Plane of Undermining and Incision Lines

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When Performing a face-neck rhytidectomy, the first question will be which is the best plane to operate with the purpose of redistributing the various volumes and which will be the incision lines to get access to the tissues responsible for the volume displacement and alteration.

Avoiding hairline distortion is a must in modern facial rejuvenation surgery. A facial aesthetic surgery creating a juvenile contour of the jawline but leaving a zone of baldness in the temporal hair is conterpro-ductive!

Cervicofacial rhytidectomy with a wide undermining and mobilizing the midfacial and cervical skin/fat layer creates a significant amount of skin to be resected. There is a direct coherence between laxity (or skin excess) and the necessity of skin excision [3]. The periauricular incision lines - and the scars - should be kept as short as possible [1, 15] but must have an extent allowing sufficient skin removal in advanced stages of facial aging [3, 17].

Wide mobilization with osteocutaneous ligament release and the good vascularity of the flap in ESP or SACS lifting techniques allows a large advancement with significant skin excess to be removed. therefore, the skin incision lines have to be placed in front of the temporal sideburn, if hairline recession is to be avoided. This is of further importance in secondary rhytid-ectomy procedures with a high incidence of hairloss from a primary facelift 10 or 20 years ago.

The hairline should be respected as an aesthetic unit of the face. Fullness of the hairline is a sign of youth (Fig. 44.11); a receding hairline with baldness of the sideburn area-as pointed out by Connell [5] - is a sign of aging and should not be "produced" by using

Hairline Incision
Fig. 44.11. The fronto-temporo-cervical hairline is describing a curved line in the shape of a "triple S"
Receding Hairline Sideburns
Fig. 44.12. a Temporal traditional incision inside the temporal hair always leads to posterosuperior displacement of the sideburn. b Hairline distortion and hairloss inside the temporal hair-bearing skin can be avoided with a prehairline incision

Fig. 44.13. Beveling the incision provides regrowth of hair through the prehairline scar in a later stage of healing

Surgical Scar Healing Stages

the traditional incisions inside of the temporal hair removing hair-bearing skin! (Fig. 44.12). The incision is performed with a beveled blade 2-3 mm inside the hairline in a way that through the transected hair follicles a small zone of new hair can grow through the scar in a later stage of the healing process (Fig. 44.13).

The line of cutting describes a pattern of multiple waves, while the excision line is simply curved to end up with a congruence of the sutured edges (Fig. 44.14). The prehairline incision is situated on a transition zone of skin pigmentation, comparable to the peri-areolar incision in breast surgery (Fig. 44.15a).

The healing process in that area is extremely good if a correct suture technique is applied. After 1 year the incision lines will be hardly visible (Fig. 44.15b).

Fig. 44.15. a The prehairline incision is situated on a transition zone of skin pigmentation, comparable to the periareolar incision in breast surgery. b Prehairline incision after 1 year

Periareolar Technique

Fig. 44.15. a The prehairline incision is situated on a transition zone of skin pigmentation, comparable to the periareolar incision in breast surgery. b Prehairline incision after 1 year

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