Facial Rejuvenation for Men: Dr. Botti's Modern Approaches and Unique Considerations
Aesthetic surgery has become increasingly popular among men in recent years. According to data from the International Society of Plastic Surgery in 2016, there were 61,042 male requests for face lifting, accounting for 14.35% of the total, and 50,735 requests for neck lifts, which represented 19.2% of the total.
Performing a face-lift on a bald individual presents a unique challenge for the surgeon. In such cases, each scar becomes crucial as it cannot be easily hidden by hair. Therefore, it is essential to minimize the length of skin incisions, which requires careful planning. While there are numerous articles in the literature discussing the psychological, anatomical, and surgical differences between male and female facelift patients, there is currently a lack of specific focus on the distinct aspects of bald male patients.
A study done by Dr. Giovanni Botti, Dr. Chiara Botti, and Dr. Michele Pascali, showcases the effectiveness of a specific face-lifting technique, which aims to minimize the length of visible scars in bald men. A crucial aspect of their technique is the redistribution of the longer lower skin flap edge to align with the shorter initial incision. The management of this issue represents the most significant innovation introduced in this article.
Preoperative Evaluation
When preparing for a face-lift procedure, it is important to thoroughly assess both the firm and soft tissues of the face. Specific issues such as sagging jowls, platysma bands, malar bags, and grooves like nasolabial and labiomandibular grooves need to be identified. Additionally, the amount of excess skin to be removed must be estimated.
If the excess skin and laxity exceed what can be effectively treated with a short-scar technique, there are two options:
Proceed with a short incision initially, and then schedule a subsequent incidental scar revision to address any remaining wrinkles.
Propose an extended incision from the beginning, following more traditional approaches.
Furthermore, when dealing with individuals who have excessive fat in the neck area, it is crucial to consider that after performing liposuction, there will be a significant amount of redundant skin that needs to be appropriately addressed.
When there is a need for an increase in volume of the soft tissues or underlying bone structures, the use of implants and/or fat grafting should be considered. These filling techniques can help reduce the amount of skin that needs to be removed and, consequently, minimize the final length of scars, although the reduction may only be moderate. In cases where the patient is bald, it becomes crucial to minimize cutaneous scars. In the retroauricular/occipital area, the general guideline is to avoid extending the scar beyond the projection on the mastoid of the posterior edge of the helix. Therefore, the posterior transversal section should not exceed approximately 2 cm in length. Behind the ear, the scar should be positioned over the concha, approximately 5 mm away from the groove, as it has a tendency to shift downward during the first 6 months following the surgery. The incision continues anteriorly around the auricular lobe and upward into the tragal region, where it can proceed along the posterior margin of the tragal cartilage (retrotragal incision), in the pretragal groove (pretragal incision), or along the posterior edge of the sideburn/beard. The patient should be involved in deciding which one to adopt. If a retrotragal incision is preferred and consequently the hair-bearing skin is moved over the tragal cartilage, it is necessary to eliminate the follicles in this area, surgically or by laser/intense pulsed light epilation. The pretragal incision is most frequently used by the authors. It leads to almost invisible scars and it is to be preferred in the presence of a clearly defined pretragal groove. Finally, in cases where the beard is thick and dark, and its posterior edge therefore particularly evident, an incision at this level would be less visible and can therefore be considered as well.
Regardless of the chosen approach, it is crucial that the incision is not a straight line but rather interrupted at least two times above and below the tragus (a small pointed prominence in front of the external opening of the ear). Moving upwards, the scar then follows the front edge of the helix (the curved outer rim of the ear) before slightly bending posteriorly. The extension of the scar in the temporal region should be kept as short as possible and proportional to the amount of skin that needs to be removed. While it may be possible to avoid this extension in cases where the amount of excess skin is moderate, it is generally necessary to achieve an appropriate redistribution of the different lengths of the two cutaneous edges that need to be sutured.
The extension of the incision in the temporal region, either on the scalp or along the hairline, can be made with a moderate forward bend of approximately 120 degrees, spanning 2 to 4 cm. However, the majority of excess skin will need to be primarily redistributed in the retroauricular area, where any wrinkles can be hidden and are likely to diminish over time. Furthermore, if a hypertrophic scar were to form (possibly due to the varying lengths of the skin edges that need to be sutured), it can easily be concealed by the ear or removed if necessary.
See the figure below showing various incision patterns demonstrated:
"Z" represents the retrotragal incision.
"Y" represents the pretragal incision.
"X" represents the prebeard incision.
It is important to take note of the short temporal extension indicated by the line from point A to point B.
The retroauricular portion of the incision is confined to the area corresponding to the projection of the helix's posterior border.
It is worth mentioning that these incision patterns and descriptions depict the specific characteristics of the procedure being discussed. However, it's important to note that the actual incision patterns may vary depending on individual patient factors and the specific techniques employed by the surgeon (Source: G. Botti, C. Botti, and M. Pascali):
Surgical Approaches
In this study, all the patients underwent general anaesthesia. To prepare for the procedure, each side of the face was injected subcutaneously with 100 cc of a saline solution containing 0.25% mepivacaine, 500 mg of tranexamic acid, and 1:500,000 epinephrine. As part of the authors' protocol for male face lifting, a clonidine transdermal patch was applied 6 hours before the start of the operation, unless the patient had hypotension, in which case the patch was not used except in rare cases.
