of what techniques are used under the skin. So it's important, particularly for the incisions, because you're going to see those for your surgeon to explain what they have planned based on what you've asked to correct and based on what they think you need.

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I feel like I have to keep up with social media these days just so I can stay hip on what the new terms are in facelifting and these coined facelift techniques because it's confusing.

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Yeah, I mean, the terminology doesn't mean that much. It's something that catches on in social media or that catches on in beauty magazines or by influencers where it's trending. The surgical techniques don't trend. They evolve slowly with a lot of deliberation and care to make sure they're safe and effective. And working with an experienced facelift surgeon understanding their rationale for why they prefer or why they think you need a particular approach is probably more useful than jumping on a trend that may not be right for your features and that almost certainly isn't the one and only answer to how to do a procedure.

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Okay, so you two have kind of alluded to it, but what kinds of variations are there in these incisions?

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Well, let's start with that incision in front of the ear that Dr. Edinger was talking about. There are two major variations in where that incision is placed.

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And there are two major variations in two different spots in front of the ear. The first one being kind of along the hairline, whether that goes along the sideburn or into the hair. And then the second being in front of the ear, whether that goes in front of the tragus or whether that grows behind the tragus or within the ear itself. So we often call that a pre-tragal incision, which is what I said in front of the tragus, or a retro-tragal incision that sort of runs within the ear itself.

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And, you know, that incision in front of the ear is the one that everyone worries about because of all the incisions in facelifting, that's the one that's out where it can be seen. Other incisions are in the crease behind the ear or they're in hairline areas where they can be covered with hair or they're within the scalp and the actual hair-bearing skin. So this incision is the one that everyone spends a lot of time, energy, and anxiety thinking about.

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What are the advantages and disadvantages of each incision? Well,

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if we focus on the one with the tragus first, being either in front of the tragus or behind the tragus, sort of within the ear. If you're a male and you have hair-bearing skin, then a pre-auricular or pre-tragal incision is often helpful. Because if it goes retro-tragal, you're actually going to have hair growing along your tragus, which you'll have to shave or get hair removal from. On the flip side also, a retro-tragal incision hides really nicely because it's not in front of the ear, it's actually sort of within the ear. However, it's challenging to restore that tragal anatomy with that retrotragal or in-the-ear incision because the tragal anatomy has this pre-tragal sulcus or indentation that's hard to recreate after surgery. You can also run the risk of distorting the tragus if the skin is tensioned too tightly with that post or retrotragal incision. You can actually pull the tragus anteriorly, which affords an odd-looking tragus or blunts that pre-tragal sulcus in the aftermath of that.

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And I think that's a good summary of the relative benefits and disadvantages. The crag is that this is this button-like little piece of cartilage that sits about midway along the ear, sticks in to cover over the external auditory canal. And that's a very distinct but also very delicate shape, and it is challenging to restore that. So sometimes in men, both because of the issue of hair and because of the thickness of that skin, the incision will be made in the preauricular or pre-tragal area. However, if the skin is thin enough in a man, you can still use this. And the skin can be thinned both to remove the hair follicles so that there isn't hair growing out of this tragal skin because men have a zone of non-hair-bearing skin in front of their ear, and also to thin the skin so that a more delicate appearance of the tragus is obtained. But in a man with very thick, plethoric skin, they're probably going to get a preauricular incision in my hands, and that usually heals and fades. So everyone likes the idea of having the hidden incision at the edge of the tragus really within the ear itself, but given how the preauricular or pretragal incision usually heals, that may not be an advantage. And if you end up with thick skin on the tragus or an unnatural shape to the tragus, or you efface the definition of the tragus, Sometimes the tragus gets blunted and you lose that shape if it's not carefully reconstructed as you sew the closure. So each surgeon will look at the skin on the patient, look at how they may have healed other incisions, what other scars they've made, and make a decision about what's going to be best in that individual facelift.

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Okay, and you mentioned a little bit just now, but when do you typically use each incision?

