Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

214
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.8  Temporal hairline incision in the male patient. In many male patients,
skin shifts and the presence of sparse temple hair can result in unnatural, telltale,
and effeminate-appearing displacement of the temporal hairline and sideburn if
such a plan is used. Placing the incision along the hairline prevents this problem
and results in a well-concealed scar if the incision is closed properly. (A) Plan for
temple hairline incision in the male patient. Note that, unlike the incision plan in a
female patient that is made as a soft curve, the incision in men should be planned
in a more angular fashion echoing the shape of the male sideburn. (B) Close-up of
healed incision. Hairline displacement has been avoided and the scar is well
concealed. The sideburn has an angular masculine shape. (All surgical procedures
performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of
Plastic Surgery.)
A
B
Fig. 6.9.9  Traditional location of the preauricular incision. This places the scar in
most men in an area open to inspection by others and “brands” the patient as
having had facelift surgery. Gradients of color and texture between smooth pale
auricular skin and coarse red cheek skin draw additional attention to the scar (see
Fig. 6.9.10A,B). (Courtesy of the Marten Clinic of Plastic Surgery.)
This plan, however, works well only for the unusual male
patient with cheek and tragal skin of similar characteristics
who, in addition, exhibits favorable healing. Unfortunately,
most male patients have a marked gradient of color, texture,
and surface irregularities over these areas; thus a telltale
mismatch will be evident, even in the presence of an incon­
spicuous scar (Fig. 6.9.10).
For these reasons, and in all but the unusual case, the
preauricular portion of the facelift incision in men is usually
best placed along the posterior margin of the tragus, rather
than in the pretragal sulcus (Fig. 6.9.11). In this location, a
mismatch of color, texture, or surface irregularities will not
be noticed and the scar, if visible, will appear to be a tragal
highlight (Fig. 6.9.12A,B). In addition, if properly planned
and executed, an incision along the margin of the tragus will
not produce tragal retraction or other anatomical irregularity
(Fig. 6.9.13A,B).
If tissue repositioning is achieved using SMAS advance­
ment and not excessive skin tension, as it rightly should be,
modest displacement of skin will occur in many male patients
and no bearded skin will be advanced onto the tragus. In the
male patient in whom large skin flap shifts occur, beard
growth on the tragus can be reduced by intraoperative
destruction of beard follicles from the underside of the tragal
flap.
Because beard hair grows in three phases, “beard shift”
encroachment on the tragus cannot usually be completely
eliminated at the time of surgery. Most mature men in the
facelift age group have some stray hair growth on the tragal
area naturally, however, and some visible hair growth on the
tragus is not necessarily seen as a sign a facelift has been
performed in the eyes of most casual observers and in typical
social situations. To obtain the most natural appearance, some
men may wish to undergo electrolysis following their surgery.
In general, it is prudent to wait 3–6 months after surgery
before that is done.
The superior portion of the preauricular incision should be
planned as a soft curve paralleling the curve of the anterior
border of the helix. This will result in a natural-appearing
“width” to the helix in keeping with the rest of the ear, and
the resultant scar, if visible, will appear to be a helical high­
light. As the tragus is approached, the mark for incision is
carried into the depression superior to it and then continued
along its posterior margin. In this location, the scar, if visible,
will appear to be a natural highlight (see Figs. 6.9.11–6.9.13).
At the inferior portion of the tragus, the incision must turn
anteriorly and then again inferiorly, into the crease between
anterior lobule and cheek. If a more relaxed plan is made, or
if a straight line incision is used, skin settling and scar contrac­
tion will result in crowding of the incisura, obliteration of the

215
Preoperative planning in the male facelift patient
the cheek and to avoid destruction of, or excision of, this
functionally and aesthetically important anatomic subunit.
This is accomplished by marking the perilobular incision
2–3 mm inferior to the lobular–facial sulcus and slightly lower
than it would be made a woman (Fig. 6.9.14B). All other
factors being equal, a superior result will be obtained when
such a plan is used, in comparison to any plan in which the
incision is placed directly in the sulcus and an attempt is
subsequently made to directly join thin, soft earlobe with
coarse, thick cheek (Fig. 6.9.14A).
Planning the postauricular incision
Traditionally, the postauricular portion of the facelift incision
has been made up over the posterior surface of the concha.
This was done as part of a well-intended effort to offset inevi­
table descent of the postauricular flap and inferior migration
of the resulting scar that occurred when skin was tightened
in an attempt to improve neck contour. Many surgeons have
come to realize that such a plan embodies erroneous assump­
tions and can result in undesirable effects including hypertro­
phic scarring, postauricular webbing, and obliteration of the
auriculomastoid crease. If such a plan is used in men, bearded
skin from the neck can also be moved onto the posterior
surface of the ear resulting in considerable difficulty in shaving
for many men.
The postauricular portion of the facelift incision should,
instead, be marked 2–3 mm posterior to the existing auricu­
lomastoid groove with the ear pulled forward as little as
possible, and the mark turned posteriorly to cross the mastoid
at the approximate level of the anterior crus of the antihelix.
Such a plan places the scar at a natural anatomical interface
where it will be difficult to detect, even on close inspection
inferior tragal border, and a telltale elongated and “chopped-
off” tragal appearance.
Planning the perilobular incision
To obtain a natural perilobular appearance, and to facilitate
shaving in men, it is essential to preserve the natural sulcus
of beard-free skin naturally present between the earlobe and
Fig. 6.9.11  “Retrotragal” plan for the preauricular portion of the facelift incision.
Placing the incision along natural anatomic contours conceals the scar and
disguises differences in color and skin texture on each side of it (see also Figs.
6.9.12 & 6.9.13). (Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.10  Typical irregularities seen when a pretragal incision is used in male patients. (A) An unknown surgeon has mistakenly tried to “hide” the preauricular incision
along the posterior border of bearded skin. The scar is easily seen in the exposed location. A gradient of color and texture on each side of it draws additional attention to it,
and the patient’s attempt to hide it by growing a long sideburn has failed. Retrodisplacement of bearded skin against the scar has resulted in a thin, spindly, unnatural, and
unmasculine-appearing sideburn. (B) An unknown surgeon failed to recognize the difference in color and texture of the ear (tragal) and cheek skin and the use of a pretragal
incision has resulted in and obvious irregularity even though the scar itself is well healed. The difference in color and texture on each side of the scar would be better
concealed along anatomic interfaces if a retrotragal (see Fig. 6.9.11) incision plan had been used. (Photos courtesy of the Marten Clinic of Plastic Surgery – procedures
performed by unknown surgeons.)

216
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.12  Retrotragal incision plan and
resulting scar. (A) “Retrotragal” plan for
concealed preauricular incision. The
incision is planned along natural anatomic
interfaces to disguise gradients of color and
texture typically seen between the ear and
cheek. (B) Retrotragal scar in a male
patient. The scar is situated along anatomic
interfaces concealing gradients of color and
texture that would be obvious if a pretragal
incision plan had been used. In this
location, the scar, if seen, fools the eye and
appears to be a reflected highlight. (Photos
courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
Fig. 6.9.13  Healed “retrotragal” facelift scars in male patients. A retrotragal placement of the preauricular portion of the facelift incision has resulted in an inconspicuous
and well-concealed scar. In the upper third, the scar sits in the interface between the helix and the cheek and tricks the eye into thinking it is the anterior helical border. In
the middle third, the scar sits along the poster margin of the tragus and cannot be seen. Some coarse and bearded skin has been shifted up against and onto the tragus, but
this is less obvious than the presence of a pretragal scar. In the lower third, the scar sits in a well-concealed location 2–3 mm outside the lobular–facial sulcus but far
enough away from it that shaving in that area is not difficult. (Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C
(Figs. 6.9.2 & 6.9.15), and facilitates shaving of beard hair that
might be advanced onto this area.
Planning the occipital incision
Planning the location for the occipital portion of the facelift
incision is conceptually similar to that of the temple region
and the incision plan must address similar concerns of hairline
displacement and scar visibility. Traditionally this incision is
placed transversely extending into the occipital scalp, in a
well-intended, but usually counterproductive, attempt to hide
the resultant scar (Fig. 6.9.16).
For patients in whom neck skin redundancy is small and
excision of postauricular skin is unnecessary, such a plan may
be acceptable and will result in a well-concealed scar. Male
patients in this category are usually young and troubled by
mild neck deformity only, and in these situations the incision
is used for access to the lateral neck only, and not as a means to
remove postauricular skin. Mistakenly using this incision to
excise skin will predictably result in the advancement of neck
skin into the occipital scalp and “notching” of the occipital
hairline (Fig. 6.9.17A,B).
Although women sometimes can hide such a deformity
due to the presence of longer hair, creating a step-off and

217
Preoperative planning in the male facelift patient
Fig. 6.9.15  Planning the postauricular
incision. (A) The retro-conchal incision (red
dotted line) should be made 2 to 3 mm
posterior to the existing auriculomastoid
groove and the mark turned posteriorly to
cross the mastoid at the approximate level of
the anterior crus of the anti-helix (black square
and black dished line). Such a plan places
the scar along a natural anatomical interface
where it will be difficult to detect but
facilitates shaving of beard hair that might be
advanced into this area. The occipital portion
of the incision (white dotted line) should then
extend down along the occipital hairline.
Placement of the occipital incision along the
hairline protects the hairline from
displacement and notching when the neck
skin flap is advanced and will result in an
inconspicuous scar that is well concealed
even in a man with short hair. (B)
Postoperative view of a man with short hair
with scar along the occipital hairline. (Photo
courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
hairline displacement on a male patient can result in a problem
that is difficult to conceal.
Planning the submental incision
Optimal improvement in the neck can generally not be
obtained in most male patients unless a submental incision is
made, owing to collections of subplatysmal fat, the presence
A
B
Fig. 6.9.14  Erroneous elimination of the lobular–facial sulcus and proper perilobular incision plan. (A) The perilobular incision has been placed too close to the earlobe
and the lobular–facial sulcus eliminated. The thin, soft earlobe has been inserted into coarse, thick cheek skin resulting in an unnatural transition between the two structures
and a “facelifted” appearance. Failure to preserve a cuff of lobular facial suclus also makes it difficult for men to shave. (B) To obtain a natural perilobular appearance, and
to facilitate shaving in men, it is essential to mark the perilobular incision 2–3 mm inferior to the lobular–facial sulcus and slightly more inferior than it would be made a
woman. All other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the
sulcus and an attempt is subsequently made to directly join thin, soft earlobe with coarse, thick cheek. (Photos courtesy of the Marten Clinic of Plastic Surgery. Procedure in
(A) performed by unknown surgeon.)
of large submandibular glands, and hypertrophic anterior
bellies of the digastric muscles typically present in most men
presenting for facelift surgery. Simply performing liposuction,
suspending the lateral platysma border, and/or tightening
skin over these problems (see Fig. 6.9.26) cannot correct them
or produce the type of necklines associated with a fit, athletic,
youthful, and healthy-appearing man (see Figs. 6.9.3 & 6.9.4
and
Case studies 6.9.1–6.9.3).

217.e1
Preoperative planning in the male facelift patient
Case study 6.9.1 
Facelift, necklift, small incision forehead lift, upper and lower eye
lifts, fat grafting, and chin implant: 42-year-old man
Front view (Fig. 6.9.50): (A) before surgery, age 42, and (B) 2
years and 3 months after surgery. Oblique view (Fig. 6.9.51):
(A) before surgery, age 42, and (B) 2 years and 3 months after
surgery. Side view (Fig. 6.9.52): (A) before surgery, age 42, and
(B) 2 years and 3 months after surgery.
Fig. 6.9.50  Patient in Case study 6.9.1. Front view:
(A) The patient has full upper eyelids, ptotic, hollow
upper cheeks, deep cheek folds, and a weak appearing
jawline. (B) Same patient, 2 years and 3 months after
facelift, necklift, small incision forehead lift, upper and
lower eye lifts, fat grafting, and chin implant. Note
corrections of hooded eyelids, diminished cheek folds,
and creation of a youthful and masculine facial shape
without a tight or pulled appearance. (All surgical
procedures performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
A
B
Fig. 6.9.51  Patient in Case study 6.9.1. Oblique view:
(A) Before surgery view of patient, age 42. Note
hooded upper eyelid, sagging cheek, hollow lower
orbit, and loss of youthful neck and jawline contour.
(B) Same patient, 2 years and 3 months after facelift,
necklift, closed forehead lift, upper and lower eye lifts,
fat grafting, and chin implant. Note softer appearance
to eyes, improved cheek contours, masculine jawline,
and improved neck contour. The chin contour is also
improved and the patient has a rested, fit, athletic,
decisive, and masculine appearance. (All surgical
procedures performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of Plastic
Surgery.)

217.e2
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.52  Patient in Case study 6.9.1. Side view:
(A) Before surgery view of patient, age 42. Note lower
eyelid fullness, poor transition from the lower eyelid to
the cheek, poor jawline, weak chin, and full neck.
(B) Same patient, 2 years and 3 months after facelift,
necklift, closed forehead lift, upper and lower eye lifts,
fat grafting, and chin implant. The transition from the
lower eyelid to the cheek is smoother, the cheek
position has been improved, chin contour is improved,
and a fit, athletic, masculine-appearing jawline and
neckline can be seen. The face has a natural
appearance and all scars are well concealed. (All
surgical procedures performed by Timothy Marten, MD,
FACS. Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B

217.e3
Preoperative planning in the male facelift patient
Case study 6.9.2 
Facelift, necklift, small incision forehead lift, upper and lower eye
lifts, and partial facial fat transfer: 60-year-old man
Front view (Fig. 6.9.53): (A) before surgery, age 60, and
(B) 1 year and 2 months after surgery. Front smiling view
(Fig. 6.9.54): (A) before surgery, age 60, and (B) 1 year and 2
months after surgery. Oblique view (Fig. 6.9.55): (A) before
surgery, age 60, and (B) 1 year and 2 months after surgery.
Side view (Fig. 6.9.56): (A) before surgery, age 60, and (B) 1
year and 2 months after surgery.
Fig. 6.9.53  Patient in Case study 6.9.2. Front view:
(A) Before surgery view of patient, age 60.
Hollowness can be seen in the under eye and upper
cheek area. Loss of youthful facial contour can be
seen in the cheek and jowl areas. (B) Same patient,
1 year 2 months after facelift, necklift, small incision
forehead lift, upper and lower eye lifts, and partial
facial fat transfer. Fat injections have provided filling
of the under eye and cheek areas. Note restoration of
youthful facial shape without a tight or pulled
appearance. (All surgical procedures performed by
Timothy Marten, MD, FACS. Photos courtesy of the
Marten Clinic of Plastic Surgery.)
A
B
A
B
Fig. 6.9.54  Patient in Case study 6.9.2. Front
smiling view: (A) Before surgery view of patient, age
60. (B) Same patient, 1 year 2 months after facelift,
necklift, closed forehead lift, upper and lower eye
lifts, and partial facial fat grafting. Note a natural
appearance is present, even when smiling. (All
surgical procedures performed by Timothy Marten,
MD, FACS. Photos courtesy of the Marten Clinic of
Plastic Surgery.)

217.e4
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.55  Patient in Case study 6.9.2. Oblique view:
(A) Before surgery view of patient, age 60. Note lateral
forehead wrinkling, sagging cheek, and loss of youthful
jawline contour. (B) Same patient, 1 year 2 months
after facelift, necklift, closed forehead lift, upper and
lower eyelifts, and partial facial fat grafting. Note
smoother forehead, restoration of cheek fullness,
improved transition from lower lid to cheek, smooth,
stronger jawline and improved neck contour. (All
surgical procedures performed by Timothy Marten, MD,
FACS. Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
Fig. 6.9.56  Patient in Case study 6.9.2. Side view:
(A) Before surgery view of patient, age 60. Note cheek
flatness, sagging jawline, and neck laxity. A protruding
salivary gland can also be seen in the neck area.
(B) Same patient, 1 year 2 months after facelift,
necklift, forehead lift, upper and lower eye lift, and
partial facial fat grafting. The protruding portion of the
salivary gland has also been removed. Note the
restoration of cheek fullness, smooth jawline, and
improved neck contour. The face has a natural
appearance and all scars are well concealed. (All
surgical procedures performed by Timothy Marten, MD,
FACS. Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B

217.e5
Preoperative planning in the male facelift patient
Fig. 6.9.57  Patient in Case study 6.9.3. Front view:
(A) Before surgery view of patient, age 68. The patient
has eyebrow ptosis, full upper eyelids, sagging
cheeks, deep cheek folds, and jowls. Loss of youthful
facial contour can be seen in the cheek and jowl areas.
(B) Same patient, 1 year and 9 months after facelift,
necklift, small incision forehead lift, upper and lower
eye lifts, partial facial fat grafting, and earlobe
reduction. Note improved eyebrow position and
configuration, correction of hooded eyelids, diminished
cheek folds, elimination of jowls, and restoration of
youthful and masculine facial shape without a tight or
pulled appearance. (All surgical procedures performed
by Timothy Marten, MD, FACS. Photos courtesy of the
Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.58  Patient in Case study 6.9.3. Front smiling
view: (A) Before surgery view of patient, age 68. Note
suboptimal upper dental show and tired and
disinterested appearance despite broad smile.
(B) Same patient, 1 year and 9 months after facelift,
necklift, small incision forehead lift, upper and lower
eye lifts, partial facial fat grafting, and earlobe
reduction. Note alert and composed appearance and
fit, masculine-appearing jawline. A more natural smile
with improved dental show is also seen. (All surgical
procedures performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of Plastic
Surgery.)
A
B
Case study 6.9.3 
Facelift, necklift, small incision forehead lift, upper and lower eye
lifts, partial facial fat grafting, and earlobe reduction: 68-year-old
man
Front view (Fig. 6.9.57): (A) before surgery, age 68, and
(B) 1 year and 9 months after surgery. Front smiling view
(Fig. 6.9.58): (A) before surgery, age 68, and (B) 1 year and 9
months after surgery. Oblique view (Fig. 6.9.59): (A) before
surgery, age 68, and (B) 1 year and 9 months after surgery.
Side view (Fig. 6.9.60): (A) before surgery, age 68, and (B) 1
year and 9 months after surgery. Side view – looking down
(Fig. 6.9.61): (A) before surgery, age 68, and (B) 1 year and 9
months after surgery.

