Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 1449e1458

Avoiding the operated on look in multiple face lifts

Daniel Marchac a,*, Marwann Nasr au lieu de Nask b
a b

130 rue de la Pompe, 75116 Paris, France Beirut, Lebanon

Received 11 March 2008; accepted 4 May 2008

KEYWORDS
Face lifts; Rhytidectomy; Multiple procedures; Secondary face lifts; Facelift scars

Summary Aim: Reviewing 43 patients of ours who have had three or more face lifts, we wanted to demonstrate that it is possible to avoid the multi-operated on look. Material and methods: Forty-three patients have been operated on three times or more: 42 females and one male. Thirty-six patients had three face lifts, six had four face lifts, one patient had ve face lifts. The mean age at time of surgery was 50.3 years for the rst face lift, 56.7 for the second, and 64.2 for the third face lift. These patients were operated on by the same surgeon using a technique which has evolved over the years but with the same basic goal of hiding the scars and of minimising hairline displacement. General appearance, scars and hairline displacement were evaluated in patients who had had three or more face lifts. Results: The results of the evaluation of our 43 multi-operated on face lift patients were as follows: 35 patients did not appear to have had face lifts, eight patients did appear to have had face lifts, but with satisfactory appearance, 30 patients had no visible scars at a conversational distance, 10 patients had slightly visible scars when their hair was lifted, ve had obvious scars when the hair was lifted, 34 patients had a normal hairline, six patients had a slightly receding hairline at the temporal level and three had hair loss at the level of the temporal scar. Conclusions: New technical improvements allow the preservation of a natural appearance, with well-hidden scars and a well-placed hairline. The common opinion that several repeated face lifts should be avoided because they give an unnatural appearance and severe sequelae in terms of scars and hairline displacement has not been conrmed by our clinical experience with 43 patients having undergone at least three face lifts. 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 33 1 47 27 44 31; fax: 33 1 47 27 65 15. E-mail address: danielmarchac@hotmail.com (D. Marchac).

There is a common belief that repeated face lifts are responsible for an unnatural appearance with signicant sequelae in terms of scars and hairline displacement. This opinion does not correspond with our experience with our own patients.

1748-6815/$ - see front matter 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.05.039

1450 Reviewing our 43 patients who have had three or more face lifts, we want to demonstrate that it is possible to avoid the multi-operated on look.

D. Marchac, M. Nasr au lieu de Nask

Material and methods

Forty-three patients have been operated on three times or more: 42 females and one male. Thirty-six patients had three face lifts, six had four face lifts and one patient had ve face lifts. The mean age at the time of surgery was 50.3 years for the rst face lift, 56.7 for the second, and 64.2 for the third face lift. Operations were performed with local anaesthesia (lidocaine and epinephrine) plus i.v. sedation with propofol. These patients were operated on by the same surgeon using a technique which has evolved over the years but with basically the same goal of hiding the scars and of minimising hairline displacement.1e3 Since 2000, we have used the vertical U technique4: in the temporal region the incision is vertical above the base of the anthelix for about 4 cm and then turns horizontally (Figure 1). In front of the ear, the incision is made on the edge of the tragus, turns around the earlobe, and follows the retroauricular sulcus as long as it is vertical. When the retroauricular sulcus turns anteriorly, the incision continues vertically, parallel to the temporal incision, about 3 cm behind, for about 4 cm. At the temporal level, the skin undermining comes close to the lateral canthus, above the orbicularis muscle. This dissection is supercial, subcutaneous with the exception of the upper part (the horizontal part of the incision) where the connection is maintained with the deep level. Sometimes, we replace this temporal approach with a horizontal incision below the hair, in front of the ear, stopping before the limit where hair implantation turns posteriorly. We usually then add a separate horizontal incision in the upper temporal area to be able to spread out the temporal skin. This approach is used when the patient is a smoker, or has thin hair in the temporal area, or has experienced hair loss in this area after previous operations. At the cheek level, the dissection is performed subcutaneously, keeping a thin layer of fat under the dermis. The extension of the undermining varies, from a vertical line at the malar level, to a more extensive dissection getting close to the nasolabial fold. Behind the ear, the dissection is also supercial, under the scalp and the skin of the neck. The neck dissection is extensive when there is a fat deposit to remove and signicant skin excess, but is more limited otherwise. When there is a sagging of the deep layers of the cheek, we perform a supercial muscular aponevrotic system (SMAS) dissection and elevation, anchoring it to the temporal aponevrosis.5 We also usually then cut the posterior part of the platysma horizontally, to allow an upward rotation.6 When the pull on the deep layers is not effective, we used to perform a plication of the SMAS and lateral pull on the platysma, but now we prefer to perform a suspension of the deep layers. Instead of several loops,7 we use the simple big loop anchored above