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So that's a summary for that. And then men don't get that incision as often, although I will make a retrotracheal incision in men. However, they're more likely to get a pretracheal or preauricular incision. and women, it's going to be based more on what kind of scar former they are. Patients that tend to make hypertrophic scars have to think hard about having a facelift in the first place, but they may better have incisions placed retro-tragal where it's going to be hidden and that avoids worrying about how that scar is going to show on the outside. And usually that scar behaves pretty well.

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Okay, and then what about the upper part of the incision in the front?

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What are the options here? So a classic facelift extends up into the hair behind the temples. In modern facelifting, we usually extend the incision along the sideburn rather than straight up into the hair from the root of the ear or at the helix. Sometimes this carries completely along the sideburn. Sometimes it goes up along the anterior hairline to chase out any residual laxity, and sometimes it runs along the hairline and then dives up straight up into the hair as a classic facelift would.

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And the issue with this incision is this is the stopping point superiorly and modern facelifting tends to be more of a vertical lift. And so if you pull skin up, it can tend to curl up or project, basically create a dog-ear or rounded protuberant irregularity at the top of the work area. And there are a lot of tricks to get this to settle, and it's partly going to be a product of how much skin needs to come out. So some surgeons will need more skin removal if there's a lot of laxity, if the patient's somewhat older, and they'll extend that incision beyond the sideburn along the anterior hairline.

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But won't that show?

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Yes, it can show. So sometimes that will heal to be very faint. Sometimes it's somewhat more visible. Some surgeons put the vertical component in the mid-sideburn within the hairline to hide it, taking a wedge out there to allow full removal of the redundancy and flattening down the areas. Another way is to use the classic incision, which is a little further back by the root of the helix, the beginning of the ear in front at the very top. Yet another way to hide the anterior hairline incision is to cut it obliquely. This leaves hair follicles at the back edge of the incision and it allows hair to grow through overlapped closure hiding the scar.

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Okay, got it. Now tell me about how the incision is made at the earlobe.

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This is a critical area to preserve a natural appearance. How the incision is made and how it's inset, by which I mean positioned and sutured back in place, must be done with a lot of skill and finesse.

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Some surgeons choose to place the incision within the crease of the earlobe itself, while others might choose to leave a small cuff of facial skin just along the earlobe so that the incision is not directly within that crease to preserve that crease. There are a lot of techniques to inset the earlobe in a way that prevents earlobe tethering, or a pixie ear as you might hear it called, and to prevent incision migration that would cause the incision to move down onto the face itself, or maybe perhaps pull on the earlobe in an unusual way. And the earlobe should be set in in a neutral position so that we don't disturb the positioning of the earlobe when we insert it and change it from what it was before. This is a very finesse position and a point of surgery, like Dr. Bass said, in terms of getting the ear right so that no one knows you were there.

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So generally speaking, the earlobe should be properly released. In other words, before lifting, before mobilizing the flap, when the incisions were made, the earlobe should be adequately released, not left tethered in position. But then during closing, that incision has to be carefully done. And Dr. Edinger alluded to fixing the earlobe down in a neutral position. Some surgeons will do that. Others will position the earlobe so that with healing, the earlobe will be in the proper neutral position. And different surgeons do it each of those ways, and it seems to work well. The important thing is that there has to be a lot of thought on ensuring the earlobe lands up at the proper height or elevation. In terms of making the incision in the crease versus slightly off of the crease, leaving a little more tissue, my 30 years plus of experience, I haven't seen a problem either way. I think both ways can give a very natural and virtually imperceptible appearance to the incision in that location. So I think that's largely a matter of surgeon preference.

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Okay, moving on to the next incision. What is the submental incision and what are the options here?

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The submental incision is the incision made right underneath your chin in the submentum. It's usually about two to four centimeters in size. That really depends on how much visualization and access we need during surgery. It's usually just within a submental crease. That's just a natural wrinkle that everybody has underneath their chin. Some people put it just anterior to this, just posterior to it, but somewhere in the realm of the submental crease is what we aim for. And then we'll discuss what this incision is used for in subsequent episodes, but basically it just allows us access to the central areas of the neck during the neck lift portion of the facelift.