Fig. 6.9.59  Patient in Case study 6.9.3. Oblique view:
(A) Before surgery view of patient, age 68. Note
drooping eyebrow, hooded upper eyelid, sagging
cheek, and loss of youthful facial contour. There is
little, if any, transition from the lower cheek to the
neck, and a poor jawline is present. (B) Same patient,
1 year and 9 months after facelift, necklift, closed
forehead lift, upper and lower eye lifts, partial facial fat
grafting, and earlobe reduction. Note eyebrow position
and configuration, restoration of cheek fullness,
diminished cheek (“nasolabial”) fold, smooth
masculine jawline, and improved neck contour. The
patient has a rested, fit, decisive, virile and masculine
appearance. An improved transition from the lower
cheek to the neck is evident. (All surgical procedures
performed by Timothy Marten, MD, FACS. Photos
courtesy of the Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.60  Patient in Case study 6.9.3. Side view:
(A) Before surgery view of patient, age 68. Note lower
eyelid puffiness, sagging cheek, poor jawline, heavy
jowl, and neck laxity. A protruding salivary gland can
also be seen in the neck area. (B) Same patient, 1
year and 9 months after facelift, necklift, closed
forehead lift, upper and lower eye lifts, partial facial fat
grafting, and earlobe reduction. An improved transition
from the lower eyelid to the upper cheek can be seen,
the cheek position has been improved, and a fit,
masculine-appearing jawline and neckline is evident.
The protruding portion of the salivary gland has also
been removed. The face has a natural appearance and
all scars are well concealed. Note also that the earlobe
has been subtly reduced, adding to an overall more
youthful appearance. (All surgical procedures
performed by Timothy Marten, MD, FACS. Photos
courtesy of the Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.61  Patient in Case study 6.9.3. Side view,
looking down: (A) Before surgery view of patient, age
68. Note poor neckline when looking down. (B) Same
patient, 1 year and 9 months after facelift, necklift,
closed forehead lift, upper and lower eye lifts, minor
partial facial fat transfer, and earlobe reduction. Note
improved neck contour in the flexed position. The face
has a natural appearance and all scars are well
concealed. (All surgical procedures performed by
Timothy Marten, MD, FACS. Photos courtesy of the
Marten Clinic of Plastic Surgery.)
A
B

218
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
should be approximately 3–3.5 cm in length, but may be made
longer – as long as neither end will be advanced up upon a
visible portion of the face when cheek skin flaps are shifted.
Healing will be best, and the scar will be best concealed, if it
is made as a straight, and not as a curved line, precisely paral­
lel to beard follicles (see Fig. 6.9.19).
Treating the forehead in the male
facelift patient
One of the most frequent errors made by plastic surgeons in
treating the male patient is performing upper blepharoplasty
when a foreheadplasty is needed. As the forehead ages, the
brow descends and infrabrow skin moves into the upper orbit
producing an illusion of eyelid skin redundancy. This false
excess of upper eyelid skin is known as “pseudoblepharocha­
lasis”, a term that emphasizes the deceptive origin of the
problem and one that rightly draws attention to the need to
consider forehead surgery in its treatment.
Attempts to treat pseudoblepharochalasis with blepharo­
plasty alone will, at best, result in a sad, tired-appearing
patient with less eyelid skin and a long scar extending off the
eyelid onto the lateral periorbital skin. More likely, however,
isolated blepharoplasty performed when significant forehead
ptosis is present usually results in a loss of the stimulus for
brow elevation, further descent of the eyebrow as the frontalis
muscle relaxes, and the reappearance of a pseudo skin excess
in the superiolateral orbit and across the upper eyelid. This,
in turn, results in an exacerbation of the existing “pseudo-
sad”, “pseudo-tired”, or disinterested appearance, rather than
improvement in it. This sequence of events explains why both
many male patients and their surgeons are often disappointed
with the patient’s overall appearance after upper blepharo­
plasty, despite technical proficiency in the excision of upper
eyelid tissue.
A key requirement in planning rejuvenation of the male
forehead when it is indicated is understanding male brow
aesthetics and optimal position and configuration of the male
eyebrow. Proper position and configuration of the eyebrow is
ultimately a subjective judgment in all patients, influenced by
racial, cultural, and other factors that cannot be determined
precisely by a fixed mathematical formula or arbitrary
Case Studies 6.9.1–6.9.3 appear online only.
Traditionally the submental incision is placed directly in
and along the submental crease in a well-intended but
counterproductive attempt to conceal the resulting scar
(Fig. 6.9.18A). This incision plan should be avoided, however,
as it will surgically reinforce the crease and accentuate a
“double chin” deformity. Exposure of the submental region
will also be compromised, and difficulty will be encountered
when suturing or dissecting low in the neck. A more posterior
placement of this incision will eliminate these problems, but
still result in an inconspicuous and well-concealed scar (Figs.
6.9.18B & 6.9.19).
The submental incision should be placed well within the
mandibular shadow and well posterior but parallel to the
submental crease at a point lying roughly half the distance
between the mentum and hyoid. This usually corresponds to
a site situated 1–2 cm posterior to the crease. The incision
Fig. 6.9.17  “Notching” of the occipital
hairline due to poor incision planning.
Examples of “notching” of the occipital
hairline seen in two patients whose
surgeons used traditional occipital incision
plans that resulted in neck skin being
advanced into areas where hair-bearing
scalp should be present. (Photos courtesy
of the Marten Clinic of Plastic Surgery
– procedures performed by unknown
surgeons.)
A
B
Fig. 6.9.16  Traditional plan for the occipital portion of the facelift incision. The
incision is placed transversely on the occipital scalp in a well-intended but usually
counterproductive attempt to hide the resultant scar. This incision plan does not
allow for the excision of neck skin without resulting in notching and displacement
of the occipital hairline (see Fig. 6.9.17) and is only applicable to young men with
minimal neck skin excess. (Courtesy of the Marten Clinic of Plastic Surgery.)

219
Preoperative planning in the male facelift patient
flawed in that rigid linear measurements are ultimately
inaccurate in that they assume each subject’s head and facial
features to be the same size. A more accurate and appropriate
guide to what is appropriate and attractive is the “Golden
Proportion”. Simply stated, the Golden Proportion specifies
that when the proportions of a facial feature, or relationship
between two facial features, can be described by the ratio
1 : 1.618, they will appear attractive and pleasing to the eye.
A careful analysis of the attractive upper face will show
that the aperture of the eye (the vertical distance between the
upper and lower eyelids in forward gaze) and the distance
between the margin of the upper lid and arch of the eyebrow
are related to one another by the Golden Proportion.
It is a commonly observed fact that male and female
eyebrow positions are not the same and intuitively obvious
that eyebrow position connotes sex differences. For most men,
however, the attractive eyebrow will fall in inverse relation to
that of the female but remain in golden proportion to the
palpebral aperture (Fig. 6.9.20).
While more useful that any arbitrary fixed linear distance,
the Golden Proportion should also be recognized as a guide­
line to eyebrow position and not an absolute ideal, and that
under certain circumstances a higher or lower position may
be regarded as appropriate and attractive. Perhaps the most
useful clinical guideline is simply that the male brow will gener­
ally be regarded as attractive at a variety of heights if it is in a hori­
zontal or near horizontal configuration with its tail at the same
height as its medial aspect, or slightly superior to it (Fig. 6.9.21).
Said differently, our goal is not so much to lift the eyebrow
higher as it is to tilt it and shape it, and if one can achieve
good eyebrow shape most patients and their surgeons will be
happy.
There are several useful forehead lift strategies applicable
to the male patient and there is no one procedure that will be
appropriate for all patients. Coronal- and hairline-incision
forehead lifts are only occasionally indicated in the male
patient, and most male patients’ objectives can be met by
Fig. 6.9.19  Healed submental incision in a male patient. Placement of the
submental incision posterior to the submental crease will still result in an
inconspicuous, well-concealed scar and allows the submental crease to be released
and the “double chin” to be corrected. The submental incision should be made
precisely parallel to beard follicles to prevent injury to them. (Surgical procedure
performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of
Plastic Surgery.)
Fig. 6.9.18  (A) Traditional, but incorrect plan for the submental incision and skin undermining. The incision should not be placed directly along the submental crease as
this will accentuate it and reinforce the “double chin” appearance. Note that typical plan of skin undermining (yellow shared area) also promotes a double chin because the
crease is not undermined and retaining ligaments are not released. (B) Correct location for the submental incision. Placing the submental incision posterior to the
submental crease prevents accentuation of the “double chin” and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck (compare with
Fig. 6.19). Note that this incision plan allows the submental crease to be undermined (yellow shaded area) and released, and the fat of the chin pad and neck to
subsequently be blended.
A
B
measurement; rather, marks, measurements, and published
parameters should be regarded as guidelines in planning
surgery. They will not be appropriate in every situation or
absolutely correct for every face. Ultimately, the artistic impera­
tive is to achieve proportion and balance with other facial features.
Traditionally, surgeons have tried to define ideal eyebrow
position in simple linear and absolute terms. While convenient,
and useful to some extent, any such analysis is intrinsically

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CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.20  The Golden Proportion and eyebrow position. A careful analysis of the
attractive upper face will show that the aperture of the eye (the vertical distance
between the upper and lower eyelids in forward gaze) and the distance between the
margin of the upper lid and arch of the eyebrow can be described by the “Golden
Proportion”. It is a commonly observed fact that male and female eyebrow positions
are not the same and intuitively obvious that eyebrow position connotes sex
differences. (A) The “golden eyebrow” in a woman. (B) The “golden eyebrow” in a
man. For most men, the attractive eyebrow will fall in inverse relation to that of the
female but remain in golden proportion to the palpebral aperture. (Courtesy of the
Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.21  Male eyebrow aesthetics. The male brow will appear attractive at a
variety of heights if it is in a near horizontal configuration with its tail at the same
height as its medial aspect, or slightly superior to it. (Courtesy of the Marten Clinic
of Plastic Surgery.)
Fig. 6.9.22  “Small incision” temple and forehead lift. Most men need conservative
treatment of their forehead and brow and are well served with a “short scar” small
incision plan as shown. The incision on the temporal scalp is used to make a
subgaleal dissection and the incision on the parietal scalp is used to make a
subperiosteal dissection. A lateral forehead flap can mobilized and elevated by
subsequently releasing the temporal line of adherence and dividing the periosteum
under the lateral aspect of the eyebrow. An endoscope is not required and the latter
maneuvers can be accomplished under direct vision through the incision on the
temporal scalp. (Courtesy of the Marten Clinic of Plastic Surgery.)
simpler strategies including “small incision”, partial hairline,
forehead crease, and supercilliary lifts.
Small incision lifts are possible in men with receding hair­
lines and the bald or balding man if incisions are carefully
sited (Fig. 6.9.22, see also
Case studies 6.9.1–6.9.3). Often,
these lifts are much more technically difficult to carry out in
men than in women, however, due to the thick heavy forehead
tissues typically present in men, and the greater distance at
which one is working due to retrodisplaced, receded hairlines.
Partial hairline incisions are useful in some men as a means
of reducing temporal hairline recession and actually reducing
forehead redundancy and should result in an inconspicuous
scar if the wounds are closed carefully and under no tension.
In most men, hairline position and hair density will be
mostly stable by the time they reach facelift age, and con­
cerns that hair might recede from the scar are largely unwar­
ranted. This plan (Fig. 6.9.23) may be off-putting to some
men, however, who wear shorter hairstyles, have had hair
transplants, or who are otherwise concerned with the visibil­
ity of the scar.
Bald or balding men, men who wear very short hairstyles,
men who have previously had hair transplants and fear dis­
ruption of their hairline, and men with shaved heads can be
effectively treated using an incision in a horizontal forehead
crease (Fig. 6.9.24) or in a supercilliary location along the
superior margin of the eyebrow (Fig. 6.9.25).
The latter strategy is particularly useful and well aligned
for the older male with significant eyebrow ptosis who is
resistant to a more complicated procedure employing inci­
sions along the hairline or within the scalp. It is simple,
straightforward, easy to perform, and if performed carefully,
will result in a well-concealed scar.
Treating the neck in the male facelift patient
A well-contoured neck is an artistic imperative to an attractive
and appealing masculine appearance. A bold, well-defined
neckline conveys a sense of youth, health, fitness, strength,

221
Preoperative planning in the male facelift patient
Fig. 6.9.25  Supercillary eyebrow lift incision plan. Bald or balding men, men who
wear very short hairstyles, men who have previously had hair transplants and fear
disruption of their hairline, and men with shaved heads can be effectively treated
using an incision along the upper margin of the eyebrow. Skin only is excised and
minimum undermining only is usually required. The scar once healed is typically
inconspicuous, especially in men in the facelift age group. (Courtesy of the Marten
Clinic of Plastic Surgery.)
vitality, and decisiveness (Fig. 6.9.26). Neck improvement is
of high priority to almost every male patient seeking facial
rejuvenation, and the results of male “facelift” procedures are
often largely judged by the outcome achieved in the neck. If
the neck is not sufficiently improved, most male patients will
feel we have failed them.
Despite the fact that it is a common practice, it is not
enough to perform submental liposuction and tighten the
skin in most patients, as such an approach ignores a number
of anatomical problems present in most male patients seeking
neck improvement, including platysmal laxity, platysma
Fig. 6.9.23  Partial hairline forehead–temple lift incision plan. Partial hairline
incisions are useful in some men as a means of reducing temporal hairline
recession and reducing forehead redundancy. This plan should result in an
inconspicuous scar if the incisions are closed under no tension. (Courtesy of the
Marten Clinic of Plastic Surgery.)
Fig. 6.9.24  Forehead crease temple–forehead lift incision plan. Bald or balding
men, men who wear very short hairstyles, men who have previously had hair
transplants and fear disruption of their hairline, and men with shaved heads can be
effectively treated using an incision in a horizontal forehead crease. Skin only is
excised and minimum undermining only is usually required. The scar, once healed,
is often less conspicuous that the forehead crease it was planned around. (Courtesy
of the Marten Clinic of Plastic Surgery.)
bands, excess subplatysmal fat, large submandibular glands,
digastric muscle hypertrophy, and developmental factors
such as the size and shape of the bony jaw and chin. Remov­
ing subcutaneous fat and tightening skin over these problems
does not correct them, and the presence or absence of each
must be looked for in order to create and apply an appropriate
surgical plan (Fig. 6.9.27).
Large anterior neck Z-plasties have been put forth as a
means for direct treatment of the male neck by surgeons who
have failed to meet their patients needs with submental
liposuction and other conceptually flawed schemes. In some
cases, anterior neck Z-plasties are combined with subplatys­
mal fat reduction and platysma muscle suturing. In either
case, a large and objectionable-appearing, telltale anterior
neck scar is created that is often hypertrophic, and Z-plasty
flap transposition results in abnormally directed beard growth
– both of which are often quite troublesome for the patient. It
is far more productive to treat deep layer neck problems in
the male patient though a far smaller and better concealed
submental incision, and to remove excess skin against the
occipital hairline where the scar is far better concealed when
indicated.
Treating the chin in the male facelift patient
The difference between the presence of poor neck contour and
microgenia is commonly misunderstood, and it is a common
misconception that placement of a chin implant improves
neck contour. A chin implant is a treatment for microgenia – not
a poor neckline – and the presence or absence of microgenia and the
need for a chin implant is a cephalometric determination that is
independent of the condition of the neck. Placement of a chin
implant when microgenia is not present is a conceptual and
artistic error that will create unnatural appearances.
When true microgenia is present, however, placing a chin
implant in combination with a necklift will produce a more

222
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
harmonious and balanced profile, a more aesthetic and attrac­
tive cervicofacial relationship, and a bolder more athletic
masculine appearance (Fig. 6.9.28, see also
Case study 6.9.1).
The male chin differs considerably from that of the female
and the surgeon treating male patients must keep this in mind
when planning and performing procedures. The male chin is
broader, stronger, more square, and has more vertical height
than that of the female, and a strong chin and balanced profile
are arguably more important to male attractiveness than to
female beauty. A man with a weak chin typically is regarded
as appearing weak and indecisive – and in some cases, even
unmasculine and effeminate. The male chin should also be
smoothly confluent and well integrated with the jawline, with
a smooth and seamless transition across the geniomandibular
confluence (see Figs. 6.9.4 & 6.9.31 and
Case study 6.9.1).
Fig. 6.9.27  “Deep layer” neck problems. The patient has undergone a previous
face and necklift performed by an unknown surgeon in which submental liposuction
and tightening of neck skin was performed. It can be seen that while the submental
area has been stripped of subcutaneous fat this approach ignored a number of
anatomical problems present in most males including platysmal laxity, platysma
bands, excess subplatysmal fat, large submandibular glands, and digastric muscle
hypertrophy. Removing subcutaneous fat and tightening skin over these problems
does not correct them. (Courtesy of the Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.26  The neck comprises a key element of
rejuvenating the male face. A well-contoured neck is
an artistic imperative to an attractive and appealing
masculine appearance. A bold, well-defined neckline
conveys a sense of youth, health, fitness, strength,
vitality, and decisiveness. Neck improvement is of high
priority to almost every male patient seeking facial
rejuvenation, and the results of male “facelift”
procedures are often largely judged by the outcome
achieved in the neck. If the neck is not sufficiently
improved, most male patients will feel we have failed
them. (All surgical procedures performed by Timothy
Marten, MD, FACS. Photos courtesy of the Marten
Clinic of Plastic Surgery.)
Some strengthening of the male chin can be accomplished
with fat grafting, and fat grafting provides a means to readily
increase vertical chin height. Often a chin implant can be used
together with fat grafting to optimize lower facial contour in
the male patient, with the chin implant providing a reliable
increase in chin projection and the fat used to increase vertical
height and to avoid an overly deep and unnatural labiomental
groove.
Eyelid surgery in the male facelift patient
The attractive male orbit and eyelid is distinctly full, and,
however well intended, traditional blepharoplasty procedures
in which eyelid skin and fat are aggressively removed can
degrade the appearance of the eye and result in an overly
changed appearance in men.
Brow ptosis is often marked in many men and simply
looking at and then treating the upper eyelid can result in
inappropriate over-excision of eyelid skin and functional and
aesthetic problems. For many men, subtly repositioning the
lateral brow and fixing it in the position the patient holds it
as a result of frontalis muscle contraction, will lift the upper
lid skin fold off the eyelashes and preclude the need for
potentially harmful upper eyelid surgery. When upper eyelid
surgery is performed in men, it should be done very conser­
vatively. It is far better to perform a second-stage skin excision
at some future date, than to remove too much skin at the
primary procedure and create an overly “changed”, hollow,
unmasculine, or ill appearance.
As is the case with many women, atrophy often plays a far
greater role in the changes seen in the male orbital area with
age, and replenishing lost orbital fat can be profoundly reju­
venating in male patients (Fig. 6.9.29).
The typical male facelift patient will often express concern
about his lower eyelids but lower blepharoplasty, if indicated,
must be performed cautiously due to the predictable presence
of lower lid laxity. If the lower lid distracts more that 4–5 mm,
which is common, some form of canthopexy is indicated if lid

