The redraped skin flap is closed with no tension whatsoever except for two anchoring points. The superior fixation suture anchors the cheek flap to the superficial temporal fascia, under moderate to high tension. A second suture anchors the more caudal portion of the posterior flap, to the mastoid fascia. The rest of the skin surface is sutured with essentially no tension.
To emphasize a natural pretragal crease, a distinct depression is created by a through-and-through suture entering the skin of the external auditory canal, through the tragal cartilage, tacking the dermis of the skin flap and exiting back into the external auditory canal (Fig. 64.9).
Together with proper defatting of the skin flap and the pretragal region when indicated, this depression is essential for the natural look of the preauricular region, and also serves as a pivot point allowing an angle change form cheek to ear.
Infraauricular skin is redraped around the lobule with no tension. The flap is inset under the lobule with no skin resection, allowing the lobule to hang tension-free before being sutured into place.
Fig. 64.8. The axis of superficial muscolo-aponeurotic system (SMAS)-ectomy is marked, from the malar eminence to the mandibular angle and platysmal border, after excision and before closure
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