In both the temporal and the retroauricular areas, we favor a technique of wide undermining and repositioning of tissues with very limited skin and scalp resection. It is more a redistribution than a resection. In the temporal area, the backward displacement of the hairline is no longer acceptable. The precapillary incision is the old way to avoid compromising the hairline. Studies by Connell , Camirand , and Cami-rand and Doucet , have shown that a precise technique can produce excellent results. We use it sometimes, especially in secondary cases in which the temporal area has already been altered, but it is still unpredictable in our hands, and we prefer an incision within the hair-bearing area.
The incision of Guyuron , which is below the hairline in the horizontal position and then enters the hair-bearing portion vertically, is interesting. Its drawback is for secondary face lifts because a new elevation creates a step at the anterior portion. Another way to maintain the temporal hairline at its horizontal level is to resect the extra skin below the horizontal portion. This technique is advocated by Little . One must then add a pull at the upper part of the temporal area to be able to pull on the skin of the malar area. We prefer to elevate a temporal flap that will allow redistribution of the skin area located between the lateral canthus and the hairline. In secondary face lifts, Rees  has described the resection of a triangle below the temporal hairline when there is considerable skin excess; however, his technique pulls and lifts the temporal scalp area upward. We prefer the contrary, namely, a downward movement of the temporal
flap that maintains the hair at its original level and avoids significant resection of the scalp (Fig. 47.7). The lowering of the temporal flap recruits most or all of the excess scalp at the upper edge. In secondary cases, when the temporal hairline has been elevated and is often already too high, the downward temporal rotation flap will avoid further elevation and result in a lower temporal hairline.
In the retroauricular area, many attempts have been made to eliminate the visible retroauricular scar, ranging from a high transversal incision to the high retroauricular flap by the senior author  to techniques by innovative precursors like Claoue  (Fig. 47.15). The vertical incision relies on a different approach, using mostly redistribution and skin retrac tion after extensive subcutaneous undermining. Our previous approach with a horizontal scalp incision and vertical back cut  was already creating a significant skin discrepancy between the realigned hairline and the retroauricular sulcus, but we observed that the posterior excess of the thin retroauricular skin was easily addressed and rapidly flattened.
The description of Eanes et al.  of an endoscopic neck lift with transfer of excess scalp skin has shown that posterior shifting of the elevated scalp is possible. When Little  described his omega approach, we were very interested and developed our method with several of his ideas, but also with some radical changes. His incision is omega, that is, oblique posteriorly in the scalp, whereas ours is strictly vertical. The level
of undermining under the scalp is different. He uses a deep dissection downward, under the muscle, close to the periosteum, whereas our dissection is superficial and subcutaneous. Little exerts a significant pull on the lower edge of the scalp and excises 1-3 cm, whereas we exert no tension and there is minimal resection (a few millimeters) at the scalp level. The redistribution of retroauricular skin is equivalent, but we excise much less skin. Little  warns about the danger of this extensive dissection, particularly the risk of damaging the posterior branch of the lesser occipital nerve and the greater occipital neurovascular bundle. We stop the undermining under the scalp at 5 or 6 cm from the retroauricular sulcus, and we have neither seen nor damaged these nerves.
The ease with which dissection in the retroauricu-lar area is done varies greatly from one patient to another. Infiltration with lidocaine and epinephrine followed by progressive, gentle dissection above the aponeurosis are the ways to maintain a continuous layer without damaging the deep structures, such as muscles and nerve branches. According to Little , his technique requires an additional hour of work, whereas our approach lengthens the operating time by 20 min.
All our primary cases are now treated this way because we do not see any contraindication. An additional significant advantage of the vertical scar is the increased viability of the retroauricular flap. It is one large advancement flap with a good blood supply, and we no longer experience the occasional limited retro-auricular slough at the tip of the triangular classic flap. We had only two problems in 100 patients, as discussed before.
We also use this technique in secondary face lifts when the existing transverse retroauricular scar is of good or acceptable quality (Fig. 47.8). In these cases, we simply ignore the old scar and perform the vertical approach. In the 22 patients treated - with an average of 8 years between the primary and secondary face lifts - we have not observed any slough or healing problems above the previous scar. When the old scar is of poor quality (i.e., wide or conspicuous), we then prefer to excise it and reproduce the original approach.
Objections to this well-hidden and vertical scar might be insufficient cervical pull and hairline displacement. It is true that the cervical pull is exerted only in the retroauricular area and not lower in the posterior aspect of our neck skin under tension. It is according to the teaching of Millard et al. , who advocated pulling the main vector behind the ear, along the Frankfurt line.
Some think it is necessary to pull lower and perform a low precapillary incision. For these clinicians, the vertical approach will not obtain their approval because it does not create a transversal tension in the lower part of the neck. We strongly think that this lower tension is not necessary and that many of the precapillary incisions widen conspicuously.
When the platysma muscles are sagging, a strong pull on the deep layer, cervical platysma mobilization with sutures under tension to the sternocleidomastoid aponeurosis, defatting of the neck, and a reasonable retroauricular skin pull are, in our experience, the best way to produce a good result in the neck.
There is mostly a redistribution of retroauricular skin with this technique, occasionally accompanied by a moderate recession of the retroauricular hairline (about 2-4 mm). This is of no consequence in the majority of patients whose hairline is rather close to the ear. When the hairless retroauricular area is wide, it can be objectionable to enlarge it further. On the other hand, it is with these patients that the classic transverse retroauricular scar will be most conspicuous and, thus, these patients derive greater benefit from the vertical approach, even at the cost of this very moderate hairline displacement.
Recently, Baker  proposed a short face lift incision with a very limited retroauricular incision at the inferior aspect of the posterior sulcus. He elevates an teriorly and preauricularly to correct the ptosis of the cheek and neck. He states that there is frequently a skin fold under the lobule because of the absence of retroauricular pull; this is demonstrated in the cases he has presented. His main goal in presenting this short-scar face lift is to avoid a visible transversal ret-roauricular scar. If we understand it correctly, he does not object to the length of the retroauricular scar, but to its visibility. The vertical retroauricular scar eliminates the visibility and achieves a satisfactory retro-auricular pull with better skin distribution. It also allows correction of considerable skin excess with a hidden scar, whereas Baker does not recommend his short-scar technique in cases in which the skin excess is significant.
When a patient presents with very heavy cheeks, we perform a suspension as proposed by Tonnard . Two or three loops of 2/0 Prolene are passed on the cheek and fixed to the periostium of the zygomat-ic arch or the temporal aponeurosis. Irregularities or lumps are smoothed out with 4/0 resorbable stitches.
In the temporal area, the downward rotation flap both maintains the lower hairline at about the same level and places the malar and crow's-feet areas under tension. The downward movement enables one to perform a limited scalp resection at the upper part of the flap (or sometimes even to avoid resection entirely). The horizontal temporal hairline scar is usually of very good quality, hidden by the hair that grows downward at this level. Despite a careful dissection and the absence of tension on the temporal flap, we have observed 10% of patients presenting with significant loss of temporal hair, usually in front of the scar. Complete regrowth is usually obtained within 2-3 months, but that is why we sometimes perform two incisions, one below the hairline, one in the temporal area.
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