The science and art of Plastic Surgery have made tremendous advances over the last 10 years. New insights into the aging process have improved our approach to the aging face. How skin is handled during the procedure and how the deep tissue can be manipulated to minimize scarring have all been worked out. Natural youthful results without the stigma of surgery are easily obtained when in the hands of a well trained aesthetic plastic surgeon.
Although this is true we still see people on a daily basis with these obvious signs of surgery. It is important to understand that each of these "Telltale Signs of a Facelift" is avoidable. The following observations and explanations are offered for your education. Recognizing these problems will help you evaluate your surgeon and improve your overall satisfaction with your result.
Temporal Hair Loss
The hairline in front of and above the ear is pulled back increasing the distance from the beginning of the hairline to the corner of the eye. Not only is this unnatural in appearance it has the effect of aging the face. This occurs when an incision is placed in the hairline without accounting for the elevation of the facial skin. The second reason is when a surgeon cannot create fine scars they choose to place an incision in the hairline to hide them. Hair is then mistakenly removed permanently altering the hair style choices of the individual.
Occipital Hair Loss
As with the temporal hair loss, a misplaced incision within the hair bearing skin behind the ear will mistakenly remove the hair. This creates an unusual step off in the hair preventing the person from wearing the hair up ever again. Both of these conditions can only be corrected with hair transplantation. This usually requires multiple treatments at significant additional cost.
Poorly Placed Scars
An artistic eye is required to identify the appropriate placement of the facelift incision. Scars are less obvious when placed in areas of color change or shadow. These areas exist about the anterior ear which is the most common area for misplaced incisions. Cheek skin is a different color and has a different texture than the skin of the ear. The most common error is to place the incision in front of the ear or at the border of the sideburn. White scars can form here and are obvious from across the room. This is particularly true in male patients who are condemned to maintaining long sideburns regardless of hair style trends. Incisions must be placed in the natural curves of the ear and in areas of color change to achieve a near imperceptible scar.
Scars become wide when the skin is closed under tension or if there is suboptimal wound healing. The skin is not a supporting structure, it is a veneer. The tension created when the face is lifted must be born by the deeper tissues. If a traditional skin lift is done the incidence of wide scarring both in front of and behind the ear is unacceptably high. A small percentage of the population will develop hypertrophic or keloid scars. These are biologic conditions which are more prevalent in populations with darker skin tones. However, surgical technique also contributes to this problem. Delayed wound healing after sugery will also lead to wide scarring. This occurs most commonly, immediately in front and behind the ear just below the hair. This is related to tension on closure which compromises blood supply. The blood supply can also be compromised by bulky compressive dressings and poor head postioning after surgery.
You have all seen this one. The skin is pulled so tight the person looks like they have been in a wind tunnel. A few months later as the skin relaxes semicircular lines form across the cheeks. There are no natural lines which run in this orientation. This is again created by techniques which pull skin back toward the ear without deep tissue elevation or support for the skin. Aging is a vertical and radial process which can not be addressed solely by tightening the skin. The deeper tissues need to lifted vertically while the skin is redraped in a more natural orientation.
This is defined as an ear lobe which has been pulled forward on the cheek and placed under tension. Rather than having a sharp or distinct transition from the cheek to the lobule, the ear lobe has been blended with the cheek. The lobule position is advanced in front of the ear and is lower on the cheek than it should be. It derives its name from early drawings of the mythical pixies. The lobule of the ear should maintain a distinct transition from the cheek but should also sit about 15 degrees behind the long axis of the ear.
Over the last 10 years greater attention has been paid to the neck contour during facelifting procedures. In fact, a great majority of patients present to my office more concerned about their neck than their face. Current techniques allow greater manipulation of the deeper structures of the neck. If done well the results are excellent, if done poorly or in the wrong patient type, a depression immediately below the chin can be created. Instead of a soft curve in the submental area there is a central depression with fullness on either side. There is nothing natural about this appearance.
Vertical Skin folds behind the Ear
The Short Scar facelift was developed to help surgeons who consistently developed wide scars behind the ears. The scar is short because the skin is gathered behind the ear rather than extending the incision to allow the skin to lie smoothly. Over time many of the folds become smooth. However, many of the folds do not, creating unnatural vertical skin folds behind the ear. This problem is now seen with increasing frequency because of the increasing popularity of this technique. As previously discussed, wide scarring can be avoided by placing tension on the deep tissue and avoiding tension on the skin.
Loss of Tragal Definition
The firm prominence in front of the ear which prevents visualization of the auditory canal is the tragus. It is well defined and has distinct borders. There is a depression in front of the tragus which is an aesthetic separation from the cheek. It is oriented to partially cover the auditory canal. The tragal defintion can be lost by failing to recreate the anterior depression, leaving the skin over the tragus too thick, in males failing to remove the hair follicles which subsequently grow on the ear and finally placing incisions which fail to respect the boundaries of the tragus. The thick skin over the tragus blurs the normal transition of these separate structures, the cheek and the ear. Tension placed in this area will also pull the cartilage forward changing the orientation of the tragus and allowing visualization into the auditory canal.
Use this information to improve your decision making process. Ask to see your surgeons’ before and after photos and scrutinize them looking for the points mentioned above. The more you know about your procedure the happier you will be with your results. I hope this will help you achieve the results I know are possible.