The skin incisions are made following the preoperative markings. A subcutaneous dissection is performed, which is narrower in the preauricular region (6 to 7 cm) and wider in the retroinfraauricular area (8 to 10 cm). It is important to note that male patients have a tendency to bleed more, so it is crucial to minimize the risk of developing a hematoma by avoiding excessive subcutaneous undermining.
In cases where the incision in the temporal area needs to be extended, it is preferable to perform the dissection along the subfascial plane down to the hairline. The authors generally prefer a high superficial musculoaponeurotic system (SMAS) procedure, except when an implant or fat graft is planned for the zygomatic region or when a midface lift is also required. In such cases, a regular SMAS technique is carried out.
See the table that shows list of procedures and number of patients encountered (Source: G. Botti, C. Botti, and M. Pascali):
The sub-SMAS dissection is performed bilaterally, extending to the midline in the neck area. However, in the cheek region, it is limited to the necessary extent for achieving satisfactory flap mobilization. In most cases, the zygomatic ligament is released to ensure proper correction of jowls and nasolabial folds.
The SMAS flap, after mobilization, is primarily shifted and repositioned in a superior or superolateral direction. For cases where there is significant soft-tissue sagging in the lower portion of the neck, the authors prefer lifting the SMAS along a purely vertical vector. However, when the main objective is to achieve a sharper cervical angle, a superolateral vector is deemed more effective. In such cases, the SMAS flap is divided into two parts, with one part moved in a vertical direction and the other in a posterosuperior direction.
See the figure below that shows the deep dissection behind the SMAS reaches bilaterally the midline in the neck but is limited in the cheek to the extent required to obtain satisfactory mobilization of the flap (Source: G. Botti, C. Botti, and M. Pascali):
Ensuring Long-Lasting Outcomes
To ensure a stable and long-lasting outcome, it is crucial to secure the SMAS flap to solid structures during the face-lift procedure. These structures include the periosteum (the connective tissue covering the bone) of the mastoid region behind the ear, Lore's fascia in front of the earlobe, the periosteum of the posterior third of the zygomatic arch (cheekbone), and the deep temporal fascia (a layer of connective tissue covering the temporal muscle).
By using the SMAS flap as a suspender, all soft tissues are lifted without putting excessive tension on the skin margins and minimizing dead space. This approach helps prevent an unnatural flattening of the posterior cheek and malar areas while also reducing the risk of hypertrophic scar formation in the preauricular region (in front of the ear).
The regular use of fibrin glue has been incorporated into the procedure to reduce the occurrence of hematomas and enhance the flexibility of the cutaneous flap. When repositioning the anterior portion of the skin flap, it is primarily moved in a horizontal or slightly posterosuperior direction to avoid the need for extending the temporal scar upwards. On the other hand, the posterior portion of the flap is rotated in a superomedial direction, allowing the posterior scar to be sufficiently short and completely hidden by the ear. By implementing this technique, most of the difference in length between the two cutaneous edges is distributed in the retroauricular area, ensuring a more balanced and natural outcome.
See below the back part of the flap is rotated in a superomedial direction, specifically to confine the extent of the posterior scar solely within the region that is concealed by the ear. By doing so, the majority of the disparity in length between the two cutaneous edges is absorbed in the retroauricular area (Source: G. Botti, C. Botti, and M. Pascali):
Following the placement of preauricular and retroauricular cutaneous key sutures, multiple short perpendicular incisions are made on the skin, intersecting with the margins of the cutaneous flap. These incisions are then joined at their base to remove the appropriate amount of excess skin. It is important to ensure that the undermined area is thoroughly dried using gauze and air spray before the application of fibrin glue. Once the glue is applied, during the first minute, the skin margins can be carefully adjusted with the fingertips to achieve the best possible alignment and a seamless appearance. Finally, the skin is sutured using 5-0 and 6-0 nylon stitches to secure the incisions.
During the first minute after glue application, the skin margins can be guided by one’s fingertips into the best position to obtain a perfect match. Finally, the skin is sutured with 5-0 and 6-0 nylon. A moderately compressive dressing is applied and removed 12 hours later to check that there are no blood collections. The protocol used by the authors involves the use of clonidine for male patients even if they have no history of hypertension. It is crucial to prevent postoperative hypertension peaks by means of an adequate analgesic coverage and avoiding excessive fluid administration.
Within the initial minute after applying the fibrin glue, one can use their fingertips to carefully manipulate the skin margins into the optimal position to achieve a seamless and precise alignment. Subsequently, the skin is sutured using 5-0 and 6-0 nylon stitches. Following the procedure, a moderately compressive dressing is applied, and it is removed after 12 hours to inspect for any potential accumulation of blood. The authors' protocol includes the administration of clonidine to male patients, even if they do not have a history of hypertension. This measure is taken to prevent surges in blood pressure following the surgery. Adequate analgesic coverage and careful management of fluid administration are crucial to avoid excessive postoperative hypertension.
