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| André Camirand MD, Jocelyne Doucet IL |
Montréal (Québec) Canada
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Communications should be sent to:
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| André Camirand, MD |
| 12245, Grenet Street, bureau 112B |
| Montréal (Québec) H4J 2J6 |
Telephone number: (514)745-1360 Fax number: (514)745-5906
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Abtract
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In facial rejuvenation, one must advance the hairline mostly in the frontal and temporal area. The resultant abundance of hair will give an illusion of youth. We will describe a method to get excellent hairline scars. Elimination of tension and a proper beveling of the incision will facilitate hair growing through and anterior to the scar and make them inconspicuous.
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Key Words: Facelift scars, facelift incision, facelift, browlift, hairline incision
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Résumé
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Lors du rajeunissement du visage, il est impératif de mobiliser vers l'avant la ligne des cheveux tout particulièrement au niveau du front et de la tempe. Il en résultera une abondance capillaire créant ainsi une illusion de jeunesse. Nous mettrons en évidence une technique qui nous rend d'excellentes cicatrices à la ligne des cheveux. En éliminant la tension lors de la fermeture de la peau et en bizotant dans le bon sens l'incision, les cheveux pousseront dans la cicatrice et devant celle-ci. Il en résultera en allégement de la rançon cicatricielle.
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As you age the hairline recedes at the frontal and temporal regions. In the forehead, the brow comes down and the hairline recedes and we get a wide forehead giving the face a cadaveric look. In the temporal region, as we age, the distance between the brow and temporal hairs increases, aging the face.
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Any incision behind the hairline will increase these distances and further ages these patients. This goes for coronal, endoscopic and behind the hairline face lifts incisions.
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| Fig. 1. Incision perpendicular to the hair follicles |
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On the contrary, if one knows how to do a hairline incision (a few millimeters behind the hairline) one can reduce the width of the forehead or temporal area and the resulting abundance of hair can give a look or an illusion of youth. However, one must know how to exploit this alternative by obtaining very good scars. We intend to show how to get better scars and give good examples of what can be accomplished.
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| Fig. 2. (top left) Reoperation of a bad facelift scar. (top right) The result of reoperation one year after the operation. (bottom left) The temporal scar before using the beveled incision. (bottom right) The result of using the beveled incision. |
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In the literature, we have examples of physicians improving bad scalp scars by grafting hair follicles containing dermal grafts under the epidermis of healed scars (4) . These grafts would allow the hair growing through the epidermis to grow and camouflage the scars. Some surgeons improve hairline scars by grafting hair. If grafts can work, I felt one should expect flaps to work even better.
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| TABLE 1. Advantages of W plasty |
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real length of the of the proximal scar by 40% without increasing the apparent length |
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tension by 40% |
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facilitates closure since the distal flap stretches by 30-40% because of the pull - no pleating - no dogs ear |
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multiple hinges: scar mobile and stretchable with motion or facial expression |
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improve neovascularization as in Z plasty: less oedema |
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different tension and different points of the scar: more natural |
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breaks the hair line therefore: more natural (hairline never linear) |
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One day, a top surgeon suggested "If I bevel my incisions to preserve the deep follicles of the proximal flap, hair could grow through and anterior to the scars". This surgeon meant to incise the skin with a bevel parallel to the hair follicles not to injure any follicles.
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I misunderstood him and I beveled my incision in order to contain cut hair follicles in my proximal flap so they would grow under the distal flap and grow in front of the scar (Figure 1) . I began doing this and my facelift and browlift scars were dramatically improved (Figure 7) .
Anatomically the skin is composed of the epidermis, the dermis and lies over the hypodermis.
The epidermis is composed of many layers of cells; from the deeper layer we have the stratum germinativum, spinosums, granulosums and corneum at the surface of the skin.
The lower cells are the stratum germinativum and these cells grow toward the surface and finally loose their nucleus to become a dead protective layer called the stratum corneum, that eventually shed off to be replaced by younger cells. This migration takes approximately 30 days under normal circumstances. However the normal cycle is greatly accelerated under the following circumstances such as an injury, surgery, dermabrasion or incision. Under such circumstances the cycle may last from 3 to 4 days instead of the usual 30 days.
