Incisions Planning and Execution

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Our keys to fine scars are comprehensive preopera-tive planning, particularly regarding the auricular contour, the sideburn, the temporal hairline, and posterior scalp hairline, and flap inset with no tension.

Today, our scars are only as long as necessary to directly correct an area that needs improvement. Any facelift incision should preserve the anatomic details of the ear and hairlines. The length, orientation and location of the temporal incision may vary, depending on individual parameters.

In patients with low and anteriorly positioned sideburns, the incision is located within the hair-bearing temporal scalp, proceeding into the temple cephali-cally.

It is important to realize that unless this incision is carried out well beyond the temporal line of adhesion and the periorbital septum (orbital periosteum) released from the orbit, there will be no lifting effect on the temporal area [2].

Carrying the incision up in that direction will only serve to treat the "crowding" and excess of hair-bearing scalp created by the vertical pull, thus paying a high cost for a relative poor return. On the other hand, a recessed hairline requires intratrichial incision at the sideburn horizontally, curling up as necessary.

4cm Incision
Fig. 64.1. If the distance from the lateral cantus to the sideburn is more than 4 cm, then the incision is made at the hairline, in order to avoid further recession

If the distance from the lateral canthus to the hairline at the sideburn exceeds 4 cm, it is considered to be receded and therefore further posterior pulling should be avoided [3] (Fig. 64.1).

The incision is carried out in accordance with the guidelines of Camirand [4] using a no. 11 blade, held at 45°, leaving intact hair follicles distally within the underlying dermis (Fig. 64.2). Hair growth through the scar will follow and make the scar inconspicuous to invisible.

Contrary to what has classically been taught for years, the proper hairline incision should be perpendicular, and not parallel, to the hair follicles (Fig. 64.3). If the incision is made parallel to the hairs, the subsequent scar frames the border of the hairline and is visible.

The preferred incision that we suggest is made 1-2 mm inside the hairline and is beveled perpendicularly to the hair follicles, keeping a residual dermis abundant with hair follicles in the dermis (Fig. 64.4). Frequently, patients allow their hair to be styled in a way that exposes the invisible suture line (Fig. 64.5).

Incision Through Hair Follicles
Fig. 64.3. The hairline incision should be oblique and perpendicular, and not parallel to the hair follicles
Hairline Incision
  1. 64.5. These scars become so inconspicuous that patients allow the hair to be styled, exposing the scar
  2. 64.4. The hairs grow through the scar, making it less conspicuous, as these different close-ups demonstrate a, b
  3. 64.5. These scars become so inconspicuous that patients allow the hair to be styled, exposing the scar
Planning Incision
Fig. 64.6. The intratrichial w-plasty incision produces inconspicuous-to-invisible scar

Being relatively short, a vertical "zigzag", or w-plasty incision is made through the hair-bearing scalp, enabling compensation for the incongruent length between the proximal and distal margins, thereby preventing dog-ears, as well as preventing the contracture potential of the linear scar (Fig. 64.6).

Though controversy exists regarding the tragal part of the preauricular curvilinear incision, we prefer a retrotragal placement in women. Commonly quoted reasons for avoiding a retrotragal incision are greater likelihood of distortion of external ear anatomy, including blunting the fold anterior to the tragus, tragal distortion due to tension, external auditory me-atal show, and loss of the natural cheek/ear interface [5-7]. A simple through-and-through transtragal suture and no tension as described later, maintains its natural appearance. These possible unfavorable stigmata are rare when using appropriate guidelines and techniques.

After exiting the tragus with a near 90° angle, the incision proceeds anterior to the lobule at the base of the intertragal incisure, and then hugs the inferior aspect of the lobule, towards the postauricular sulcus.

Retroauricular extension is necessary only when significant neck skin redundancy is present. Otherwise the incision is short, ending just posterior to the lobule.

When active platysmal bands are present or whenever opening of the neck is indicated, the submental incision is placed anterior to the crease. This helps obliterate and soften the crease.

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