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Before Surgery


Written instructions are provided. A simple blood test is performed, and a cardiogram is obtained for those patients over the age of 50 or with any history of cardiac problems. Sometimes additional tests are ordered. An ultrasound scan may be performed as a screening measure for blood clots.




Smokers are at an increased risk for wound healing problems after surgery, so we instruct smokers to refrain from smoking for 2 weeks before and 2 weeks after surgery. Patients often ask about using nicotine patches or gum. Unfortunately, these substitutes cannot be used because they also contain nicotine and nicotine causes the small blood vessels to constrict, compromising healing.


Most plastic surgeons realize that smoking is a tough addiction to break and the reality is that patients are very unlikely to stop smoking, regardless of what we tell them. However, patients need to know that they are at increased risk of delayed wound healing. They will do themselves a favor by quitting, or at the very least minimizing their smoking. It is up to them. If they continue to smoke, they may take longer to heal and may have more scarring, particularly behind the ears.


Pain Medication Prior to Surgery


Because of its effect on platelets and the risk of increased bleeding, all products containing aspirin are avoided for 2 weeks prior to surgery and 2 weeks after. Many over-the-counter pain relievers and headache medicines contain aspirin, also called ASA, so it is worth checking to be sure. We instruct patients to avoid non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen (Motrin) or naproxen (Aleve) for 3 days before surgery and 3 days after. It is fine to take Tylenol right up until before surgery because it does not affect platelets. Patients with arthritic pain or headaches can take their NSAID or COX2 inhibitor up to 3 days before surgery and then take Tylenol.


Vitamins and Nutritional Supplements


High doses of vitamins, particularly vitamin E, which can prolong bleeding time, are prohibited before surgery. Also patients should avoid herbal medicines or supplements, starting 2 weeks before surgery, because of possible interactions with anesthetic medications and undesirable effects on platelets and blood pressure. Popular herbal remedies include garlic, ginkgo, ginseng, ginger, St. John’s wort, and ephedra, to name a few. Do not take any diet medications such as phentermine for at least 2 weeks before surgery.


Medications for Healing and Bruising


Don’t take any product that is supposed to “speed healing” or reduce bruising, such as arnica montana. Despite claims to the contrary, there are no medications known to accelerate healing or make you scar better. There are plenty of advertising claims for such products as Mederma and StriVectin but little scientific support. Bruises go away and scars improve with time regardless, which is great for those who market products that purport to reduce bruising and scarring.


Support Before and After Surgery


Do not eat or drink for at least 6 hours prior to surgery. Patients need a ride to the Surgery Center on the day of surgery and a ride home afterward. They need a caregiver to stay with them overnight and bring them to the office the day after surgery. Patients need close assistance for the first several days after surgery. In fact, our surveyed patients recommended having someone around to help for an average of 5 days.




Surgery is performed under total intravenous anesthesia, using a propofol infusion, with supplemental intravenous doses of fentanyl and Versed. A laryngeal mask airway (LMA) is used. Patients are not routinely intubated, paralyzed or ventilated mechanically. This type of anesthesia is called SAFE anesthesia (Spontaneous breathing, Avoid gas, Face up, Extremities mobile) (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160). This type of anesthesia offers many safety advantages compared with traditional general endotracheal anesthesia and there is clinical evidence that it also reduces the risk of deep venous thromboses (blood clots in the legs).


The Incisions


The incision (See Illustration, below) is modified to avoid visible scars. It starts in front of the ear and passes within the groove under the earlobe and up the crease behind the ear, turning at a right angle and continuing straight back into the hair a few inches. The incision behind the ear is placed so that it eventually will lie in the crease behind the ear, not on the exposed skin of the back of the neck.


One popular variation is to make the facelift incision obliquely, following the hairline rather than disappearing straight back into the hair. An advantage of making the incision within the scalp rather than along the hairline is that it is well-concealed. This is the ideal placement in men or women who would like to wear their hair short, up or bathe without a conspicuous scar behind the ear—a telltale sign of a facelift.


The incision in front of the ear is kept close to the ear, often along the line of an existing skin crease. A running stitch is used under the skin so that it is not visible while it’s in and leaves no suture tracks. Patients are always concerned about the facelift scar before surgery, but it is almost always inconspicuous and few patients find it objectionable (2.2% in our series). I do not shave the hair so that patients do not have to wait for it to grow out and the incisions tend to be well-concealed during the healing period. Men need to know that the facelift moves some of the hair-bearing skin up behind the earlobe; they will need to include this area when they shave.


Sutures are used rather than staples for comfort and ease of removal. Sutures also do a better job of lining up the edges. Staples are fast, but that’s their only advantage. An extra 5 or 10 minutes to sew is inconsequential. I don’t even keep staples in my operating room.


It is important to place minimal tension on the skin. Tension may cause a scar to spread. If there is minimal tension, the scar is usually thin and inconspicuous. Another telltale sign of a facelift is tension on the ear, pulling the earlobe down. This is known as a “pixie ear.” To avoid this operative stigma, minimal tension is placed on the skin closure under the ear lobe.


The Tragus


A common surgical approach is to make an incision behind the tragus, which is the bump in front of the ear canal. This is called an intratragal or retrotragal incision. Patients sometimes ask me about this “hidden” incision they have heard about. The problem is that his incision placement regularly causes deformities of the tragus. The tragus may end up flattened so that there is unnatural exposure of the ear canal. This is a stigma of surgery and one that is difficult or impossible to correct. I prefer the pretragal approach. By staying close to the tragus, even a little on it, this scar tends to blend in nicely, and the unique beauty of the tragus is not compromised. This incision should “hug” the tragus. If it is made even a little too far forward, it will migrate and be visible. If you look closely, you can sometimes see this scar in close-up shots of movie actors. Fortunately, this problem may be corrected at the time of a redo facelift.


It is often said that surgery is all about fine points of technique. Although each one individually may seem insignificant, taken together they may make the difference between a mediocre result and a superb one. Any time a surgical deformity is created (such as a flattened tragus or a pixie ear), this “cost” must be subtracted from any surgical benefit.


Submental Lipectomy


Another incision is placed under the chin. This incision is used to access the fat deposit under the chin. Most patients have extra fat here that is removed by liposuction. The neck muscles (platysmal bands) are sutured together at the front of the neck like a zipper to further improve the neckline and relieve vertical bands. The same muscle is also tightened on each side of the neck through the facelift incision, also helping to define the jawline. A well-defined neckline is a very desirable feature. It is also very achievable in most patients and a vital part of every facelift, which might be more accurately called a “face and neck lift.”


I am judicious in the use of liposuction in the neck and avoid its use in the face. Cheek fullness is both youthful and desirable. As we age, we lose facial fat, so we do not want to deplete our existing stores of facial fat. However, liposuction is very useful in the neck, where it is needed to achieve the desired flat contour under the chin.


Perhaps wishing to avoid a facelift, patients sometimes ask if their jowls (the fold sagging over the jawline) can be treated with liposuction. They need to know that it is usually better to elevate the jowls rather than treat them with liposuction, because liposuction can cause excessive tissue thinning over the bony jawline which looks unnatural and is not youthful. It makes more sense to lift this tissue back up where it came from, eliminating the jowls, and simultaneously restoring the youthful curvature (“ogee”) of the cheeks.


Dr. Eric Swanson-Facelift incisions and dissection planes-illustration

Facelift Incisions



Dr. Eric Swanson-Facelift incisions and dissection planes-illustration