Moving the skin flap

Once adequate deep fascial lifting has been achieved to provide a long-term foundation for the changes made, the necessary advancement and reshaping of the skin flap can be performed. With minimal tension, the excess skin that covers the ear in a posterosuperior direction can be seen. The anterior auricular skin is advanced primarily posteriorly and slightly upward so that the temporal hair bundle is not pulled too high. The neck skin is elevated posteriorly and primarily upward behind the ear so as not to create a large step-like deformation of the hairline behind the ear. When the skin is fixed high behind and in front of the ear, an adapting incision is made and a staple is applied. The skin along the hairline behind the ear and on the back of the head is successively incised obliquely; surgical staples are used to approximate these scalp tissues. The skin in the hairless areas behind the ear is sutured with a running, overlapping suture of 5/0 catgut. Since there is no tension, deep sutures are not applied. The ear is held in place with deep 5/0 Vicryl sutures and the skin is undercut so that the ear is repositioned upward. It is often important to elevate the ear significantly so that the ear does not droop after healing and the tissues have been displaced downward. A retracted ear gives the appearance of a satyr's ear and is an obvious postoperative deformity. The tissue in front of the ear is excised according to the planned preoperative incision. The tragal flap is left obviously redundant so that when it is sutured in place there will be absolutely no tension on the ear. The tragal flap is folded into a pie shape to form a new, redundant tragus. When healed, it will contract very closely to the normal tragus and will not be pulled forward as would occur with cicatricial contracture following a rash flap excision. The skin in front of the ear is closed with a running, overlapping suture of 5/0 catgut. The temporal incision is closed like the occipital scalp, using surgical staples. Before complete closure, a 4-mm drain is inserted into the incision hidden in the occipital hair for active aspiration. The drain is brought to the level of the anterior angle of the mandible. Then, excess submental skin, if any, is trimmed off with a crescent incision so as not to create "dog ears" on the sides or excess skin.

Before applying the dressing in the operating room, the patient's hair is untwisted and washed of all traces of blood. Antibacterial ointment is applied to a non-drying dressing around the ears. Several napkins ("tens", 10 x 10 cm) are applied to the areas where the flaps were cut, then an elastic cotton bandage is loosely wound across the chin and parietal area. It is held in place with a minimally compressive elastic chin strap. This should be done carefully so as not to compress the displaced skin flaps.

The patient is transferred from the operating room to the recovery room. Once the patient feels well, he or she is escorted to the car and driven home. Before discharge, the patient should be able to walk with someone's help and should spend the night in someone's company. It is important to contact the patient by telephone the evening after surgery. The patient should also remain within 15 to 20 minutes by car from the operating room in case of immediate need for postoperative medical care. The patient is asked to return the following morning, 12 to 18 hours after surgery. At that time, the dressing is removed, the drain is usually removed, and a light chin bandage is applied for another 24 hours. The patient is advised to shower once a day, keep the wounds clean and treat them with a hydrogen peroxide solution, then apply an ointment containing an antibiotic. The stitches and staples are removed one week after surgery.

The patient is asked to return 10 to 14 days after surgery for a follow-up visit to meet with the make-up specialist. At this visit, he or she is instructed on the application of make-up to cover up any residual bruising and on facial skin care. The make-up specialist suggests appropriate moisturizers, cosmetics, and sunscreens, informing the patient of how to continue to care for the skin to maintain the results of the facelift. Patients should be seen at 1 month, 3 months, 6 months, and 1 year after surgery to monitor progress. The second through fourth weeks are often when the patient requires emotional support as he or she adjusts to his or her new appearance and reintegrates into work and social relationships. The person experiences many post-operative feelings as the minor healing details that were explained are forgotten and reassurances are needed that everything is going as expected. Reiterating post-operative instructions and expectations is critical to creating a sense of success for cosmetic surgery patients. Your office should be a place where patients feel comfortable calling or coming in for post-operative care. They should feel like you are there for them, answering questions and checking in with them. This is essential to their long-term satisfaction.

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