The periauricular incision is before the hairline in front of the ear; the postauricular incision is never before the hairline but extends into the hair-bearing zone dorsal to the mastoid.
After a soft-tissue undermining in the cheek and neck area and hemostases (the anesthetist raises the blood pressure to about 110 mmHg during that period) and application of the two-component fibrin seal (Tissucol), the key stapler clamps in front and behind the ear are positioned, followed by stepwise resection of the redundant skin. The hairline behind the ear is readapted through a third stapler clamp. A drain is applied over the mastoid. The prehairline requires meticulous suture technique. An intradermal running suture with 5.0 Vicryl rapid is recommended.
The excised skin in the prehairline cervicofacial rhytidectomy is not hair-bearing except for a small triangle of the posterior hairline over the mastoid (Fig. 44.16).
With the mainly vertical orientation of vectors and the significant amounts of advanced skin to be resected, especially from the cheek, a dramatic elevation and postero-superior displacement of temporal hair would occur with the traditional incision inside the hairline.
Short scar and minimal incision techniques [1, 15] are without doubt highly appreciated but seen from another perspective - the necessity of skin reduction - it is the author's experience that patient satisfaction depends more on the quality and position of the scars than only on their length. Especially for good access to the neck/platysma, a postauricular incision is unavoidable. Good-quality prehairline and periauricu-
lar scars can be obtained by avoiding traction of the skin edges.
The only moment when a tension is applied is the positioning of the pre- and postauricular key stapler clamps before skin excision. Choosing the right tension in that maneuver will determine the quality of the result. Every following redraping of the mobilized skin flap is done without tension. The sutures have to be applied with meticulous precision, respecting every single hair follicle!
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