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| Fig. 3. Mathematical formula demon- strating that a W incision with a 45o angle can lengthen the scar by 41% |
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If we take the example of the dermabrasion of a man's cheek. We eliminate the epidermis and part of the dermis. With a proper physiological dressing such as "Vigilon" the skin reepithelializes within 3 days. Besides, because of the healing and inflammation, the local heat is increased and the beard grows faster than usual.
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This can be because of the same mechanism that is responsible for the accelerated migration of the cells from the stratum germinativum to migrate to the surface in 3 days and become stratum corneum.
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With the dermabrasion, we remove the superficial part of the skin and it certainly does not prevent the underlying hair to grow to the surface. Men continue shaving after a dermabrasion.
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Technique
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We incise approximately 2-3 mm within the hairline, anteriorly at an angle of 30° to 45° with the proximal scalp (Figure 1) . As we excise the excessive skin from the distal flap, we incise it with at least as much beveling. This is imperative. Hair will not grow through fat nor through hypodermis.
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Besides, we make micro "w" for the following reasons: we increase the real length of the incision of the proximal flap by 45% (Fig. 4) without increasing its apparent length as we know the straight line is the shortest distance between two points. Later, as we pull on the distal flap for closure we increase the length of the distal flap. Of course as we excise from the distal flap, one should not "w" plasty the incision because this would further increase the length of the distal flap that will be increased in length by stretching it (30%-40%) as we put tension on it. We try to suture skin edges of the same length to prevent pleating and obtain a better closure (dog ears when present, they persist so they must be avoided). |
| Fig. 4. Incision perpendicular to the skin |
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The "w" plasty creates a multitude of hinges that will make the scar a mobile one and make it more inconspicuous, with facial motion and expression.
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| Fig. 5. Incision parallel to the hair follicles |
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Increasing the length of the incision by 45% will inevitably reduce the tension by 45% and furthermore improve the scar, the quality of which is inversely proportional to the tension of the level of the closure. Also, swelling at the level of the scar will be reduced because the "w" plasty like the "z" plasty reduces the "trap door" phenomenon and facilitate the neovascularization. I believe this is because of the beveling of the blood vessels incised increases the diameter of the cut vessels and capillaries.
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At the venous level where pressure is low it will increase the caliber of vessels and will improve the venous return; the same goes for capillaries. By increasing the caliber of arteries it will lower their pressure and improve the local haemodynamic equilibirium. Beveling the distal flap is very important. The distal stratum corneum will behave as a biological dressing allowing the proximal flap hair to grow for a few days as it is sheds off.
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In the proximal flap the hair shaft cuts in the stratum spinosium, in the stratum granulosum and germinativum, do not stop growing because they are cut. On the contrary they migrate toward the surface more rapidly than usual, as the opposite cells of the distal flap migrate at the same rate which is faster than usual because of the surgical stimulus.
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| TABLE 2. To improve facelift or browlift scar |
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Proper beveling of the incision |
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Bevel the distal flap equally |
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Avoid : |
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tension |
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remove excess subcutaneous fat |
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extensive undermining, beyond osseocutaneous
ligaments of Furnas |
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tension mostly on the smass and platysma |
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"W" plasty incision |
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contamination |
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laser or cautery can destroy: |
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hair follicles |
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melanocytes and cause: |
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local ischemia |
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local scarification |
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W plasty the proximal flap only (not the distal flap) |
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Meticulous closure |
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Of course tension should be avoided because the local schemia will interfere with the cellular response and the resulting scarification will be unesthetical. Contamination and infection will also interfere with the normal healing process. If the wound is not reapproximated very well, it will never be comparable to one meticulously sutured, even if plenty of hair grows anterior to the incision. Cauterization and laser should not be used near the hair follicles. It can also destroy melanocytes and cause an hypochromic scar. Besides, one gets local ischemia and scarification of a burn.
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| Fig. 6. (top left) Browlift scar following an incision parallel to the hair follicles. (top right) Browlift scar following incision maintaining cut follicles in the proximal flap. (bottom left) The scar is linear and devoid of hair clinically and historically. (bottom right) Histology of the scar shows the presence of hair in the scar. |
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We improve the tension on closure 1- by removing the excess cervical fat, 2- with a good extensive undermining, beyond the osseocutaneous ligaments of Furnas, 3- by putting tension on the SMASS and platysma and 4 by using key points in front and behind the ear for facelifts. For browlifts, we apply the tension on the galea.