223
Preoperative planning in the male facelift patient
dissuade others from believing any surgery was performed:
“He must not have had a facelift because the plastic surgeon
would have surely fixed his baggy eyes”.
Fat grafting in the male facelift patient
A facelift procedure only addresses tissue ptosis and redun­
dancy and often produces a “lifted”, but telltale hollow,
unhealthy, frail, and under-rejuvenated “geezer” appearance
in men. Fat grafting allows loss of facial fat to be treated
simultaneously with the facelift and ensures these sorts of
appearances are avoided. All things being otherwise equal,
simultaneous facelift and fat grafting will produce a better
result than either technique performed alone, and when a
retraction and a sad, melancholic, aged appearance (and potentially
dry eye problems) are to be avoided.
Often what appears to be a large lower eyelid “bag” is, in
reality, merely a pseudo-herniation of orbital fat and, in truth,
an atrophic cheek. As such, replenishing lost midface and
upper cheek volume is often more appropriate than removal
of the lower eyelid “bag”.
A good strategy that is commonly employed in treating the
eyelids in men undergoing facelift surgery, especially if they
are recognizable public figures or are worried about an overly
changed appearance, is to not perform traditional blepharo­
plasties as part of the procedure. Leaving the upper eyelid
redundant, and a bag in the lower orbital area, preserves the
patient’s appearance in important loci of identity, and can
Fig. 6.9.28  Treating the chin in the male patient. The difference between the presence of poor neck contour and microgenia is commonly misunderstood, and it is a
common misconception that placement of a chin implant improves neck contour. Placement of a chin implant when microgenia is not present is a conceptual and artistic
error that will create unnatural appearances. (A,C) Patient seen preoperatively has poor neck contour made worse by the presence of mild to moderate microgenia. When
true microgenia is present, placing a chin implant in combination with a necklift will produce a more a more aesthetic, athletic, and attractive cervicofacial relationship.
(B,D) Same patient following “short scar” necklift (note: a submental incision only was made and the patient has no scar around the ears), and chin implant placement. The
patient has not only better neck contour, but a more harmonious and balanced profile. (All surgical procedures performed by Timothy Marten, MD, FACS. Photos courtesy of
the Marten Clinic of Plastic Surgery.)
A
B
C
D

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SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.29  Fat grafting the upper orbit. Atrophy often plays a far greater role in the changes seen in the male orbital area with age than is appreciated, and replenishing
lost orbital fat can be profoundly rejuvenating in male patients. Traditional blepharoplasty in these patients will actually degrade the appearance of the eye. (A) Patient seen
preoperatively with hollow upper orbits. He has an aged and unmasculine appearance. (B) Same patient after periorbital fat grafting. The patient has a younger, more fit,
healthy, attractive, and masculine appearance. (Note: patient has also undergone fat grafting to his temples, radix, cheeks and midface as well.) (All surgical procedures
performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
Fig. 6.9.30  Fat grafting the face. Atrophy often plays a far greater role in the changes seen in the male face with age than is appreciated, and replenishing lost facial fat
can be profoundly rejuvenating in male patients. (A) 68-year-old patient seen preoperatively with facial atrophy. He has an aged appearance and is requesting a facelift.
(B) Same patient 1 year and 9 months after facelift and facial fat grafting. (Note: patient has undergone fat grafting to his cheeks, mid-face, buccal recess, geniomandibular
groove, jawline and chin). The patient has a younger, more fit, healthy, attractive, and masculine appearance that could not be achieved by a facelift alone. (All surgical
procedures performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B

225
Preoperative preparations in the male patient
masculine and eye-appealing transition from the face to the
neck can be obtained (Fig. 6.9.31).
It is commonly believed that fat grafting the lips in men
will feminize the mouth, but the young, attractive, healthy
male mouth is full, and replenishing lost perioral volume is
an important part of creating a harmonious and natural-
appearing rejuvenation of the male face. The key, in most
cases, is filling of the lower lip and photographs of the patient
when he was younger are often helpful in explaining the need
for lip and orbital fat grafting, as these will almost uniformly
show a full appearance of those areas. Fat grafting the lips
(predominantly the lower lip) combined with upper lip lift is
an excellent approach for rejuvenation of the male mouth.
Preoperative preparations in the
male patient
It is important to ensure that all patients are in good general
health and all undergo a preoperative physical evaluation,
and any with significant medical problems or those over the
Fig. 6.9.31  Strengthening the male jawline using fat grafting. The young attractive, athletic and masculine face is also characterized by a rectangular shape and a strong
mandibular contour. Replenishing lost volume along the mandible restores a more youthful male facial shape and a more bold and decisive appearance. (A) Patient seen
preoperatively. The posterior jawline is weak and an indistinct transition is present from the face to the neck. (B) The same patient after a facelift and necklift that included
fat grafting. Fat grafting has been used to strengthen the cheek and jawline and create a more bold, athletic, youthful and masculine mandibular contour. A distinct transition
from the cheek to the neck is now present. No facial implants were placed. (All surgical procedures performed by Timothy Marten, MD, FACS. Photos courtesy of the Marten
Clinic of Plastic Surgery.)
A
B
facelift is performed in conjunction with fat grafting, both loss
of facial contour and facial atrophy can be corrected, and
optimal overall improvement can be obtained (Fig. 6.9.30).
Areas in need of treatment will vary from patient to patient,
but any area that can be treated with non-autologous inject­
able fillers is potentially treatable with fat grafting including,
but not limited to, the temples, radix, upper orbit (“upper
eyelid”), lower orbit (“lower eyelid”), cheeks, midface, buccal
recess, lips/perioral, nasolabial crease, geniomandibular
groove, chin, and jawline areas. Fat grafting is particularly
useful in filling the hollow upper and lower orbits (see Fig.
6.9.29) in men, as the youthful, attractive male eye is full and
traditional blepharoplasty procedures only exacerbate hol­
lowness, and often actually degrade the appearance of the
male eye.
The young attractive, athletic and masculine face is also
characterized by not only a full upper and lower orbit, but by
a rectangular facial shape and a strong mandibular contour.
Replenishing lost volume along the mandible, though initially
counterintuitive, restores a more youthful male facial shape
and a more bold and decisive appearance. In addition, a more

226
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
leaving the entire head, neck, and scalp regions unobscured
from the clavicles up. This allows unimpaired examination of
cervicofacial contours throughout the procedure and provides
complete access to all areas of the scalp. No hair is cut or
shaved at proposed sites for incisions, and no head drapes are
used. Shaving or trimming hair will preclude accurate assess­
ment of hair shaft inclination relative to the scalp and this can,
in turn, result in incisions that injure hair follicles. Head
drapes will limit scalp access and also make it difficult to
determine hair shaft inclination and make incisions properly.
Placing hair in small “pig tails” with rubber bands, or saturat­
ing it with surgical lubricants, as is commonly done, is avoided
for similar reasons.
The breathing circuit is draped separately from the patient
by wrapping it with a sterile sheet, or by placing it inside a
sterile stockinette or sterile plastic sleeve. This allows it to be
moved during the procedure as the patient’s head is turned
from side to side.
After the general prep of the scalp, face and neck is com­
plete and drapes have been applied, the auditory canals are
prepped with povidone–iodine (Betadine) using cotton-tipped
swabs by a scrubbed member of the surgical team. Each nasal
vestibule and the perioral area are prepped with povidone–
iodine as well. “Peanut” (Kitner) sponges are subsequently
placed in each auditory meatus and these are changed as
necessary during the procedure to prevent the accumulation
of blood in the ear canals.
Local anesthetic administration
Local anesthetic is administered even if general anesthetic is
used. This limits stimulation of the patient during surgery and
the overall amount of narcotic and anesthetic needed. A sig­
nificant hemostatic effect is also obtained when epinephrine-
containing solutions are used.
Sensory nerve blocks are performed using 0.25% bupivic­
aine (Marcaine) with epinephrine 1 : 200 000. Sites marked for
incisions are then infiltrated with the same solution. Areas
where subcutaneous dissection is to be made are subsequently
infiltrated with 0.1% lidocaine (Xylocaine) with epinephrine
1 : 1 000 000) using a blunt infiltration needle or 22-guage
spinal needle, taking care to ensure that the total dose of
lidocaine (Xylocaine) does not exceed 7 mg/kg per 4 h. No
direct infiltration of the SMAS or platysma is necessary if the
overlying subcutaneous tissues are infiltrated generously at
the beginning of the procedure.
Fat grafting
Fat grafting is often mistakenly regarded as a simple proce­
dure that can be performed in a few minutes. This is rarely the
case, however, and such an attitude will lead to frustration,
disruption of workflow, and suboptimal outcomes. Fat must
be harvested in a specific, atraumatic manner if viable tissue
is to be obtained that can be expected to survive and “take”
at the facial donor site, and it must then be processed and
injected in a technically demanding and time-consuming
process using special instruments. Fat grafting is also an
artistically demanding activity that will require a considerable
amount of the surgeon’s creative energy. When anything other
than a few areas of the face are being treated, the entire pro­
cedure can take 1 h or more, something that can overwhelm
age of 50 years are cleared by their internist or personal physi­
cian before their procedure is performed. Each patient is
required to avoid agents known to cause platelet dysfunction
for 2 weeks prior to surgery and a list of products that contain
aspirin, ibuprofen, ketoprofen, naproxen, non-steroidal anti-
inflammatories, vitamin E, and other prohibited products
with an anti-platelet effect is provided.
All patients who smoke are asked to quit 4 weeks before
their procedure and are required to avoid smoking and all
second-hand smoke for 2 weeks after surgery. Patients who
smoke, or have a significant past history of smoking but
have quit, are advised in writing that their risk of serious
complications, including poor healing, flap necrosis, skin
slough, and thromboembolic phenomena, is significantly
higher than in non-smokers or patients who have not smoked
in the past. Smokers should always be approached with caution,
and it should be recognized that these patients are suboptimal can­
didates for surgery and at high risk for serious local and systemic
complications. It is often best for the young or less experienced
surgeon to refer the male facelift patient who smokes to a
more senior colleague.
Patients are required to shower and shampoo with antibac­
terial soap the night prior to surgery, paying careful attention
to thoroughly cleansing the periauricular areas. Male patients
are asked not to shave for the 2 days prior to their procedure
to allow assessment of beard follicle inclination when inci­
sions are made and to facilitate destruction of beard follicles
shifted onto the tragus if indicated.
It is important that adequate operating room time be allot­
ted for contemporary facelift procedures, especially in men,
as they are deceptively time consuming when compared to
more limited traditional techniques. The male head is 20–30%
larger than that of the female, and will entail 20–30% more
dissection, suturing, tissue manipulation – and time. Most
males will also present more difficulty in terms of bleeding
and hemostasis, and the surgeon will typically need to spend
extra time accommodating issues related to beard shift. A
SMAS facelift, when performed in conjunction with necklift,
forehead and eyelid surgery, fat grafting, and other procedures
in a male patient, will often require 6–8 h or more, even when
performed by a “fast” surgeon working with a well-organized
and experienced operating room team.
Surgical technique
Patient positioning
The patient is placed supine on a well-padded operating
table and attached to appropriate physiological monitors. The
lower extremities are then elevated and anti-embolic pedal
compression devices applied. An indwelling balloon-tipped
urinary catheter is placed after deep sedation is begun or
anesthesia administered, and the face carefully marked before
the skin prep is performed or local anesthesia is administered.
Skin prep and draping
Patients receive a full scrub of the entire scalp, face, neck,
shoulders, and upper chest with full strength (1 : 750) benzal­
konium chloride (Zephiran) solution after bland opthalmic
ointment is instilled into each eye. Drapes are then applied,

226.e1
Anesthesia in the male facelift patient
Anesthesia in the male facelift patient
The majority of our facelifts are now performed under deep
intravenous (IV) sedation administered by an anesthesiologist
using a laryngeal mask (“LMA”) airway (Fig. 6.9.32).
A laryngeal mask allows the patient to be heavily sedated
without compromise of their airway, but the patient need not
receive muscle relaxants and can be allowed to breath spon­
taneously. In most cases, the cuff need not even be inflated. A
laryngeal mask is also less likely to become dislodged during
the procedure than an endotracheal tube, and it is less likely
to trigger coughing and bucking when the patient’s head is
turned or when he emerges from the anesthetic. Despite some
assertions to the contrary, a laryngeal mask is well suited to
long cases, and we have used laryngeal mask airways for
6–8-h long procedures for over a decade without any signifi­
cant related problems.
Most patients receive preoperative medication tailored to
their specific circumstances including age, weight, height,
personality, and general health. The preoperative regimen is
modified depending upon the type of anesthetic and prefer­
ences of the anesthesiologist. Oral narcotics should not be given
as part of the premedication as they commonly result in nausea and
vomiting. Cocaine, anticholinergics, and parasympathomimet­
ics are also avoided.
Hypertension is common in many male patients seeking
facelifts, and male patients are more prone to associated
bleeding-related complications, including hematoma, than
female patients. As such, hypertension must be carefully
managed in the perioperative period in male patients. An
important part of perioperative management of hypertension
is the formulation a proactive plan for preoperative, preemp­
tive treatment and prevention, and most male facelift patients
receive a beta blocker (atenolol 12.5–25 mg p.o.) and clonidine
(0.1–0.3 mg p.o.) preoperatively. Perioperative blood pressure
is then closely monitored and aggressively treated intraopera­
tively if it becomes elevated (labetolol 5–10 mg IV every
10 min p.r.n.), with the goal of operating on a normotensive
patient (mean arterial pressure within 10–15% of preoperative
value). Many male patients with pre-existing hypertension
will preoperatively be undermanaged by their internist and
in some cases it will be prudent for the surgeon (in conjunc­
tion with the anesthesiologist if possible) to tighten blood
pressure control in the preoperative and postoperative
periods. Employing hypotensive anesthesia, as advocated by
some surgeons, carries an increase risk of postoperative
bleeding-related complications, and increasing evidence is
accumulating that such a practice can lead to significant
cognitive dysfunction postoperatively.
A proactive plan for the prevention of postoperative nausea
and vomiting should also be put in place, and anti-emetics are
given routinely at the beginning of each procedure, and most
Fig. 6.9.32  The laryngeal mask airway. A laryngeal mask allows the male patient
to be heavily sedated without compromise of his airway, but the patient need not
receive muscle relaxants and can be allowed to breath spontaneously. A laryngeal
mask is also less likely to become dislodged during the procedure than an
endotracheal tube, and it is less likely to trigger coughing and bucking when the
patient’s head is turned or when he emerges from the anesthetic. A device with a
standard stiff shaft is shown but a LMA with a flexible shaft is available and most
often used. This allows free movement of the anesthesia circuit when operating on
the neck.
patients are given several agents in an effort to block the
emetic reflex at multiple levels (ondansetron 4–8 mg and
dexamthasone 0.1 mg/kg). Limiting the use of IV narcotics
and inhalation anesthetics is also helpful in reducing postop­
erative nausea and vomiting. In patients with a prior history
of postoperative nausea and vomiting, additional agents
should be considered (scopolamine patch and aprepitant
(Emend) 40 mg p.o. 1–3 h preoperatively).

227
Surgical technique
nerve in the lateral neck and in preauricular region where a
deep dissection can injure the underlying SMAS and compro­
mise it usefulness as a flap. If dissection is made in the proper
plane in male patients, beard follicles will typically be visible
on the under surface of the flap. This will not cause injury to
them, but care must be taken when cauterizing on the under­
surface of the flap in these areas.
Although subcutaneous undermining is necessary, it should not
arbitrarily include the entire face. If a SMAS dissection is planned,
preservation of the platysma cutaneous ligaments will allow
attractive and youthful appearing elevation of perioral tissue
that cannot be obtained with a “skin-only” technique, or when
wide skin undermining is performed (Fig. 6.9.34).
These ligaments anchor the dermis of the perioral cheek
to the SMAS and upper platysma, and provide a means of
lifting the lateral perioral area without over-tightening the
skin of the lateral face. Preservation of the platysma cutaneous
ligaments and attachments between the perioral skin and
SMAS in this way prevents the “lateral sweep” deformity that
typically occurs if the skin flap is over-dissected. Such a
strategy also preserves important accompanying perforating
vessels to the cheek flap, and this, in turn, reduces the likeli­
hood of vascular compromise.
Temple dissection
The temple incision is made according to the preoperative
plan based on the amount of skin redundancy present over
the upper cheek and the predicted degree of displacement
of the sideburn and temporal hairline (see discussion in
preceding section). In most men this will best be along the
temporal hairline.
The incision along the anterior portion of the temple hair­
line (“sideburn”) is made a few millimeters within it, with a
slight bevel, or parallel to the hair follicles, in a more rectan­
gular fashion than that typically used in the female patient
(see Figs. 6.9.8 & 6.9.13). A temporal skin flap is carefully
undermined subcutaneously and joined with the subcutane­
ous dissection in the cheek.
an already overburdened surgical team engaged in a long
and demanding facelift operation consisting of multiple
procedures. Time must, therefore, be carefully planned and
allocated appropriately.
Fat grafting cannot be performed arbitrarily, and a specific
plan must be conceived and marked preoperatively with the
patient seated in an upright position. Marking will require
concentration on the surgeon’s part and consume a significant
amount time, and is best carried out in a private area that is
free from distractions.
Although there is no consensus on when fat grafting is best
performed during facelift surgery, as a practical matter it is
most expedient to inject fat at the beginning of the procedure
before the facelift itself has been performed. The reasons for
this include the fact that it is easier to harvest the fat at the
beginning of the procedure before the face has been prepped or
draped and when the patient is typically in a deeper plane of
anesthesia. At the beginning of the procedure, the tissue planes
of the face have also not been opened, the face is not swollen,
and preoperatively made pen marks and facial landmarks are
easier to identify. In addition, surgical principles suggest that
it is best to limit the time the graft is out of the body. Perhaps
the most important reason to perform fat grafting first, however,
is that the surgeon is more technically and artistically energetic
in the morning, and will do a better job than if the procedure is
performed at the end of a long facelift operation.
Skin flap elevation
After incisions are made, skin flaps are elevated in a subcutane­
ous plane according to the preoperative plan (see Fig. 6.9.18B).
Partial separation of the skin flap from the SMAS (“lamellar dissec­
tion”) is necessary because skin and SMAS flaps need to be advanced
in different directions if an optimal outcome is to be obtained. This
“bidirectional” tissue shift is not possible if a “composite” eleva­
tion of a combined skin–SMAS flap is made (Fig. 6.9.33).
Skin flaps should be elevated sharply under direct vision
and blind dissections and scissors pushing avoided. This is
especially important over the course of the great auricular
Fig. 6.9.33  “Lamellar” and “composite” dissections facelift flap dissections. Partial separation of the skin flap from the SMAS (“lamellar dissection”) is necessary because
skin and SMAS flaps need to be advanced in different directions if an optimal outcome is to be obtained. This “bidirectional” tissue shift is not possible if a “composite”
elevation of a combined skin–SMAS flap is made. (A) Lamellar (dissecting the skin and SMAS as two separate layers) dissection allows the skin and SMAS flaps to be
treated independently and shifted in different directions and this allows for a more natural and less “lifted” appearance. (B) Composite (dissecting the skin and SMAS as
one layer) dissection requires skin and SMAS to be advanced along the same vector. A “bidirectional” tissue shift is not possible if a “composite” dissection is made.
(Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B

