Preoperative counseling

The main goals include attempting to ascertain the patient’s desires and expectations while incorporating reasonable aesthetic goals. Using computer photo imaging programs can help accomplish this.

Informed consent must contain risk of hematoma, infection, sloughing, nerve damage, hypertrophic scarring, hyperpigmentation, asymmetries, and a need for revisions. The male patient must be educated about the unattractive appearance of an over-operated look which can appear unnatural, feminizing, and alien. The emphasis should be on retaining a natural masculine, relaxed look where one or two character lines may remain, rather than a “pulled” unnatural result.

The classic “SIMON” patient described in the plastic surgery literature (see Table 14.3) should be avoided as well as patients with body dysmorphic disorder. These patients can be easily recognized, screened and referred for psychiatric evaluation.

Table 14.3 SIMON patient

As male patients generally refrain from wearing makeup, it is especially important to take this into account in terms of incision placement. The use of the short-scar technique remains extremely useful in terms of minimizing scar length behind the ear and avoiding extension into the retroauricular scalp or temporal region.

Preoperative management

0.1–0.2 mg of clonidine is administered to the hypertensive patient at least 45 minutes prior to the procedure. Ten minutes before, the patient is also infused with local tumescent fluid (0.5% lidocaine, 1 : 200,000 epinephrine) bilaterally. These two steps will help blood pressure control intra- and postoperatively. It is especially important to maintain a dry intra-operative field as the hypervascularity of the male follicular skin contributes to the increased incidence of hematoma formation.

The incision options for the male facelift are illustrated in Fig. 14.3. The preauricular hairline incision chosen depends on the amount of skin laxity, skin quality, and previous incisions. The incision is initiated a short distance anterior and superior to the root of the helix in the temporal scalp, may extend transversely into the sideburn, and if necessary, sparingly follows the anterior temporal hairline (see Fig. 14.4). As discussed previously, the preauricular incision then proceeds caudally in the pre-tragal region if there is a natural skin crease and very little sun damage. The scalpel should bevel in line with the hair shaft. Alternatively, a post-tragal incision with defatting and follicular cauterization is performed. For the short-scar facelift, the incision passes beneath the earlobe and extends into the retroauricular sulcus staying 2 mm on the concha, so any scar migration that may occur will pull the scar no farther than into the sulcus. If there is severe laxity of the neck skin, the incision then traverses the hairless skin in the retroauricular region for 3–5 mm at a point which is superior enough in this region to be hidden if the patient opts for short hair. The final result should not be compromised simply to rigidly commit to a shorter retroauricular incision. If there is too much cervical laxity, the surgeon must extend the incision into the hair. Going into the retroauricular scalp with a sigmoid curve, instead of the occipital hairline incision, is preferred as men tend to retain their hair growth in this region and it allows the patient to have closely cropped hair without a visible incision.

Fig. 14.3 Standard incisions on the male patient.

Fig. 14.4 Details of the periauricular incision. A, Incision made pre- or retrotragal and extends superiorly and transversely into sideburn as needed. B, The retroauricular incision stays high on the concha to avoid visible scar with postoperative migration. Limited extension may continue into the hair-bearing scalp sparingly. C, The midface flap is rotated into position and set anteriorly at the root of the helix. D, Staples or nylon sutures are used for the temporal portion. 5-0 and 6-0 nylons are placed anteriorly. The tragus may be set with 5-0 plain gut suture.

Regardless of the technique chosen, incisions are designed to be virtually invisible, not distort the hairline, ear, cheek, retroauricular sulcus, or posterior hairline. If the incision is made properly and the patient experiences uncomplicated wound healing, it should be difficult even for the surgeon, friends, or the barber to find the incisions.

Submental dissection and undermining

In patients with abundant excess skin in the submental region, a 1.5–2.5 cm submental incision is made and submental liposuction (see Fig. 14.5) and subcutaneous undermining is performed. In younger patients with minimal laxity or early aging, the incision is omitted and submental liposuction centrally or lateral undermining is performed via the inferior pole of the retroauricular incisions only. The author prefers to make the incision at the submental crease. Dissection is then performed retrograde to undermine the crease. Rarely, in patients in whom the crease is deep, the crease is completely excised. It is especially important to retain a cuff of subcutaneous fat at the incision to avoid deepening the submental crease.

Fig. 14.5 Submental liposuction may be performed through a limited incision. Judicious limitation of dissection when possible may decrease the surgical hematoma rate.

