Pretragal versus retrotragal incisions are always discussed. Incisions in front of the pinna can be either vertical or oblique; however, if they are oblique and support the facial skin with a large amount of tension, they can become hypertrophic. A perilobular incision is lifted or pulled in the retroauricular area. The retro-auricular incision should be in the sulcus but not situated on the ear since it could obliterate the postauricular fold. The mastoid incisions could be either horizontal or oblique, lying high or low. If they are oblique and there is a fair amount of tension on the skin, they could be hypertrophied, especially in younger patients. If they are horizontal, they might need to be placed very high, thus allowing a bald area to be situated behind the ear, which is not a pleasant situation. If the mastoid incision is performed in the hair scalp junction, the best technique is then to perform a W-plasty which will hide the visibility of the scar and give a better appearance to the hair implantation.
The retrotragal incision, which is useful in hiding the pretragal scar should be done carefully. A rectangular portion of the flap should be left on the skin to allow coverage of the tragus without an unnatural look since a straighter or less-rounded or squared flap could make the appearance of the tragus unnatural. This flap can be defatted, however carefully, and in addition, in men the hair can be plucked. Careful dissection should be performed to avoid sloughing of the skin in that area. The perilobular excision should not leave a low scar which could cause an unnatural look. If the scar is too high, it could pull the ear up, also leaving an unnatural look. It should be performed carefully and with checking that the right amount of skin is removed. It is a good idea to have it rounded around the earlobe and to leave a scar on the skin itself with a very thin amount of skin on the earlobe. This allows a more natural appearance of the earlobe.
Scalp incisions should be closed with relatively small tension. A careful galea approximation might release some of the tension from the skin itself but not totally; a second subcuticular level closure should be absolutely tension-free. Muscle excision should be limited to the corrugator and possibly the external superior portion of the orbicularis oculi muscle.
Frontalis muscle excision leaves a thin atrophic expressionless forehead. Extreme tension on the temporal area could result in hair loss of the whole temple and even skin slough.
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