228
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
SMAS dissection
Once skin flaps have been elevated they are gently retracted
and a line is then traced “high” over the midportion of the
zygomatic arch in water-soluble surgical ink (methylene blue)
from the level of the infraorbital rim to a point approximately
1 cm anterior to the superior aspect of the tragus. This line
lies “higher” than the dissection made in most other tech­
niques, and well above the malar origin of the zygomaticus
major muscle. The mark is then turned inferiorly and carried
over the preauricular portion of the parotid 1–2 cm anterior
to the ear. Inferior to the lobule, it is carried inferiorly and
posteriorly to the anterior border of the sternocleidomastoid
muscle 2–3 cm below the mandibular margin (Fig. 6.9.35).
A basic “high” flap of this type is used on most patients
and there are several important advantages in its design
worth considering. First, planning the superior margin of the flap
over and along the zygomatic arch, rather than inferior to it, expands
the effect of the flap to include the midface and infraorbital regions,
and allows a better vector to be applied to them (Fig. 6.9.36).
Carrying the incision posteriorly and inferiorly over the tail
of the parotid to the anterior border of the sternocleidomastoid
muscle in the upper-lateral neck also maintains a “safety
zone” between the incision and the anterior border of the
inferior portion of the parotid gland and moves the dissection
away from the marginal mandibular nerve (Fig. 6.9.37).
Flap elevation is begun by incising the SMAS over the
zygomatic arch. This is accomplished by grasping the preau­
ricular tissue overlying the lateral arch with an Allis clamp on
Fig. 6.9.34  Plan for subcutaneous undermining. Subcutaneous undermining
(yellow shaded area) should not arbitrarily include the entire face. If a SMAS flap is
planned, preserving the platysma cutaneous ligaments (black dots) will allow
attractive and youthful-appearing elevation of perioral tissue that cannot be obtained
with a “skin-only” technique, or when wide skin undermining is performed. If the
check skin flap is over-dissected and these ligaments divided, a suboptimal
outcome will be obtained. (Photo courtesy of the Marten Clinic of Plastic Surgery.)
Fig. 6.9.35  Plan for “high SMAS” flap. The superior margin of flap is planned over
the zygomatic arch and not below it. The frontal branch of the facial nerve (dashed
line) lies safely posterior and deep to the majority of the dissection. (Photo
courtesy of the Marten Clinic of Plastic Surgery.)
each side of the marked line. An incision is then made with
Metzenbaum scissors and continued medially 1–2 cm along
the marked line in the tensed plane (Fig. 6.9.38). Allis clamps
are then released and reapplied incrementally as the dissec­
tion proceeds further medially along the marked line in the
tensed plane in 1–2 cm segments in a similar fashion. A con­
siderable amount of tissue lies over the arch, and the frontal
branch will be safely concealed beneath several millimeters of
fibrous fat.
The posterior part of the SMAS incision is then made using
a similar technique over the posterior parotid along the
marked line in the preauricular region. It is continued inferi­
orly and posteriorly to the anterior border of the sternocleido­
mastoid muscle. These two incisions define the “high” SMAS
flap to be elevated (Fig. 6.9.39).
After initial SMAS incisions have been completed, preau­
ricular tissue comprising the posterior–superior corner of the
of the SMAS flap is grasped with Allis clamps and flap eleva­
tion is then begun using careful scissors or low-current
needle-tipped cautery technique. Undermining should be
limited in the preparotid cheek, but must be more extensive
over the zygoma and upper midface (Fig. 6.9.40).
SMAS flap elevation will entail dissection in the plane
of the facial nerve in close proximity to important motor
branches. Although flap elevation over the parotid is safe,
great care must be taken when the dissection moves more
medially, medial to the anterior border of the parotid and over
the zygomatic arch. Frequently motor nerve branches lie near
vessels and each bleeding point must be carefully identified
when hemostasis is being performed. Blind clamping should
not be performed and low coagulation current should always
be used. The patient’s face should also be carefully watched
whenever cauterization is performed and current discontin­
ued immediately if facial twitching is noted.
SubSMAS dissection must generally be carried up to the
anterior border of the parotid in the lower cheek to ensure
that parotidomasseteric ligaments tethering the SMAS are
released. These are most easily identified by fingertip palpa­
tion along the front of dissection. If these restraining attach­
ments are not released, an optimal SMAS effect will not be

229
Surgical technique
realized in the lower cheek and along the jawline, and minimal
overall benefit will be obtained.
As SMAS flap dissection is carried anteriorly and medially
in the upper cheek over the superior portion of the parotid
and its accessory lobe, the SMAS envelopes the lip elevators.
At this point, the dissection must be taken superficial to the superior
portion of the zygomaticus major muscle and its uppermost
portion carefully exposed in most cases. Just at the malar
Fig. 6.9.37  Plan for “high SMAS” flap and the marginal mandibular nerve. The
marginal mandibular branch of the facial nerve (yellow line) emerges from the
anterior border of the parotid gland well anterior to the SMAS incision in the
preauricular region. (Note that mark for posterior incision curves posteriorly to the
anterior border of the sternocleidomastoid muscle.) (Photo courtesy of the Marten
Clinic of Plastic Surgery.)
Fig. 6.9.38  Incising the SMAS. Flap elevation is begun by incising the SMAS over
the zygomatic arch. This is accomplished by grasping the preauricular tissue
overlying the lateral arch with an Allis clamp on each side of the marked line. An
incision is then made with Metzenbaum scissors and continued medially 1–2 cm
along the marked line in the tensed plane. Allis clamps are then released and
reapplied incrementally as the dissection proceeds further medially along the
marked line in the tensed plane in 1–2 cm segments in a similar fashion. A
considerable amount of tissue lies over the arch and the frontal branch will be
safely concealed beneath several millimeters of fibrous fat. (Photo courtesy of the
Marten Clinic of Plastic Surgery.)
A
No midface improvement
Low SMAS
B
High SMAS
Midface improvement
Fig. 6.9.36  “High” and “low” SMAS techniques compared. (A) Low SMAS procedure. Note that upper border of the flap lies below the zygomatic arch. Area of flap effect
(blue circle) is limited to the lower cheek and jowl and no improvement is obtained in the midface, infraorbital or perioral regions (red dashed circle). (B) High SMAS
procedure. Note that upper border of the flap lies over the zygomatic arch. Area of flap effect (blue circle) includes not only both the cheek and jowl, but the midface,
infraorbital, and perioral regions (red dashed circle) as well. When a high SMAS plan is used, the entire face is lifted, not just part of it, and no separate midface lift is
needed. (Courtesy of the Marten Clinic of Plastic Surgery.)
origin of the zygomaticus major muscle, the zygomatic liga­
ments will be encountered. These fibrous connections between
the periosteum and skin restrain the upper cheek and midface
and must be divided if an optimal “high SMAS” effect is to
be obtained (Fig. 6.9.41).

230
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Dissection of the SMAS flap and release of restraining liga­
ments is continued until gentle traction on the flap produces
motion at the cheek, nasal ala, philtrum and stomal angle, and
elevation and compression of infraorbital and lower eyelid
region. This “traction test” clinically confirms adequate flap release
and is a more important indicator of a complete dissection than any
arbitrary anatomical endpoint. If flap release is incomplete,
residual tethering fibers are identified and carefully divided
and the traction test repeated. When dissection is complete,
the malar pad and attached skin will move freely as part of
the “high” SMAS flap superiorly and laterally, and no separate
midface suturing or subperiosteal midface dissection is
required.
SMAS suspension
Once the SMAS flap has been elevated and adequately
released, the superior edge of the flap is grasped and it is
shifted variously to determine which direction produces the
best effect on the upper midface, cheek, and jowl. In all but
the unusual case this is along a posterior–superior vector
parallel to the long axis of the zygomaticus major muscle. If a
“vertical” or more posterior directed vector is used, the function of
the zygomaticus major muscle will be compromised and abnormal
appearances during animation may result (Fig. 6.9.42).
Management of the superior margin of the SMAS flap and
the technique of flap suspension will vary depending on
considerations particular to the patient including sex, race,
and overall facial morphology. In most cases, however, the
excess tissue on the superior margin of the flap is resected in
men as the overlapping of tissue segments that add volume
to and restore lost projection over the zygomatic arch in
women would produce unwanted rounding of the more
ideally rectangular and angular male face. After excision of
excess SMAS along the superior edge of the flap, the trimmed
flap edge is anchored with multiple interrupted sutures of 3-0
poly(glycolic acid) (PGA; Vicryl) to the cut edge beneath it
over the arch (Fig. 6.9.43).
No suturing is needed or should be performed anteriorly
over the zygoma or along the infraorbital rim. These parts of
Fig. 6.9.39  Completed incision of the superior and posterior margins of the high
SMAS flap. The posterior part of the SMAS incision is then made using a similar
technique over the posterior parotid along the marked line in the preauricular
region. It is continued inferiorly and posteriorly to the anterior border of the
sternocleidomastoid muscle. These two incisions define the “high” SMAS flap to
be elevated. (Photo courtesy of the Marten Clinic of Plastic Surgery.)
Fig. 6.9.41  Completed SMAS flap dissection. The zygomatic ligaments (blue
dots) restraining the upper cheek and midface and the parotidomasseteric ligaments
(black dots) restraining the lower cheek and jowl have been released. The platysma
muscle extending up from the neck into the SMAS flap can be seen, as can the
origin of the zygomaticus major muscle (lying between the blue and black dots).
For a proper SMAS effect to be obtained, these ligaments must be released. (Photo
courtesy of the Marten Clinic of Plastic Surgery.)
Fig. 6.9.40  Extent of SMAS undermining. Undermining should be limited in the
preparotid cheek, but must be more extensive over the zygoma and upper midface.
Round dots near the origin of the zygomaticus major muscle represent the
zygomatic ligaments that restrain the upper cheek and midface. The squares along
the anterior border of the parotid gland represent the parotidomasseteric ligaments
that restrain the lower cheek and jowl. If these ligaments are not released, an
optimal SMAS effect is not obtained. (Courtesy of the Marten Clinic of Plastic
Surgery.)
Directly inferomedial to the origin of the zygomaticus
major muscle, and superomedial to the accessory lobe of the
parotid and the parotid duct, lies the zone of transition
between the zygomatic and parotidomasseteric ligaments and
the most potentially dangerous part of the SMAS dissection.
Proper liberation and release of the SMAS flap usually requires
at least partial division of restraining attachments in this area,
but moves the dissection into very close proximity to the
zygomatic branch of the facial nerve.

231
Surgical technique
of a given face, the degree of release of the flap, and the chosen
vector of advancement. It is counterproductive and an error,
however, to place significant traction on the SMAS in the preauricu­
lar region, and the posterior margin of the flap should be
trimmed carefully to avoid over-excision and a tight closure.
Posterior traction on the SMAS will result in accentuation of
risorius muscle action, perioral distortion, a “pulled” “clown-
mouth appearance”, and objectionable appearances.
After trimming of the posterior margin of the SMAS flap,
the cut edge is approximated to the preauricular remnant with
multiple interrupted inverted 3-0 PGA (Vicryl) sutures. Upon
completion of suturing of the cheek SMAS, improved facial
contour should be seen and a faint smile should be evident
on the ipsilateral side of the patient’s face. Usually elevation
of the lid–cheek junction and compression of lower eyelid
tissue will also be seen if a high SMAS procedure has been
properly performed.
the face are mobile and need to move during animation and
for natural expression. Directly suspending the midface along
the zygoma or infraorbital rim can result in tissue tethering
and dimpling upon animation.
After trimming and suturing of the superior margin of the
flap, some trimming of the posterior margin of the SMAS flap
is invariably required to allow an edge-to-edge approxima­
tion to the SMAS remnant in the preauricular region and
reconstitution of the SMAS layer over the parotid gland.
Failure to reconstitute the SMAS layer over the parotid could
lead to gustatory sweating and Frey’s syndrome.
Trimming of the posterior margin of the cheek SMAS flap
should be performed after the superior margin has been
suspended over the zygomatic arch. Excision is accomplished
by placing gentle traction on the SMAS flap and tracing a line
in marking ink over the cut edge laying beneath it. The
amount of tissue excised will vary depending upon the size
Fig. 6.9.42  Proper (A) and improper (B,C) vector of SMAS shift. (A) Correct shift of SMAS flap is along the
long axis of the zygomaticus major muscle (green arrow). This allows for natural muscle function and
maximum improvement in posture of the mouth. (B) If the SMAS is shifted along a posteriorly directed vector
(red arrow) and not along the long axis of the zygomaticus major muscle, the muscle will be pulled off its axis
and its function compromised. This can result in deepening of the nasolabial fold and abnormal appearances
during animation. A posterior shift of the SMAS flap also accentuates the action of the risorius muscle and
produces a pulled, “clown mouth” appearance. (C) Similar problems are encountered when a purely “vertical”
vector (red arrow) is used in a “vertical facelift”. (Courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C

232
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Drain placement
Drains are routinely used and experience has shown that they
reduce postoperative ecchymosis and induration, and allow
patients to return to their work and social lives sooner. Three
10 Fr round “end-perforated” “Jackson-Pratt” style closed-
circuit suction drains are typically placed in male patients if
necklift is concomitantly performed. A drain is placed subcu­
taneously across the anterior–inferior neck through a small
stab incision on the occipital scalp 1–2 cm superior to the apex
of the occipitomastoid incision on both the right and left sides.
A third drain is then placed in a similar fashion but pulled
into the subplatysmal space. No drains are placed cheeks.
Skin flap repositioning and suspension
suture placement
As in the female face, but more critically so in the male patient,
the goal of skin excision is to remove redundancy, and not to
tighten the skin flap. Skin must also be shifted along a vector
that is compatible with its covering function and one that
does not result in secondary deformities. Shifting skin along
an overly “vertical” vector, or suspending skin flaps under
tension, will result in hairline displacement, poor scars, and
other objectionable problems. Shifting skin too posteriorly can
result in distortion of the mouth and typically results in a
“facelifted look”. Cheek skin flaps should be properly shifted
along a vector approximately perpendicular to the nasolabial
fold.
In the postauricular area skin should be shifted along a
vector parallel to the mandibular border. This provides
optimal improvement in the anterior neck where it is needed
most, and allows maximum excision of skin flap redundancy
without shifting cervical wrinkle lines onto the lower face
(neck-to-face “wrinkle shift”). If the postauricular skin flap is
shifted along a more superiorly directed vector, improvement
in the anterior neck will be compromised, skin will be inap­
propriately excised over the apex of the occipitomastoid
Fig. 6.9.43  SMAS suspension and management of the superior SMAS margin. Management of the superior margin of the SMAS flap and the technique of flap suspension
will vary depending on considerations particular to the patient, including sex, race, and overall facial morphology. In most cases, however, the excess tissue on the superior
margin of the flap is resected in men, as the overlapping of tissue segments that add volume to and restore lost projection over the zygomatic arch in women would
produce unwanted rounding of the more ideally rectangular male face. (A) The SMAS flap is elevated, the excess along its superior margin marked, and the excess excised.
(B) After excision of excess SMAS along the superior edge of the flap, the trimmed flap edge is anchored to the cut edge beneath it over the arch. (Photos courtesy of the
Marten Clinic of Plastic Surgery.)
A
B
incision, and a wide scar will likely be present once healing
is complete.
There are two points of skin flap anchoring that set the
stage for the remainder of the closure. The first point is located
in the supra-auricular area where the anterior–superior-most
part of the ear joins the scalp. To set this point, the cheek skin
flap should be shifted along a vector roughly perpendicular
to the nasolabial fold and skin redundancy then gauged with
a facelift marker (Fig. 6.9.44). A small “T”-shaped incision is
then made into the flap at the marked point. Making the
incision in a “T”-shape facilitates suture placement and sim­
plifies subsequent trimming of adjacent skin. The flap is then
anchored at this point with a half-buried vertical mattress
suture of 4-0 nylon with the knot tied on the scalp side. No
deep sutures are necessary or used.
The second point of anchoring is located in the postauricu­
lar area at the anterior–superior aspect of the occipitomastoid
incision (junction of postauricular and transmastoid incisions,
see Fig. 6.9.15). To set this point, the postauricular flap is
shifted posteriorly and somewhat superiorly, roughly parallel
to transverse neck creases and the mandibular border, in such
a manner that skin is suspended under minimal or no tension
and that little or no skin need be trimmed from the anterior (post­
auricular) flap border.
Once the two key anchoring sutures have been placed, the
flap overlying the inferior portion of the ear should be cau­
tiously divided guided by a facelift marker, and the lobule
exteriorized. This is a key step in the procedure that must be per­
formed with great care if a visible scar, lobular malposition, a “pixie
ear”, and other objectionable secondary deformities are to be avoided.
If the incision to exteriorize the lobule is made correctly, the
apex of the incision should rest snugly against the inferior-
most portion of the conchal cartilage.
Skin flap trimming and closure
Skin flap trimming and incision closure is typically begun in
the postauricular area along the auriculomastoid sulcus after