Figure 1 The vertical U incision. The incision is vertical in front of the ear and curves in the temporal area. Behind the ear it continues vertically in the scalp. The undermined area is under the scalp and the retroauricular skin. From: Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002; 109: 2539e2551eReproduced by permission.

the ear as described by Stocchero8 which elevates the neck and the cheek en bloc, often associated with a minimal skin undermining (Figure 2). To determine the positioning of the loop, we start by looking for the point of the platysma dened by D. Labbe9 which gives the best denition of the neck when pulling on it. From this point the 2/0 prolene loop will pass through the tissues of the cheek at the SMAS level and go up and backward to the temporal area. With our vertical technique we do not need the circular needle of Stocchero8 and use just a straight stitch passer9 between the upper part of our posterior vertical incision and the temporal area.10 After anchoring the key points behind the ear and at the supratrageal area, the skin is adjusted (Figure 3). At the temporal level, to avoid the elevation of the hairline, we lower the temporal ap, folding it on itself under the lower hairline, and we resect the triangle thus delineated. We excise only the epidermis in the triangle for two reasons: (1) improvement of the blood supply to the hair triangle; (2) to prevent a depression. Before we implemented this technique, we had observed a depression at the level of the horizontal scar on long-term follow up. Keeping the dermis and fat sometimes creates a temporary bulge, which disappears, and leaves a at nal result (Figure 4).

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Figure 2 Monobloc face lift. Often, in the patients with moderate sagging, we can perform a suspension with one single loop of 2/0 Prolene, as advised by Stocchero.10

Figure 3 After treatment of the deep layereusually liposuction and SMAS elevationethe skin is redraped. Behind the ear there is a signicant discrepancy between the anterior and posterior edges. This difference is resorbed by suturing together the edges with small stitches on one side and big stitches on the other side, with several layers. From: Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002; 109: 2539e2551eReproduced by permission.

Behind the ear, the hairline is re-established, and the posterior excess appearing at the scalp and skin level is adjusted by the suture (Figure 5). When the backward displacement is signicant, and we often have a 4 to 6 cm displacement, it is in fact not difcult to adjust two edges so different in size, posterior to the key sutures placed on the mid-ear, at the Frankfurt line level. Firstly the hair line is realigned, with a stitch on the periosteum on the upper edge to avoid scalp posterior displacement. The difference between the two scalp edges is easily taken care of by a running suture of 3/0 Vicryl Rapide, a big stitch on the lower edge, and small stitches on the upper edge. There is sometimes a bulge of the scalp below the suture. It will atten out in a few weeks. One is left with the skin discrepancy between the hair line and the mid-ear key stitch. The retroauricular skin at this level is very thin and adjusts easily. Pulling the lower ap up with moderate tension, a minimal skin excision is performed, and the sutures are performed in two layers: a series of inverted stitches and a subcuticular resorbable 4/0. Occasionally, some small folds appear. They usually disappear after a few weeks. This technique avoids any hairline displacement (Figure 6) and no hair-bearing area resection is involved. The scars are well hidden. We usually ignore the old transversal scar, perform a vertical incision, and the old scar will be better hidden and higher (Figure 7). In smokers, patients with thin hair, or when a moderate upward check displacement is planned, we replace the temporal rotation ap with a staged approach: an incision under the hairline in front of the ear and a separate superior incision, corresponding to the horizontal upper limb of the ap. A good lighted retractor is essential for dissection and haemostasis.

