Plastic Surgery for Men QotD: What is the Retrotragal Approach?

MALE FACELIFT CONSIDERATIONS
Male facelift incisions deserve special considerations and need to be modified to accommodate the male beard and also the male sideburn which usually has an infinite inferior extent because of the beard itself. Rarely is loss of the temporal tuft a problem because of this inferior beard. Therefore, a curving vertical incision into the post-tuft scalp is permissible in most males (Figure 7). However, if one can estimate that a large amount of skin is going to be removed, then the most anterior extent of the beard especially in the temporal area may be pulled back significantly so that the sideburn is noticeably narrowed or even non-existent. In such cases, a horizontal sideburn incision might also be considered.

When one makes a post-tragal incision, the beard may be pulled onto the tragus and oppose the anterior lobule and the region just anterior to the root of the helix. Because most men do not wish to shave this area on the tragus and because a clear non-hair bearing preauricular space is more normally evident, most surgeons will make a vertical preauricular incision in front of the tragus and preoperatively tell the patient that the vertical limb will be visible (Figure 7). However, in our practice, we have noted an increasing number of male patients who would much rather have a retrotragal incision, shave this hair and have a less noticeable incision. In those patients on whom we do perform a post-tragal incision, we do attempt to inactivate the hair follicles that would abut against the tragus or the immediate pre-auricular area by directly cutting the follicles from the undersurface of the flap with fine scissors prior to suturing and/or by using the cautery unit on the hair follicle bulbs. If needed, electrolysis can be later utilized for persistent hairs.

The incision around the lobule in the male is also usually not made exactly in the sulcus, but slightly more anteriorly to leave a tuft of non-hair bearing skin so that the hair-bearing skin is not pulled into the lobule sulcus. Again, rather than having this incision, one can make an incision in the sulcus and attempt to destroy the hair follicles.


Most candidates for male facelift are in the aging population and have already noted an increase of tragal and ear canal hair. These individuals often state that they wind up having to trim that hair on an almost daily basis anyway and do not object to trimming any further hair that grows from the post-tragal incision. We carry out a very thorough discussion with males on this subject so that they can decide which incision they would prefer and allow them to actively participate in the decision making process. All males, no matter what incision is used, must be warned that the neck beard will be pulled postauricularly to a certain extent when skin is removed and will need to shave this area posteriorly. Obviously, the more skin that is removed, the more posterior and superior the beard will be redraped.


SALVAGE FOR POOR FACELIFT INCISIONS
Unfortunately, some of the visible incisions due to too much tension cannot be immediately repaired or camouflaged. These require the facial skin to loosen to allow for redundant skin that can be excised with the old scar under minimal tension. When another facelift can be accomplished and there is enough laxity, care should be taken to place the new incision so that the scar itself will be excised with the excess skin. For instance, in the preauricular area, one should place the new incision posterior to the scar. With posterior (and superior) advancement of the skin flap, the scar is removed along with the redundant skin.

Loss of hair, however, can be remedied soon after an unsuccessful facelift. Usually, after three to four months the surgeon can be more assured that a telogen phenomenon is not occurring where the hair follicles are in a state of shock from tension from the previous facelift. At this point, reimplantation techniques are employed. Micro-follicular unit hair transplantation is utilized, and several hundred plugs can be placed just in one temporal sideburn tuft alone (Figure 8). Usually, two sessions are necessary to get adequate coverage since one is attempting to give full natural density and thickness in this area. The grafts are placed to orient the hair shafts in the naturally occurring direction. Hair transplantation can also be utilized for those post-auricular incisions that are placed right along the hairline. Alopecia that occurs within the hair bearing areas of the scalp, again usually secondary to excess tension, whether in the posterior scalp or in the temporal area, can usually be excised with incisions that parallel the hair follicles and then reapproximated. Usually, one would wait until enough skin laxity has returned to avoid cicatricial alopecia.


Keloid scarring can be a problem in the keloid prone patient after a facelift. Careful questioning of the patient pre-operatively should be able to ascertain whether keloids have been a problem for that patient. Because of the rather large incisional area that is made, keloids could present an unacceptable cosmetic complication after facelift. Hypertrophic scars may occur in the post-auricular incisions either in the sulcus, in a non hair-bearing area, or at the lobule. These incisions, if they do occur, can be injected with triamcinolone acetonide (Kenalog) beginning at a 10 mg/cc concentration advancing up to 40 mg/cc depending upon the response to the Kenalog and the thickness of the hypertrophic scar. If steroid injections are ineffective after repeated injections, usually spaced out six weeks apart, then one can consider re-excision.


DISCUSSION
This technique has been used successfully in over five hundred consecutive facelifts. Most other papers concentrate on one area whether it be the preauricular regions, prevention of temporal alopecia, or the postauricular hairline. We have attempted to address and integrate all of these into a single all encompassing method.