233
Surgical technique
It is an error to excise any skin over (superior to) the apex
of the occipitomastoid portion of the postauricular incision
and to shorten the postauricular skin flap along the long axis
of the sternocleidomastoid muscle as commonly practiced
and shown in many textbooks (Fig. 6.9.46). Despite an appar­
ent redundancy in this area when the patient is supine on the
operating table, there is no true skin excess at this location.
This pseudo-excess of skin is present only because of the
patient’s high shoulder position in the supine position and it
will vanish when she or he sits up and the shoulders drop to
a normal position. Skin along the axis of the sternocleidomas­
toid muscle is also needed for side-to-side head tilt. Inap­
propriate excision of skin over the apex of the occipitomastoid
defect is the ultimate underlying cause of hypertrophic
healing in the postauricular region, and of a wide postauricu­
lar scar.
If the temporal portion of the facelift incision has been
within the temporal scalp (see Fig. 6.9.7), it is closed in one
layer without excision of any hair-bearing temporal tissue
with multiple simple interrupted sutures of 4-0 nylon. A small
amount of cheek skin and scalp only will be excised immedi­
ately above the ear at the completion of the closure. Because
the incision on the temporal scalp is usually beveled when
properly made, sutures, and not staples, are generally
required, if malalignment and step-offs are to be avoided.
If the temporal portion of the facelift incision has been
made along the temporal hairline (see Fig. 6.9.8) as is usually
best in the male patient, skin only will be trimmed when it is
closed. A facelift marker should be used to gauge temporal
skin excess and the flap intentionally trimmed with 2–3 mm
of redundancy. If trimming is performed correctly, wound edges
should abut one another, and no gaps should be present, before
sutures are placed. The incision is then closed in one layer with
a combination of half-buried vertical mattress sutures of 4-0
nylon with the knots on the scalp side and simple interrupted
sutures of 6-0 nylon.
Preauricular trimming and closure should be performed
next. Skin flap redundancy should be gauged using a facelift
key anchoring sutures have been placed and the lobule exte­
riorized. It is carried out by conservatively trimming the
anterior border of the postauricular skin flap into a soft curve
to match the curve of the incision made in the auriculomastoid
sulcus. No attempt should be made to excise large amounts
for tissue from this area. The incision is then closed with
several interrupted sutures of 4-0 nylon. No deep suture is
needed or used.
Trimming and closure of the occipital portion of the inci­
sion should be performed after closure of the postauricular
area. A facelift marker should be used to gauge skin flap
excess over the occipital part of the postauricular incision, and
all points along the flap should be intentionally trimmed
with 2–3 mm of redundancy. If trimming is performed correctly,
wound edges should abut one another, and no gaps should be present,
before sutures are placed. The incision is then closed in one layer
with multiple half-buried vertical mattress sutures of 4-0
nylon with the knots tied on the scalp side and simple inter­
rupted sutures of 6-0 nylon. No deep sutures are required and
staples should not be used. This suturing scheme will provide
precise wound edge alignment and prevent cross-hatched
scars (suture marks). In addition, if the incision is closed
under no tension as described, an inconspicuous scar will be
obtained, even in men wearing short, military style haircuts.
If the postauricular skin flap has been shifted along a
proper vector, and tissue distributed appropriately under no
tension over the occipital area, a precise fit should be obtained.
If neck skin redundancy is large, however, a “dog-ear” will
often be present at the inferior-most portion of the occipital
incision. This should not be chased inferiorly down the occipi­
tal hairline, as an obvious scar will result in the fine hair on
the nape of the neck. A better result is obtained under these
circumstances if the dog-ear is inset posteriorly into the occipi­
tal scalp, at the junction of thick and fine hair, and secured
with simple interrupted sutures of 4-0 nylon. This requires
that a small ellipse of scalp be excised from the scalp side of the
incision, but moves the end of the incision into dense hair
where it is well concealed (Fig. 6.9.45A–D).
Fig. 6.9.44  The “Marten” facelift marker. The use of a
flap marker provides a reliable means for appropriate
excisions of skin to be made. The pin on the lower jaw of
the marker is designed to be placed near the edge of the
incision. The skin flap is then pulled over the lower jaw of
the instrument, and when proper tension is set the
instrument is closed. On closing, the upper jaw of the
instrument marks the precise position of the edge of the
scalp flap beneath it. This serves as a valuable guide to
the degree of redundancy present and is particularly
useful in gauging the depth of “pilot” anchoring incisions
initially made into the flap at points of initial flap
suspension. Top: close-up view of the tip design. Bottom:
schematic illustration of the instrument in use. (Courtesy
of the Marten Clinic of Plastic Surgery.)

234
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Fig. 6.9.45  Insetting the postauricular “dog-ear”. (A) A wound length discrepancy is typically present along the occipital portion of the postauricular incision resulting in a
“dog-ear” at its inferior aspect. When a dog-ear does form, as shown, the redundant tissue is best managed by insetting it into the occipital scalp (green line and see B,C).
Trimming the dog-ear off in a traditional fashion (red line) will not fully accommodate the wound length discrepancy present and will move the scar into a more visible
location in the fine hair on the nape of the neck. (B) An ellipse of scalp tissue (in forceps) is excised from the scalp flap into which the dog-ear will be inset (note that the
dog-ear itself on the neck side is only minimally trimmed or not trimmed at all). This creates a curved, geometrically longer (longer distance between two points) curved
surface over which the dog-ear is fit into on the scalp side (see C). (C) The ellipse of tissue has been excised from the scalp side of the incision and removed, and the
wound length discrepancy has as a result been eliminated. The dog-ear itself has been undermined and released, but not trimmed. (D) After suturing, it can be seen that
the dog-ear has been eliminated and the inferior most part of the incision moved into thicker hair on the scalp where it is less visible than if it had be excised in a
traditional fashion. (Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C
D
Fig. 6.9.46  Incorrect trimming of postauricular skin flap. It is
an error to excise any skin over (superior to) the apex of the
occipitomastoid incision and shorten the postauricular flap along
the long axis of the sternocleidomastoid muscle as shown. There
is no true excess of skin along this vector nor any aesthetic
benefit from shifting skin in this direction. Excision of skin in this
fashion is the underlying cause of hypertrophic healing in the
postauricular area and of a wide postauricular scar.

235
Surgical technique
critical to avoid such deformities in men who have fewer
options to conceal them. For this reason, the lobule should be
inset into the cheek flap as the last step in the closure of the periau­
ricular area. Trimming the cheek flap to inset the lobule must
be performed with great care and should always be performed
incrementally in stages to prevent overexcision. The cheek
flap should be trimmed and the earlobe inset in such a manner
that the lobular–facial scar is tucked up under the earlobe and
the lobule ends up situated in a posterior and somewhat
superior position, even it if was in a more anterior or inferior
position before surgery. This is because the long axis of the
earlobe of an artistically ideal, “non-surgical appearing” ear
ideally sits approximately 15° posterior to the long axis of the
ear itself in the lateral view (Fig. 6.9.48A). As this angle is
reduced or shifted anteriorly, or if the lobule is mistakenly
placed too far inferiorly, the lobular–facial scar will be visible
and an unnatural-appearing “loving cup” earlobe and “face­
lifted look” is produced (Fig. 6.9.48B).
Insetting the lobule into the cheek so that its long axis sits
posterior to the long axis of the rest of the ear often requires
that the lobule be released from tethering tissue. It is then
secured in two layers. The first layer consists of several deep
dermal sutures of 5-0 Monocryl. These sutures provide initial
alignment and protect the incision from disruption in the first
few weeks after surgery. Final approximation is then made
with simple interrupted sutures of 6-0 nylon or 6-0 fast-
absorbing gut sutures.
If the lobule has been inset correctly, skin redundancy will
often be present on the posterior surface of the ear at the
lobular–conchal junction. This is easily and conveniently
managed by excising a triangle of skin corresponding to the
tissue redundancy present. Closure is made in one layer with
several simple interrupted sutures of 4-0 nylon or other suture
of choice.
Closing the submental incision
After all other incisions have been closed and after all other
procedures have been performed (forehead and eyelid surgery,
etc.) the submental incision is closed. Waiting to close the
submental incision until the end of the procedure provides
marker while the pretragal portion of the skin flap is held
down into the pretragal hollow with an instrument by the
assistant. This ensures that enough skin will be present to fill
the pretragal sulcus and to provide a natural and attractive
transition from the cheek to the ear once healing is complete.
This is also is a key step in avoiding “retracted tragus” and
“buried tragus” deformities.
Using marks made by the facelift marker as points of refer­
ence, the preauricular portion of the flap is trimmed to form
soft curves that match the preauricular incision. As is the case
when trimming flaps at other locations, if trimming is performed
correctly in the preauricular area, wound edges should abut one
another, and no gaps should be present, before sutures are placed.
Preauricular beard follicle epilation
Before closure of the preauricular portion of the facelift inci­
sion, an opportunity exists to reduce the beard follicles present
on the part of the flap advanced onto the tragus in older men
with larger flap shifts. Small skin hooks are used to invert the
preauricular skin flap over the surgeon’s fingertip, pushing
the beard follicles up out of the subcutaneous fat on the
undersurface of the flap. This is facilitated greatly by not
having the patient shave for 2 days prior to surgery. Using
loupe magnification, individual follicles are then directly
excised with small serrated scissors or epilated using a needle-
tipped (“Colorado”) cautery set on low cautery current. Beard
follicles can similarly be removed from a small cuff of skin in
the prehelical and perilobular parts of the cheek skin flap as
well. Care must be taken to apply the cautery precisely and
only to the individual follicles themselves. If current is applied
carelessly or at too high a level, or otherwise allowed to
flow to the skin, vascular compromise and slough could occur
(Fig. 6.9.47).
Following epilation, if required, the incision is then closed
in one layer with multiple simple interrupted sutures of 6-0
nylon. No deep sutures are necessary or should be used.
Insetting the lobule
There is nothing as telltale or as aesthetically objectionable as
the abnormal position of an earlobe, and it is arguably more
Fig. 6.9.47  Epilation of beard follicles from tragus. In the male patient in whom large skin flap shifts occur, beard growth on the tragus can be reduced by intraoperative
destruction of beard follicles from the underside of the skin flap. (A) The facelift flap has been trimmed but has not been sutured. Beard hair has been shifted into a
normally non-hair-bearing area (area posterior to purple dotted line). Note patient has not shaved for 2 days preoperatively. (B) The preauricular skin flap is inverted over the
surgeon’s fingertip using small skin hook retractors. Because the patient has not shaved for 2 days preoperatively, beard stubble pushes the beard follicles out of the plane
of the skin on the underside of the flap. Excising subcutaneous fat as shown further exposes the unwanted beard follicles and results in the direct removal of some follicles.
(C) Using loupe magnification and a needle-tipped cautery set on a very low setting, remaining follicles and residual follicle elements are epilated. Care must be taken to
only cauterize follicles and not apply cautery current to the skin itself. (Photos courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C

236
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
Ancillary and procedures and
alternative strategies in the
male patient
Earlobe reduction
Many men presenting for facelift surgery will be seen to have
overly large earlobes that lend them a telltale old and aged
“grandfatherly” appearance, and reducing them can signifi­
cantly lighten male facial appearance and improve overall
outcomes (Fig. 6.9.49, see also
Case study 6.9.3).
Earlobe reduction can be performed simply and in a
straightforward manner by marking the excess lobule, trim­
ming off the excess, and closing the wound with a seam on
the inferior margin of the lobule, and when this is done a well
access to the neck should additional hemostasis come to be
needed, and allows for a final check for hemostasis to be made
in the neck area at the end of the case.
The submental incision must be closed meticulously if
irregularities are to be avoided, and proper realignment
usually requires a two-layer closure. It is often the case that
the wound edge is slightly thinner on the posterior side of the
incision due to retraction of tissues while working in the neck,
and careful thinning of the wound edge on the anterior side
is often needed to ensure a smooth and even transition across
the wound once it is sutured and healed. When this is done,
care must be taken not to injure beard follicles present along
the wound edge. The first layer consists of several deep
dermal sutures of 5-0 Monocryl. Care must be taken that
sutures are placed in the deep dermis only and not deeper.
The inclusion of subcutaneous tissue can result in irregular
alignment of beard follicles. Final approximation is made with
multiple simple interrupted sutures of 6-0 nylon.
Fig. 6.9.48  Proper insetting of the earlobe. (A) In the artistically ideal non-surgical-appearing ear, the long axis of the earlobe (dotted line) sits approximately 15° posterior
to the long axis of the ear itself (solid line) in the lateral view. (B,C) As this angle is reduced, or the axis of the lobule shifted anterior to the long axis of the ear, an old,
unnatural, and “facelifted look” is produced. (Courtesy of the Marten Clinic of Plastic Surgery.)
A
B
C
Fig. 6.9.49  Earlobe reduction.
(A) Preoperative close-up view of male ear.
The large earlobe lends the patients a
telltale old and aged “grandfatherly”
appearance. (B) Same patient after a facelift
that included earlobe reduction. The ear
appears smaller, younger, and more
proportionate. (All surgical procedures
performed by Timothy Marten, MD, FACS.
Photos courtesy of the Marten Clinic of
Plastic Surgery.)
A
B

237
Postoperative care of the male facelift patient
procedure for men who have had a previous or recent facelift
but have insufficient improvement in their nasolabial fold,
men who have modest overall facial laxity but largely isolated
nasolabial folds, men with bald or shaved heads, and men
who are ambivalent about having a preauricular scar.
The procedure is planned so that the resulting scar mimics
the existing nasolabial crease. A mark is made along the exist­
ing crease and a second mark 10–15 mm (occasionally more)
posterior–superior to it to define an elongated ellipse, with its
ends at the superior and inferior portions of the fold. The
marked ellipse is cross-hatched to facilitate tissue realignment
and wound closure after excision of outlined tissue. The
marked areas are infiltrated with dilute local anesthetic solu­
tion and skin is incised along marked lines. The intervening
ellipse of skin is excised, and when indicated and appropriate,
along with some subcutaneous tissue. Wound edges are then
undermined slightly to facilitate closure, more so on the
posterior–superior wound margin, using a needle-tipped
cautery. A two-layer closure is then meticulously made. The
first layer consists of multiple deep dermal sutures of 5-0 PGA
(Vicryl or Monocryl) followed by simple interrupted sutures
of 6-0 nylon using hash marks to carefully and realign and
reapproximate the tissue.
Dressings
After all planned procedures have been completed and all
incisions have been closed, the patient’s hair is washed with
shampoo and rinsed. A final inspection of sutured incisions is
made. If poor alignment is found in any area, it is locally
re-prepped and sutures are removed and replaced as required.
No dressing is required or applied. Traditional facelift “mummy”
dressings were historically placed due to the presence of
Penrose drains to capture fluid running out of wounds and
the perceived need to “close dead space”. The use of closed
suction drains precludes the need for a dressing for fluid
capture, and the drains create a vacuum effect sucking the
skin flap down upon the facial tissues below it, negating the
need for external pressure to close dead space. Traditional
facelift dressings also suffer the distinct drawbacks that they
are uncomfortable for the patient, compromise flap blood
flow, can crease the flap, obstruct lymphatic drainage, and can
hide evolving problems.
Postoperative care of the
male facelift patient
All patients are discharged to an aftercare facility or to their
home or hotel with an aftercare provider with specific written
instructions as to the care they are to receive. Patients are
asked to rest quietly and apply cool compresses to their faces
for 15–20 min of every hour they are awake for the first 3 days
after surgery. For most patients, edema peaks at about this
time. In many cases, patients use a special water-cooled dis­
posable facial mask (AqueCool Masques, Aqueduct Medical,
Inc., San Francisco, CA).
All patients are provided with oral analgesics, sleeping
pills, anti-emetic oral dissolving tablets, and preservative-free
ophthalmic ointment and “artificial tears” solution, with
instructions for their use. Patients are required to use ophthal­
mic ointment each night for the first 3 weeks after surgery or
concealed scar will almost always be obtained. Marks are
made in marking ink and the lobule then generously infil­
trated with dilute local anesthetic solution to stiffen it and
facilitate excision of the redundant part. Skin is incised on the
inferior margin of the marked line on the anterior surface of
the lobule and on the superior margin of the marked line on
its posterior surface, and the redundant tissue excised. Incis­
ing the redundant portion of the lobule in this way subtly
moves the resulting scar along the margin of the lobule
slightly onto its inner aspect. The wound is then closed with
a simple running suture of 6-0 propylene (Prolene) suture and
then inset into the cheek flap as previously described.
Upper lip lift
Many men presenting for facelift surgery are often older than
women undergoing the procedure and have a “long” upper
lip (increased vertical distance from the base of the nose to
the vermilion–cutaneous junction) and compromised upper
dental show when smiling; as such, they are excellent candi­
dates for upper lip lift procedures. The beard–skin interface
at the base of the nose also provides an excellent location to
place and hide the scar in most men.
The upper incision is marked along the beard–skin interface
at the base of the nose or in whatever location allows optimal
concealment of the scar. Typically, this will be a curvilinear
incision along each alar base, sweeping up into the nostril sill
on each side and across the base of the columella. A second
mark is made 4–6 mm more inferiorly as indicated, and the
marked gull-shaped ellipse cross-hatched to facilitate subse­
quent wound closure.
The marked area is infiltrated with dilute local anesthetic
solution, skin incised along marked lines, and the intervening
ellipse of skin excised. Wound edges are then undermined,
more so on the inferior wound margin, using a needle-tipped
cautery. A subcolumellar excision of orbicularis oris muscle is
made leaving the mucosa in the upper gingival–labial sulcus
intact. No orbicularis oris muscle should be excised below the
nostril sills as volume is needed there to prevent nostril sill
retraction. A four-layer closure is then typically made. The
first layer consists of a 3-0 PGS (Vicryl) suture suspending
the upper lip orbicularis oris to fascia at the columellar–labial
angle. The second layer consists of several simple interrupted
sutures of 5-0 PGA (Vicryl) to complete reapproximation
of the orbicularis oris muscle. Skin is the reapproximated
with multiple deep dermal sutures of 5-0 PGA (Vicryl or
Monocryl) and simple interrupted sutures of 6-0 nylon using
the previously made cross-hatch marks to carefully realign the
tissue.
Nasolabial fold excision
Many mature men will be seen to have heavy facial skin and
deep nasolabial folds with sharp nasolabial creases that are a
concern to them that will be minimally improved when even
an aggressive facelift is performed; these patients are candi­
dates for nasolabial fold excision.
Nasolabial fold excision exploits the sharp creases and
coarse skin present on many men’s faces, and the fact that a
carefully closed wound will result in a scar that is not more
conspicuous, or even less conspicuous, than the existing
nasolabial crease. Nasolabial fold excision is an excellent

