Las Vegas — A visible scar, earlobe distortion, and bald areas in the temple and postauricular regions are some of the more common untoward sequelae of rhytidectomy that can be corrected with secondary surgery but may be avoided through careful planning and execution of the primary procedure, says Tolbert S. Wilkinson, M.D., who spoke at Facial Cosmetic Surgery 2004.
"Incorrect placement of incisions and failure to adequately shape the internal structures of the face can leave rhytidectomy patients with unwanted stigmata of that surgery. The end result should be a natural and refreshed appearance without telltale signs," says Dr. Wilkinson, a plastic surgeon with a private practice based in San Antonio.
Common complaints of patients displeased with the outcome of their rhytidectomy are that they are unable to wear their hair pulled up because of a visible scar or that they look bizarre when the wind blows because hairless areas around the ear are revealed. Over time, patients who have had a poorly performed facelift might also be dissatisfied by earlobe distortion as the earlobe stretches progressively down toward the chin.Incision placement Noting that he has never met a post-rhytidectomy patient with a visible scar who is pleased with the outcome of surgery, Dr. Wilkinson reminds his colleagues that a major principle in planning the procedure is to keep the incisions well inside the hairlines.
As an addendum, Dr. Wilkinson notes that he will occasionally breach that rule if he is performing a reverse forehead lift and aiming to create eyebrow central elevation in a patient with a very high forehead and recessed hairline. To establish a more normal hairline in that situation, the incision must be placed anteriorly, and then techniques are used when mobilizing the scalp from back to front to salvage the existing hair follicles.
Erasing errors Correcting problems relating to visible scars and unnatural hairlines can be accomplished using a double-opposing rotation in which the surgeon rotates tissues in seemingly incompatible directions. In that technique, skin from the cheek region is rotated upward while the temple hairline is rotated downward to restore the hairline so that it covers the top part of the ear.
Next, skin is rotated beneath the lobule in order to make sure the ear hangs in its normal position with the lobule free. Working directly behind the ear, hair-bearing scalp skin is rotated forward in an opposite direction with neck skin to move available hair closer to the back of the ear and to conceal any posterior scar.
Valuable adjuncts To enhance facial contours when performing primary rhytidectomy or in patients who present for revision, Dr. Wilkinson also advocates the use of external ultrasound and autologous fat grafts. The external ultrasound procedure is performed with a "superwet" anesthetic technique and can be very helpful for reducing fat in the jowl and submental regions and for flattening nasolabial lines.
"The ultrasound energy acts to dislodge fibrous attachments and allows the fat cells to be dispersed or absorbed while it simultaneously targets tissues of the deep dermis to induce contracture. Even patients who have not had any more invasive facial surgery can appear as if they have had a facelift because the external ultrasound causes skin tightening and dissipation of fat deposits contributing to jowl lines and folds in the mid-cheek and nasolabial regions," he says.
Fat grafting is also used as a safe and more permanent filler to address defects in the sub-commissure region, across the wrinkled upper lip, and to reduce the appearance of glabellar frown lines. In addressing the glabellar region, Dr. Wilkinson first introduces a blunt dissector through a stab wound in the scalp and uses it horizontally to elevate the frown rhytids from their deep dermal attachments. When that step is completed, the instrument is withdrawn, reinserted vertically, and used to shred the corrugator and other muscles just above the nose.
The space created in the subdermal and intramuscular region by those manipulations provides an excellent receptacle for autologous fat injections. In addition, the shredding technique weakens the muscles so that the glabellar lines are less likely to recur and also helps to smooth out some of the bulkiness that may be present in the region between the eyebrows.