Hi Anxious in nj,Great question. The way that the incision is performed around the tragus is a big pet-peeve of mine. I think you can tell a lot about a facelift surgeon by how they "finish" the facelift procedure in this small area of the face. Review the surgeon's before and after photos for facelifts. These photos ideally will show the front of the ear and how the face transitions to the ear and how the tragus is affected or not affected. If you feel these photos are acceptable, then you should be fine. I will give some tips for reviewing Facelift Before and After photos. Since most of the surgeons on Realself have before and after photos you will have plenty of photos to go over.This surgical dilemma is is a tough one to fully explain without pictures and diagrams. There are several factors which I take into consideration when making the decision to go in front of the tragus versus on the edge or behind the tragus. I did write a web article with pictures and diagrams in 2006 entitled, "Dr. Yang Explains ... Pre- vs. Post- tragal incisions" (Google it.)In the article, I diagramed a pre-tragal incision based off Calvin Johnson, MD, a New Orleans Facial Plastic surgeon. I interviewed with him for a fellowship position in 2003, and he told me that he preferred Pre-tragal incision, but during the fellowship year, they would occasionally perform a post-tragal incision for the fellow's sake and he will point out why I didn't like it. At the time, I didn't really understand his preferences and also thought post-tragal incisons were the better way to perform facelift incisions. I really respect Dr. Johnson, so I didn't understand why he preferred pre-tragal incision. Since I didn't do my fellowship with him, I still thought through fellowship, that the post-tragal incision was superior. I didn't purchase Dr. Johnson's textbook which pretty much only showed pre-tragal incisions. Until I started my own practice and tried both techniques and took standardized photos to check my work, did I truly understand what he meant. The only difference since 2009, is now I try to intentionally recreate the "No-wrinkle/Wrinkle appearance" of the Pre-tragal area (which I will explain more later in this response.) The incision design essentially is the same as Dr. Johnson's except with minor modifications on the upper half of the tragus.As the other surgeons have said, both the pre-tragal and post-tragal incisions can performed well, and both can be performed poorly and be tell-tale signs of a facelift. Probably it is better to let the surgeon do the technique that they feel comfortable. If you really don't want a pre-tragal incision, then find another surgeon whose post-tragal before and after photos look good to you. If you like your current surgeon's work and can't really tell that they are performing pre-tragal incisions, but the idea of it scares you, simply communicate with your surgeon and explain your worries. This will give you a chance to see how your surgeon communicates with your worries before surgery. If you don't feel reassured with the game plan before surgery, you may not feel comfortable with the surgeon after the surgery is already performed. Comfort and confidence with your surgeon's ability to consistently delivery great results in paramount. Also, you want to know that if anything goes wrong, your surgeon will be there for you to take care of any problems or offer a touch up to make sure you are happy. Not dissimilar to a good contractor, who will "actually" come back to do those minor touch up things which always pop up after the renovation is done.If the Before and After photo of just the front of the ear looked essentially the same, then there is really nothing to worry about ... right? This means there are no Tell-tale signs that a surgeon made an incision on the front of the ear. Are there Tell-tale signs only for the Pre-tragal incisions? Post-tragal incision? Here is a list of my Pet Peeves for both Pre- and Post- tragal incision.Tell-tale signs for Pre-tragal incisions"Straightness of incision is not natural"- Straight vertical incisions in front of the ear/tragus, without lining up the incision in the natural wrinkles and curves around the front of the ear. Clearly a straight incision is man-made and not natural. It is surprising when I see it, and think that a facelift surgeon made that incision."Poor scarring"- Hypertrophic (raised scar) or widened flat and wide scar (like a stretch mark) are a sign that too much skin was removed and too much tension was placed in the incision. This causes the incision to pull apart. If the patient has good elasticity of the skin, then it will likely be hypertrophic or thickened. If the patient has poor elasticity, then it will stretch out wide and have a wide, white scar. Poor scarring is obviously to be avoided. SMAS techniques to secure the deeper layer and only excise the excess skin under "zero