Incision Location for Lower Facelift and Neck Lift

Hi Brooke in Colorado,

Excellent question.  

Preauricular Incision [incision in front (pre-) of the ear (auricular)]

In general, the lower facelift requires some kind of incision in front of the ear in order to "tailor" the excess skin that will result from lifting the soft tissues of the lower face and cheek.  As the "loose" or lax soft tissues of the lower face and cheek are tightened in an upwards and backwards direction (diagonal) the incision in front of the ear will result in varying amounts of overlapping skin depending on the patient.  This extra skin is then trimmed and meticulously sewn together for an inconspicuous incision.  

Traditional or short?

The traditional facelift incision in front of the ear goes straight up into the hairline, behind the sideburn hair.  The "short-scar" incision goes forward and under the sideburn hair tuft, also known as the temporal hair tuft.  The advantage of the short scar incision is that the sideburn hair is left intact, whereas the traditional longer incision may result in a loss of the sideburn hair.  This loss of sideburns can be a "tell-tale" sign of a facelift.  The advantage of the traditional incision is that the cheek skin can be smoothed out even higher, resulting an more of a cheek lift than with the short scar incision.  For a patient with a very "hairy" sideburn which extends downwards towards the tip of the ear, this can still be a good option.  However, for someone who already has either thinning hair of minimal sideburn hair to begin with, the short scar incision will be a better option.

What's a tragus? Pre- or Post-?

There are two variations of the preauricular incision.  To understand the two variations, first you need to learn the name of the small "flipper-like" piece of cartilage on the front edge of the opening of the ear.  It is called the tragus.  Some people have a prominent tragus which may stick up between 20-45 degrees.  These patients tend to have a prominent wrinkle in front of this tragus.  I feel for these patients, men or women, a pretragal incision seems to look better.  For people, with a flatter tragus laying 0-10 degrees, a post-tragal incision tends to look better on these patients.  Sometimes using a post-tragal incision on a patient with a prominent tragus can flatten out or distort the natural separation that the face and ear have.  If the tragus is already flat, then it doesn't matter as much for those patients.

Sometimes I hear patients saying that the incision was performed behind their ear, but what they were really referring to was a post-tragal incision, hiding the incision behind the edge of the tragus cartilage.

Post-auricular incision for necklifts?  Why is it needed?

The "real" incision behind the ear is call the postauricular incision.  Post- means behind, and auricular means ear in Latin.  When we perform necklifts and liposuction and tighten the muscles of the neck, we often end up with excess neck skin, which needs to be trimmed and tailor fit to the patients neck.  The preauricular incision in front of the ear, can help get rid of some of the skin that is directly under the chin, but the extra skin which is below that on the neck itself, is better removed using the incision behind the ear.  

Traditional or short?

The traditional postauricular incision follows directly in the fold behind the ear, toward the mid- to upper third of the ear, before making a horizontal or broken line (which can be less noticeable) going toward the hairline.  Once at the hairline, it can either go diagonally into the hairline hiding the incision inside of the hair, or along the hairline itself, which will be visible for a man with short hair, or a woman who wears her hair up, or in a ponytail.  The higher the incision before it transitions into the hairline, the less noticeable.  Why?  The fold in the back of the ear and the hairline form a triangle.  If the transition is performed closer to the top of the triangle, the shorter this incision.  If the incision is performed toward the mid or base of the triangle the more noticeable it will be.  

The short scar for the postauricular incision can mean that the incision does not transition into the hairline at all.  The entire incision is in the fold behind the ear.  That sounds great, right?  Everyone should have that, right?  Not necessarily.  Yes, for some patients with minimal excess skin in the neck will be able to avoid the transition incision into the hairline.  But if a patient had a significant amount of extra skin on their neck.  When the neck is tightened, the patient will have a lot of extra skin which may require 3-5 inches of incision in order to trim it off.  But the incision behind the ear is only 1 1/2 to 2 inches at most.  For those of you who known how to sew, in order to match two pieces of fabric of differing lengths, the tailor will need to take a small amount of fabric on the short side to a longer amount on the long side.  This will result in pleats.  Pleats behind the patients ears will be more noticeable especially if it ends up not flattening out completely.  If the incision is extended high on the triangle toward the top of the ear, this horizontal incision can be relatively short and hidden by the top of the ear.  It is much easier to match 3-5 inches of extra skin to 3-4.5 inches of incision without causing any pleats.  The skin behind the back of the ear should appear flat and smooth.  If the incision is further hidden inside the hairline itself, while maintaining a straight hairline (meaning no step-offs on the hair line or mis-aligned hairline) then this incision should still allow for the patient to wear their hair up.  Consider the alternative which might be pleats of skin behind the ear.

I hope you find this "crash-course" on facelift incisions helpful.  Good luck with your possible future face and necklift.

Best,

Dr. Yang

The length and location of lower facelift incisions can vary depending upon the surgical goals.   In someone with little skin laxity or looseness in the neck the facelift incision can be shortened behind the ear and not extend into the hairline or stopped just behind the earlobe.   Incisions that are put together well with good facelift technique are well concealed not matter what the length of the incision(s) allowing the patient to wear any hair style they wish. 

Each surgeon's particular technique is different. Short-incision face or neck lift techniques (often termed mini-lifts) are appropriate for some patients, but not everyone. Patients with significant laxity in the neck or jowls will not get as dramatic of an improvement by limiting the incision simply because it makes it difficult to remove the amount of skin needed and to achieve proper tightening. These short-incision techniques work best in patients with minimal laxity.
When placed properly, the incision behind the ear that is carried into the hairline is almost always extremely difficult to find, even when patients have their hair pulled back. Be sure to discuss any concerns regarding incisions and/or surgical expectations with your surgeon prior to the procedure, and find a surgeon who specializes in facial aesthetic procedures.
All the best,