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Ask Dr. Yang any questions about facial plastic surgery, including facelifts, necklifts, eyelid surgery (blepharoplasty), browlifts, otoplasty, and non-surgical treatments such as Botox and injectable fillers.
Hi Dr. Yang
I loved your post about the pre vs post tragal incisions. It was very informative. I have a question about incisions inside the tragus. Is it possible to have that type of incision without the line of demarcation where the earlobe meets the lower cheek? Or will there always be a separation line there? Is this something the doctor can control?
Note: If you can't see what is in the pictures (for those of you reading), don't worry about it.
Yes, it's possible, but I think it is difficult to have it look consistently good. Even if it looks good from far away, any close inspection of the ear will be obvious that the tragal skin looks odd. Close inspection of a pre-tragal incision will show a transition line from the facial skin to the ear skin at the facial-ear junction.
The face and ear are separate entities and if you try to combine them it will look odd. I call the area when the shadow ends and the highlight on the ear and tragus begins, the facial/ear junction. The face ends at this junction and the ear begins at the junction. Look at this photo from the internet of Audrey Hepburn:
Of note, a poorly perform pre-tragal incision can be converted to a post-tragal incision in the future. However, once a poorly performed post-tragal incision it is not possible to convert back to a pre-tragal incision. Any cartilage distortion is usually permanent. I have tried to improve poorly performed post tragal incisions, but I am not able to get the cartilage to regain some of its soft curves which it probably had prior to surgery.
Or will there always be a separation line there?
Note on the above photos, that these are actually pretty well performed post tragal incisions. The reason I say this, is that the skin that covers the tragus was "thinned" enough to create a "dip" or shadow in front of the tragus. You hit on a very good point that, even though there is a dip in front on the tragus, this "demarcation" between the earlobe and the lower cheek somehow does not replicate a facial-ear junction.
In the vast majority of ears, the tragus and the earlobe should be in the same "plane" and should not have a demarcation or "web" of skin separating the tragus and earlobe.
Instead of going in a straight line from the edge of the tragus directly to the attachment of the earlobe, a small segment of skin in front of the earlobe can be left attached. From the lower opening of the tragus, a short 1/8" horizontal incision can be made, to maintain the 1/8" bridge of the skin which makes the tragus and earlobe stay on the same level. Without doing this, the tragus appears to be "above" or higher than the surface of the earlobe. This is what causes the demarcation.
Before (same patient).........................................................After (8 months)
Note, that some of the "softness" of the tragal cartilage is maintained even at 8 months. However, I worry that it may still flatten out in the future. The web or demarcation is not there, but I still think it looks a bit odd.
Here is a diagonal view. Before (same patient).........................................................After (8 months).
This patients tragus is too prominent, and should have had a pre-tragal incision. I perform the post tragal incision by the request of the patient (she's the boss) and did the best that I could.
I think that there are other people who would do better with a post-tragal incision and if that is the case I would recommend the post-tragal incision.
Does this mean that I never perform a post-tragal incision? Of course not. There are definitely some people that I think will do better with a post-tragal incision than the pre-tragal incision. Who are these people?
1. The ear cartilage is naturally very flat 2. There is no wrinkle or cartilage edge in front of the ear 3. the quality of the skin on the cheek matches the natural skin on the ear cartilage with a relatively high sideburn 4. There is a natural wrinkle or skin web that comes down directly from the lower opening of the ear crossing in front of the earlobe
With these patients, the post-tragal incision matches their pre-operative ear cartilage "almost" perfectly. Side View Before..............................................................Side View After
Oblique View Before........................................................Oblique View After
This incision can be placed in front or inside the ear for pretty much any facelift technique is and is mainly dependent on surgeon preference, some of which do both types depending on the patient. Again, I want to emphasized the goal to avoid any obvious signs of a facelift, is more than just the fact that there is no incision in front of the ear. Routinely placing the incision only in front or only behind is too simplified approach when avoiding the facelift give aways.
Although we are mainly talking about post-tragal incisions, I think it is worth taking a look at pre-tragal incisions in comparison to the post-tragal incisions.