tension" has helped to avoid this problem for most facelift surgeons. This may be one reason some surgeons only perform Post-tragal incisions, so that they may be able to excise a touch more skin without worrying about poor scarring."Change in appearance of the the Wrinkle-No Wrinkle in front of the tragus"- In general when performing the pre-tragal incisions in 2006, I was happy overall with the appearance, except for the upper half of the pre-tragal incision. Once the incision reachs to top level of the tragus, the incision around the upper third of the ear is the same for both pre- and post- tragal incisions. This incision curves around round transition at the top of the ear. This incision around the front of the top third of the ear and usually heals well. If hiding the incision is so important, then why not strip the skin on the top third of the ear and wrap facial skin on to there, too? This natural groove between the ear and the face makes for a great location to hide/camouflage the incision. This incision is also curved which may be a clue in how to make the pre-tragal incision look even better. The part that bothered me is when the wrinkle stopped midway on the tragus on the before photo, then the wrinkle/indentation continued all the way above the halfway point above the tragus. This made the wrinkle appear to go around the entire front of the tragus, which to me looked like a tell-tale sign of a facelift, even though the scar is paper thin, but the contours in front of the ear, didn't look natural to my eye. I showed these early 2006 photos to potential patients, and it didn't seem to bother them, but I knew I could do better. Other times in 2006, the exact same incision did not make this wrinkle extend above the halfway point, so I decided to see if I could do this consistently.Tell-tale signs for Post-tragal incisions"Disappearing Tragus"-The skin on the tragus is very thin (1/16"), while the facial skin is pretty thick (1/8"-1/4"). If this thick facial skin is sewn on top of the tragus, the shape of the tragus can disappear altogether. I have had consultations with patients after they had facelifts with other surgeons. They thought the other surgeon "cut off their tragus" because they couldn't see their tragus protrude from the side of their face anymore. On the revision facelift, the tragal cartilage is still present under the thick facial skin, but appeared to be "removed or excised" because the tragus disappeared. It is important to spend time to thin out the facial skin as much as possible without losing blood supply to the skin, in order to maintain a slight dip in front of the tragus. Additionally, adding a "basteing" stitch can help to compress the skin in front of the tragus and force it into the small groove in front of the cartilage. This can help maintain the appearance of the Tragus. I think it is hard to do."Thick Tragus"- Sometimes, the skin is thinned and the dip in front of the ear is present, but when the patient turns, somehow the tragus appears thick. I can't really explain why that happens, but I know when I see it."Line of demarcation in front of the earlobe"- This is a less obvious tell-tale sign and I would consider it the standard of care for facelifts, since I see this all of the time on the Upper East Side of Manhattan when I walk around the neighborhood. This line of demarcation is a thickened flap of skin, which sits in front of the earlobe. One way to avoid this is to also thin the facial skin from the facelift and make it match the thickness of the skin on the earlobe. This way the face smoothly transitions to the earlobe without a thickened flap of skin."Loss of facial ear junction"- This is combination of the above three tell-tale signs can cause the 4th tell-tale sign, which is when the face appears to "grow over" the front of the ear and the natural transition from the face to the ear is distorted. In this tell-tale sign, The face appears to continue to the opening of the ear, and the skin from the opening of the ear extends directly downwards to form a line of demarcation in front of the earlobe. The tragus is vitally important is telling our brain to help us identify where the face ends and the ear begins. If this facial ear junction is lost or seems to overlap, then our brain is confused. Thus the 4th tell-tale sign. In this case, it appears that the facelift patient has a mask-like appearance similar to the white masks people wear in a Masquerade Ball. These masks sit over the face and you don't really see the front part of the ear (where the tragus is located.)"Loss of the soft curved skin of the tragus"- If you google images of the ear, you will notice that the ear skin as a whole is similar to baby skin, with a very slight peach fuzz on it. Now compare the this baby skin on the earlobe and tops of the ear and compare this skin to the skin on top of the tragus. The tragus skin is also baby