tendon, and inferiorly to the zygoma (Fig. 32.2). Once this elevation and the facelift subcutaneous dissection are complete, the skin is excised in a tailor-tacking fashion with the placement of key sutures and rotation of forehead skin. The first key suture involves proper placement of the lateral canthal tendon (Fig. 32.3). The lateral canthal tendon should be placed with superior and lateral tension, placing it higher than the medial canthal tendon. The next key suture ensures the vertical pull of the check and neck lift and is placed near the root of the helix. The excess skin or dogear of the forehead is excised by rotating the skin medial to lateral. This is accomplished by removing a Burrow’s triangle of skin in the receding hair line along the most lateral position of the temporal incision (Fig. 32.4).

Rotating the skin from the medial incision to the lateral incision closes the Burrow’s triangle. The length of the medial incision is significantly longer than the recipient lateral incision. This discrepancy necessitates a bunching or imbrication of the medial incision to accommodate closure, which is completed differentially down the lateral superior (cephalad) suture line to minimize bunching anteriorly (Fig. 32.5). This imbrication principle is similarly applied in a large breast reduction, where the skin on the inferior aspect of the breast incision is bunched to minimize the length of the scar into the axilla. The corresponding W-plasty incisions can be made in a tailor-tacking fashion and the incisions are closed with deep interrupted sutures of 5–0 Monocryl and either running 5–0 Prolene or interrupted 4–0 silk figure-of-eight sutures along the entire length (Fig. 32.6).

b

Fig. 32.1 (a) Leading point is shown as a green circle at least 2 cm from the lateral brow. A 4 cm incision (red line A) is into the temporal receding hairline and W-plasty incision along temporal hairline to lobule. (b) Beveled angle of scalpel to skin that preserves hair follicles

32.3 Complications

No scar revision was necessary and no complications were reported with the surgery. All patients were satisfied with the results of their surgery.

32.4 Discussion

Virtually all patients are candidates for this procedure, with only exception being the patients who have no hair follicle skin in this area, including balding men

b

Fig. 32.2 (a) Area between temporal incision and dotted line shows planned subcutaneous dissection. (b) Skin flaps undermined in the subcutaneous plane and canthal tendon is seen

Fig. 32.3 Arrows delineate the direction of tension along the three key areas. First the canthal tendon is set. Second the vertical pull of the facelift with the key suture placed in the preauricular area. Third the rotation of the forehead skin from medial to lateral eliminates a dog ear

B

A

with significant recessive hairlines. Thin hair itself is not a contraindication because the skin of the scalp heals fairly well. The procedure described has been limited to patients with Fitzpatrick I through IV. Patients with thicker skin may also have thicker scars.

The thickness of the hair, the natural hairline, skin quality, and the amount of brow ptosis all need to be evaluated prior to surgery. In a patient with better skin elasticity and better skin health, less skin excision is necessary. Conversely, the more damaged the skin and the less elasticity, the more skin needs to be removed to support the brow laterally as well as to obtain the vertical lift laterally.

Proper management of temporal skin excision is important particularly when doing a vertical facelift because this is a critical area for support of the

Fig. 32.4 The Burrow’s triangle of skin incision is marked in green that is superolateral to line A. Line B is then drawn longer and parallel to line A

B B

A A

Fig. 32.5 Differential line lengths, excision of Burrow’s triangle, and imbrication technique

Fig. 32.6 Tailor-tacking technique of W-plasty incision and figure-of-eight sutures with the first key suture setting the height of the canthal tendon

facelift [3–7]. The more skin we are able to excise, the more options we have in what we can do with supporting the brow and the cheek areas. The design described significantly reduces, if not eliminates, the bunching at the anterior part of the brow. Basically, this bunching is displaced laterally over a much bigger area, thereby reducing the consequences. Because of the thinness of the skin, scarring is rarely a problem. Because of the design, hair follicles are preserved where they are most needed and the aesthetic quality of the hairline is retained (Figs. 32.7–32.10).

32.5 Conclusions

Over the past 10 years, the authors have progressed from the classic hair excision to the vertical with the aggressive temporal excision as described earlier by the senior author [8]. The significant advantage of the vertical lift

is the natural vector pull of the facelift is respected, which gives a much more natural look to the patient. The initial disadvantage was the anterior scar line across the hairline, which was originally described as a straight line. The revision rate was unacceptable. Replacing the straight-line closure with multiple Z-plasty flaps and a beveled cut helped reduce scarring [4].

The excess tissue in the apex of the temporal area, however, continued to be an issue because of the significant amount of excess skin that gathered there, which resulted in an unattractive three-dimensional quality. A potential solution to this problem brought about the design as presented. Essentially, the gathering of tissue is redistributed now laterally across the naturally occurring recessive hairline, allowing more temporal skin removal.

In addition, over the past years a subcutaneous lateral brow dissection to the vertical facelift has been added, which significantly helps to permanently improve the position of the brow laterally. The dissection extends subcutaneously to the forehead region, over the temporalis muscle, inferiorly to the lateral eyebrow, and anteriorly to the zygomatic arch. The lateral brow lift can be combined with a central lift [9], a canthopexy [10], and/or the vertical facelift when indicated. Surgical dissection between the lateral canthal ligament and the tendon allows for increased tension on the lateral canthal ligament with superior repositioning of the lateral canthus itself. The increase in our ability to remove more skin in the temple area results in more tension on the lateral canthal ligament, resulting in lateral and superior rotation of the lateral canthus.

Management of the temporal incision line is important for the long-term appearance of the scar as well as for proper positioning of the lateral canthus, brow, and hairline. The authors’ approach utilizing W-plasty technique, proper design, and dissection is very successful. Modification over the years has resulted in this approach, which is reproducible, safe, and effective. While the anterior hairline scar is not eliminated, it is reduced enough to make the vertical lift worthwhile.