Here is a new example of a pre-tragal incision as it is healing at 8 days after surgery, 2 months after surgery, and 14 months after surgery.
Before .................................................After (14 months no makeup)
Before .................................................After (14 months no makeup)
I think that either way, if the incision is closely inspected you can find the incision with either technique. My feeling is that the incision should be imperceptible, but if I can spot a post-tragal facelift incision, because of tragus distortion or the "dermarcation" of the earlobe and lower cheek from more than 50 feet away, then it defeats the purpose of placing the incision behind the tragus.
Of note, there can be poorly performed pre-tragal incisions as well as post-tragal incisions, so don't pick a surgeon just because they say they perform the incision a certain way. Both ways can be "messed up." The surgeon is more important.
Thanks so much for the explanation. Yes this is exactly what I am talking about and the photos you chose were very appropriate.
Is it common that doctors will do both types of incisions? I have been interviewing a couple of doctors about facelifts and they both do post tragal incisions. Does this mean that they would not do pre-tragal incisions if I asked? Would it be a mistake to go to someone who usually does one type yet ask for the other type?
Also, are you completely set against doing lifts on slightly younger patients? I would love to have a consult with you. If I sent photos do you think you could tell me if a consult would be worth it?
I think that some surgeons will perform both types of incisions. Many facelift surgeons will perform pre-tragal incisions for men and post-tragal incision for women. This is done to prevent men from needing to shave the tragus. Looking closely at the facial skin on women, although there is no bearded skin, it can definitely have a different texture than the ear skin.
I am very critical of my own work, and will be the first to notice if something doesn't look great. I think that this helps me get better. I could pretend that this type of incision looks great and play up the fact that there is no incision in front of the ear, but I think it looks "weird" and it is something I can spot from very far away. So I figure that other people with a "keen" eye are also noticing this problem. In fact, I bet many people who would consider a facelift may not have one, just because they are afraid of this potential problem.
Today during the day, while I was walking out to get lunch in New York, I was looking at some peoples ears, while waiting to cross the street. I noticed a couple of men and women who have a flatter cartilage and a fold/wrinkle that comes out from the "opening" of the ear instead of the in front of the tragus. However, these people definitely did not have a facelift, and their ears don't look strange either.
I guess the best way to avoid a potential distorted tragus is to "read" the tragus shape, and try to "replicate" however it looks prior to surgery.
I have operated on younger patients before, but I did not think that they looked that different after surgery. So I felt that they didn't get their money's worth. While other younger patients, had early menopause or some illness which cause them to age prematurely. In these patients, they did get a very nice improvement, because they were looking older than their stated age, and the facelift made them look more like their chronologic age if not a few years younger than that. This is the reasoning behind my philosophy.
If the patient is aware that by having a facelift so young, they are more likely to have a second facelift in another 10+ years, then I guess I would consider operating on them. But if the patient wants to only have a facelift once in their lifetime, I would tell them to wait until the biggest "sagging" occurs around menopause (normally or prematurely), to get their money's worth, and hopefully avoid a second facelift.
I would be happy to look at your photos. You can email them to Admin@nycface.com. We can have a Virtual Consultation by telephone and computer conferencing through my GoToMyPC.com program. These virtual consultations are designed to educate and screen potential patients so that the ones that are not candidates for surgery don't need to fly into New York for a one-on-one consultation. I think that at worst, you will learn a lot about facelifts and which type of incision may be best suited for your type of tragus. You can use this information when you are researching your potential surgeons.
Last edited by MillenniumFPS on Wed Dec 24, 2008 8:55 pm, edited 1 time in total.
Hi Dr. Yang
Thanks so much for reply. This is interesting. Looking at my own ears I might be one of those rare people who would do better with post tragal incisions. My ears are totally flat and I have a little crease where the lobe meets the ear. Still, what I really don't like is that tucked in look where there looks to be a flap of skin at the lobe covering the other part of the ear, like they are separate. The first photo you posted really looks like that. The other thing that I think makes the post tragal incision look strange is that the cartilage that attaches to the cheek does not have the same curves that it did pre surgery. There is usually one large curve instead of a few small ones. Can anything be done about that? Do you ever take patient photos of ears in to the OR?