Regarding the placement of the preauricular incision, Becker agrees that the post-tragal incision yields improved cosmesis.5 In his study, four surgeons compared postoperative close-up photos of 18 female patients receiving pretragal incisions to 18 with posterior tragal edge incisions, all at least six months from surgery. Three specific properties of a natural appearing tragus, all of which are achieved by our technique, were common in the incisions that were rated to have a superior result - the presence of a pretragal sulcus, maintenance of a gentle posterior curve in the center, and prevention of lateral and anterior deflection.
Other techniques have been described to prevent temporal alopecia. Brennan et al. categorizes the preauricular hair tuft into three types according to the level of the hair tuft in the vertical dimension.6 In type 1, the tuft is located superiorly at the supra-auricular crease, and a pretrichial temporal incision is made with a V-Y advancement of hair bearing skin into the incision. In type 2, the tuft is in an intermediate position and a horizontal incision only is made at the inferior edge of the tuft. In type 3, a low positioned tuft, the incision is made within the hair. These authors also describe a novel anteriorly based transposition flap of hair bearing skin with primary closure of the donor site to correct iatrogenic temporal alopecia. We agree with the ensuing discussion by Dr. Barrera that micrografts allow for more exact replication of the natural hairline and better control of the natural inferior direction of hair growth.7

Knize outlined a similar wedge-like excision of nonhair-bearing skin between the temporal hairline and the superior pole of the ear.8 This skin removal allows transposition of the temporal hairline down to the level of the superior pole of the ear and prevents temporal hairline migration superiorly. To address specifically the posterior scar, Little advocates what he terms the “omega incision” to conceal the scar and maintain the natural posterior hairline.9 However, drawbacks include significant dissection of the posterior scalp, additional operative time with increased expense to the patient, increased risk of hematoma formation, and increased risk of sensory nerve damage of the posterior scalp. Our technique avoids these disadvantages but still achieves the same goals.

Camirand and Doucet compared the invisibility, nonlinearity, absence of hypopigmentation, and amount of hair at the incision between incisions made parallel versus perpendicular to the hair shafts.10 They concluded that in 95% of patients (thirty total), the perpendicular incision healed better by subjective evaluation. In the temporal area, they perform micro W incisions inside the hairline with linear excision of excess skin from the distal flap. In our experience, beveling the incision depends upon the location of the incision with respect to how the surgeon anticipates if hair-bearing skin will be on both sides of the incision. Thus, in our practice there are indications for both.


Regarding male facelifts, some authors prefer routinely using only pretragal incisions or solely retrotragal incisions. Cremone et al favor retrotragal incisions and in 1982 described their technique for cauterization and removal of hair shafts from the immediate preauricular skin to maintain an area of non-hair bearing skin.11 This technique is similar to the one described here; however, we have found that despite these efforts, sometimes the hair is not permanently removed. Botta describes a continuous incision in the male temporal incision and a lower blepharoplasty incision.12 He claims this provides an advantage in rotation, leaves the preauricular nonhair-bearing skin undisturbed, and does not elevate the temporal hairline (he makes a pre-tragal incision usually at the hairline). The tradeoff is a visible scar in the temporal area which he believes heals exceptionally well.

CONCLUSION
In summary, we believe that the facelift surgeon must pay careful attention not only to the technique of the facelift for achieving neck, jaw, and cheek lines, but also must take extreme care to ensure that facelift incisions are as least visible as possible and that no natural hairlines are significantly altered so that loss of hair is apparent. We have noted patients who have had previous facelifts with loss of hair who have avoided having any future facelifts for fear that they would lose even more hair - the “facelift cripples.” Patients should be weary of surgeons who do not show them close-up photographs of their post-operative incisions with the hair worn up. It seems incongruous that a surgeon would attempt a rejuvenation procedure to make a person appear younger and more well rested to his or her friends while at the same time leave visible incisions that tell everyone the patient has had surgery, thus negating any benefits from the lift.
resource:  http://www.todaysface.com/Inconspicuous-Facelift-Incisions.html


Male Face Lift What not to do:

The Sideburn Area
Do not make an incision behind the sideburns and elevate the skin flap since it will elevate the sideburns to too high a position leaving a bald spot in front of
the ear pinna.

Unless the elevation is minimal it should not be done. To achieve proper excision of thick skin after undermining, a counterincision below the sideburns
is necessary. The excess skin is then not removed at the expense of hairy skin and it is only done in removing bald skin and elevating the lower incision edge to
the actual sideburn area.

Often also in men this approach is necessary and it could prevent a thinning of the sideburns in front of the ear if the beard happens to develop low in front of
the ear. If the hairy cheek occupies a large zone, its elevation will prevent a thinning of the width of the sideburn and will be adequate. A curved incision at
the sideburn is less visible than a horizontal incision.

The Tragal Area
The placement of the face-lift incision behind the tragus reduces the appearance of the preauricular scars; however, a few important points must be kept in
mind. Avoiding tension on the skin flap will prevent the distortion of the tragus, which is pulled forward and leaves the ear canal open.

Although it might be necessary to defat the flap going over the tragal cartilage,
excessive defatting will lead to skin necrosis: thus the maneuver should be done with care. Before suturing the skin flap, which should be rounded or
rectangular, it is a good technique to defat the anterior portion in front of the tragus and in front of the auricular canal in an attempt to allow a depression to
be created in front of the tragus, keeping a natural look. If this technique is not performed, an unnatural look of the pretragal area will result, taking away the
advantages of the postauricular tragal scar.