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| Fig. 7. (top left) Before rejuvenation of the face. (top right) After rejuvenation of the face. (bottom left) Hair is beginning to grow through and anterior to the incision six weeks after the browlift operation. (bottom right) Three months after the operation, the scar is invisible because of the presence of hair. |
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We always try to suture the different cellular layers of the epidermis of the distal flap opposite to the equivalent cellular layers of the proximal flap. The closure must be meticulous and perfect.
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Since the scalp hair, temporal or frontal grows anteriorly if one incises perpendicular to the skin surface, one will incise hair shafts (Fig. 2) that will grow into and in front of the scar. However, if one bevels the incision perpendicular to the hair (Figure 1) (at an angle with scalp surface), then many more hair will grow through the distal flap and camouflage much more the scar. In a double-blind study, we compared this incision perpendicular to hair shaft to an incision parallel to the hair follicles (Fig. 3) .
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| Fig. 8. Facial rejuvenation showing inconspicuous scars in the temporal and postauricular area. |
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The incision parallel to hair follicles even if it was a beautiful scar, it was linear and regular as compared to the incision perpendicular to hair follicles. In this last incision, the hair would grow anterior to the scar which was invisible, non-linear, the hairline was more anterior and it was not possible in some cases to see any sign of a surgical scar. This was confirmed with a biopsy (Figure 5) from both approaches on the same patient. The scar from the perpendicular incision showed the presence of hair whereas the incision parallel to hair shaft showed the absence of hair in front of the scar.
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As shown in figure 6 , one can see hair growing through and anteriorly to the incision after six (6) weeks. Three (3) months post-operatively, because of the abundance of growing hair, the scar becomes invisible as shown in figure 6D, figure 8 and figure 9 . These photos not only demonstrate good scars but also demonstrate that one can obtain a good clinical result without much tension on the skin.
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| Fig. 9. Invisible scars in the temporal and postauricular area after a facelift operation |
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Conclusion
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By properly beveling incisions at an angle with the hair follicles of the scalp, one can get them to grow through and anteriorly to the scar. We explain this and mention a few other subtilities that can give us good hairline incisions and a more youthful result in facelifts and brow lifts.
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Bibliography
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- Camirand, A., Doucet, J. A Comparison Between Parallel Hairline Incisions and Perpendicular Incisions when Performing a Face Lift. Plastic and Reconstructive Surgery, Volume 99, Number 1, January 1997, p. 10-15.
- Camirand, A. Amélioration des cicatrices de lifting temporal et frontal. Ann. Chir. Plast. Esthet. 36: 215, 1991.
- Camirand, A. Improvement of the Scars of Temporal and Frontal Face Lifts. In P. McKinney (Ed.), Mosby Yearbook of
Plastic Surgery. St. Louis: Mosby, 1993.
- Nataf, J., Elbaz, J.S., and Pollet, J. Etude critique des transplantations du cuir chevelu et propositions d'une optique.
Ann. Chir. Plast. Esthet. 21: 199, 1976.
- Camirand, A. How to Improve Face Lift Scars. Presented at the VIIth Congreso Iberolatinoamericano de Cirugia Plastica, Cartegena, Colombia, 1988.
- Camirand, A. How to Improve Face Lift Scars. Presented at the Franco-American Congress, Paris, June 1989.
- Camirand, A. How to Improve Face Lift Scars. Presented at the Xth Congress of the International Society for Aesthetic Plastic Surgery, Zurich, Switzerland, 1989.
- Camirand, A. How to Improve Face Lift Scars. Presented to the Annual meeting of the Canadian Society of Aesthetic Plastic Surgeons, Toronto, Canada, 1989.
- Camirand, A. Advanced Facial Contouring and How to Improve Face Lift Scars. San Diego, 1991.
- Camirand, A. Presented at the Xth Congress of the International Confederation for Plastic and Reconstructive Surgery,
Madrid, Spain, 1992.
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