INNOVATIVE TECHNIQUES AESTHETIC

Rhytidoplasty Without Periauricular Scar

Alfonso Riascos

Received: 6 May 2011 / Accepted: 10 October 2011 / Published online: 15 November 2011

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011

Abstract As plastic surgeons, it has always been our goal

to reduce the scarring associated with facial plastic sur-

geries. These scars generally occur on the scalp and in both

the pre- and retroauricular areas. In 194 of our patients who

underwent rhytidoplasties, we successfully eliminated

these retroauricular and preauricular scars. To achieve

these results, we did not make periauricular incisions;

instead, we made a superior incision, a subcutaneous dis-

section, and used various surgical maneuvers such as

subdermal plication and structural grafting. By utilizing

this facelift technique, we were able to eliminate the

appearance of periauricular scars associated with facial

plastic surgery, reduce complications, achieve natural-

looking results, and increase patient satisfaction.

Keywords Rhytidoplasty � Periauricular � Grafting �Suspension

In the field of plastic surgery, facial rejuvenation can be

achieved by using various surgical techniques, many of

which leave scars. Scarring is the stigma of plastic surgery.

Patients can undergo various types of facelift procedures

and be left with varying degrees of scarring. Rhytidopla-

sties can leave large scars that extend throughout the scalp

and into the preauricular and retroauricular areas from the

use of different types of suspension of the internal tissue, as

well as plication or dissection [1] of the superficial mus-

culoaponeurotic system (SMAS) [2]. Another facelift pro-

cedure that uses an endoscope on a different level of

dissection leaves small scars on the scalp as well [3].

Rhytidoplasty surgery as proposed by Baker [4] leaves the

patient with preauricular scars but no retroauricular scars;

in this procedure, the subdermal tissue is suspended. Cur-

rently, we use this facelift procedure for nearly 90% of our

facial plastic surgeries.

To perform a successful rhytidoplasty, surgeons should

know and understand the effects of aging on a patient’s

face. Not only does the skin lose its elasticity, thickness,

and youthful appearance, but the subcutaneous, muscular,

and ligamentous tissues begin to descend [5]. This conse-

quence of aging causes the external skin to sag. Atrophy of

fat and bone tissues also occurs during aging, along with a

general decrease in tissue mass, which produces depres-

sions and wrinkles in the skin, which vary in severity from

person to person (Fig. 1). Changes in the skin are deter-

mined by a person’s genetics; however, external factors

such as changes in weight, lifestyle, sun exposure, and

smoking [6] can further contribute to skin damage.

Our goal is to present an alternative technique for facial

rejuvenation. This approach gives plastic surgeons another

way to satisfy the patient by avoiding the periauricular

scars related to this procedure and reducing complications.

Materials and Methods

Over 2 years (from October 2008 to October 2010) we

performed 194 rhytidoplasties using our proposed approach.

All patients underwent normal preparation procedures.

In the preoperative stage, the patient receives a thorough

consultation so that he or she is well-informed about how

A. Riascos (&)

Centro Medico Imbanaco (Laskin),

CRA. 39 # 5a – 91 Piso 3, Cali, Colombia

e-mail: alfonso.riascos@imbanaco.com.co;

alfonsoriascos@gmail.com

123

Aesth Plast Surg (2012) 36:540–545

DOI 10.1007/s00266-011-9837-2

they have aged and what can be done to remedy the effects

of this aging. Presurgical markings are made on the

patient’s face while he or she is standing up. Ideal patients

for this surgery are in their mid-40 s to mid-60 s. Patients

over 70 years old or patients with wrinkled and loose

flaccid skin are generally not considered for this procedure

unless they fully understand that following the surgery,

they may still have some wrinkles and excess skin.

During the surgery, the patient is sedated and local

anesthetic is utilized in the same areas as in an extended

classic subcutaneous rhytidoplasty (from the temporal to

the cervical areas). Fatty tissue is then gathered from the

abdominal region for grafting, if necessary.

To rejuvenate the neck and the cervical region, a small

submental incision is made, followed by suction-assisted

lipectomy, a wide subcutaneous skin dissection, a strong

medial plication of the platysma muscle [7] (which joins

its fibers medially by way of four or five separated stit-

ches), and, in most cases, a suture suspension of the

platysma muscle (as published by Giampapa et al. [8]).

To improve the appearance of the neck, it is always best

to move toward joining the tissue—medially, superiorly,

and posteriorly—to achieve a 90� angle [9] by stretching

the skin in a 1:1.4 proportion (as in an isosceles triangle).

This can be seen in Fig. 2a, b. The neck treatment is of

major importance, so even when the patient is looking

down, the cervical region stays intact.

A horizontal incision is made at the level of the auricular

superior vertex, with the scalpel cephalically inclined. The

incision is about 2–5 cm long (Fig. 3). This incision can be

elevated (and elongated), following the hairline, and should

always be made in a zigzag pattern [10]. It can be extended

up to the superior temporal region, well over the eyebrow

level (Fig. 4). This zigzag incision on the hairline is a

practice that many surgeons have used over the years in

conventional facial surgeries and has yielded excellent

results.