skin. In fact, this baby skin can even extend a 1/4" or more toward the temple hair tuft/Sideburn. This baby skin is irreplaceable. If your take a closer look at facial skin, you will notice large pores, and in some cases, women's side burns extend very low, and this sideburn hair can end up on top of the tragus. So with a post-tragal incision, the surgeon would be stripping off the baby skin and replacing it with a facial skin which needs to be thinned. If we look even closer at the edge of the tragus, notice the soft rounded skin, which is almost ball-like and wraps around the edge of the tragus. If the incision is placed directly on the edge of the tragus, the facial skin acts like a skin graft and flattens out the tragus into a straight line as the thinned skin contracts down. Bye-bye soft curved skin of the tragus. The best post-tragal incisions I have ever seen (not performed by me) actually are pre-tragal incisions which are simply very close to the edge of the tragus, but still not wrapping the facial skin around the edge of the tragus. I was surprised to see that these patients had a facelift, since I could still see the soft skin curve of the tragus, and I did not see any line of demarcation in front of the earlobe. Needless to say I was very impressed. I could still see a very faint white line right on the edge of the tragus, but the baby skin was maintained and wrapping the side edge of the tragus."Change in appearance of the Wrinkle-No Wrinkle in front of the Tragus"- A majority of people have their tragus angle away from their face at more than 30 degrees. The minority of people have a completely flat tragus, which may angle out not more than 15 degrees. The people with a flatter tragus which does not stick out at all, will sometimes have a wrinkle which starts at the opening of the ear. So this is considered normal for that person. The majority of people have a wrinkle which starts below the mid-point of the tragus. But above the skin on the upper half of the tragus does not have any wrinkle. I think it is important to maintain the appearance of the facial ear junction/tragus appearance for each patient. Although it may look normal by itself, I have tried to identify all of the "Pet-peeves" which bothered me with before and after photos of facelift patients. When performing a post-tragal incision on a patient, whose tragal cartilage angles out more than 30 degrees, the thickened facial skin and loss of the natural wrinkle in front of the tragus, is another tell-tale sign (albiet hard to detect for most lay people.) In order to avoid this, I cannot perform a post-tragal incision and need to perform a pre-tragal incision.As you can hopefully see, I may be over the top when analyzing this seemingly inconsequential area which most surgeons do not give much thought to, other than taking care to thin the skin so the skin levels match. I will offer the patient both types of incision and also explain to them my criteria for choosing one over the other.Since you are interested in the post-tragal incision, I will give my criteria for recommending this type of incisionThe ear cartilage is naturally very flatThere is no wrinkle or cartilage edge in front of the earthe quality of the skin on the cheek matches the natural skin on the ear cartilage with a relatively high sideburnThere is a natural wrinkle or skin web that comes down directly from the lower opening of the ear crossing in front of the earlobePerforming a post-tragal incision on this type of patient, will be easier, since their before anatomy is already somewhat like a postoperative post-tragal incision. As my mother taught me, if you borrow something, you should return it the way that you found it. I took that to heart. Even though the post-tragal incision may look normal by itself, the fact is that patients will know their own faces, and may notice that the front of their ear appears different. For this reason, I don't simply offer one type of incision, I recommend incisions in order to try to maintain the anatomy which they have before the facelift. Most patients may not appreciate the thought and care that went into the decision, but most of my patients are very picky, so they do seem to appreciate it.If the patient has olive or more pigmented skin, and their ear skin/tragus skin is light colored baby skin, I feel it is more important to match the tragus skin to the rest of the ear. If you look carefully, the earlobe has a small baby skin extension which connects to the tragus. To my eye, it looks like a small whale's tail. The ear and earlobe is the body of the whale, and the small skin extension is the tail, and the tragus is the flipper of the whale's tail. I prefer not to strip this baby skin and place darker skin over the tragus. If the patient's skin is very fair, to the point that the facial skin is practically baby skin, then this anatomic configuration will be very