The platysma is defatted under direct vision and the anatomy of the medial borders of the platysma is identified (see Fig. 14.5). Subplatysmal fat may occasionally be directly resected. Submandibular gland resection should be avoided because of the increased risk of hematoma with this practice. Also, gland resection can result in a feminizing “popsicle on a stick” appearance of a skeletonized, over-operated neck. A midline plication of the platysmal muscles may be performed using buried 3-0 PDS sutures. A wedge of platysma may be excised bilaterally caudal to the plication to break the continuity of the platysmal bands (see Fig. 14.6).

Fig. 14.6 Central platysmal resection and plication. A, Direct open lipectomy. B, Central resection of redundant platysma. C, Running 3-0 PDS suture.

SMAS/platysma flap

Depending on the amount of midface and neck laxity, there are three approaches to the SMAS in order of increasing aggressiveness: (1) SMAS imbrication alone; (2) lateral SMASectomy with plication (D. Baker); or (3) a full SMAS (S. Aston, FAME) dissection.

A SMAS imbrication alone may be preferred in cases of a secondary facelift or in cases of minimal laxity in a slender patient with a thin SMAS. The area to be imbricated should be initiated from 1 cm inferior to the earlobe and extend to 1 cm lateral and inferior to the lateral canthus (Figs 14.7D and Fig. 14.7E). The medial “dog-ear” from this imbrication will create an attractive rejuvenating malar fullness. It is of the utmost importance to ensure that this malar eminence is symmetrical.

Fig. 14.7 Intraoperative photos of the male facelift in a 56-year-old man. A, The anterior incision is made, in this case pretragal incision was chosen. B, The retroauricular incision: staying high on the concha. C, Subcutaneous dissection with facelift scissors. D, Indicator demonstrates lateral endpoint of the lateral SMASectomy one centimeter inferior to the earlobe. E, Indicator demonstrates medial endpoint of the lateral SMASectomy one centimeter inferior and lateral to the lateral canthus. F, Indicator demonstrates lateral SMASectomy. G, Double Alice-clamp setting superiolateral vector. Emphasis should be on vertical lift to avoid a laterally pulled appearance. H, Trimming skin flap conservatively to inset lobe. I, Insetting midface flap anteriorly at the root of the helix. J, Posterior extent of short scar incision with redundant skin sparingly trimmed. Placement of #7 closed suction drain or open penrose drain posteriorly either through separate incision or within retroauricular closure. K, Insetting temporal flap with staples (“cheating” tissue in place and avoiding transverse excision of sideburn in this case). L, Insetting anterior flap with 5-0 nylon intertragal interrupted and running 6-0 nylon (5-0 plain gut running tragal suture is chosen for retrotragal incisions). Limited retroauricular gathering to close with a short incision which will remodel in postoperative phase. M, Anterior worm’s eye view demonstrating elevated malar repositioning, hollowing of lower midface, and improvement of neck and jawline on right side.

Similar to the SMAS imbrication, a lateral SMASectomy may be designed using the same landmarks as the imbrication with the addition of a 2 cm elliptical excision of SMAS followed by the re-approximation of the mobile lower SMAS to immobile upper SMAS.

For the full SMAS dissection, a transverse incision is made in the SMAS at the level of the infraorbital rim, above the zygomatic arch. An intersecting vertical incision is made in the SMAS in the preauricular region and extended along the anterior border of the sternocleidomastoid muscle. The SMAS and platysma muscle are elevated in continuity and advanced beyond the anterior border of the parotid gland resulting in a significant release and subsequent elevation of the midface structures. The SMAS is rotated in a cephaloposterior direction; the excess is resected, and the flap is sutured to the temporal fascia. A second set of sutures are placed in the platysma muscle which is tightened below the angle of the mandible and sutured to the fascia of the sternocleidomastoid muscle. A tongue of excess SMAS may be transposed behind the ear to reinforce the platysmal tightening. Additional sutures are then placed along the entire suture line to reinforce this maneuver.

In select patients, the deep plane or foundation facelift may be an attractive approach for the correction of midface descent without extensive dissection of the skin flap medially. In this way, the risk of postoperative hematoma can be further minimized without compromising the midface result, particularly in patients at an increased risk for mild bleeding possibilities. The disadvantage is that the skin and SMAS are less independently redraped, sometimes resulting in excessive vertical redraping of the skin.

Once the SMAS/platysma has been rotated, the platysma is defatted beneath the inferior border of the mandible. Hemostasis is obtained using a fiberoptic retractor and electrocautery.

