Achieving natural-looking results without visible signs that surgery has been performed is the key goal of facial rejuvenation surgery.Nevertheless, one of the untoward outcomes of face lift surgery is the so-called face lift look. Conspicuous preauricular scars, earlobe malposition, distortion of the tragus, and high sideburns are responsible for most face lift stigmata. The “face lift look” does not occur if procedures are followed to properly place incisions, preserve ear contour, and maintain the sideburns in their normal position.

Preoperative planning, particularly with regard to observation of the ear contour and the location of the sideburns, is a fundamental requirement for achievement of satisfactory results in rhytidoplasty. The preauricular area and sideburns are sites where face lift stigmata are easily detected (Figure 1). In addition to proper evaluation of facial changes caused by aging, precise assessment of ear contour, sideburn location, and distance between the hairline and lateral canthus is mandatory to obtain a satisfactory outcome that preserves ear contour, tragal shape, earlobe location, and sideburn position ( Figure 2).

Stigmata of facial plastic surgery. A, Elevation of sideburns; B, destruction of the tragus.

Preoperative evaluation of the preauricular approach. A, The preauricular approach is appropriate in this 67-year-old patient with sideburns in a natural position and a nice ear contour. B, The retrotragal approach is appropriate in this patient, given the long earlobe and thin tragus

Incision planning

Placement of the incision above the ear may vary, depending on the position of the sideburns. If the sideburns are low, the incision should be made in the hair-bearing temporal area. If the sideburns are located in a higher position, the incision should contour the sideburns and extend farther into the hair-bearing zone. If the distance between the hairline and the lateral canthus of the eye is relatively long, the incision should enter the hair-bearing area at a higher site.

The preauricular incision must follow an imaginary line dividing the auricle and face (Figure 3, A). The markings should follow the natural curves of the ear. The incision should not be a straight line; incisions may be placed in front, on, or behind the tragus. Whatever your choice, the shape of the tragus should never be changed. Sutures should be placed without any tension ( Figure 3, B and C). In most patients, there is a crease in front of the tragus where the incision can be made. Whenever possible, I prefer to use the pretragal incision.

A, The incision is made along an imaginary line that divides ear and face. B, Intraoperative appearance immediately after the incision. C, Intraoperative placement of the final sutures. Sutures should be placed without any tension

When performed with careful surgical technique, the preauricular incision is rarely noticeable after surgery. It can result in a very natural-looking appearance, without distortion or alteration of the ear contour, and with sideburns that are correctly located (Figure 4 and Figure 5). In some patients, scarring from previous procedures (performed elsewhere) is improved ( Figure 6).

A, Preoperative view of a 49-year-old woman.B-D, Evolution of the preauricular scar at 4 days, 45 days, and 1 year, respectively, after face lift.

A, Preoperative view of a 54-year-old woman. B, Postoperative view 1 year after face lift. Note the position of the sideburns.

A, Preoperative view of a 62-year-old patient who presented with scarring of the preauricular area and earlobe contour distortion after surgery. B, Postoperative appearance 6 months after reoperation shows improvement.

If the tragus is thin and the anterior crease is not perceptible, I recommend a retrotragal incision. When this incision is used, proper defatting of the flap is also necessary (Figure 7).

A, Defatting of the tissue in front of the ear. B, Intraoperative appearance before the final suture.

Conclusion

Sophisticated maneuvers in rhytidoplasty are counterproductive if they result in conspicuous scars or other visible signs of surgery. Careful technique with regard to incision placement is mandatory for optimal results. Frequent causes of the face lift look include ear distortion, tension of the flaps, improper direction of the flaps, excessive distance between the hairline and lateral canthus, and elevation of the sideburns. The patient should be able to wear any kind of hairstyle after undergoing rhytidoplasty.