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D. Marchac, M. Nasr au lieu de Nask

Figure 4 Downward temporal ap, to avoid elevation of the hairline. The triangle is desepidermised to improve blood supply. From: Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002; 109: 2539e2551e Reproduced by permission.

Evaluation of the results has been made following three criteria:  Appearance: natural or operated  Scars: visible or not  Hairline: preservation or displacement. A four-grade scale was used. Appearance 1 The patient does not appear to have undergone a face lift. 2 One can guess the patient has undergone a face lift, but patient looks good. 3 The patient looks like they have undergone a face lift, with visible anomalies. 4 The patient presents with severe anomalies and distortions.

Scars 1 No visible scars. 2 Slightly visible scars when hair is lifted. 3 Obvious scars when hair is lifted. 4 Severe scars impossible to hide. Hair displacement 1 Normal hairline. 2 Slightly receding hairline. 3 Signicantly displaced hairline. 4 Severe loss of hair in temporal and/or retroauricular areas. The evaluation was performed by observers who were not involved in the surgery, and at least 6 months after the last operation.

Avoiding the operated on look in multiple face lifts

1453 - Six patients had a slightly receding hairline at the temporal level, - Three had hair loss at the level of the temporal scar. Among the 43 operated on patients 25 had had two SMAS ap elevations and four had three SMAS elevations. Thirtyone patients had two temporal downward aps and 10 had 3 temporal aps.

Clinical examples
An elegant women had her rst facelift at 48 years of age. At 62 years old, after three face lifts, she looks natural and has kept the contour of the face she had at 35 (Figure 8). This patient had a beautiful face at 40 years of age. After her third face lift, at 71 years of age, she still looks younger than her age and still has a natural appearance (Figure 9). This 75-year-old old woman had two face lifts done elsewhere, with abnormal skin fold and adherences. A third face lift allowed us to redrape the different layer and to ll the left cheek depression with an autogenous fat injection (Figure 10). This 72-year-old woman is seen after she had already had ve face lifts. Five other face lifts were performed by us, the last at 93 years old. The ageing of the skin is visible, but the shape of the face has not changed and she maintains a natural appearance. Her hair is also well preserved (Figure 11). In ageing patients, a complete medical evaluation is of course obtained and operations are more limited. Patients recover very well from these operations performed with local anaesthesia plus i.v. sedation.

Figure 5 A section drain is placed in the cervical area and the skin excess removed. No hair-bearing area has been removed or displaced. From: Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002; 109: 2539e2551eReproduced by permission.

Discussion
Improvement of techniques has transformed the problem of repeated face lifts. Previously, the operation largely consisted of a large subcutaneous dissection, followed by an elevation with a strong posterior pull. The hairline was elevated and recessed in the temporal area and was disrupted in the retroauricular area. All these aspects have been addressed: 1 The pulled look has to be avoided by a precise repositioning of the deep layers. The extent of skin undermining is variable. In repeated face lifts, one sometimes has an irregularity of fat in the neck or lower jaws, or adherences (Figure 10) and this requires a wide skin undermining, both to obtain a smooth deep level and to properly redrape the skin. When there are deep winkles on the cheeks, and/or fat excess in the neck, a large undermining is necessary. But often in secondary cases with no or limited cervical fat (removed by liposuction with no.3 cannula), a limited skin undermining of 5 cm around the ears is sufcient. For the deep layers, the SMAS (supercial musculoaponevrotic system)5 is our preferred option, but when the pull on the SMAS is not effective, we perform a monobloc suspension with a great loop of 2/0 prolene.8

