Should a facelift incision be in front of or behind the tragus?

Question

What is more commonly done (for a less noticeable scar) and why? (I would assume behind the tragus, but I just saw a video saying that could cause a blunted tragus...)

Ronald Schuster, MD · Answer

There is always a gret deal of discussion it seems about whether the facelift scars should be infront or along the edge (behind) the tragus of the ear. I personally prefer to place it along the edge BUT it takes longer to do a meticulous job so that the tragus is not distorted and everything looks normal. Not all surgeons take the time to do thi and as a result either get a bad result or prefer the scar to be in front of the tragus. Sometimes, beause of the difference in quality of the skin it might be better to put the scar in front, but this is rare. As long as the scars heal so tha you can't see them, either placement is ok.

Andrew Turk, MD, FACS · Answer

I prefer to place the incision behind,  without blunting the tragus.  It is a more natural appearance in the female patient. With men, often a pretragal incision is made so the hairbearing skin is not placed behind the tragus.The surgical technique of the plastic surgeon is most important in planning and creating hidden facelift incisional scars. Consultation with a trained board certified plastic surgeon is very important. You do not want to be persuaded to undergo a "shortcut" facelift by a surgeon.

Michael Kulick, MD, DDS · Answer

My personal preference is to put the incision behind the tragus. You can look at the pictures in the weblink provided to show you why. For sure every surgeon has their preference and the final decision should be predicated upon a face to face consultation. This is your next step.Sincerely,

Michael Kulick MD

Board Certified Plastic Surgeon

Member of ASPS, ASAPS

Clinical Editor of the Aesthetic Surgery Journal

Recipient of the Klingbeil Award – Teaching Safe Techniques and Advanced Technologies

Garrett Griffin, MD · Answer

Most surgeons (myself included) I think go behind the tragus because it can be truly hidden...however, it can blunt the tragus if you don't thin the skin over the tragus and don't try to reform the depression in front of the tragus.  Long term a pre-tragal incision heals great as long as the skin is closed carefully, just most patients won't tolerate a visible incision there for 2-3 months until it fades.

Michael Boggess, MD · Answer

Hello.  Thank you for your question.  The ideal placement of facelift incisions, behind the tragus (post-tragal) or in front of the tragus (pre-tragal), depends on surgeon preference.  There is not a right or wrong answer to this question, and a skilled surgeon will get a good result with either technique.  The advantage of a post-tragal incision is that it hides the scar better, but it can lead to some potential blunting of the tragus, and in men it can pull facial hair up onto the tragus.  Blunting of the tragus can usually be avoided by thinning the skin flap over the tragus when closing the incision, and by avoiding tension on the tragus with the closure.  I personally prefer a post-tragal incision in all women and a pre-tragal incision in all men.  I would encourage you to seek a consultation with a board-certified Facial Plastic Surgeon, or Plastic Surgeon, with extensive experience and expertise in facial rejuvenation and allow them to assess your individual anatomy, concerns and goals, in order to determine the best treatment plan for you.  I wish you the best in achieving your aesthetic goals.

Alexander Anzarut, MD · Answer

This is an excellent question and there is no write or wrong answer. It is important for your surgeon to use the incision she or her is most comfortable with and avoid tension at the time of closure.
In my own practice the majority of patients have incisions placed behind the tragus. It is less visible. Patients who may have incision in front of the tragus include those with pre-existing deep creases in front of the ear. Patients who's cheek skin is very different from their tragus skin should have their incision in front of the ear. To help understand this, consider the male facelit. If the incision was made behind the tragus the beard skin would end up on the tragus itself. This would lead to beard growth on the tragus. 
The most important thing is the tension placed on the skin at the time of closure. A tight closure will lead to distortion of the ear, wide scars, and disfigurement. This is something I see all too often.
Best wishes, 
Alexander Anzarut