Addressing Post-Operative Challenges
No significant complications were observed in any of the cases. However, two patients experienced hematomas 12 hours after the surgery. One patient required surgical evacuation of the hematoma, while the other had it removed using a microcannula. Additionally, two patients experienced temporary paralysis of the buccal branch, which resolved spontaneously within one week and three months, respectively.
Among the cases, five patients developed hypertrophic scars on one side of the retroauricular area. In two of these cases, satisfactory improvement was achieved through triamcinolone injections following standard protocols. In the remaining three cases, the scar tissue was surgically excised to create a new scar of better quality. It is worth noting that in this series, there were no instances of postoperative dog ears (excess skin folds), likely due to careful preoperative evaluation and patient selection. However, it should be acknowledged that the occurrence of dog ears is a potential complication when the amount of excess skin exceeds what can be effectively addressed with a short-scar technique.
Psychological and Anatomical Considerations In contemporary society, men are increasingly interested in achieving a youthful and appealing look. While tailored suits can be purchased and a fit physique can be maintained through regular exercise, a smooth and youthful face can only be obtained through surgical procedures. A more rejuvenated and youthful appearance can also contribute to enhanced credibility and professional success.
Male patients seeking a face-lift have unique considerations related to psychological and anatomical factors. Many men who opt for a face lift lead busy professional lives and have limited time for recovery. Meeting the specific demands of male patients can be challenging for surgeons. On one hand, these patients desire a swift recovery, which suggests the use of minimally invasive techniques. On the other hand, they also desire natural-looking and long-lasting results, which often necessitate more aggressive approaches. Additionally, men may have concerns about their perceived virility if it becomes known that they have undergone cosmetic surgery. This concern adds an additional layer of complexity to the decision-making process for male face-lift patients.
Apart from psychological factors, there are also significant anatomical considerations to take into account. One such consideration is the presence of facial hair, particularly in the neck and cheeks. This eliminates concerns about raising sideburns since the hair can naturally regrow at the desired level if it is moved upward during the procedure. However, the presence of facial hair also influences the choice of incision site. When repositioning the flap in a superoposterior direction, the hair follicles will inevitably grow in that direction as well. This means that shaving will be necessary not only in the visible areas but also behind the earlobe. Therefore, careful decision-making is required in consultation with the patient to determine the most suitable incision site, taking into account the presence of facial hair.
It is important to note that men tend to have a higher incidence of health problems compared to women, particularly in relation to cardiovascular and pulmonary conditions. This is especially relevant when considering face-lift procedures, as patients seeking such procedures are often at an age where these health issues may be more prevalent. Therefore, it is crucial to screen all patients for any underlying medical conditions prior to surgery and ensure that they are effectively treated before proceeding with the procedure.
Furthermore, an important consideration specific to men is the fact that over 50% of them experience hair loss as they age, unlike women. This poses technical challenges in face lifting, as it becomes difficult to conceal the resulting scars. However, the solutions developed and standardized by the authors of this study appear to provide an effective approach to addressing this problem.
Dos and Dont's
Don'ts: The authors do not recommend "liquid lifts" as a suitable option because these procedures can alter facial volumes in a way that may not be well accepted by men. Instead, the technique proposed in the article involves short cutaneous scars combined with appropriate dissection and lifting of the SMAS (superficial musculoaponeurotic system) to achieve excellent results that meet the expectations of bald male patients.
Dos: Simply dividing the two edges into equal parts for an even redistribution would result in excess skin in the preauricular region, where it is crucial for the two edges to have identical lengths to achieve a perfect scar. Extending the incision in the occipital or temporal area is also not considered a favorable solution according to the authors' findings.
To achieve the best possible alignment of the two skin margins, it is crucial to distribute the difference in length primarily in the retroauricular region. This area is ideal for concealing any wrinkles that may arise and these wrinkles tend to diminish over time. Additionally, any hypertrophic scars that may occur can be easily hidden by the ear.
In cases where there is a significant amount of excess skin in the preauricular region, a temporal extension of the incision is necessary to avoid the formation of unattractive dog-ears. However, this extension should be kept as short as possible, not exceeding a length of 3 to 4 cm.
The results of the study demonstrate a high level of patient satisfaction, both in terms of scar appearance and overall facial aesthetics. It is noteworthy that both the patients and the jury members consistently rated the quality of the scars favorably. However, it should be acknowledged that managing cutaneous excess becomes slightly more complex with shorter scars. Therefore, when the scars can be easily concealed within the hair, the authors continue to use traditional incisions.
Reference
Face Lifting in Bald Male Patients: New Trends and Specific Needs (2019)
International Society of Aesthetic Plastic Surgery (2017)
Classifications of patterned hair loss: A review (2016)
Androgenetic alopecia: Pathogenesis and potential for therapy (2011)
Comparison of commercial fibrin sealants in facelift surgery: A prospective study (2013)
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