Through this zigzag incision, the dissection is performed

on a subcutaneous level, in the same manner as in a normal

rhytidoplasty (Fig. 5), leaving 3 mm between the dissec-

tion and the preauricular-pretragal limit. Often, the dis-

section is connected with the wide cervical dissection that

has already been made. After hemostasis is achieved,

suspension of the subdermal and SMAS tissue [11] is

performed, tailored to the level of mobility of each

patient’s tissue, using three to five absorbable stitches.

Deep plane structural tissue grafting is performed in

many thin layers (6–10 cc are introduced in the malar area

with a 1.5-mm cannula), depending on the patient’s needs.

This grafting restores volume to the face and contributes

Fig. 1 a–c Changes in skin

with age vary from person to

person

Fig. 2 To improve the neck, it

is best to achieve a 90� angle.

a Red line length = X. b Redline length = 1.4X

Aesth Plast Surg (2012) 36:540–545 541

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some to the skin tightening (especially the skin in the

lower-eyelid area).

Two to four centimeters of skin is cephalically removed;

if a high zigzag incision is made, some skin is pulled pos-

teriorly. The surgical incision is closed with four subdermal

absorbable stitches. Next, the skin is sutured with a 4-0

running suture (Fig. 6a, b). Because this midface subcuta-

neous dissection connects to and is used in conjunction with

the cervical dissection, cephalic skin excision contributes to

some of the cervical and jowl skin tightening.

If necessary, a blepharoplasty is then performed. Other

ancillary procedures such as otoplasties, lobeplasties,

peelings, chin implantations, cilioplasties may also be

performed if required. Following the surgery, bandages are

gently applied and no drains are left behind.

After the procedure, ambulation begins 2–4 h after

surgery. Bandages are used for 1 day. In the first few days

after the surgery, patients appear to experience less surgical

trauma than after conventional rhytidoplasties (Figs. 7, 8).

In general, more edema develops in patients who have

undergone structural grafting in this rhytidoplasty proce-

dure than in conventional rhytidoplasty procedures without

grafting. For the five temporal asymmetry cases that we

reported as complications (Table 1), the patients’ malar

area appeared to be 10–15% more swollen on one side than

on the other side, and in three of these cases, there was

more bruising on the swollen side. These cases, however,

resolved gradually within the first month and the patients

healed normally.

Because the scar caused by the procedure is located

within the hairline, it is virtually invisible, especially when

hair grows into the scar; however, some patients are made

aware of the possibility of having to fix the scar a few days

after surgery.

Facial wrinkles, jowls, and loose skin can be improved

with skin removal and neck tightening; however, the suc-

cess of these procedures sometimes depends on where the

incision is made (how high it goes) and how much skin can

be pulled upward and posteriorly. The appearance of

wrinkles and loose skin can be further improved if the

patient’s sub-dermal tissue is elevated with plication (stit-

ches) and even more so if autologous tissue grafting for

volume addition is performed.

Even if the ear becomes deformed by pulling it cepha-

lically during the procedure (Fig. 9a), both the skin and ear

return to normal within the first 20 days after surgery

(Fig. 9b).

Fig. 3 A horizontal incision is made at the level of the auricular

superior vertex, with the scalpel cephalically inclined. The incision is

about 2–5 cm long

Fig. 4 The incision can be elevated (and elongated), following the

hairline, and should always be made in a zigzag pattern. It can be

extended up to the superior temporal region, well over eyebrow level

Fig. 5 Through this zigzag incision seen in Fig. 4, the dissection is

performed, on a subcutaneous level, in the same manner as in a

normal rhytidoplasty

Fig. 6 a, b The surgical incision is closed with four subdermal

absorbable stitches and the skin is sutured with a 4-0 running suture

542 Aesth Plast Surg (2012) 36:540–545

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Results

Additional autologous grafting was performed on the malar

area and nose radix and dorsum (Fig. 10). The patients

shown in Figs. 11 and 12 also underwent structural malar

grafting and neck tightening. The patients in Figs. 13 and

14 underwent skin tightening, neck suspension, structural

grafting, superior blepharoplasty, and nasal supratip, and

Fig. 15 shows a patient who had skin tightening, neck

suspension, structural grafting, and superior blepharoplasty.

Discussion

To prevent the ‘‘stigma’’ of facial surgery, the periauricular

scar, we advanced the procedure presented here. By

extending the incision cephalically into the hairline, more

skin can be removed and more skin tightening can be

achieved, even in the cervical area. Dissections made

during the rhytidoplasty surgery are large, but because both

sides of the dissection keep skin continuity, the tissue

recovers quickly and skin necrosis, hypochromia,

hyperchromia, and other skin complications are avoided.

We can improve results (as for any facial technique used)

by means of peelings, grafting different areas (like chin,

eyebrows, mandibular border, nasal spine, nasal radix,

nasolabial folds, and lips), and other ancillary surgeries.