Results
General appearance, scars and hairline displacement were evaluated in patients who had had three face lifts or more. Using these scales, the results of the evaluation of our 43 multi-operated on face lift patients were as follows: Appearance - Thirty-ve patients did not look as if they had undergone a face lift. - Eight patients looked like they had undergone a face lift, with a satisfactory appearance Scars - Thirty patients had no visible scars at conversational distance. - Ten patients had slightly visible scars when their hair was lifted. - Five had obvious scars when hair was lifted. Hair displacement - Thirty-four patients had a normal hairline.

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D. Marchac, M. Nasr au lieu de Nask

Figure 6 (A) Five days after vertical incision in a 60-year-old woman with 5 cm of retroauricular displacement. (B) Six months later: the retroauricular scar is well hidden behind the ear and the hairline is not displaced. From: Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002; 109: 2539e2551eReproduced by permission.

The undermined surface is diminished signicantly by the suspension, helping to minimise postoperative oedema and ecchymosis. 2 To avoid displacement of the hairline in the temporal area, for the last 20 years we have adopted the downward rotation ap4 which maintains the hairline in its normal position (Figure 4). 3 Behind the ear, we have modied our approach several times, always preserving the hairline. We now use a purely vertical retroauricular approach4 (Figures 1, 3, 5, 6). The hairline does not change, and the scar is not visible, hidden behind the ear.

We are, of course, aware that there are other options. Some advocate a retroauricular pre-capillary incision to be sure not to displace the hairline. Even if some excellent results have been presented,10 we avoid this pre-capillary incision because we consider it is unpredictable: we have seen cases with hardly noticeable pre-capillary scars, and others, done just as carefully by the same surgeon which remain permanently quite visible, with a tendency to widening. There has also been a trend towards a short scar technique, stopping below the ear lobes, and often using suspension techniques to limit the undermining and modication of the deep tissues.7e11 There are indications for

Figure 7

In a secondary case, the old transverse scar is ignored, and is elevated at the end of the adjustment.

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Figure 8

(A) At 35 years of age. (B) At 62, after three face lifts.

these scar-minimising techniques, but when the cervical sagging is signicant, with an excess of skin, a longer scar, hidden behind the ear, allows an efcient redraping. The scar is denitely longer, but perfectly hidden. With the short scar approach and its vertical cheek upward pull, there is a surplus of skin in the temporal area which makes it necessary to perform a pre-capillary incision to remove it.12 We disagree with the extension of the pre-capillary temporal scar. When the scar comes in front of the hair

growing backwards, there is always a risk of visible scars and to take such a risk, especially in a young woman, is not advisable. When performing a second or third face lift on a previously operated on patient, one encounters several problems: The previous scars: When the rst operation was performed by us, we can just reincise along the same scars. In the retroauricular area, since we have used the vertical

Figure 9

(A) At 40 years of age. (B) At 71 years old, after three face lifts, this patient maintains a natural look.

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D. Marchac, M. Nasr au lieu de Nask

Figure 10 (A,B) This patient, operated on elsewhere for her second face lift, ended up with retractions and an abnormal fold at 75 years of age.(C,D) The third face lift allowed us to redistribute the tensions, and the depression of the left cheek was corrected with fat injections.

approach only since 2000, our patients operated on previously present with a horizontal retroauricular scar, usually of good quality. We ignore it and perform a vertical incision. We have never seen a skin necrosis because of the old scar. When the retroauricular transversal scar is visible, distended, then one can excise it and try to improve it. Usually we prefer to ignore it and make a vertical incision, elevating higher the old scar (Figure 7). When the patient has been operated on elsewhere the situation can be difcult: 1 In the temporal area, one can nd a precapillary scar. For safety, we prefer then to reincise the same scar, and try to do a good pre-capillary suture. In other cases, there is an elevated inferior hairline.

