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Preserving The Natural Pretragal Depression After Rhytidectomy

Lior Heller, MD, Oscar M. Ramirez, MD, and Keith M Robertson, M.D.

Stigmata of face lift surgery are one of the main concerns of the esthetic surgery patients. Failing to preserve the natural look of the tragus and the pretragal depression can betray the best and most innovative rejuvenation procedure. A relative simple technique to preserve the pretragal depression has been applied to all the patients that underwent rhytidectomy in our practice.

The standard face-lift incision we use extends from the sideburn in a slightly curvilinear

fashion to the root of the helix and then down into the marginal tragal area ( endotragal)

and around the earlobes retro-auricularly. The amount of subcutaneous dissection is

tailored to the specific needs of each patient. After completing the subcutaneous

dissection and before closing this incision the component added to recreate the pretragal

depression includes separation of the SMAS fascia attachments from the cartilage in the

preauricular area. Then this fascia is sutured over the anterior SMAS with several

interrupted 5-0 Prolene sutures to exaggerate the creation of a preauricular groove.

The skin tragal flap is deffated and a thin flap is achieved. The pretragal depression is

further defined by anchoring with the anchorage of one or two 5-0 Prolene suture from

the deep surface of the base of the tragal flap (usually the fatty layer) to the depression

created in the preauricular area. These sutures also help to decrease the tension on

the incision line and decrease the chances for a widening of the scar. Caution is advised

to avoid too thick of a bite on the base of the flap which may occasionally produce an

indentation or compromise the vascularity of the tragal flaps. The rest of the periauricular

cutaneous flap is inset in two layers. The dermal layer is anchored to the preauricular

fascia with interrupted 5-0 Prolene sutures and the epidermal layer is sutured with a 5-0

Prolene continuous suture after segments of skin are trimmed based on the skin laxity. Beginning from the ear-lobe area and continuing in the posterior auricular area closure is also done in two layers.

Any face lift incision should preserve the anatomic details of the ear, hairline and

pretragal area and at the same time be "invisible" to the casual observer. Several points

of concern regarding the periauricular incision have been previously mentioned: wide

hyperthrophic or hypopigmented scars, especially in the preauricular area, hidden or

buried tragus, loss of pretragal definition and deformed ear lobe. There is a continuous

debate in the literature whether a better aesthetic result can be achieved with a pretragal

incision versus an endotragal incision. The endotragal incision is in reality a "marginal"

tragal incision however the main advantage of this incision is the fact that is almost

invisible. However the advocates of the pretragal incision mention the following points as

negative features of the endotragal incision:

1) loss of the natural cheek/ear interface and sulcus because of the difficulty to recreate

the subtle crease that is normally present in the skin just anterior to the ear,

2) tragus distortion to a more anterior orientation due to tension on the sutures pulling

the tragus

3) exposure of the external auditory canal as a result of the tragal distortion that

removes the protective hooding effect that the tragus normally has in shielding the

external auditory canal.

A technique that takes advantage of the hidden location of the endotragal incision and

preserves or recreates the natural pretragal depression as well as diminishes the tension

on the suture line could be ideal. The active creation of the pretragal sulcus during

rhytidectomy eliminates this factor from the equation of decision making regarding the

location of the tragal incision. Sutures between the pretragal fascia and the SMAS as well

as the anchoring sutures between the base of the pretragal flap and the subfascial

depression created in the preauricular area absorb some of the tension applied to the

cheek skin flap and diminish the tension in the line of sutures. Closure of the suture line

is done in two layers except the tragus. The tragal flap is further more left long enough to

redrape without tension. The sutures located under the petragal cutaneous flap enable the

skin incision to heal under condition of minimal tension and the result is a fine line of

scar without widening or hypertrophy.

With this small addition to the facelift technique the natural look of the pretragal

depression is preserved and a more discrete endotragal incision can be used. In the last 5

years we implemented this technique we good results in more than 300 patients that

underwent rhytidectomy. The addition of this component to the operation didn't elongate

the operative time and only minor complications were observed. These were two cases of

partial necrosis that healed with secondary healing and two cases of indentation that

required release under local anesthesia. No widening of the incision line was reported. In

two cases loss of the pretragal definition were observed. These were due to probably

disruption of the deep layer support.

Preservation of the natural look in the tragal and pretragal area was mentioned by the

patient as a positive point. From our perspective the preauricular area looked more

natural and without noticeable scars or the stigmata of a facelift surgery.

Conclusion: We suggest that the addition of this simple technique to rhytidectomy

help to preserve the natural pretragal depression and avoid one of the most visible

postoperative stigmata frequently observed after face lift. In addition it helps to locate the

tragal incision in the endotragal area by this achieving a more discrete incision.

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