Even though hemostasis is harder to perform during this

type of rhytidoplasty procedure, making appropriate infil-

trations and blunt dissections (with scissors) help to ease

this step of the surgery.

The skin must be always stressed cephalically, which

can change the shapes of the ear and earlobe. It takes

between 10 and 20 days for the ears to return to normal.

The results are natural, lasting, and reproducible, with very

few complications. We have had a high rate of patient

satisfaction because this rhytidoplasty leaves patients

without any visible periauricular scarring.

Despite these good results, patients with too much loose

skin and/or too many wrinkles are not good candidates for

this rhytidoplasty procedure unless they fully understand its

limitations, and probably a facelift with periauricular scars

could bring better results for these cases in which larger

skin resections are needed.

Fig. 7 a Preoperative view. b Five days after surgery

Fig. 8 a Preoperative view.

b One day after surgery. c Two

months after surgery

Table 1 Postoperative complications

Complication Occurrence %

Infections 0 0

Scar dehiscence 0 0

Hypertrophic scars 2 1

Nonaesthetic scars 4 2

Necrosis 0 0

Seromas 0 0

Local hematomas 1 0.5

Temporal asymmetries 5 2.6

Permanent asymmetries 0 0

Major edema 0 0

Nerve injury 0 0

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Fig. 9 a Ear is deformed by pulling it cephalically during the

procedure. b Skin and ear return to normal within the first 20 days

Fig. 10 Additional autologous grafting was performed on the malar

area and nose radix and dorsum. a Preoperative view. b Three years

after surgery

Fig. 11 Patient also underwent structural malar grafting and neck

tightening. a Preoperative view. b Four months after surgery

Fig. 12 Patients also underwent structural malar grafting and neck

tightening. a Preoperative view. b One year after surgery

Fig. 13 Patient underwent skin tightening, neck suspension, struc-

tural grafting, superior blepharoplasty, and nasal supratip. a Preoper-

ative view. b Six months after surgery

Fig. 14 Patient underwent skin tightening, neck suspension, struc-

tural grafting, superior blepharoplasty, and nasal supratip. a Preoper-

ative view. b Two years after surgery with a 4-kg weight loss

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Conclusions

This new rhytidoplasty approach eliminates the appearance of

periauricular scars associated with facial plastic surgery, redu-

ces complications, achieves natural-looking results, and

increases patient satisfaction. The incision in the hairline must

be made in the well-grown hair area, with the scalpel inclined.

In this way, some new hair will grow into the incision and hide

the scar. Because skin is not removed in large quantities, it never

looks too stretched out or has a mummification appearance.

The problem of facial aging can be approached from

several perspectives and treated with several different

procedures and techniques. By employing this rhytido-

plasty technique, we have achieved the patient’s desired

objectives without making periauricular incisions. Using

this new approach and seeing its results has also helped to

change our perception of aging.

Disclosure The author declares that he has no conflicts of interest to

disclose.

References

1. Skoog T (1974) Plastic surgery: new methods and refinements.

WB Saunders, Philadelphia

2. Mitz V, Peyronie M (1976) The superficial musculoaponeurotic

system (SMAS) in the parotid and cheek area. Plast Reconstr

Surg 58:80–88

3. Ramirez OM, Maillard GF, Musolas A (1991) The extended

subperiosteal facelift: a definitive soft-tissue remodeling for

facial rejuvenation. Plast Reconstr Surg 88:227–236; discussion

237–238

4. Baker DC (2001) Minimal incision rhytidectomy (short scar face

lift) with lateral SMASHectomy: evolution and application.

Aesthet Surg J 21(1):14–26

5. Gonzalez-Ulloa M, Flores ES (1965) Senility of the face: basic

study to understand its causes and effects. Plast Reconstr Surg

36:239–246

6. Gilchrest BA (1989) Geriatric dermatology. Clin Geriatr Med

5(1)

7. Fuente del Campo A (1998) Midline platysma muscular overlap

for neck restoration. Plast Reconstr Surg 102:1710–1715

8. Giampapa V, Bitzos I, Ramirez O, Granick M (2005) Suture

suspension platysmaplasty for neck rejuvenation revisited: tech-

nical fine points for improving outcome. Aesthetic Plast Surg

29:341–350

9. Ramirez OM, Robertson KM (2001) Comprehensive approach to

rejuvenation of the neck. Facial Plast Surg 17:129–140

10. Camirand A, Doucet J (1997) A comparison between parallel

hairline incisions and perpendicular incisions when performing a

face lift. Plast Reconstr Surg 99:10–15

11. Stuzin JM, Baker TJ, Gordon HL, Baker TM (1995) Extended

SMAS dissection as an approach to midface rejuvenation. Clin

Plast Surg 22:295–311

Fig. 15 Patient had skin

tightening, neck suspension,

structural grafting, and superior

blepharoplasty. a–

c Preoperative views. d–f Views

1 year after surgery

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