In a facelift, how do surgeons ensure that they preserve the intertragal notch of the ear when making the post-tragal incision?

Many surgeons seem to distort the little curved portion at the base of the ear opening (intertragal notch?) when making the anterior ear incisions. Instead of a curve it ends up as sharply pointed V, with a "seam" where the lobe joins the cheek. (I posted some photos of my ears on a previous question.) I understand that to avoid this, some surgeons make a pre-tragal incision, instead of going behind the tragus, although the scar is more visible. How can it be preserved with post-tragal incision?

Doctor Answers 9

Facelift Incisions Tailored for Each Patient

Deciding on the best surgical approach for a facelift — including where to make incisions — is one of a plastic surgeon's primary responsibilities. There is no universally superior incision, and each patient needs to be evaluated before the surgeon decides on which incision option will produce the "best" scar. Some patients have well-established vertical creases directly in front of the ear, for example, which can be used to hide incisions. The quality of a patient's skin and the surgical technique used also make a difference in determining the incision location. And finally, each surgeon's own preferences play a part.

Long Island Plastic Surgeon
4.6 out of 5 stars 22 reviews

Tragal incision natural results.... secrets revealed.

the quick answer is based on recreating the original feature. the technique is based on thinning the skin as much as possible to achieve better definition. in addition a pretragal stitch to keep the tissues with out tension will favor pretragal definition as well as preventing anterior curving or arching or the area.Finally, make sure that you have a consultation with a board certified plastic surgeon. Wishing you the best in your journey

In a facelift, how do surgeons ensure that they preserve the intertragal notch of the ear when making the post-tragal incision?

 Hi, I have performed many Facelifts over the past 30 years.  The "secret" is knowing how to re-create the pre tarsal dip so it appears natural.  I have a two-step process to recreate the natural tragal dip that I perform for all facelifts.  Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face. If the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.   I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.

 If you have "jowls” these are sagging facial tissues and an indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.  My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
  • very small incisions
  • minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
  • can be performed in 90 minutes or less, with or without general anesthesia
  • no incisions within the hair = no hair loss
  • excess fat can be removed
  • excess skin removed
  • cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
  • most patients fly back home to parts all over the world in as little as 3 days post-op
 I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.

Hope this helps.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.6 out of 5 stars 24 reviews

Tragus deformity following tragal incisions at facelift.

Dear petaross:The art of facelift is in the suspension of underlying tissues with the gentle tucking and not-tight redraping of the overlying skin. If the skin over the tragus is pulled too tight, the healing forces of collagen/scar formation will deform the tragus.Discuss this concern at your facelift consultation and obtain other opinions by a Board Certified Plastic Surgeon talented in up-to-date facelift techniques. All the best! 

Dean P. Kane, MD, FACS
Baltimore Plastic Surgeon
4.8 out of 5 stars 81 reviews

Incision tailoring

When the incision goes behind the tragus, it has to come out from behind the tragus onto the anterior surface of the cheek at the cheek lobule junction. By the very nature of incision design, it is most commonly a straight line from behind the tragus onto the anterior cheek skin just at the lobule junction.  This may be the reason the intertragal notch is not curved post operatively.  I'm not sure what you mean by a V because that seems to infer how the lobule joins the cheek, which is a different issue.  This is all a matter of incision design and attention to detail.  However, even in the best of hands, normal anatomy can be distorted by incisions, even with the utmost care.

Brian K. Machida, MD, FACS
Ontario Facial Plastic Surgeon
4.1 out of 5 stars 22 reviews

In a facelift, how do surgeons ensure that they preserve the intertragal notch of the ear when making the post-tragal incision?

To prevent an operated appearance, tension needs to be evenly dispersed around the ear, and not on the skin. For women, I prefer to go behind the tragus to camouflage the incision. This works well for even short hair styles. Good luck!

Keith Hodge, MD
Leawood Plastic Surgeon
5.0 out of 5 stars 27 reviews

Scars in facelifts

Many thanks for posting your questionThere are several keys to getting good scars in facelift surgery - the first is to minimise tension on the skin. This is done by ensuring there is a good lift on the SMAS, the underlying supportive soft tissue skeleton of the face. Following that, the skin must be carefully tailored to fit around the previously planned incisions.Whether the surgeon makes a pre- or post-tragal incision will not affect the position of the earlobe - that is a separate issue. (The tragus is the curved cartilage that points into the ear)I hope that answers your question

Marc Pacifico, MD, FRCS(Plast)
London Plastic Surgeon
5.0 out of 5 stars 47 reviews

Facelift incision

Although there are some aspects of healing that are impossible to predict, technique can have a great impact.  Deformity or malposition of the ear lobe will always be a sign that surgery was done.  This is not minimized by a pretragal vs. retrotragal incision.  Rather, the ear lobe must be inset in the right position, without tension on the skin.  This requires good surgical technique.

David A. Lickstein, MD
Palm Beach Gardens Plastic Surgeon
5.0 out of 5 stars 5 reviews

Considerations in facelift incision planning

Hi there. Thank you for the question. Planning incisions appropriately is a crucial step in getting a great outcome in facelift surgery. In women, a retrotragal incision is generally preferred as it is less conspicuous. Several manoeuvres help deliver a natural and normal looking ear (including intertribal notch and earlobe) - these include careful shaping of the facial skin after redraping, thinning of the edge of the facial skin flap and avoidance of over resection. This is a very detailed and thoughtful question and I would therefore suggest you would be best seeing a Plastic Surgeon with a genuine interest in facial aesthetic surgery. Good Luck!

William Townley, MD, FRCS(Plast)
London Plastic Surgeon
5.0 out of 5 stars 52 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.