Facelift surgery

Planning and marking the appropriate locations for the incisions required for a facelift have a major impact on the long-term results. Changes in the hairline or the appearance of scars in visible places can cause complete dissatisfaction of the patient, despite the good result of the facelift itself. A natural-looking hairline, freedom of choice of hairstyle and unnoticeable scars distinguish a good plastic surgeon from one whom patients consider to be one of the best. Hairdressers and cosmetologists, who perceive the results of a facelift from their specific position, often praise and recommend to their clients surgeons who pay attention to detailed planning and incision size.

There are three defining points to consider when planning your facelift incisions:

• How to treat the parotid tuft, including the sideburns? Each patient has a different preference for the location of the lower part of the sideburn and the width it extends anterior to the helix. If the temple hairline is 1-2 cm below the attachment of the upper helix, an incision that curves upward and back can be planned. A curved incision, rather than a straight vertical incision, is necessary to resist contractile forces, create a minimal scar, and prevent hairline alopecia. Since the hairline does not extend above the attachment of the upper helix, the patient will not have cosmetic problems in this area. If the preoperative sideburn line is at the attachment of the helix, an incision below the hairline is required; this usually requires an additional temporal incision if a lift is needed in this area. The incision should never be made in front, around the temple tuft, or along the anterior temporal hairline. Any scars in this area will be visible and will not be hidden by thin, highly angled hair, as they extend backwards onto the skin.
• The incision in the anterior auricular area should at least follow the natural curves of the auricle itself. Patients certainly prefer an incision hidden behind the posterior edge of the tragus, so that it is "inside the ear." The preauricular incision will not be visible if it follows the natural curvature of the helical attachment and extends approximately 1-2 mm behind the tragus and then emerges at the junction of the ear and face. Alternatively, in patients who use hearing aids or who have a very deep pretragal depression and a high tragus, a curved incision can be made, extending into the notch and then outward around the curvature of the helix. However, the loss of pigment in the scar, no matter how thin, will permanently create a visible line and may require a change in hairstyle in the future.
• The incision behind the ear should be directed upward, toward the back of the ear and over the sulcus, so that when it has healed with some contraction of the scar and the ear has been moved posteriorly, the latter will fall on the postauricular sulcus and not on the skin behind the ear. The incision should make a gentle curve around the insertion of the ear so that the postauricular scar does not intersect the skin where the ear projects to the hairline. In most cases, the incision should be angled gently backward into the hair behind the ear. By moving the postauricular skin backward and upward, the posterior hairline can be brought into alignment without a step or other distortion. However, when the patient has excess skin on the neck that must be moved posteriorly, it is often necessary to extend the incision along the hairline behind the ear before moving it posteriorly into the hair. In this way, a large amount of skin can be moved backward and upward without going beyond the postauricular hairline. The incision should never be visible at the base of the hairline, which points toward the front of the neck.

To facilitate manipulation of the anterior surface of the neck in the submental area, an additional 1-3 cm incision is required, immediately anterior to the existing submental fold. Before infiltration of the anesthetic, a dotted line is drawn on the skin to mark the area of anesthesia and subsequent tissue preparation. Some surgeons prefer to mark the area of the zygomatic arch, the McGregor flap, and the angle of the mandible. Additional drawing of the contour of the jaw and the protruding edges of the subcutaneous muscle can help in highlighting areas that require correction during the operation.

An option for facelifting in men, as well as women with significant hair growth in the parotid area, is an incision that gently curves in the parotid area, into the often present anterior auricular groove. Such an incision should not be completely straight; it is preferable for it to recede from the notch and pass in front of the tragus. By moving the hair-bearing skin backwards and upwards, it is necessary to leave a section of skin without hair (a very important part of the consultation is the precise determination of the course of the incisions and their designation on the map, in graphic and written form).

Pain relief for facelift surgery, even with adequate sedation, requires infiltration of an appropriate amount of local anesthetic with epinephrine to reduce bleeding from the skin. Although many surgeons prefer inhalational anesthetics to achieve complete pain relief. Intravenous sedation is always required with constant monitoring of blood pressure and blood oxygen saturation. A special staff member - an anesthesiologist, a certified anesthesiologist or a nurse is assigned for this under the direction of the operating surgeon. For the success of sedation anesthesia, it is necessary to fully examine the patient before the operation. If the patient is confident that he will not experience pain, discomfort or other inconvenience during the operation, he will be mentally prepared for the effects of the administered sedative. In general, it is good practice to prescribe oral premedication to the patient to relax before the intravenous sedative is administered. Modern drugs provide sufficient amnestic effect along with full sedation and analgesia. Any anesthetic administered should have some duration of action so that the patient remains comfortable for several hours in the early postoperative period. Infiltration of the incision lines is best done with 1% xylocaine with epinephrine 1:50,000.

This ensures not only good anesthesia but also maximum hemostasis due to vasoconstriction. Infiltration of the areas requiring undercutting should be done with 0.5% xylocaine with adrenaline 1:100,000 or 1:200,000. Some hemostasis is required here.

The total amount of xylocaine should be carefully calculated. Never should more than 500 ml of xylocaine with adrenaline be administered, simultaneously or within 1-2 hours. Overdose of xylocaine with subsequent intoxication may result from the administration of an unnecessarily large volume of this local anesthetic. It may be advisable to complete the infiltration on one side of the face before starting it on the other side. This sequential infiltration, since it is performed 10-15 minutes before the incision is made on the incision side, is safe and effective.

The patient should then be prepared for surgery by twisting small strands of hair and securing them away from the incision lines and surgical site. The hair can be secured with adhesive tapes. After the surgical site is prepared and covered with sterile linen, the surgery begins. No shaving is required. Preoperative prophylactic antibiotic administration is given to all patients using a cephalosporin drug 1 day before surgery and for 4 days after surgery.

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