238
SECTION I
CHAPTER 6.9 • Facelift: Male facelift
until all signs of eye irritation have subsided. Artificial tears
are used throughout the day as needed.
All patients are instructed to sleep flat on their backs without a
pillow. A small cylindrical neck roll is permitted if the patient
requests it. This posture assures an open cervicomental angle
and averts dangerous neck flexion, folding of the neck skin
flap, and obstruction of regional lymphatics that inevitably
occurs if the patient is allowed to sleep on a standard pillow.
In addition, swelling will drain to the back of the head instead
of the neck when the patients lies flat, where it is not harmful,
less noticeable, and more rapidly transmitted away from the
head and neck area when the patient sits upright. If the patient
sleeps in a more upright position, swelling tends to collect and
be trapped in the jowl and jawline areas.
All patients should be examined the morning after surgery
if circumstances allow it. This visit, although sometimes
inconvenient, is important if incipient problems are to be
identified early in a treatable stage. All sutures should be
checked and any appearing too tight should be cut but left in
place. Releasing potentially over-tight sutures prevents necro­
sis, alopecia, and suture cross-hatch marks. Leaving the cut
suture in place, rather than removing it, averts annoying
bleeding from the suture site that inevitably occurs if the
suture is completely removed at that time.
Patients are advised to stay on a soft, wet, easy-to-chew
diet for 2 weeks after surgery and are encouraged to avoid
dry, salty, sour, and difficult-to-chew foods that stimulate sali­
vation. Patients are asked to abstain from the intake of alcohol
for 2 weeks after surgery and until they are no longer taking
pain pills or sleeping medication.
Patients begin a daily routine of showering and shampoo­
ing no later than 3 days after their procedures, but may shower
the next day if they wish. This helps remove crusting about
the suture lines, keeps incisions clean and bacteria counts
down, and usually improves the patient’s general overall
well-being. It also facilitates suture removal. Patients are
assured that shower water, shampoo, and conditioner are not
harmful and will not cause infection. Showering and sham­
pooing are permitted even when drains are still in place.
Drains are usually left in place at least until the first suture-
removal visit. Sutures are removed in two visits over a period
of 7 days. 6-0 Nylon sutures are removed on the first visit 5
days after surgery and drain output and tissue induration and
edema assessed. If collections are present, if the patient
appears to not be following dietary instructions, or if it
appears otherwise indicated, one or several of the drains are
left in place and the patient’s condition re-evaluated at their
second suture-removal visit. Half-buried vertical mattress
sutures and 4-0 nylon scalp sutures are removed on the second
visit 7 days after the procedure.
It is usually easiest for men to forgo shaving for the first
7–10 days after surgery. Shaving before that can result in
sutures inadvertently being shaved off. Not shaving also
provides for useful camouflage and a distraction to others
during the early postoperative period.
When patients return to work and their social lives will
depend upon their tolerance for surgery, their capacity for
healing, the type of work they do, the activities they enjoy,
how they feel overall about their appearance, and their need
Bonus content for this chapter can be found online at

Anesthesia in the male facelift patient
Case study 6.9.1 Facelift, necklift, small incision forehead lift, upper and lower
eye lifts, fat grafting, and chin implant: 42-year-old man
Case study 6.9.2 Facelift, necklift, small incision forehead lift, upper and lower
eye lifts, and partial facial fat transfer: 60-year-old man
Case study 6.9.3 Facelift, necklift, small incision forehead lift, upper and lower
eye lifts, partial facial fat grafting, and earlobe reduction: 68-year-old man
Fig. 6.9.32 The laryngeal mask airway.
Fig. 6.9.50 Patient in Case study 6.9.1. Front view.
Fig. 6.9.51 Patient in Case study 6.9.1. Oblique view.
Fig. 6.9.52 Patient in Case study 6.9.1. Side view.
Fig. 6.9.53 Patient in Case study 6.9.2. Front view.
Fig. 6.9.54 Patient in Case study 6.9.2. Front smiling view.
Fig. 6.9.55 Patient in Case study 6.9.2. Oblique view.
Fig. 6.9.56 Patient in Case study 6.9.2. Side view.
Fig. 6.9.57 Patient in Case study 6.9.3. Front view.
Fig. 6.9.58 Patient in Case study 6.9.3. Front smiling view.
Fig. 6.9.59 Patient in Case study 6.9.3. Oblique view.
Fig. 6.9.60 Patient in Case study 6.9.3. Side view.
Fig. 6.9.61 Patient in Case study 6.9.3. Side view, looking down.
or not for secrecy. Patients are asked to set aside 2–3 weeks to
recover from surgery. Additional time off is recommended
before an important business presentation, family gathering,
vacation, or like event. If the patient is doing well and not
experiencing problems, he is allowed to return to light office
work and casual social activity 9–10 days after surgery. If a
patient’s job entails strenuous activity or physical labor, a
longer period of convalescence may be required.
Patients are advised to avoid all strenuous activity during
the first few weeks after surgery including heavy lifting,
stooping, straining, and bending forward. At 2 weeks after
surgery patients are allowed to begin light exercise and gradu­
ally work up to their pre-surgical level of activity. At 4–6
weeks after surgery they are allowed to engage in more vigor­
ous activities, including most sports, as tolerated.
Patients are informed that will often take 2–3 months to
look good in a photograph or to be seen at an important
function. They are also advised to expect some numbness and
firmness in the face and submental areas for 6–9 months.
Summary
Treatment strategies in men will be different to those in
women and it is not appropriate to arbitrarily apply concepts
and techniques that evolved largely for treating the female
face to that of a man. The male face is arguably more nuanced
than that of a female, whom we have come to accept as having
a more contrived and made-up appearance, and certain
aspects of male facial aging are often regarded as signs of
experience, wisdom, and power that many men wish not to
lose. In these and other ways, men often have different goals
to women when seeking rejuvenation of their faces, with men
arguably more concerned about a natural appearance, free of
signs that a surgical procedure has been performed.

239
Summary
Connell BF, Marten TJ. Facelift for the Active Man. Instructional Courses in
Plastic Surgery. St Louis, MO: C.V. Mosby Co.; 1991.
Connell BF, Marten TJ. Foreheadplasty for men – recognizing and
treating aging in the upper face. Clin Plast Surg. 1991;18:653–687.
Marten TJ. Forehead aesthetics and preoperative assessment of the
foreheadplasty patient. In: Knize D, ed. The Forehead and Temporal
Fossa: Anatomy and Technique. Philadelphia, PA: Lippincott Williams
and Wilkins; 2001.
Marten TJ. Open foreheadplasty. In: Knize D, ed. The Forehead and
Temporal Fossa: Anatomy and Technique. Philadelphia, PA: Lippincott
Williams and Wilkins; 2001.
Marten TJ. Facelift. In: Guyuron B, Eriksson E, Persing JA, et al., eds.
Plastic Surgery: Indications and Practice. Philadelphia, PA: Saunders
Elsevier; 2008.
Marten TJ. Closed, nonendoscopic, small-incision forehead lift. Clin
Plast Surg. 2008;35:363–378, discussion 361.
Marten TJ. Lamellar high SMAS face and midface lift. In: Nahai F, ed.
The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
Quality Medical Publishing; 2011.
Marten TJ, Elyassnia DR. Neck lift. In: Farhadieh R, Bulstrode N,
Cugno S, eds. Plastic and Reconstructive Surgery: Approaches and
Techniques. Wiley-Blackwell; 2015.
Marten TJ, Elyassnia DR. Fat grafting in facial rejuvenation. Clin Plast
Surg. 2015;42:219–252.
Access the complete reference list online at

239.e1
Further reading
Further reading
Connell BF, Marten TJ. The submental crease and elimination of the
double chin deformity at rhytidectomy. Aesthet Surg. 1990;10:10–12.
Connell BF, Marten TJ. Facelift for the Active Man. Instructional Courses in
Plastic Surgery. St Louis, MO: C.V. Mosby Co.; 1991.
Connell BF, Marten TJ. Foreheadplasty for men – recognizing and
treating aging in the upper face. Clin Plast Surg. 1991;18:653–687.
Connell BF, Marten TJ. Surgical correction of the crow’s feet deformity.
Clin Plast Surg. 1993;20:295–302.
Connell BF, Marten TJ. Deep Layer Techniques in Cervico-Facial
Rejuvenation. Deep Face-Lifting. New York, NY: Thieme Medical
Publishers; 1994.
Connell BF, Marten TJ. Facial rejuvenation: Facelift. In: Cohen MM, ed.
Mastery of Plastic Surgery. Boston, MA: Little, Brown and Co.;
1994:1873–1902.
Connell BF, Marten TJ. Orbicularis oculi myoplasty: surgical treatment
of the crow’s feet deformity. In: Jurkiewicz MJ, Culbertson JH, eds.
Operative Techniques in Plastic and Reconstructive Surgery.
Philadelphia, PA: W.B. Saunders; 1995.
Hartley JH Jr, Little JW, Marten TJ. Customized incisions in facial
rejuvenation. Aesthet Surg J. 1999;19:231–238.
Marten TJ. Facelift. Planning and technique. Clin Plast Surg.
1997;24:269–308.
Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg.
1999;103:224–236.
Marten TJ. Periauricular face lift incisions and the auricular anchor.
Discussion. Plast Reconstr Surg. 1999;104:1521–1523.
Marten TJ. Forehead aesthetics and preoperative assessment of the
foreheadplasty patient. In: Knize D, ed. The Forehead and Temporal
Fossa: Anatomy and Technique. Philadelphia, PA: Lippincott Williams
and Wilkins; 2001.
Marten TJ. Open foreheadplasty. In: Knize D, ed. The Forehead and
Temporal Fossa: Anatomy and Technique. Philadelphia, PA: Lippincott
Williams and Wilkins; 2001.
Marten TJ, Dinh TA (eds). Facelift – State of the Art. Semin Plast Surg.
2002;16:301–422.
Marten TJ. Maintenance facelift: early facelift for the younger patient.
Semin Plast Surg. 2002;16:375–390.
Marten TJ. Secondary rejuvenation of the face. In: Mathes S, ed. Plastic
Surgery. Philadelphia, PA: Saunders Elsevier; 2006:715–764.
Marten TJ. Facelift. In: Guyuron B, Eriksson E, Persing JA, et al., eds.
Plastic Surgery: Indications and Practice. Philadelphia, PA: Saunders
Elsevier; 2008.
Marten TJ. Closed, nonendoscopic, small-incision forehead lift. Clin
Plast Surg. 2008;35:363–378, discussion 361.
Marten TJ. High SMAS facelift: combined single flap lifting of the
jawline, cheek, and midface. Clin Plast Surg. 2008;35:569–603.
Marten TJ. Lamellar high SMAS face and midface lift. In: Nahai F, ed.
The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
Quality Medical Publishing; 2011.
Marten TJ, Elyassnia DR. Neck lift. In: Scuderi N, ed. International
Textbook of Aesthetic Plastic Surgery. 1st ed. New York, NY: Springer;
2012.
Marten TJ, Elyassnia DR. Neck lift. In: Farhadieh R, Bulstrode N,
Cugno S, eds. Plastic and Reconstructive Surgery: Approaches and
Techniques. Wiley-Blackwell; 2015.
Marten TJ, Elyassnia DR. Fat grafting in facial rejuvenation. Clin Plast
Surg. 2015;42:219–252.
Marten TJ, Elyassnia DR. Forehead lift. In: Farhadieh R, Bulstrode N,
Cugno S, eds. Plastic and Reconstructive Surgery: Approaches and
Techniques. Wiley-Blackwell; 2015.
Marten TJ, Feldman JJ, Connell BF, et al. Management of the full,
obtuse neck. Aesthet Surg J. 2005;25:387–397.
Stuzin JM, Feldman JJ, Baker DC, et al. Cervical contouring in face lift.
Aesthet Surg J. 2002;22:541–548.
Trussler AP, Hatef SP, Schaverien M, Meade R, Barton FE. The frontal
branch of the facial nerve across the zygomatic arch: anatomical
relevance of the high-SMAS technique. Plast Reconstr Surg.
2010;125:1221–1229.

SECTION I • Aesthetic Surgery of the Face
6.10 
Facelift: Secondary deformities and the
secondary facelift
Timothy J. Marten and Dino Elyassnia
SYNOPSIS
■ Although many aspects of planning and performing secondary facelift
surgery are similar to those of the primary procedure, one must
identify and treat not only new problems that are the product of age,
but those that have resulted from any prior procedure as well. Often it
is these secondary deformities that present the biggest challenge in
terms of creativity, planning, preparation, and technique.
■ Recognizing the problems in the secondary facelift patient and
appreciating their underlying anatomical abnormalities is fundamental
to planning and performance of any repair. Although not all problems
can always be completely corrected, any surgeon able to recognize
their anatomic basis can, through the application of logic and careful
planning, select techniques that are safe, effective, and rational.
■ Secondary deformities are worth every surgeon’s consideration, even
if he or she performs only the occasional secondary procedure, as
they exist as compelling reminders of mistakes to avoid in the planning
and performance of any primary procedure.
■ Hairline displacement and disruption remain predictable outcomes of
many currently used facelift plans and are a source of disappointment
and frustration for patients and surgeons alike. These problems are the
result of poor analysis and planning and failure to use an incision
along the hairline when indicated.
■ The placement of an incision and thus of the resultant scar along a
hairline at secondary surgery represents a choice between two
imperfect alternatives but the best overall artistic and aesthetic
compromise in many patients.
■ Using the superficial musculo-aponeurotic system (SMAS) to lift
sagging facial tissues and restore facial contour circumvents the
problems associated with skin-only facelifts, as it is an inelastic
structural layer capable of providing meaningful and sustained support.
Although skin must be excised in SMAS procedures, only redundant
tissue is sacrificed and closure can be made under normal skin tension.
■ “Lamellar” dissections, in which the skin and SMAS are dissected as
two separate layers, offer the important advantage that skin and SMAS
can be advanced different amounts, along separate vectors, and
suspended under differential tension. This allows each layer to be
addressed individually as indicated and, in turn, results in a more
comprehensive and natural appearing improvement.
■ It is not enough in most secondary facelift procedures to limit
treatment of the neck to preplatysmal lipectomy and postauricular skin
excision in secondary facelift patients. For many patients, subplatysmal
fat accumulation, submandibular salivary gland “ptosis”, and digastric
muscle hypertrophy will contribute significantly to their neck deformity
and necessitate additional treatment.
■ As experience is gained in evaluation of patients presenting for
secondary surgery, prominent submandibular glands will increasingly
be recognized as a frequent part of the secondary neck deformity and
the underlying cause of objectionable residual bulges in the lateral
triangle of the lateral submental region. In most instances, the
secondary facelift will provide an opportunity for proper diagnosis and
appropriate treatment, when present.
■ The secondary facelift will generally require a comparatively small
resection of skin and an increased focus on correcting deep layer
problems and secondary deformities, depending upon the skill of the
surgeon performing the primary procedure and the type of technique used.
■ Secondary facelifts are often time consuming and technically
demanding when compared to primary procedures and are likely to
test the patience and composure of most surgeons.
■ Many patients requesting secondary facelifts are chronologically
elderly, but deceptively young in appearance. A careful medical history
must be taken because they often have medical problems consistent
for their age group.
■ The opportunity to perform a facelift is a unique artistic privilege
granted to us by our patients that carries a significant responsibility. It
deserves nothing less than our best effort, and a few extra hours of
our time in the operating room benefits them for the rest of their lives.
■ Performing a secondary facelift is frequently a considerable
undertaking and its difficulty should not be underestimated. The
procedure must be carefully planned, meticulously carried out, and the
patient’s safety and well-being unfailingly ensured.
■ Performance of the procedure itself only fulfills part of our obligation to the
patient and the care they receive perioperatively is arguably as important
as the surgery itself. Diligent perioperative care will ensure the best result
and reduce the likelihood that problems and complications will occur.
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241
Identification and analysis of secondary surgical deformities
Identification and analysis of
secondary surgical deformities
The number and degree of secondary deformities present will
determine the difficulty of any additional surgery and the
overall potential for improvement possible. Typical problems
seen in the patient presenting for secondary facelift include
hairline displacement, hair loss, poorly situated scars, thick
scars, wide scars, scleral show, eyelid dysfunction, tragal
distortion, earlobe distortion, over-excision of cervicofacial
fat, distortion and abnormal appearances due to inappropri­
ate tissue shifts, and abnormal appearance when emoting.
Less commonly, problems related to nerve injury, skin slough,
or other surgical complications may be present. These prob­
lems are worth every surgeon’s consideration, even if he or
she performs only the occasional secondary procedure, as
they exist as compelling reminders of mistakes to avoid in the
planning and performance of any primary procedure.
Hairline displacement and disruption
Hairline displacement and disruption remain predictable
outcomes of many currently used facelift plans and are a
source of disappointment and frustration for patients and
Introduction
The increased number of patients seeking facelifts at a younger
age, coupled with the continued good health of an older
group of patients who have already undergone one or more
procedures, has resulted in a significant increase in requests
for secondary and tertiary procedures. Although many aspects
of planning and performing secondary surgery are similar to
those of the primary procedure, additional considerations
must be taken into account in the evaluation and treatment of
the patient presenting for secondary facelift, as one must
identify and treat not only new problems that are the product
of age, but those that have resulted from any prior procedure
as well. Often, it is these secondary deformities that present the
biggest challenge to the surgeon in terms of creativity, plan­
ning, preparation, and technique.
Consideration must also be given to possible underlying
anatomical damage that may have resulted from previous
procedures but is not evident as a visible deformity. This
includes possible damage to skin, fat, the superficial musculo-
aponeurotic system (SMAS), and deeper layer structures.
Injury to these tissues at the time of the primary procedure
can preclude certain maneuvers and limit the overall amount
of improvement possible at the time secondary surgery is
performed. “Red flag” procedures in this regard include
radiofrequency and ultrasonic “skin tightening” treatments,
prior “suture lifts”, and prolonged large-volume use of facial
fillers (“filler fibrosis”).
As in primary procedures, recognizing the problems in the
secondary facelift patient and appreciating their underlying
anatomical abnormalities is fundamental to planning and
performance of any repair. Although not all problems can
always be completely corrected, any surgeon able to recognize
their anatomic basis can, through the application of logic and
careful planning, select techniques that are safe, effective, and
rational.
Identification and analysis of
secondary aging deformity
Surgery does not halt the aging process and patients
requesting secondary or tertiary facelifts usually present
with many of the same problems seen when they presented
for their primary procedures. This is particularly true if
the primary facelift was limited and consisted of skin exci­
sion and skin tightening only. In such instances, a tight or
pulled appearance will typically be present, but problems
of deep layer origin will still be evident and will likely
have worsened over time. These include nasolabial folds,
labiomental folds, cheek ptosis, infraorbital hollowing, malar
flattening, jowl laxity, subplatysmal fat accumulation, sub­
mandibular gland hypertrophy, and cervical band formation
(Fig. 6.10.1).
Regrettably, many surgeons have been traditionally taught
to perform a limited “tuck” or “touch-up” in secondary pro­
cedures consisting of additional skin excision and skin tight­
ening. This does not address the true underlying problems,
however, and compounds the secondary deformities present
in many patients.
Fig. 6.10.1  Identification of secondary aging deformities. Surgery does not arrest
the aging process, and patients requesting secondary facelifts usually present with
many of the same problems seen when they presented for their primary procedures.
This is particularly true if the primary facelift was limited and consisted of skin
excision and skin tightening only, as with this patient. Problems typically seen
include nasolabial folds, labiomental folds, cheek ptosis, infraorbital hollowing,
malar flattening, jowl laxity, submental fat accumulation, and platysma band
formation. Note that although some wrinkling and atrophy are present, the patient’s
predominant problem is deep layer tissue ptosis. Additional skin excision and
tightening under these circumstances will be of little benefit to the patient.
(Previous procedure performed by an unknown surgeon.)