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and as dr edinger said you know it can be made right in the crease most people as they age have a little crease under their chin but also a lot of surgeons and i usually try to do this if there's if there's room and i think the incision will remain hidden underneath is to put the incision just in front or anterior to the crease so that as you lift the skin flap to get into the neck, rather than ironing in the crease by putting the incision right in the crease, you're ironing flat the crease a little bit because you release that crease as you come across it to raise the skin flap. Again, it's an area that most people don't see. Your pet sees it, but nobody else really sees up under your chin unless you're literally basketball player height. But if we can efface that little wrinkle there, I think that's usually a good thing, and it helps minimize the development of the witch's chin.

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Okay, so we're working our way around the ear. Tell me about the options for the incision behind the ear. Well,

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we're here to please both pets and hairdressers, and this is the one that your hairdresser's going to see. But we either carry this within the ear crease or up onto the back of the ear. Either way, it ends up hidden behind the ear. This will then continue superiorly or up along your ear until you reach kind of your ear wigglers behind your ear or that superior cruciate of the ear, basically where your ear almost touches your hair is usually where we cross over to the hair bearing portion in the incision.

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So as Dr. Edinger said, this incision is hidden even in men with short hairstyles, but your hairstylist is going to see it. So hopefully they're not talkative or gossipy, but they're going to be able to see it, but most other folks are not. This one, because of the very thin skin, because of the relative lack of blood supply in that very thin skin, and the base that it's applied to on the back of the ear often is not quite as imperceptible a scar if you were able to look at it closely. So fortunately, it's hiding in the crease or behind the ear where people can't really see it. A lot of surgeons will choose not to put it in the crease, but again, a little bit further up onto the back of the ear itself, because as it heals, and particularly with subsequent aging, it may pull down. And if it starts in the crease, if that pulls down, it may leave the incision visible. So I typically put it not literally in the crease, but a little bit up beyond the crease and that helps keep it hidden.

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Okay, and finally, we've come to the posterior incision. What are the options? There's two broad categories.

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We either extend it into the hair directly from the ear in some variable fashion. There's a lot of different ways that people tend to do this. Or we go along the hairline itself, traveling inferiorly along your neck.

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And, you know, each of these has pluses and minuses. In the hairline, you have to restore the edge of the hairline, keep it looking natural. If it's not properly done, you can have a step or a regularity in the edge of the hairline that looks unnatural. And particularly in anybody with a short hairstyle, man or woman, that can be a tell that you had a lift. But using that incision within the hair bearing area, the hairline edge can be properly restored to look natural. You have a greater ease in getting out a large amount of skin if you go along the edge of the hairline. but that incision, and again, doesn't tend to heal quite as imperceptibly as the one in front of the ear, is going to be a little more visible. If you wear a long hairstyle and your hair is down, that may not matter to you a lot. But if you have a short hairstyle or you wear your hair up, then that area is going to show. And if the incision is less favorable, people may be able to see it. If the scar turns out less favorable than desired, it can be lasered, injected, revised, so there are options, but sometimes it's mischief better left avoided. So more often than not, I make the incision within the hair bearing area. However, that's going to vary a little bit depending on how much skin has to come out and some other factors which we're coming to.

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Okay, so we've talked a lot about different incisions. Can you tell me a little bit about what to expect with scars and how they will fade? This depends on skin type and where you started out with,

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but scars typically go through a progression of dark and red, and then they typically lighten in color. Most people on Caucasian skin, they typically fade to a lighter color or a white, but they can also heal darker in patients of other skin tones. But the important thing to know is that scars are going to continue to mature over the course of sometimes a full year before they're fully healed and done. So along the way, you may see some variations where some redness holds on. Things may get raised. There are things we can do along the way to help these along. But the most important thing to remember is that they're not going to be healed in a month or a couple of weeks. It's going to take months to a year to heal, sometimes even beyond that.