Skin redraping

The skin is redraped using a vector which is slightly less vertical than the SMAS elevation. In the face, the vector is oblique and in the neck, is slightly more transverse. It is important not to redrape the transverse neck creases up onto the face.

All the tension of the skin flap is supported by two points of fixation. The first is placed posteriorly at the apex of the post-auricular incision and the second (with less tension) is at the root of the helix. The remaining skin is trimmed so that there is absolutely no gap between the skin edges and, therefore, no tension on the closure. Beneath the earlobe, the skin is trimmed so that the incision is tacked up beneath the earlobe, exaggerating the separation of the earlobe from the cheek. Be very conservative in skin resection around the lobe to prevent the tell-tale “pixy ear”.

In those patients where a short temporal incision has been made within the hairline, a transverse wedge is always removed within the sideburn so as not to elevate it above the root of the helix. In cases where an anterior hairline incision extension is made, skin excess is removed along this incision, once again making sure that there is no tension on the closure. Any incisions in the hair-bearing regions may be closed with skin staples.

Tragus

In patients in whom the incision is made in the pre-tragal region, the facial skin flap is trimmed so there is absolutely no gap between the skin edges. In patients where the incision has been made at the posterior border of the tragus, a tragal flap of skin is created which is larger in all dimensions than is necessary to cover the tragus. This allows the inevitable contraction of the skin to occur without deformation or “blunting” of the tragus. The flap is defatted judiciously and undergoes follicular cauterization prior to insetting.

Drains

Closed-suction or penrose drains are placed in the neck bilaterally and brought out through a separate stab wound in the hair-bearing scalp. If the male patient has high probability of hair loss in this area, the drain should be brought out through the uppermost portion of the retroauricular short incision.

Hematomas

Hematomas represent the most frequently occurring complication following male facelifts and vary from large collections of blood that threaten skin flap survival to small ones that are evident only when facial edema has subsided. The incidence of hematomas in men reported in literature (7.9–12.9%) is more than twice that in women. Most major hematomas occur during the first 10 to 12 hours postoperatively.

The etiology of hematomas is multifactorial, but correlates most closely with perioperative hypertension, with hematomas occurring 2.6 times more frequently in hypertensive patients than those with normal blood pressures. Any medications or substances (aspirin-containing medications, herbal teas and other agents) which affect the coagulation cascade must be discontinued 2 weeks before the procedure.

Baker et al. analyzed the incidence of hematoma formation after instituting a strict and aggressive perioperative blood pressure control regimen. In this study, the incidence of hematomas requiring surgical evacuation decreased from 8.7% to 3.97%.

The most common presentation of a hematoma is an apprehensive, restless patient experiencing pain out of proportion, isolated to one side of the face or neck. In these cases, the clinician must regard this as a sign of a hematoma until proven otherwise. Rather than providing analgesics for pain relief, the dressing is removed immediately to permit examination. In addition to causing skin flap ischemia, a hematoma expanding into the neck has the potential to cause respiratory compromise.

The treatment of expanding hematomas initially involves the removal of sutures to relieve tension on the skin flaps. The surgeon must decide whether to return to the operating room or treat at the bedside. In recent years, the technique of bedside draining, and flushing with cold, epinephrine-containing solution has been used more frequently and the trend has generally been welcomed with success. This option can avoid additional anesthesia, cost, and the emotional trauma of a return to the operating room for the patient, family, and the surgeon. If bedside drainage is unsuccessful or the initial hematoma appears more extensive, the surgeon must have a low threshold for going directly to the operating room. After the patient is prepped and draped, the remaining sutures are removed, facial flaps are elevated for visualization, and the hematoma is completely evacuated. Rarely, a single bleeding vessel is detected.

Small hematomas that do not become evident until edema subsides may be treated with a No. 11 blade placed tangentially through the skin allowing drainage and good healing. Hematomas that are not detected and evacuated during the period of liquefaction result in skin firmness, irregularity, and hemosiderin discoloration. Warm compresses, gentle daily massage, and intralesional injections of dilute steroids are occasionally helpful.

Skin sloughing

Full-thickness skin sloughing predictably results in some degree of permanent scarring. The retroauricular and mastoid areas are most frequently involved due to thin skin in an area farthest from adequate circulation, but may be concealed by the ear and hair. The incidence of skin sloughing is 1% to 3%, mostly caused by (1) undiagnosed hematomas; (2) a skin flap that is too thin or that is damaged during flap dissection with excessive retraction by the surgeon or the assistant; (3) excessive tension on wound closure; and (4) cigarette smoking (12× increase in relative risk). Thus, patients are required to abstain from smoking for 2 weeks preoperatively.