Jonathan Britto, MB, MD, FRCS(Plast) · Answer

Thank you for this question .. it is a regular one on this side of the World also! Whether 'in front' (pretragal; Pre-T) or 'behind' (post-tragal; Post-T) the surgical principal is that the incision closure should be tension - free. Where the 'weight' of the facelift or facial reconstructive procedure is borne by the deeper tissues in the face, the skin 'flap' can be lightly  inset and the skin can be closed without tension. The 'lift' is in the deeper face, so that the excess skin that is generated (typically 15-30mm of excess skin at the tragus in facelifts), can be trimmed in a tension free manner and lightly inset with low tension sutures. There is minimal scar sketch, maximal scar quality, and then the pros and cons of Pre-T and Post-T become less of an issue.
'Buried' or 'blunted' tragus with a post-T scar is avoided when the tension is reduced and the scar inset is accurate. 
In men, where I seek to avoid carrying beard/sideburn hair onto the tragus, I use a Pre-T scar. In women I tend to use a post-T scar (or, more accurately, a scar that crests the apex of the tragus), and I have not seen a blunted tragus in my practice. 
The scar risks, including blunted tragus, stretched scar and hairloss (when the scars are carried into the scalp) are all reduced when the closure is free of tension. This favours SMAS-based and subperiosteal facelift techniques, which avoid the 'weight' of the facelift being carried in the skin flap.
I hope that this helps you and thanks for posting the question!
Jonathan A Britto, Consultant plastic and craniofacial surgeon, London, UK.

George Sanders, MD · Answer

This issue has been discussed for years with excellent surgeons doing both and with excellent results. Those who favor the incision on the edge of the tragus cite the absence of a visible scar as a major advantage. Those who favor the incision in front of the tragus in a natural crease are equally adamant about the difficulty seeing the scar and also tout the absence of any potential hair growth from the surface of the tragus. They also point out that this incision avoids placing the thicker cheek skin on the tragus that can sometimes look unnatural as well as potential deformity of the tragus due to tension.Despite this, at present the majority of surgeons favor the incision on the edge of the tragus.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts.  The reality is, there are many different ways to perform a facelift from incision length, incision placement, level of tissue dissection (skin only, SMAS, Deep Plane, Subperiosteal), different degrees of tissue undermining, how to lift and support (imbrication versus plication of the SMAS layer), how much excess skin to trim, is excess fat going to be reduced and finally will the overall shape of the face be made more feminine or masculine (while avoiding the over pulled, windswept appearance).  I prefer placing the incision behind the Tragus.  Price is determined by the reputation, location and experience of the Facelift Surgeon.
In my humble opinion however, there are some basic requirements that must be met in order for a facelift to be "effective", yielding "aesthetic pleasing" and "naturally attractive" results.  These include: 
 1. Some type of incision either curved around the front (preferred) or straight in front of the ear.  This is how excess skin is removed which is not possible with an incision behind the ear alone.  If you have so little excess skin on the face that "none" needs to be removed you are not a candidate for a facelift in the first place.
2. The facelift must address correction and softening of the "jowls" using a long lasting and effective technique.  If you have "jowls” these are sagging facial tissues and the main 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.
3. Facial shaping must be combined to properly shape the cheeks, chin, jaw line and lips for feminizing or masculinizing the face as the case may be.
 In my experience, this is the "key" factor in making the face soft, feminine and naturally beautiful.  An essential part of any facelift on a woman.  Conversely, men look chiseled and handsome when angularity is created in the cheeks, chin and mandibular angles.  The ability to provide precise, facial shaping separately or in combination with a facelift is in my humble opinion the definition of a "facial shaping expert".
 Following my beauty principles, 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.
 A weak chin 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 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 the main 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 SMAS facelift is the minimally invasive, short incision SMAS 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 and no incisions extend or are placed within the hair.
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
proper SMAS Imbrication technique
no incisions within the hair  no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
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.

Should a facelift incision be in front of or behind the tragus?

Answers (9)

More Facelift Questions

WE SEND PRETTY
EMAILS

Answers (9)

More Facelift Questions

I'm concerned about the wrinkles around my eyes after upper and lower blepharoplasty and face lift. Need help understanding?

Is having a patient sign an arbitration clause prior to surgery standard?

3 weeks post deep plane face/neck lift--mouth stretched and pulled down. How can I fix this?

I keep reading that post-facelift swelling can last up to a year! Where is this swelling? Is it noticeable?

WE SEND PRETTY EMAILS

WE SEND PRETTY
EMAILS