I will send you photos, thanks a lot!
Am I right in thinking that you do a deep plane lift and an smas lift?
Does the cheekpad get lifted in both types? If the cheeks pad does lift, then does that give more fullness to the lateral lower lid?
Hi Dr. Yang,
Great explanations as always. Since you've seen my pics and felt I'd do best with a pre-tragal incision I requested it of my doctor. Are there any questions I need to ask him regarding how he makes the incisions? I want to encourage a really good technique so I'd like to know what that entails so I'll know what he's talking about as far as his incisions.
I don't know what to ask him. You should look at his pictures to see it you see any issues with the tragus, earlobe or sideburns.
I think that most surgeons would be annoyed if the patient becomes a "backseat driver" to their techique. If you feel that you have found the right surgeon for you, at some point you have to "let go" and let him do his thing. Just as we have no background information on airline pilots, where they went to school, what "flying" technique they use, if they have any substance abuse issues, yet we place our lives in their hands all the time and "let go."
Here is a diagram that I made of one of my incision, it's no different from one of the pictures from one of the facelift textbooks that many facial plastic surgeons have in their library.
Many of you may know Barbara741, from her prior postings around the time of her facelift. Anyway I used Dr. Calvin Johnson's facelift incision with gentle curve under the sideburns, forming a "bird's beak" just above the top of the ear then blending downward into the natural curves in front of the ear. Here is the thought that goes behind designing a facelift incision.
Below is Barbara741's incision which is a healed version of the incision as described above.
This is a close-up so you should be able to make out the edges of the incision.
Here is Barbara741's Left Oblique View.
Notice how much her ear cartilage naturally angles off of her face, if I made a post-tragal incision I believe that the cartilage would flatten and create a bit of a web from the cartilage to the earlobe. What do I mean by a web? Look back up to the picture of Audrey Hepburn, Notice that the ear cartilage and the earlobe is in one plane with a 3/8" wide segment of skin that connects the ear cartilage with the earlobe.
Now look at one of the acceptable post tragal incisions, although there is no incision in front of the ear, the ear cartilage and earlobe are no longer on the same plane. Also, the little piece of skin that connects the ear cartilage to the earlobe is blocked by a small web of skin.
My incision is actually now slightly different. Look at the healing photos above (8 Days, 2 months, 14 months.) I now switch to a thinner suture in the pre-tragal portion, and perform multiple vertical mattress sutures to make the upper portion of the pre-tragal incision as flat as possible. I don't mind if a slight wrinkle reforms in front of the earlobe. I think that makes it look more natural. This extra detail add about 15-20 more minutes on the skin closure itself. I have to stop and switch sutures to a thinner suture, then perform individual vertical mattress sutures, before I finish with the thinner continuous suture. I think in comparison to Barbara's incisions it is now flatter and a smoother transition from the tragus to the face. I would estimate the improvement in my incision to be about 5-15% better. For individual patients, they have no one to compare their incision to, but for me I can see the improvement in my technique. This extra time makes me feel better about my facelift results, even if the patient can't appreciate the difference.
You've done your research thoroughly. You've consulted with multiple surgeons, compared photos, costs, and decided that you want to stay locally. If you like your surgeon's results, without knowing what exactly his technique is, then you have to trust him at some point. He may not perform his incisions the same way, but he gets good results, too. So why should he change? Good luck with your facelift.
I was interested in your expertise on this aspect of the lift mainly because my surgeon does post tragel on women which are the bulk of his clients and I actually didn't see any of his pre-tragel results so I wanted to understand better his technique after getting your input.thanks again.
You're welcome. How do the post-tragal results look? Do the patients have a "demarcation" at the earlobe and lower cheek, as AmeliaP very astutely pointed out? If the demarcation line is not there then, that is a sign of very good technique. If he has any "tricks" or "tips," I am always willing to learn to make my facelifts even better.
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