helpful when performing the post-tragal incision.Having explained all of that, for the majority of my patients I do perform pre-tragal incisions, because I think it will maintain their pre-operative pre-tragal anatomy. I do explain to them, that the initial redness of the incision may be more obvious than the post-tragal incision (but coverable with makeup), but over time as the redness fades, these pre-tragal incisions improve with time and end up looking better than the average post-tragal incision. Why? By respecting the natural facial subunits, boundaries, different skin textures and types, keeps the anatomy more "true." Stripping baby skin off the tragus to place the thicker facial skin (even if I thin it as much as possible), breaks my heart. If the patient is a revision facelift and they already had a post-tragal incision, then I will try to make it the best possible post-tragal incision as possible, and add in some details which the original surgeon may have overlooked.Recreation the No-wrinkle/Wrinkle Configuration along the Pre-tragal area.My dilemma with the post-tragal incision for patients with a clear Pre-tragal wrinkle in front of the tragus is how do I transition the incision in the Pretragal wrinkle into the post-tragal incision. If you make a straight line from the earlobe to the post-tragal incision, you will create a line of demarcation. If you follow the pre-tragal incision to the natural wrinkle below the lowest point of the tragus, some surgeons will make a 90 degree incision to then switch to the post-tragal line from the pre-tragal wrinkle.What I decided to do is to see if I can consistently recreate the No-wrinkle upper half of the pre-tragal incision and maintain the wrinkle on the lower half of the pre-tragal incision. I have been very happy with the results, and it satisfies my criteria for avoiding the Tell-tale signs of the pre-auricular incision (incision in front of the ear.) I needed to stop the wrinkle at the patient's natural location of their wrinkle. By curving the incision on the upper half of the tragus, it helps to break up the incision. The second part is to make sure the incision is completely flat on the upper half, and naturally folds on the lower half. Plastic surgeons know how to intentionally make incisions flat or indented, so it is very reproducible.I enclosed a link below to my before and after gallery to mini-facelift with full necklift gallery. One aspect of my practice, which I think helped me notice these tell-tale sign is standardized photography and insisting to take photos each time they come in for a follow up. My patients know that I want to take photos and it has become amusing for them ("Yes, I know, you want to take photos"), since they already know what I am going to ask them to do. I do credit their cooperation helping me with to improve my surgical technique.Postoperative photos are analogous to keeping score in Golf. Some people play golf and don't keep score, or they fake their score and tell you how great they are at golf. In a real tournament, when people are competing against you, then you can't cheat without people calling you on it. Since plastic surgery is real life and I am essentially competing against everyone else who performs facelifts, then keeping score is very important. Plastic Surgery is like tournament golf and not hacking around with buddies on the weekend. If you don't do well, the patient will definitely call you on it.If you count every stroke in golf and play the ball as it lies (and also track where I miss my shots and how many chips and putts I took), you will know if you are truly improving, or what areas of your game need more work. If you fake your score, or don't keep score at all, then it will be very hard to improve. Standardized photography and lighting is keeping a true scorecard. If the photography is inconsistent or the lighting is different, or they intentionally hide the front of the ear with hair or crop the photos so you can't see the ears, doesn't it make you wonder if they are hiding anything or if the surgeon doesn't think it is important to look at the front of the ears. If the surgeon takes the time to line up their before and after photos and critique themselves, usually there is always room for improvement. Sometimes I will try something new, and use the photos to determine whether it is better than previous techniques, and check over time whether the results are durable.I hope you find this "new article" (without diagrams) helpful. Good luck on you facelift journey.Best,Dr. YangP.S. There is a new feature on Realself, which is the "Follow" button. It is similar to the "Like" button on Facebook. If you like my response or any of the doctor responses while you research on Realself, you should "Follow" them. You will get email updates, when the doctors you follow post any new answers to questions, post new photos, or have any new reviews.