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Fig. 6.10.2  (A,B) Displacement of the
sideburn and temple hair due to poor
incision planning. The temporal portion of
the facelift incision was made in the
temporal scalp in a well-intended effort to
hide the resulting scar. Because cheek flap
redundancy was large and skin elasticity
poor, advancement of the cheek skin flap
has resulted in objectionable hairline
displacement. An incision along the hairline
would have prevented this deformity.
(Procedures performed by an unknown
surgeon.)
A
B
surgeons alike. These problems are the result of poor analy­
sis and planning at the time of the primary procedure and
failure to use an incision along the hairline when indicated.
Although hairline displacement may be acceptable after
some primary facelifts in which incisions were made in the
traditional location within hair-bearing scalp, it will almost
always be intolerable after a secondary facelift if such an
incision plan is used again. For this reason, thoughtful plan­
ning of secondary and tertiary facelifts frequently requires
the use of incisions placed along hairlines, rather than
behind them.
The placement of an incision and thus of resultant scar
along a hairline at secondary surgery represents a choice
between two imperfect alternatives but the best overall artistic
and aesthetic compromise in many patients. Although inci­
sions upon the scalp produce concealed scars within the hair,
they will result in telltale and objectionable hairline displace­
ment in many patients that is usually readily apparent upon
casual glance and at some distance. These deformities are
often not subtle and frequently result in an unnatural or even
grotesque appearance (Fig. 6.10.2). In addition, they are uni­
formly difficult for the patient to disguise and a challenge for
the surgeon to correct.
Placing the incision along a hairline, however, usually
results in a fine scar only visible on close inspection when
correctly planned and proper technique is used. And unlike
displaced hair, a scar along the hairline can usually be easily
concealed with make-up or tattooed if necessary, but gener­
ally goes unnoticed in most social situations and casual
encounters. Often, they are difficult to detect even on close
inspection (Fig. 6.10.3). Attempts to disguise displaced hair by
combing adjacent hair over these areas is no more effective
than the “comb-over” hairstyles worn by many balding men.
Although this is perhaps preferable to the patient to having
bald spots and missing hair showing, it is immediately evident
that the problem is still present in most cases.
The temporal portion of the facelift incision traditionally
placed within the temporal scalp will frequently result in a
telltale and unnatural-appearing superior elevation and pos­
terior displacement of the temporal hairline. Secondary or
tertiary facelifts using the same incision plan will compound
this problem and often result in a bizarre-appearing and
objectionable absence of temple hair (Fig. 6.10.4).
This can best be minimized or avoided at secondary facelift
by the use of an incision along the hairline (Fig. 6.10.5). If it is
appropriately planned and carefully executed, an acceptable
scar will result that is artistically and aesthetically superior to
additional hairline displacement (see Fig. 6.10.3).
In choosing the location of the temporal portion of the
facelift incision, it is important to note the degree of existing
temple “skin show” (Fig. 6.10.6) and consider it in conjunction
with skin redundancy present over the cheek (Fig. 6.10.7).
This allows an estimate to be made of the degree of elevation
and/or displacement of the sideburn and temporal hair that
will occur when facelift flaps are shifted, and thus facilitates
rational planning of incision placement. In certain instances,
a sub-sideburn incision used in conjunction with a traditional
incision on the temporal scalp will be adequate in preventing
objectionable sideburn elevation and/or hairline displace­
ment. In other situations, however, the incision must extend
more superiorly along the temple hairline. Such an incision
will accommodate large posterior–superior skin shifts and
prevents telltale hairline displacement.
The occipital portion of the facelift incision is traditionally
placed high upon the occipital scalp, in a well-intended but
almost always counterproductive effort to hide the resulting

243
Identification and analysis of secondary surgical deformities
redundancy is present. As the flap is shifted along a more
superiorly directed vector, as it must be with any high trans­
verse occipital incision plan, tension will rise across the cer­
vicomental angle, but a diminished effect will be seen over
the anterior neck and submental regions. In addition, trans­
verse cervical rhytides, if present, will be unnaturally shifted
superiorly over the upper lateral neck and sometimes onto the
prelobular and postauricular area. It must also be kept in
mind that neck contour should be the result of deep layer
repair, and not skin tightening. Thus, neck skin should be
shifted and excised along a vector that allows maximum
elimination of redundancy, and not one that appears to
produce the most neck tightness.
scar. Unfortunately, any such plan embodies an inherent
defect in design that will preclude optimal improvement in
the neck and frequently result in a telltale and unnatural-
appearing displacement of the occipital hairline (Fig. 6.10.8).
A high transverse postauricular incision plan presumes
that the resultant vector of skin redundancy is directed mostly
superiorly and that the majority of skin redundancy is present
over the lateral neck. Both careful consideration and direct
observation will reveal the proper direction of postauricular
flap shift to be in a mostly posterior, slightly superior direction
that roughly parallels the mandibular border, if an optimal
result is to be achieved in the cervicosubmental area. This is
because it is along this vector that the majority of neck skin
Fig. 6.10.4  Sideburn elevation and displacement of the temporal scalp after
multiple facelifts. A secondary facelift using the same incision plan as at the
primary procedure has resulted in the telltale displacement of temple hair and
elevation of the sideburn. (Procedure performed by an unknown surgeon.)
Fig. 6.10.5  Plan of incision along the temporal hairline “for a man”. An incision
along the temporal hairline should be considered whenever objectionable
displacement of the sideburn and temple hair is predicted. Although a fine scar
is present in these patients, it is not evident upon casual inspection. Note the
preservation of lush temple hair and a full, youthful-appearing sideburn. For a
woman the incision plan should be less rectangular and more curvilinear.
Fig. 6.10.3  (A,B) Healed incisions along
the temporal hairline. The use of an incision
along the hairline, when indicated, can
prevent hairline and sideburn displacement
without compromising the end result.
Although a fine scar is present in these
patients, it is not evident upon casual
inspection. Note the preservation of lush
temple hair and a full, youthful appearing
sideburn (compare with Figs. 6.10.2 and
6.10.4). (Procedures performed by Timothy
J. Marten, MD, FACS.)
A
B

244
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Fig. 6.10.6  Temporal skin show. The distance between the lateral orbit and the
temple hairline and how it will change with flap shift must be considered when
planning the temple portion of the facelift incision.
Fig. 6.10.7  (A,B) Estimating skin redundancy over the upper cheek. Gauging the skin redundancy over the cheek assists in predicting the degree of temporal hairline
displacement that will occur when the facelift flap is shifted.
A
B
Although occipital hairline displacement may sometimes
be acceptable to patients after their primary procedure, sec­
ondary or tertiary facelifts using the same incision will com­
pound this problem and usually result in an unnatural and
intolerable absence of occipital hair and notching of the
occipital hairline (Fig. 6.10.9).
If an attempt is made to reconstitute the hairline by superior
shifting of the postauricular flap, a wide scar will usually
result as the tissue discarded in any such maneuver is neces­
sary for side-to-side head tilt and shoulder drop when the
patient is in an upright position. These problems can best be
minimized at the time of secondary facelift by the use of an
incision along the occipital hairline (Fig. 6.10.10).
If the incision is appropriately planned and carefully exe­
cuted, an acceptable scar will result that is artistically and
aesthetically superior to additional hairline displacement. In
addition, this plan will sometimes allow scalp displaced at the
primary procedure to be partially advanced back towards its
proper position (Fig. 6.10.11).
When and incision is used along the occipital hairline, it
should be planned in such a way that the inferior portion of
the incision, and thus the resulting scar, is turned back into
the scalp and at the junction of thick and fine hair on the nape
of the neck (see Figs. 6.10.10 & 6.10.11). It should not be carried
more inferiorly because it will be incompletely concealed and
is likely to be visible to others (Fig. 6.10.12).
Fundamental to obtaining an inconspicuous, well-healed
scar when incisions are placed along the temporal or occipital
hairline is the diversion of tension to deeper tissue layers and
precise flap trimming so that wound edges abut each another
under little if any tension before sutures are placed. The inci­
sion is then closed using a combination of half-buried vertical
mattress sutures of 4-0 nylon with the knots tied on the scalp
side and multiple simple interrupted sutures of 6-0 nylon. The
6-0 sutures provide precise wound alignment and are removed
in 5 days. The half-buried vertical mattress sutures of 4-0
nylon provide wound support, while simultaneously avoid­
ing cross-hatched marks. These sutures are removed 7–10
days after surgery.
Although incisions placed along the frontal, temporal, and
occipital hairlines will prevent additional hairline displace­
ment at a secondary procedure, they do not provide for cor­
rection of large and severe problems sometimes seen (see Figs.
6.10.2, 6.10.4, 6.10.8, & 6.10.9). In these situations, consider­
ation must be given to the use of hair flaps, hair transplanta­
tion, and scalp expansion.
Hair loss
Hair loss is an all-too-common and avoidable stigma of facelift
surgery seen in many patients presenting for secondary pro­
cedures. Hair loss is generally the result of technical errors,
including improperly made incisions that damage hair folli­
cles, placement of overly tight sutures, or the closure of

245
Identification and analysis of secondary surgical deformities
Fig. 6.10.10  Plan for incision along the occipital hairline. An incision along the
occipital hairline should be considered whenever objectionable displacement of the
occipital hairline is predicted. This incision plan protects the hairline and prevents
hairline displacement.
Fig. 6.10.8  Displacement of occipital scalp due to poor incision planning. The
occipital portion of the facelift incision was made high within the occipital scalp in
a well-intended effort to hide the resulting scar. Because cervical redundancy was
large and skin elasticity poor, advancement of the neck skin flap has resulted in
objectionable hairline displacement. An incision along the hairline would have
prevented this deformity. (Procedure performed by an unknown surgeon.)
Fig. 6.10.9  Elevation and displacement of the occipital scalp after multiple
facelifts. A secondary facelift using the same incision plan as at the primary
procedure has resulted in the objectionable displacement of the hairline. (Procedure
performed by an unknown surgeon.)
inadequately mobilized scalp flaps under too much tension.
It may occur, however, in smokers, certain individuals with
scalp disease (alopecia areata), eating disorders, or patients
with a variety of systemic illnesses in the absence of any
wrongdoing on the part of the surgeon. Consideration should
be given to an origin of this sort before hair loss experienced
by the patient at the primary procedure is attributed to techni­
cal error. Hair loss is also frequently the result of the ill-
conceived shifting of scalp flaps along the wrong vector. This
is commonly seen on the temporal scalp after erroneous
attempts to smooth the forehead and glabella by applying
lateral traction on the forehead flap (Fig. 6.10.13).
The use of cautery near or within the plane of hair follicles
can also result in hair loss, as can rough flap handling
and pinching or prolonged folding of scalp flaps beneath
retractors.
Small areas of hair loss resulting from tight suture place­
ment or attempts at spot suspension of the scalp can often be
corrected at the time of secondary facelift by direct excision
after adequate mobilization of surrounding tissue or by
incorporation of the hairless area into a more comprehensive
incision plan (Fig. 6.10.14).
Larger areas of hair loss resulting from excessive flap
tension, an overly tight closure, or ill-conceived scalp flap
shifting are usually much more difficult to correct, especially
if scalp excision was aggressive at the primary procedure and
little residual redundancy is present (Fig. 6.10.15). In such
instances, the patient and surgeon must accept that complete
correction may not be possible at the time of secondary facelift,
and that hair transplantation, scalp flaps, and even scalp
expansion may be necessary at a later date. The goal at any
secondary procedures in these patients is to select a surgical
plan that does not further compound the problem.
Poorly situated scars
Poorly situated scars are a common problem after primary
facelift and the result of artistic insensitivity, poor planning,
and tension-based surgical techniques. In many patients,
secondary facelift will provide the opportunity to relocate
these to a more appropriate, less conspicuous location, but in
others it must be recognized and accepted that complete cor­
rection is not possible if additional problems are to be avoided.

246
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Fig. 6.10.11  Healed incision along the
occipital hairline. The use of an incision along
the occipital hairline will prevent hairline
displacement without compromising the end
result. Although a fine scar is present in these
patients, it is not evident upon casual
inspection and they are free to wear their hair
up off their neck in any manner they choose.
(Procedures performed by Timothy J. Marten,
MD, FACS.)
A
B
Fig. 6.10.12  Improper design of an incision along the occipital hairline. The
incision has been made too low and carried too far inferiorly in front of the fine hair
on the nape of the neck. It would have been better concealed if it had been made
more superiorly and turned posteriorly into scalp hair more superiorly. (Procedure
performed by an unknown surgeon.)
Fig. 6.10.13  Temporal hair loss. Hair loss is frequently the result of improper
shifting of scalp flaps along the wrong vector. This is commonly seen on the
temporal scalp after well-intended but misguided attempts to smooth the forehead
and glabella by excising temporal scalp and applying lateral traction on the
forehead flap. (Procedure performed by an unknown surgeon.)
Poorly situated scars are typically seen in the preauricular,
perilobular, and postauricular areas. They can also be found
in the submental region in many patients. Proper placement
of incisions is important, particularly in the preauricular area,
because even a thin, well-healed scar will ultimately be visible
and noticed by others in most cases as a result of the gradient
of skin color and texture typically present on each side of it.
Although differences in skin color can sometimes be concealed
with make-up, differences in texture usually cannot. Scars
placed along natural anatomic interfaces tend to be overlooked
by the eye however, where a gradient of color and texture is
expected to be seen and where the scar appears to be a natural

247
Identification and analysis of secondary surgical deformities
Fig. 6.10.15  Large areas of hair loss. Large areas of hair loss are usually difficult
to correct, especially if scalp excision was aggressive at the primary procedure and
little residual redundancy is present. In such cases, complete correction may not be
possible at the time of secondary facelift and hair transplantation, scalp flaps, and
scalp expansion may be required. (Procedure performed by an unknown surgeon.)
Fig. 6.10.14  Hair loss resulting from tight suture placement or attempts at spot
suspension of the scalp. These problems can often be corrected at the time of
secondary facelift by direct excision after adequate mobilization of surrounding
tissue or by incorporation of the hairless area into a more comprehensive incision
plan. (Procedure performed by an unknown surgeon.)
crease on the face. Make-up becomes less necessary as the scar
is lost in shadow, appears to be a natural part of the face, or
is mistaken to be a reflected highlight (Fig. 6.10.16).
The preauricular region is a common point of reference for
those seeking to identify the facelift patient, and, as such, it is
of concern to patients and worthy of careful consideration by
the surgeon. The prehelical portion of the preauricular scar is
often situated too far anteriorly in the patient presenting for
secondary surgery and the illusion of the scar as an anatomi­
cal feature is lost. Moving this scar so that it rests in the
helical–facial sulcus will result in a less conspicuous scar and
a more natural appearance. This is generally possible in most
secondary and tertiary cases if skin resection has not been
overly excessive at prior procedures (Fig. 6.10.17).
Although it is not possible to move a pretragal scar to a
“retrotragal” position along the margin of the tragus in every
patient presenting for secondary surgery, this is preferred
when possible, for the reasons outlined above (Fig. 6.10.18).
The feasibility of relocating a pretragal scar to a retrotragal
position will depend on the amount of cheek skin redundancy
that remains after the primary procedure. Because preopera­
tive assessment of residual cheek skin redundancy can be
difficult and exceedingly deceptive at the tragus, it is some­
times best to make the initial incision along the existing pre­
tragal scar, when present. The decision to sacrifice the
remaining skin over the tragus and move the scar to the tragal
margin can then be delayed until after cheek flaps have been
mobilized, SMAS advanced, and the actual amount of cheek
skin recruited through these maneuvers, if any, determined.
Often, skin recruited is needed to recreate an absent pretragal
sulcus and to correct a “buried tragus” deformity. In such
instances, relocation of a pretragal scar to the margin of the
tragus will not be possible and the existing pretragal location
of the scar must be accepted. If the secondary facelift incision
is initially made along the margin of the tragus when a pre­
tragal scar is present, but before intraoperative assessment of
skin redundancy can be made, needed skin may be errone­
ously excised. This will force an inappropriately tight closure
and result in tragal distortion, tragal retraction, and oblitera­
tion of the pretragal sulcus.
The perilobular area is a common location for poorly situ­
ated facelift scar in secondary and tertiary facelift patients.
Typically, it is low lying due to poor planning and the skin
settling that occurs after “skin-only”, non-SMAS facelift
techniques (Fig. 6.10.19).
Unlike the prehelical and postauricular portions of the
facelift scar, however, which should be placed directly in their
respective anatomic creases, the perilobular scar should not
lie directly in the lobular–facial crease because the crease itself
constitutes a delicate, aesthetically significant anatomical
subunit that cannot be reconstructed and should not be dis­
rupted. Other factors being equal, a superior result will be
obtained if the scar is situated a few millimeters inferior to
this junction and an attempt is not made to join thin, soft
earlobe skin directly with course, thick cheek skin. As is the
situation with the relocation of other scars about the ear,
relocation of the perilobular portion of the facelift scar at the
time of secondary or tertiary facelift will depend on the
amount of cheek skin that remains after the primary proce­
dure. If cheek skin excision has been excessive at the primary
procedure, or if a “pixie” earlobe is present, relocation may
not be possible. For these patients, it must be accepted that
only partial correction can be accomplished.
A poorly situated postauricular scar, although not as
readily apparent and easier to disguise in most social situa­
tions than a poorly situated scar in the preauricular region,
is nonetheless an objectionable deformity that should be
corrected when possible. Typically, the poorly situated post­
auricular scar will be seen to lie outside the auriculomastoid
sulcus, and too low over the mastoid to be concealed by the
pinna. Such a deformity is the result of poor planning and
inferior–posterior migration of the postauricular flap due to