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And there are a number of things we do along the way to treat the scars to help get the most imperceptible scar possible. So one thing is scar gels and silicone gels are usually our best option. This starts typically somewhere around three weeks or whenever the incision is fully sealed. There's no more crusting and usually goes on for a period of six weeks to three months. Just an application of either a gel strip or an oily liquid that you put on when you're at home for as many hours in the day as you can manage it. If a scar is doing something we don't like, then we'll potentially inject with one or another anti-inflammatory medicine. and there are steroid anti-inflammatories, and there are anti-metabolite anti-inflammatories, and we typically use a combination of both. And we also use lasers, things like pulse dye lasers, intense pulse light sources, to cut back some of the blood supply and inflammation in the scar, and then fractional ablative and non-ablative lasers to blend a scar and let it be less perceptible, flattened, softened, and blended in texture with the surrounding skin. So we have a whole bunch of ways of chasing scars short of having to actually revise a scar, which means cut it out and restitch it, which is our last resort. The scar you land up with at the end of the day is probably more about your genetics than anything else. Plastic surgeons are really good at putting a lot of tiny stitches and being very precise. This is our superpower, if you will. And so we'll put it where it needs to be to get you the best scar. Then it's your biology and what kind of scar you make that takes it from there. But if the scar is not going the direction we want. We have all of those adjunctive treatments, which we're going to talk about more in a subsequent episode in this series.

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Okay, but what if you already have facelift scars from a prior lift?

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That's a great question, Summer. And usually we're just going to use the same incisions where the scars are. But sometimes we may be able to put a scar in a more favorable location, especially if there's a lot of skin laxity, because that means we can take out everything past the scar. The posterior scar may be the exception to that. If you already have a hairline incision rather than an incision that goes within the hair-bearing skin, we usually end up keeping it there. You know, once you've got that incision and that scar, that's probably where that incision is going in a subsequent facelift. Otherwise, you end up with two scars.

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And then in contrast to that, I'll say with the anterior hairline incision, if your prior surgeon used an incision that extended straight up vertically into the hairline from the ear, we usually do not repeat this incision for fear of really displacing that hairline, and we'll instead curve our incision along the sideburn area to some degree, whether it then continues along the hairline interiorly or straight up after we curve it.

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Okay, and then you've mentioned that some of these incisions are hidden, but what about men with no hair?

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So that's a great question again, Summer, because so many men nowadays are choosing to shave their heads. That's their fashion statement, or they may have lost most of their hair and not have a lot of hair remaining even in areas where an incision might typically be made. And in these circumstances, men can still have a lift. Sometimes the lift puts an incision that goes around the ear circumferentially or almost circumferentially to allow a lot of skin removal. Sometimes if the focuses on the neck and a vertical excision of skin in the neck will be made and that incision mostly hides under the jaw and allows removal of excess skin without putting a scar up on the face or by the scalp where it will be visible to most people.

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And Dr. Bass, can you share your takeaways?

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So when having a facelift, everyone worries about the scars. So this points out why it's important to understand what incisions your surgeon is planning to make, because everywhere there's an incision, there's going to be some kind of a scar. Usually this is not an issue, and the scars are nearly imperceptible. And if you make a bad scar, there are many options, many more nowadays than we had even a few years ago to treat the scars. The surgeon will usually make the selection. This is really a technical issue, and it's based on what works in their hands and based on their assessment of your skin, your features, and the degree of laxity on your face. So there are a lot of technical details about how each incision is worked and repaired to get it to heal ideally. We've gone into a few of those, but we've really just scratched the surface, and this is what plastic surgeons spend decades learning and optimizing. But basically, making the incision and sewing it up is not just zipping and unzipping. there's a lot that goes into how we get that to be the best possible scar. The good news is this is what we're trained to do and this is what we excel at in our specialty.

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Thank you Dr. Edinger and Dr. Bass for telling us about facelift incisions and how they heal. I'm looking forward to hearing about the rest of the facelift procedure in upcoming episodes. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast at drbass.net or DM us on Instagram at drbassnyc.