The skin repositioning allowing closure of the vertical retroauricular incision is then performed (Fig. 47.3). The retroauricular key stitch A is the same as in classic face lifts, in the middle of the retroauricular sulcus at the level of the Frankfurt line. In fact, we initially pull both at the preauricular temporal level and on the retroauricular skin to determine the relationship of the upwardly displaced skin to the retro-auricular sulcus. In many cases, a resection of a few millimeters of skin seems appropriate to align with the retroauricular sulcus. This incision is lengthened anteriorly for 1 or 2 cm but must stay well behind the lobule of the ear. The retroauricular key stitch A
(Fig. 47.3) is placed, and the posterior displacement is measured. It is usually around 5 cm in primary cases. To measure precisely the displacement of the flap, we scratched the skin at two points: preauricular, below the inferior crus 1 cm above the tragus, and behind the ear, across the incision, at the level of the middle of the concha.
The aim is now first to realign the retroauricular hairline, to put the neck under tension, and to obtain a smooth and flat retroauricular area. To realign the hair one uses a d'Assump^ao clamp whose upper part is stuck to the periostium at level B of the incision. The lower flap is then pulled with moderate tension up until the hairline is realigned. One needs to excise usually a very small amount of hairless skin, 3-8 mm (Fig. 47.4).
The 3/0 absorbable stitch placed there should pick up the periostium and the scalp at the upper part (B) at the limit of the hairline, to be sure not to pull down the scalp. The lower part is grasped at the hairline limit and after tying of the knot, the hairline is restored.
This maneuver creates a discrepancy between the lower (long) and upper (short) edges of the scalp incision, like 3 cm at the upper edge and 4-6 cm at the lower edge. The suture between these edges of different lengths is easily made with the principle of "small bite-big bite." We use 3/0 Vicryl Rapide (Ethicon), but staples can be used. Sometimes a vertical fold of the scalp can be palpated below the lower edge, but it flattens out in a few weeks. One understand easily that to perform this elevation and realignment of the hairline, the retroauricular undermining of the scalp should be sufficient posteriorly and inferiorly to allow easy displacement, and that the more important is the posterior displacement, the longer should be the vertical scalp incision (from 3 to 5 cm). This hairline realignment (B) has taken care of 1.5-2 cm of the retro-auricular skin discrepancy.
The temporal elevation is then adjusted. To determine its (Fig. 47.5) position, a d'Assump^ao clamp is placed 1 cm above the tragus of the ear, pushed in to hold the deeper structures and not to displace the ear. The cheek flap is then pulled up in an upper oblique direction, with the proper tension to smooth out the
We then place a cervical drainage, like a Blake drain, introduced through the scalp at the posterior end of the undermining and placed along the neck, finishing at the anterior part of the cervical undermining (Fig. 47.6). One has then to deal with the skin discrepancy existing between points A and B. The lower skin flap is pulled up and flattened upward, and a moderate resection of 0.5-1.5 cm of skin is performed. A series of inverted knots of 4/0 resorbable stitches will allow the difference of the length between the upper and lower edges to be resorbed, even if this difference is sometimes significant with 3 cm at the upper edge and 6 cm at the lower. An intradermal suture of 4/0 resorbable Monocril finishes the retroau-ricular suture. There are a few vertical skin folds. They disappear after a few weeks.
Fig. 47.7. Temporal downward flap. Top left: Once the preauricular key stitch has been placed, spreading the temporal flap would elevate the hairline. The posterior edge is grasped and the flap is folded over a thin instrument. Top right: One sees where the hairline can descend. Bottom left: The triangle thus delineated is deepithial-ized. Bottom right: After suturing of the triangle, there is very little to excise at the upper part, because of the downward movement. (Reproduced from Marchac et al. , with kind permission of the editor of Plastic and Reconstructive Surgery)
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