A downward temporal ap will be able to improve the situation, and the nal lower hairline can actually be lower than after the rst face lift in spite of the second elevation of the cheek. 2 In the preauricular area, one can nd a vertical pretrageal scar. It is then better to incise this scar, to elevate the cheek, and to hope that at the end of the procedure it will be possible to displace the cheek ap far enough backward to be able to place the nal scar on the edge of the tragus, without tension, as it is our preferred hiding position for this scar. The lobule of the ear can be pulled down. One will incise around it, free the adhesions that can exist to be able to lift it, and replace it on the elevated ap, hanging down, without any tension.

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Figure 11 The champion of our series.(A,B) The patient is seen at 72 years old having already had ve face lifts.(C,D) She is now 94 years old and had her 12th face lift 6 months ago.

3 In the retroauricular area, as mentioned above, one usually ignores the existing horizontal or oblique scars. These scars will be less visible since they are elevated by doing the vertical retroauricular approach. The dissection can be more difcult. Usually, after a previous uneventful and well performed face lift, the dissection is not difcult, and even sometimes very easy, opening up like a book. In some cases, there can be signicant adherences, especially below the ear and at the malar area. The dissection, helped by abundant inltration, should be cautious, step by step, and we use scissors and lighted retractors, and sometimes translucent lighting, through the skin, to help evaluate the thickness. Once the subcutaneous dissection has been performed, one can evaluate the possibilities. Again, when the rst operation has been performed in good planes, it is perfectly possible to repeat a SMAS ap5; we have done it many times. When there is a doubt about the possible modications of the anatomy, it is safer to perform a SMAS plication or a suspension.8 The situation at neck level is variable: when the patient has undergone neck defatting during previous operations, it

is usually not necessary to excise fat again, but a large skin dissection is helpful to redrape the skin, and the platysma is put laterally under tension. In conclusion, the common opinion that several repeated face lifts should be avoided because they give an unnatural appearance and severe sequelae in terms of scars and hairline displacement has not been conrmed by our clinical experience with 43 patients having undergone at least three face lifts.13 New technical improvements allow preservation of a natural appearance, with well-hidden scars and a well-placed hairline.

References
1. Marchac D. Preservation de la ligne chevelue dans les liftings cervico-faciaux par double lambeau de rotation temporal et retro-auriculaire. Ann Chir Plast Esthet 1992;37:519. 2. Marchac D. Preservation of the hairline in face lifts by double temporal and retro-auricular aps. Plast Surg Tech 1992;1:217. 3. Marchac D, Vandevoort M, Fischer D, et al. Avoiding hairline displacement: a high ap to eliminate transverse retroauricular scars. Aesthetic Surg J 1999;19:187.

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4. Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg 2002;109: 2539e51. 5. Mitz V, Peyronie M. The supercial musculo-aponevrotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976; 58:80. 6. Connell BF. Surgical techniques of cervical lift and facial lipectomy. Aesthetic Plast Surg 1981;5:43. 7. Tonnard PL, Vergaele A, Garin S. Optimising results from minimal access cranial suspension lifting CMACS-lift. Aesthetic Plast Surg 2005, JulyeAug;29:219e20. 8. Stocchero I. Shortscar face-lift with the round block SMAS treatment: a younger face for all. Aesthetic Plast Surg 2007; 31:275e8.

D. Marchac, M. Nasr au lieu de Nask

9. Labbe D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg 2006, May;117:2001e7. 10. Marchac D., Evaluation of the result of 50 face lifts with monobloc suspension (in french). The French Journal: Ann Chir Plast Esthet, in press. 11. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when performing a face lift. Plast Reconstr Surg 1997;99:10. 12. Baker DE. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesthetic Surg J 2001;21:14. 13. Marchac D. Multiple face lifts. Is it possible to avoid the multioperated look? Pol Przegl Chir 2006;78:1382e92.