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

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,

A person’s age is best guessed by the appearance of their face. If you feel that your face does not reflect how young you feel inside, you may be a candidate for a facelift.During your #consultation, your skin texture and elasticity, as well as your underlying skin structure and your facial bone structure will be evaluated. Based on this evaluation, your board certified plastic surgeons will create a custom surgical plan, detailing specific techniques and recommendations to meet your goals. In doing so, he or she should be sure to have a full understanding of what results you expect.If you are not a #candidate, your surgeon can make other suggestions to address your concerns and objectives.#Incisions vary depending upon whether the patient is male or female, the hairstyles, hairline, age, previous surgery, and other factors. Generally, the incision starts in the temple, in front or within the hairline. It continues in front of the ear, sometimes partially hidden within the ear. It then goes under the earlobe, behind the ear fold, and ends within the hairline or at the hairline behind the ear. The newer, shorter #scar techniques, which do not include scars in or by the hairline, can be used for most patients. Frequently another small and hidden incision is made under the chin in a natural skin fold. This allows fat removal and tightening of the platysma muscle in the neck if required.

Thank you for your question.  It does depend on the surgeon, however I have pioneered a Concept Facelift which addresses the lower/mid face.  The incisions are made just in front of the ear.  After these have been made, I would begin separating the skin from the underlying structures. Once the skin has been separated, I would then work on the muscle layer under the skin: this is where the real lifting is achieved. The muscle layer is lifted, trimmed and then sewn back in a more youthful position. Once this is complete, any excess skin is then trimmed and the skin is gently stitched back in to position.Also, regarding Neck lift incisions they would be made at the back of the ear and if Platysmaplasty was need then a small incision under the chin maybe necessary.Overall if you are wanting to target your neck and lower face then incisions in front of the ear and behind would be sufficient and least visible.Best of Luck 

Great question! It really depends on what your surgeon wants to accomplish, but incisions in front of the ear are likely required.

The incision for a lower facelift may be limited to sideburn area, to the front of the ear, to the crease behind the ear. If there is not a lot of neck laxity, this will be adequate. If there is significant neck laxity, it may be necessary to have the incision extend to the hairline behind the ear. You are right - that would be the most visible incision, so it is a nice one to avoid.

In general, the length of Facelift incisions is tailored to the degree of skin laxity, neck obliquity, degree of jowl formation, and other aging changes present.  Most Facelift and/or Mini-lift incisions employ an incision that is close to the ear in the front, follows a course behind the tragus (shield of the ear canal), and around the earlobe. If significant redundancy exists in the neck, the incision is extended along or into the hairline to facilitate hair removal.  The key in Facelift is the incision placement and the degree of tension placed on the skin.  These factors, if properly respected, will allow an incision of any length to look good.  A short incision, for the sake of being short without respect to addressing significant aging changes, often leads to a poor scar.

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. 

If the area under the chin and the anterior platysma muscle is all that needs to be addressed, a short incision just behind the chin crease is all that is needed. Some surgeons may also choose a tiny incision behind each earlobe to help sculpt the fatty tissue beneath the jawline closer to the ears (when needed).

But, if you have loose facial skin, jowls, loose neck skin ("turkey neck") and are a true facelift candidate, then you must have an incision in front of the ear. The rest of the incisions are (should be) totally hidden and therefore not an issue (if properly positioned and performed)! More about that in a bit.

The incision in front of the ear should fall in the normal curving contours of the cheek skin-ear skin interface, and should NOT pull or distort the earlobe. If you have a hanging earlobe before surgery, you should NOT have a "pixie" earlobe after surgery! BTW, the earlobe is totally unsuitable as a structure to which the cheek is attached--the earlobe will pull forward, develop a wide white scar in front of it, and be visible across a room! Bad doctor! (Actually, bad technique!)

Some doctors like to talk about their "hidden" facelift incision in front of the ear; actually, this is just the tiny portion of the incision by the tragus, which is the protruding cartilage bump just in front of the actual ear canal. The incision is made just behind the tragus, and the tightened cheek skin is folded over the tragus and sutured just out of view behind the little bump of cartilage--viola: the "hidden incision. When this is performed perfectly, it preserves the shape of the tragus and does indeed hide this 3/4 inch of the entire front of ear facelift scar. Unfortunately, even with good surgeons, this tiny folded flap of skin loses circulation, dies partially or completely, and then the tragus is pulled forward as scar tissue contracts, blunted or flattened with a widened scar on its edge (losing its nice normal rounded shape), and no longer covers the ear canal, which now looks like a "gun barrel." This ugly deformity is another one visible across a room! I can much more reliably leave the tragus anatomy, position, and normal skin covering alone by avoiding all tension on the earlobe or tragus with deeper sutures that secure the SMAS (Superficial Musculo-Aponeurotic System) to the temporal fascia (just behind the temple in the hair-bearing scalp), and the mastoid fascia just behind the earlobe. That way the skin edges "kiss" gently together without tension and with a nearly invisible scar when fully healed, leaving all of the natural facial landmarks in their normal, natural positions (earlobe and tragus), with hidden scars, and without tell-tale signs of having had a facelift!

As for the scars in the hair (both in front and behind the ear), as long as the incisions carefully preserve the hair follicles,and are accurately approximated with fine, long-acting dissolvable sutures, normal hair growth is preserved and a hairline scar is hidden between the adjacent hair follicles. The behind-the-ear scalp line must be carefully preserved so there is not a notch in the normal hairline that is another of the across-the-room giveaways. and should be positioned HIGH behind the ear so that it crosses the bare area where it is covered (hidden) by the upper part of the pinna, NOT behind the earlobe over the mastoid and along the hairline. This scar is often explained to prospective patients as "necessary" in order to remove the excess neck skin. What it really does is to leave more "across-the-room" OMG scars. This, I assume, is why you are even asking the question--you have seen examples of this incision placement and the resultant ugly and visible scars, and don't want this yourself. You are correct, since the short anatomy and technique lesson I have tried to describe can be performed by any plastic surgeon who CHOOSES to utilize this slightly more judicious incision placement and a two-layer skin closure that takes all tension off the skin surface, A fine, nearly imperceptible scar results in the vast majority of patients.

Then, you only need the rest of the lower facelift/necklift to be performed to the same higher standard--not fastest, but truly the best!

There are at least 20 different face lift incisions and techniques that have been described and the choice may be a function of how much lax skin you have and its' distribution when making the decision. Discuss your options with your surgeon