Areas of skin sloughing epithelialize and contract dramatically. The resulting scar is almost always better than would be anticipated from the initial wound appearance. Depending on the size of the sloughed area, it may be possible to excise the scar and re-advance the skin, but it generally takes years before sufficient skin laxity allows a secondary lift.

Facial nerve injury

Injury to the facial nerve in subcutaneous facialplasty is uncommon (0.9%). This rate is higher in extended SMAS and composite procedures. Most patients regain full motor function after injury to a branch of the facial nerve within a few weeks to a year, although occasionally this may take longer. Intraoperative transection of the facial nerve behoves the surgeon to perform immediate microsurgical repair. The more commonly occurring scenario, however, is that of a nerve injury is unrecognized during surgery, and the surgeon and patient are placed in the uncomfortable position of waiting for return of function. Transient numbness of the lower two-thirds of the ear, the preauricular area, and the cheeks for the first 2 to 6 weeks postoperatively occurs as a result of the unavoidable interruption of small sensory nerves during surgery. The most common preventable nerve injury during facialplasty is that of the great auricular nerve which can be injured when the dissection is too deep, piercing the fascia over the sternocleidomastoid muscle. If the great auricular nerve injury is recognized during surgery, an immediate, meticulous repair is performed.

Alopecia

Alopecia ranges from 1% to 3% of patients, depending on the report. It is imperative that this possibility and options for treatment including micrograft hair transplant are discussed preoperatively.

Scarring

Scarring after a facelift is most commonly caused by vascular compromise of the skin flaps and excess closure tension. Two points of maximum skin tension are established: in the temporal scalp at the root of the helix and at the apex of the retroauricular incision. Conservative trimming is especially required in the preauricular area and around the earlobe, where the slightest tension widens the scar and distorts the earlobe.

Hypertrophic scarring is rare, most commonly occurring with the retroauricular closure. Small-volume injections of dilute insoluble steroids often help flatten these scars. Minimize the length of submental incision, to avoid anterior displacement of the incisions “onto the face” when advancing skin flaps are advanced laterally. Elliptical submental skin excisions lead to “dog ears” and should be avoided.

Hyperpigmentation

Hyperpigmentation is caused by hemosiderin deposits in the dermis. Small, unevacuated hematomas that become apparent after edema subsides are frequent sites of hyperpigmentation. Such pigmentation is sometimes difficult to resolve, occasionally taking 6 to 8 months; in rare circumstances the pigmentation is permanent.

Pearls & pitfalls

Pearls

• During SMAS dissection, the smart surgeon must have the utmost respect for the glistening parotid fascia to avoid facial nerve and parotid duct injury.

• Generally minimize incision length without compromising the patient’s result.

• Minimizing dissection when possible will lower the rate of hematoma formation when dealing with the highly vascularized male skin.

• Don’t go for the last wrinkle and tell this to the patient preoperatively. One or two lines give a natural character. Avoid or educate the patient who wants too much.

• When dissecting the submental subcutaneous area, leave a cuff of subcutaneous fat near the incision to avoid the tell-tale incision step-off postoperatively.

• Bevel the scalpel parallel to the hair shaft in all incisions to prevent alopecia.

• Clonidine patch or hydralazine is the surgeon’s friend in the postoperative hypertensive patient.

Pitfalls

• Avoid over-retracting the skin flap during skin and SMAS dissection to prevent undue trauma which inevitably results in sloughing postoperatively.

• Knowledge of facial nerve anatomy is an absolute must and the junior surgeon should be familiar or review the danger points to avoid injury.

• When using the Bovie for hemostasis, say: “nerve” or “flap” so the assistant can monitor the face, responding with “twitch” or “burn” (denoting nerve twitch or thermal injury to the flap, respectively). This will prevent the two major Bovie injuries.

• Don’t make the submental incision too long to avoid visible scars after skin flaps are redraped cephaloposteriorly.

• Focus on a lifting vector, erring on the vertical rather than the lateral to avoid a “lateral pull” appearance.

• Don’t rely on a single running dissolvable suture for the retroauricular closure. Placing two additional interrupted sutures will save a 3 a.m. phone call and a wide scar postoperatively.

Fig. 14.8 56-year-old male patient. A, Preoperative anterior photograph. B, Postoperative anterior photograph. C, Preoperative lateral photograph. D, Postoperative lateral photograph.