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a b c
[19]
Figure 15: Complications of the vertical vector lift. (a) Vertical pleating
(large arrow) and lower eyelid skin excess (small arrow). The latter is
corrected by pinch blepharoplasty, which requires a 2‑cm incision;
(b) patient treated alio loco, presenting with vertical pleating in the
neck; (c) patient treated alio loco presenting with excess skin in the
lower eyelid

the tragus can indicate that a facelift has been performed. Figure 16: Creating the pretragal fovea. Trimming the flap to the dermis
In men, the hair follicles should be meticulously trimmed,
taking into consideration the desired sideburn shape and crescent‑shaped skin excision which continues into the
the fact that shaving the tragus (and under the earlobe) membranous septum and which may be reduced in height
is a nuisance and may lead to repeated bleeding. Two if the nasolabial angle requires sharpening and a hanging
4‑0 Vicryl sutures in this location will support lifting and columella is present. Otherwise, a full transfixion incision
shaping of the pretragal fovea. divides the medial crural footplates and the caudal
septum. The dermis of the central lip is then suspended
Trimming under the earlobe should also be conservative. to it with a 4‑0 PDS suture. The columella can then slide
The anterior skin flap created during the resection of upward slightly with the footplates for the elevation of
excess skin can usually be pulled behind the earlobe to the nasal tip [Figure 17].
determine how much needs to be resected. Because the
earlobe will be pulled forward and downward by gravity Earlobe reduction can be performed with marginal excision
and collagen contraction during the first few weeks and fine sutures, although removal of a full‑thickness
following surgery, the shape of the skin flap should push medially based wedge produces better results. The
the earlobe upward and backward [Figure 14]. facial skin flap is pulled up behind the newly formed
earlobe to allow for proper cephalad repositioning
Skin closure with 5‑0 nylon starts at the superior end of [Figures 18 and 19].
the incision and continues down to the earlobe, stopping
behind the earlobe and repositioning it upward and Recommended sequence
backward. • Premedicate
• Mark locations of the suspension loops and extent of
FIBRIN GLUE dissection
• Secure intravenous access
The use of vacuum drains and extensive bandaging is not • Prep and drape
recommended. Fibrin glue spray is preferred to prevent • Mark incision lines
hematomas, ecchymosis, seromas and discharge [Video 7]. • Intravenous sedation
The sealant should be applied while the wound is still • Infiltrate of local anesthetic in the anterior neck for
open (0.5 mL each side) to allow air to escape and prevent submental liposuction
venous air embolism. The wound bed is dried by • Perform submental liposuction
introducing a suction drain connected to the central • Perform nerve block anesthesia and infiltrate local an
vacuum system under the skin flap before skin suturing. esthetic
• Perform liposuction of jowl
LIP AND EARLOBE REDUCTION • Incise and elevate pre‑and post‑auricular flaps and connect
pockets
• Perform lateral SMAS ectomy
Whereas a turkey gobbler neck and lower eyelid bags • Weave suspension sutures into the nasolabial fold, jowl
are spotted quickly and addressed with blepharoplasty area and platysma
and liposuction, long upper lips and earlobes are often • Fixate platysma to the substernomastoid region with a
overlooked. A long upper lip (and low lower lip) expose 2‑0 PDS suture, followed by over‑suturing with 4‑0 Vicryl
[26]
the lower teeth when smiling, a typical sign of aging. suture
Pendulous earlobes can result from wearing heavy jewelry • Knot the remaining suspension sutures onto the
over many decades.
temporoparotid fascia, as described by Lore [23]
Upper lip reduction and nasal tip lift are accomplished • Mark and excise of excess skin in the preauricular region
by a modification of the “double duck” procedure, • Trim pretragal subcutaneous sutures, and place high
[27]
[28]
[26]
which is a modification of Austin sub‑nasal buffalo suspension suture to shape the pretragal fovea and drape
horn excision. This procedure involves a sub‑alar the skin
306 Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015