In advanced cases where extension of incision to the postauricular crease is inevitable, posteroanterior vectors could help to keep the incision line deep in the postauricular crease. In the meantime, this will help tighten and reduce the posterior neck skin redundancy in advanced cases [1].

These innovations and some minor ones, to be discussed, in technique of the procedure have made this a rock solid technique. Even in repeat facelifts where patients already have temporal and occipital scars, I often do a short-scar technique and do not disturb or use old scars unless there are deformities that necessitate intervention.

33.3Surgical Technique of Short-Scar Facelift

33.3.1 Marking

The patient is marked in sitting position in the holding area preoperatively. The marking gives a chance to the surgeon to refresh his memory with the particular individual characteristic of each patient’s facial structures and degree of lift to correct it. I usually mark the approximate skin dissection area and SMAS/platysma area and incision line (Figs. 33.1 and 33.2).

Fig. 33.2 Markings showing extent of skin dissection at the cheek area and SMAS/platysma dissection to the lower neck, down the midline of the neck if needed. Sternocleidomastoid muscle is marked as the posterior limit of dissection

Fig. 33.3 Skin dissection is started using a scalpel to make a thin flap and then continued with Rees/Aston scissors. Notice that a strip of skin resection at the preauricular area facilitates skin and SMAS dissection

Fig. 33.1 Markings are drawn showing that the incision line follows the anatomical creases (e.g., w-plasty idea). Incisions that are placed at the apex of the tragus will heal well enough making the scar virtually invisible

Fig. 33.4 Skin dissection is continued anteriorly in direction of the nose, nasolabial fold, and corners of the mouth

Fig. 33.5 SMAS dissection is being started. This dissection will extend anteriorly and inferiorly at the jaw line area when dissection reaches the platysma muscle. Dissection is extremely easy and can be done bluntly to prevent nerve damage

Fig. 33.6 SMAS/platysma dissection is necessary at the completion to release the platysma connections at the highest parts of the anterior edge of the SCMM to gain mobility of the flap

Fig. 33.8 When skin is draped over the pulled SMAS, the spot where skin dissection over the SMAS/platysma is stopped is seen like a demarcation area. Also notice how vertical the vector of the traction is

Fig. 33.9 Sutures are placed to actually lift the SMAS and consequently platysma and overlying skin upward resulting in extreme correction in the vertical neck and jaw line

Fig. 33.7 The traction on the now mobile SMAS/platysma unit pulls the skin upward in unison with the platysma. This is due to strong connections between the skin and SMAS/platysma

33.3.2 Anesthesia

This surgery could easily be done with local anesthesia preferably with MAC anesthesia with local infiltration. If it is being done in patients with moderate aging deformity less extensive undermining may suffice. The author uses a mixture of 50 ml of lidocaine 0.5% 50 ml of Marcaine 0.25%+1 ml of epinephrine 1/1,000 (50 ml per side).

In advanced cases or cases that are combined with other procedures, general anesthesia with local infiltration is chosen. In any case, both sides are infiltrated at the beginning of surgery.

Fig. 33.10 Multiple interrupted sutures are placed on the SMAS in a direction that will assure a smooth skin contour

Fig. 33.11 SMAS repair is complete. Now there is a lot of redundant skin to be excised. Notice the demarcation of the dissected and nondissected skin

Fig. 33.12 Skin is pulled upward at an angle close to 90°. Removal of the dog ears at the sideburn area is easier than that of the posterior auricular area. The more vertical the vector, the less skin redundancy will be behind the ear

Fig. 33.13 Guide sutures are placed and excess skin is removed. Still there is some skin redundancy behind the ear lobule to be dealt with

There are at least two reasons for this approach:

1.While injecting the second side, the first side will blanch enough to start incisions right away. This will save time and by the time first side is finished, second side is well blanched, provided the surgeon is moving on and doesn’t take more than 60–70 min to do the first side.

2.In cases where sedation is being given, most of the pain of the injection subsides in the beginning of the case and deep sedation may be avoided for the rest of the procedure.

33.4Technique of Short-Scar Facelift with Extended SMAS/Platysma Dissection and Repair

(Fig. 33.1–33.16)

The incision is made at the sideburn and carried to preauricular area. Traveling through natural lines above the tragus then in front or at apex of the tragus – not behind it – it dips under the tragus and contours at the lobular crease and stops just under the ear lobule to facilitate dissection. A piece of skin is removed from the preauricular area [4].

Fig. 33.14 Deep sutures between dermis and mastoid fascia are important. They prevent ear lobule migration inferiorly and also are helpful in tucking down the pleated areas

Fig. 33.16 Short posterior auricular scar even in advanced cases. If needed, incisions could be extended as far as necessary superiorly

Fig. 33.15 At completion of the operation there is a smooth natural-looking face and neck. Different degrees of pleating may occur that usually subside in time. Pleating usually is more noticeable at the side done first

Skin dissection is done several centimeters anteriorly and inferiorly. Then, the SMAS is identified and dissected. If the skin flap is thin, finding the SMAS is easier; otherwise, SMAS may be included in a thick flap and difficult to find.

The SMAS is dissected with direct vision anteriorly and inferiorly. When dissection reaches to platysma level dissection is very easy,so blunt dissection will suffice. I use facelift scissors and only spread with no cutting. However, any blunt dissection device could be used to mobilize the SMAS/platysma adequately. It is necessary to release attachments of platysma from anterior edge of sternocleidomastoid muscle (SCMM)

usually several centimeters at its most superior portion. At this time, pulling on the SMAS on proper direction should show immediate improvement in neck and jaw line area. If mobility is restricted you should identify the attachment band and release it until you are happy with the correction. There is not a set where the SMAS should be attached. It should be placed in an angle where the best correction is achieved. Usually my first suture is placed at the angle between the sideburn and the preauricular area and subsequent sutures are placed at the zygomatic arch and preauricular area. The bunching of SMAS at the zygomatic area may be kept to enhance the cheek area. If it is not needed, it could be trimmed off. We recommend use of 3–0 PDS sutures on SH needle for SMAS repair.

At the end of the SMAS lift, the surgeon will notice that the skin has moved up as folds of redundancy and are ready to be excised. Redundant skin is excised with moderate tension after placement of guide sutures at the points

1.Below the tragus.

2.Above the tragus.

3.Immediately behind the ear lobule.

4.At the angle between sideburn incision and preauricular incisions. Excision of skin at sideburn area and preauricular area are usually uneventful and easily done.

Difficulty often is at the area under and behind the ear lobule that may need some finesse. In this part, directly superior and posteroanterior vectors are helpful. At this area, namely under and behind the ear lobe, solid dermal