248
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
inappropriately excising tissue from the superior tip of the
postauricular flap at the primary procedure. Attempts to do
so will often result in a forced closure under excessive tension
and eventual inferior migration and widening of the scar due
to inferior traction on the postauricular flap. Although an
apparent redundancy will be present in the supine patient on
the operating table due to a high lying position of the shoul­
ders, this will be seen to vanish in the upright position when
excessive tension placed upon it at the primary procedure
(Fig. 6.10.20).
Moving the postauricular scar so that it rests directly in the
auriculomastoid sulcus is sometimes possible in secondary
and tertiary patients, if tissue sacrifice has not been excessive
or along an improper vector at the primary procedure. Moving
the scar more superiorly, although seemingly straight forward,
is often not possible because of the common practice of
Fig. 6.10.16  Retrotragal scar. (A) The scar resulting from a properly situated retrotragal incision will usually be inconspicuous, even if it is suboptimally healed, as the eye
will mistake it for a reflected highlight. Note the well-concealed scar on this darkly complexioned patient. A scar of the same type would be more obvious if the incision had
been placed in a pretragal position. (B) A healed retrotragal facelift incision in another patient with fair skin. Transitions of color and texture are hidden along natural
interfaces. (C) A healed retrotragal incision in another patient. If the incision is closed carefully, a natural appearance without anatomic distortion should result.
A
B
C
Fig. 6.10.17  Improper and proper placement of prehelical scar. The prehelical portion of the preauricular scar is often poorly situated (A,B) and the illusion of it as an
anatomical feature is lost. (A) The prehelical incision has been made too far anteriorly and the illusion of the scar as an anatomical feature is lost. (Procedure performed by
unknown surgeon.) (B) The prehelical incision has been made too far posteriorly and has obliterated the helical–facial sulcus and part of the helix itself. The illusion of the
scar as an anatomical feature is lost. (Procedure performed by unknown surgeon.) (C) A patient with a properly placed prehelical incision. The scar has been placed directly
in the helical–facial sulcus. In this location, a transition of color and texture is expected and the scar appears to be a natural anatomical feature. (Procedure performed by
Timothy J. Marten, MD, FACS.)
A
B
C

249
Identification and analysis of secondary surgical deformities
Fig. 6.10.18  Pretragal and retrotragal
incisions compared. (A) Pretragal incision
in a patient presenting for secondary facelift.
The scar has healed satisfactorily but
attention is drawn to it due to differences in
color and texture on each side of it.
(Procedure performed by an unknown
surgeon.) (B) Same patient after secondary
facelift in which incision was moved to a
retrotragal position. Color and texture
differences, and the scar itself, are hidden
along natural anatomic interfaces.
(Procedure performed by Timothy J. Marten,
MD, FACS.)
A
B
Fig. 6.10.19  Improper and proper
placement of the perilobular incision.
(A) The perilobular incision has been made
too far inferiorly and is evident even on
casual inspection. (Procedure performed by
an unknown surgeon.) (B) A different
patient seen after facelift. The perilobular
scar has been placed more superiorly and
in such a manner that it is hidden by the
lobule itself. In this location it cannot be
seen. (Procedure performed by Timothy J.
Marten, MD, FACS.)
A
B
the shoulders fall to a normal position. As a result, little if any
redundant skin is available along the needed superior vector
of shift.
The submental incision will frequently be seen to have been
erroneously placed directly along the submental crease in a
well-intended effort to hide the resulting scar (Fig. 6.10.21).
Regrettably, this serves only to reinforce the submental retain­
ing ligaments and accentuate a “double chin” or “witch’s
chin” appearance. In such situations, consideration should
be given to moving the submental incision 1–2 cm posterior
to the crease so that the existing scar car be undermined
and released. Although this results in a new scar, it will be
inconspicuously hidden in the shadow of the mandible in all
but the unusual case (Fig. 6.10.22). This is preferable and a
worthwhile trade-off for correction of the more obvious and
objectionable contour deformity that would result if the inci­
sion were made again in the same place upon the existing scar.
If only limited work in the neck is needed and minimal or no
double chin deformity is present, it may be possible and
appropriate to use an existing scar in the submental crease as
the site for secondary incision. If more extensive maneuvers
are required and a marked double chin deformity is present,
however, a new more posteriorly situated submental incision
is indicated (Fig. 6.10.23).

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SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Fig. 6.10.20  Improper and proper
placement of the postauricular incision.
(A) The postauricular incision has been
made too far posteriorly. The scar lies
outside the auriculomastoid sulcus and is
evident if hair is worn short or up off the
neck. (Procedure performed by an unknown
surgeon.) (B) A different patient seen after
facelift. The postauricular scar has been
placed in the auriculomastoid sulcus. In this
location it mimics a natural anatomic
feature and is overlooked on even close
inspection. (Procedure performed by
Timothy J. Marten, MD, FACS.)
A
B
Fig. 6.10.21  Incorrect and correct plan for the submental incision. (A) Incorrect position for the submental incision. The incision should not be placed directly along the
submental crease because this will accentuate it and reinforce the double chin appearance. Note that the traditional plan of skin undermining (shaded area) also promotes a
double chin. (B) Correct position for the submental incision. Placement of the submental incision posterior to the submental crease prevents accentuation of the double
chin and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck. Note that this incision plan allows the submental crease to be
undermined (shaded area) and released and the fat of the chin pad and neck to be blended.
A
B
If skin excision has been aggressive and excessive at the
primary procedure, relocation of poorly situated scars may
not be possible at the time of request for secondary facelift,
regardless of how much the patient and surgeon would wish
otherwise. These patients have typically undergone aggres­
sive skin-only, non-SMAS procedures and have overly tight
faces with wide and/or hypertrophic scars (Fig. 6.10.24).
Often earlobes have been pulled or placed too far inferiorly
into the cheek as well, compounding the problem. In such
cases, it is usually best to defer surgery until scars are mature,
skin has relaxed, and adequate tissue is available to make
proper repair. In most cases, this will mean waiting until
2–3 cm or more of skin can be pinched up along each jawline
along a line extending from the chin to the lobule. Reoperation
in the absence of adequate skin to make proper repair will be
a frustrating act of futility in which little if any benefit will be
gained.
Wide scars
Wide, thick, hypertrophic, and keloid scars, often attributed
to be the result of the patient’s own poor healing, are more

251
Identification and analysis of secondary surgical deformities
including hairline displacement, hypertrophy, and wide scars
(Fig. 6.10.26).
Cross-hatched scars can simply and easily be avoided by
employing a facelift technique that does not rely on skin
tension. Diverting tension to the SMAS allows skin incisions
to be closed under little if any tension with loosely tied, fine
sutures that can safely be removed in 4–5 days after surgery.
Diverting tension to the SMAS and platysma will not, in
and of itself, prevent cross-hatched scars. If skin is closed
under tension, or shifted along an improper vector after
SMAS and platysma fixation, the opportunity to avoid
tension-based secondary deformities will be lost and one of
the major benefits of the utilization of the SMAS and other
deep layer tissue will be subverted.
Accepting that skin need not be tight is difficult for most
surgeons trained in classical facelift technique. For many, it
seems not only counterintuitive, but also at cross-purposes
with traditional goals and objectives. Dismissing this idea,
and failing to accept related concepts, however, are major
stumbling blocks to achieving high-quality scars and a “non-
surgical” and natural postoperative appearance.
The correction of cross-hatched scars is often difficult
because the factors leading to the problem are still present to
some extent in the patient requesting secondary surgery, and
each case must be approached with caution. As is the situation
in the patient with hairline displacement and wide or poorly
situated scars, for the patient with cross-hatched scars, it may
be impossible to effectively treat this if skin excision has been
excessive at the primary procedure or if enough residual skin
redundancy is not present to allow simultaneous excision of
scars, skin flap advancement along an appropriate vector, and
closure without tension.
It is a common error to think that scars can simply be
excised and the skin needed for closure can be recruited by
wide undermining of overly tight adjacent areas. Experience
will show that reoperation in the absence of adequate skin to
allow excision along a proper vector, along with a tension-free
closure, will result in a recurrence of the problem and other
associated tension-based deformities. In most patients, it is
best to accept partial correction of the problem, rather than
create new or worse problems by attempting complete elimi­
nation. Make-up, tattooing, or restyling of hair may be neces­
sary to conceal the residual scars.
Distortion of tragal anatomy
Distortion of tragal anatomy is a common problem in patients
presenting for secondary facelifts. Like many other problems
associated with secondary surgery, it is the result of artistic
insensitivity, poor planning, and errors in technique. In many
patients, the secondary facelift will provide an opportunity to
improve or correct tragal distortion; but in others, complete
correction may not be possible if additional problems are to
be avoided.
Common types of tragal distortion seen after primary
facelift include changes in tragal shape, changes in tragal
contour, tragal retraction, and obliteration of the pretragal
sulcus. Less commonly, more severe degrees of distortion can
also be present. In rare cases, the tragal cartilage has been
excised and the tragus is absent.
The most commonly observed forms of tragal distortion
seen in patients presenting for secondary facelift are loss of
often due to the over-excision of skin along improper vectors
in procedures in which the surgeon has employed skin tension
as a vehicle to lift sagging deeper layer tissue, rather than the
SMAS and platysma. In fact, it is noteworthy that scar widen­
ing and hypertrophic healing are rarely seen after a primary
facelift in patients of all skin types, providing that a technique
of no skin tension has been employed.
Because the factors underlying suboptimal healing leading
to wide or hypertrophic scars are still present to some extent
in the patient requesting secondary surgery, each must be
approached with caution. Like the patient with a skin short­
age and poorly situated scars, the patient with wide or
hypertrophic scars may be impossible to effectively treat if
skin excision has been excessive at the primary procedure
(Fig. 6.10.25). This is true, regardless of how much the patient
and surgeon wish otherwise. Reoperation in the absence of
adequate skin to make proper repair will be frustratingly
ineffectual, with little or no benefit.
Cross-hatched scars
Cross-hatched scars are a completely avoidable deformity
commonly seen in patients presenting for secondary facelift.
Like most secondary facelift deformities, they are the product
of errors in both planning and technique. The underlying
cause of most cross-hatched scars can be traced directly to
skin tension and tension-based facelift techniques. When inci­
sions are closed under tension, larger sutures must be used,
and these must be tied tighter and left in longer. Inevitably,
varying degrees of necrosis occur beneath each, and these
spots go on to heal as scars. As skin relaxation occurs over
time, the hatch marks and suture hole scars stretch and
migrate away from the incision scar, giving the appearance
that the wound was closed in a crude fashion with large,
widely placed sutures. Almost always cross-hatched scars are
accompanied by other signs of over-reliance on skin tension,
Fig. 6.10.22  Placement of the submental incision. Close-up view of the submental
region of a patient after secondary facelift. A previous incision had been made
directly in the submental crease (small arrow). The incision used at the secondary
procedure was made posterior to the prior incision (large arrow), and the scar and
crease were released. Smooth submental contours are present, and both scars are
inconspicuous.

252
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Fig. 6.10.23  Correction of the double chin and witch’s chin deformities. If the submental incision is placed posterior to the submental crease, the submental retaining
ligaments can be released and the fat of the chin and the neck blended. (A,C) Patients with double chin before secondary facelift. (Procedure performed by an unknown
surgeon.) (B,D) Patients after secondary facelift. The submental incision was made 1 cm posterior to the submental crease, the submental restraining ligaments released,
and the subcutaneous fat of the chin and the submental areas sculpted and blended to achieve optimal contour. Platysmaplasty, transverse platysma myotomy, and
submandibular gland reduction were also performed. (Procedure performed by Timothy J. Marten, MD, FACS.)
A
B
C
D
tragal contour and obliteration of the pretragal sulcus. These
are frequently seen concurrently, although they have some­
what different underlying causes. Loss of tragal contour is
usually the result of improper incision planning, superior
over-shifting of cheek skin, and imprecise trimming of the
tragal skin flap. The tragus is seen to have no distinct begin­
ning or end and no posterior projection. A telltale “chopped-
off” appearance results (Fig. 6.10.27A). This is generally
correctable if tension is diverted to the SMAS, skin can
recruited from secondary advancement of the cheek skin flap,
and the skin flap is properly trimmed and fit over the tragal
cartilage.
Loss of the pretragal sulcus results from failure to leave
enough skin to fill the pretragal depression when the tragal
flap is trimmed and is almost unavoidable in any technique
in which tension is placed on the cheek skin flap. The over-
trimmed skin flap bridges the pretragal sulcus, which in turn
is gradually filled with fibrotic tissue and scar over time. The

253
Identification and analysis of secondary surgical deformities
tragus appears “buried” and indistinct from the cheek anterior
to it. It can also be seen to have a flat, two-dimensional contour
(Fig. 6.10.27B).
Correction of the buried tragus deformity requires recruit­
ment of sufficient skin from the cheek at the secondary pro­
cedure to fill the three-dimensional contours of the pretragal
area. Pretragal subcutaneous scar filling the pretragal sulcus
must also be excised, and the tragal skin flap must be redraped
under no tension. Skin must then be trimmed to a precise fit
while the flap is depressed and held in the pretragal sulcus.
No deep suture is necessary to hold the skin flap in the pre­
tragal hollow if the above steps are properly carried out.
The “retracted tragus” represents an extreme case of the
“buried tragus” deformity. It, too, is the result of technical
error and has its origin in an overly tight and excessively
trimmed cheek skin flap. The retracted tragus deformity
differs from the buried tragus deformity, however, in that not
only is the pretragal sulcus obliterated by subcutaneous scar,
but the tragal cartilage itself is pulled anteriorly by the over-
trimmed skin flap. This results in an open auditory canal and
a telltale and unnatural appearance (Fig. 6.10.27C). Simple
recruitment of skin from the cheek and excision of pretragal
subcutaneous scar is not sufficient to correct the retracted
tragus deformity because the retracted tragal cartilage is
usually stiff, fibrotic, and unable to return to its natural posi­
tion and configuration on its own. Correction usually requires
that the cartilage be scored on its anterior surface and then
Fig. 6.10.24  Poorly situated, hypertrophic scars. If skin excision has been
aggressive at the primary procedure, relocation of poorly situated incisions may not
be possible at the time of request for secondary facelift. In these situations, it is
usually best to defer surgery until scars have matured, skin has relaxed, and
adequate tissue is available to make proper repair. This may mean waiting until
2 cm or more of skin can be pinched up along each jawline. (Procedure performed
by unknown surgeon.)
Fig. 6.10.25  Wide scars. Wide, thick, hypertrophic and keloid scars, often
attributed to be the result of the patient’s own poor healing, are usually due to the
over-excision of skin along improper superiorly directed vector in procedures in
which the surgeon has employed skin tension as a vehicle to lift sagging deeper
layer tissue. As is the case in the patient with poorly situated scars, the patient with
wide or hypertrophic scars may be impossible to effectively treat if skin excision
has been excessive at the primary procedure. (Procedure performed by unknown
surgeon.)
Fig. 6.10.26  Cross-hatched scars. The underlying cause of most cross-hatched
scars can be traced directly to skin tension and tension-based facelift techniques.
When incisions are closed under tension, necrosis occurs beneath sutures and
these spots go on to heal as scars. As skin relaxation occurs over time, the hatch
marks and suture hole scars stretch and migrate away from the incision scar, giving
the appearance that the wound was closed with large, widely placed sutures.
(Procedure performed by unknown surgeon.)
secured with a mattress suture once in its proper anatomic
position (Fig. 6.10.28).
Distortion of earlobe anatomy
There is perhaps nothing as telltale and objectionable in the
patient who has undergone a prior facelift as distortion or
malposition of the earlobe. Like most other problems associ­
ated with secondary surgery, it is the result of artistic insen­
sitivity, poor planning, and errors in technique. Common
types of earlobe distortion seen after primary facelift include
the “pixie ear” and the “loving cup” ear.
“Pixie ear” is a pejorative term used by some to describe
the unnatural, impish, or elf-like appearance that the ear

254
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
artistically appropriate resetting of the lobule at the time of
surgery in a skin-only, non-SMAS facelift. The lack of deep
layer support in such cases will inevitably lead to some infe­
rior migration and settling of the cheek skin flap, and eventual
traction on the lobule. “Loving cup” ear is used to describe
the situation in which the ear resembles the handles com­
monly seen on vase-like trophy cups. In this deformity, the
earlobes are joined to the cheek in a less extreme fashion, but
also have been inset or pulled too far inferiorly (Fig. 6.10.29B).
This problem is often made worse by inferior migration of the
cheek skin flap over time after a skin-only, traction-based
facelift technique was used.
A full understanding of the origin of lobular deformity
requires that the surgeon understands and appreciates normal
lobular anatomy. This sets the stage for appropriate and
natural resetting of the lobule into the cheek at the time of the
primary procedure and the avoidance of unnatural secondary
deformities. Young patients presenting for other procedures
and friends and family members who have not undergone
plastic surgery serve as useful subjects for study in this regard.
Photographs of actors, models, and celebrities are less valu­
able, however, as many have secondary lobular deformities
that may not be immediately recognized due to concealment
of scars by photo-retouching or make-up.
A careful examination of the youthful lobule will show that
it is distinct from the cheek and that its long axis lies approxi­
mately 15° posterior to the long axis of the pinna (Fig.
6.10.30A). As the axis of the lobule is moved anteriorly to rest
anterior to the long axis of the pinna, a telltale “surgical”
appearance is produced (Fig. 6.10.30B). If the long axis of the
lobule is shifted well anterior to the long axis of the pinna
assumes when the lobule is attached directly to the cheek and
pulled anteriorly and inferiorly (Fig. 6.10.29A).
It is often the result of inartistic, improper, or careless reset­
ting of the earlobe into the cheek after the cheek flap has
been suspended. It can also result as a delayed effect after
Fig. 6.10.27  “Chopped-off”, “buried”, and “retracted” tragal deformities. (A) In the “chopped-off tragus” deformity, the tragus is seen to have no distinct beginning or end
and no posterior projection. It is usually the result of improper incision planning, superiorly over-shifting of the cheek skin and imprecise trimming of the tragal flap. (B) In
the “buried tragus” deformity, the tragus appears indistinct from the cheek anterior to it and the pretragal depression is absent. This deformity results from failure to leave
enough skin to fill the pretragal sulcus and is commonly seen when tension is placed on the cheek skin flap. (C) The “retracted tragus” represents an extreme case of the
“buried tragus” deformity and is the result of an over-trimmed cheek skin flap. The retracted tragus deformity differs from the buried tragus deformity, however, in that not
only is the pretragal sulcus obliterated, but the tragal cartilage itself is pulled anteriorly. This results in an open auditory canal and a telltale and unnatural appearance. (All
procedures performed by unknown surgeons.)
A
B
C
Fig. 6.10.28  Correction of the “retracted tragus” deformity. To correct the retracted
tragus deformity, cheek skin is undermined and subcutaneous scar in the pretragal
sulcus is excised. The anterior surface of the tragal cartilage is then incised to
allow it to bend posteriorly to its proper anatomical position. The cartilage is
secured in this configuration with a mattress suture of 4-0 nylon. Skin is then
recruited by facelift flap advancement and the tragal flap is carefully trimmed to
ensure that adequate skin is preserved to fill the pretragal sulcus. (Procedure
performed by Timothy J. Marten, MD, FACS.)