Facelift incisions and scars

What it is

Every facelift removes loose skin, and that skin comes out through an incision around the ear. Surgeons plan the incision in four parts: the temple, the front of the ear, the earlobe and the area behind the ear (PMID 39191413).

A poorly placed incision makes a facelift obvious. In 1985 Franco listed the signs of an operated face: a temple hairline pulled up or back, a visible scar in front of the ear, a flattened tragus, thick scars behind the ear and a stepped hairline at the back of the neck (PMID 4083737). Modern incision design answers that list part by part (PMID 39191413).

Patients and surgeons judge scars differently. Both rate a pale (hypopigmented) scar worst; surgeons also mark down a scar in front of the tragus and a blunted sideburn, and surgeons who had done more facelifts judged scars more strictly (PMID 35750195). Patients most often asked for a result that looked natural (PMID 35750195).

Where it came from

Franco's 1985 list set the targets (PMID 4083737). Through the 1990s surgeons moved the front-of-ear scar onto the edge of the tragus, where blinded raters found it harder to see (PMID 8297574), and showed that tightening the deep SMAS layer takes tension off the skin (PMID 8427680). In the 2000s Guyuron published a temple incision that keeps the sideburn (PMID 15692372), Mowlavi measured the angle of temple hair follicles, which supports a bevelled hairline incision that hair grows through (PMID 17440370), and the pixie ear was given an objective definition (PMID 15793461). Recent work targets the ear itself: earlobe rotation and anchoring stitches that hold the ear in place (PMID 29635413, PMID 35820446).

Who it suits

• High temple hairline or a previous facelift. An incision inside the temple hair raises the hairline and can remove the tuft of hair in front of the ear (PMID 11149791). For these patients surgeons place the incision along the hairline or at the lower edge of the sideburn so the sideburn stays where it was (PMID 15692372).
• Loose neck skin. A short-scar incision stops at or just behind the earlobe. In identical twins given one incision each, the short and full incisions looked alike at about a year, and the full incision gave the better neck at about five years (PMID 26890507).
• Men. The sideburn and beard need their own design: rotating the temple skin and trimming skin at the sideburn keeps a man's sideburn at its width and position, with the scars in hair and beard (PMID 41991801). In bald men the scar cannot hide in hair, so surgeons keep it as short as possible (PMID 31881604).
• Asian patients. Published deep-plane protocols for Asian faces close the skin without tension (PMID 40183553) and add a zigzag closure with botulinum toxin around the incision to improve the scar (PMID 35697816).
• Smokers. Smoking caused a large share of skin loss after facelift in a 1984 series (PMID 6728942); limiting how far the skin is lifted avoided skin loss in a series that included smokers (PMID 3952216).

How it is done

Temple

Temple hair grows out of the skin at a shallow angle, so an incision cut on a slant through the hairline allows hair to grow through the scar (PMID 17440370). Bevelled incisions gave better scars in every controlled study that tested them (PMID 29476262). Guyuron's design keeps a sideburn about 2 cm wide and places the vertical part of the scar inside the hair; in his practice, scar revisions stopped after the change, against about 1 in 23 patients before it (PMID 15692372). Some surgeons leave out the temple incision altogether (PMID 32309087). A newer incision along the temple and cheekbone kept the hairline and sideburn in place at one year in one surgeon's series (PMID 42380314).

Front of the ear

The incision follows either the crease in front of the ear (pretragal) or the back edge of the tragus, the small flap of cartilage over the ear canal (retrotragal) (PMID 8297574). Blinded raters scored the tragal-edge scar higher, except in people with a large or angled tragus (PMID 8297574). The risk at the tragus is a flattened tragus and a lost hollow in front of it; surgeons prevent this with deep stitches that rebuild the hollow (PMID 16163104) or by shaping the tragal cartilage with a stitch during the lift (PMID 41972770).

Earlobe and ear

The pixie ear, an earlobe pulled down and forward and stuck to the cheek, is the most common ear deformity after a facelift (PMID 41810509, PMID 15793461). It forms when the cheek and jawline skin pulls on the earlobe at closure (PMID 39013675). Surgeons prevent it by setting the lobe in without tension, rotating the earlobe skin backward and fixing the bowl of the ear to the bone behind it with a stitch (PMID 29635413). Closure tension can also pull the whole ear forward and down (PMID 11698850); anchoring the deep lifting stitches to the firm fascia of the temple, instead of the tissue in front of the ear, kept the ear in place (PMID 35820446).

Behind the ear

The incision runs up the back of the ear and then along or into the hairline at the back of the head. A zigzag closure (W-plasty) and a straight bevelled closure there scored alike at one year (PMID 28837737).

Tension

The rule under every part of the incision is that the deep layer carries the lift and the skin only covers it. Tightening the SMAS lowered the pull on the skin at the temple and behind the ear in cadaver measurements (PMID 8427680), and a tension-free skin closure is written into published deep-plane protocols (PMID 40183553). Skin closed under tension pulls the ear and earlobe out of place (PMID 39013675, PMID 11698850).

Results and how long they last

Most facelift scars heal flat and fine. After deep-plane facelifts, a raised (hypertrophic) scar formed in about 3 in 100 patients (PMID 42576065). Scar studies judge the result at 12 months or later (PMID 35750195). The choice of incision still shows years later: in the twin study, the full incision kept its advantage in the neck at five years (PMID 26890507).

No single incision has been proven best. Every published technique reports low rates of scar problems, and the studies measure outcomes too differently to rank them (PMID 39191413). Bald men given a deep-plane lift with a dedicated skin-trimming method rated their scars highly at one year (PMID 31881604).

Risks and how surgeons lower them

• Raised or thick scars. About 3 in 100 after deep-plane lifts (PMID 42576065). A zigzag closure plus botulinum toxin around the incision gave better scar scores at one year than a straight closure in Asian patients (PMID 35697816). A silicone plate on the hairline scar improved scar scores in a small one-sided study (PMID 26930341).
• Skin loss at the edges (necrosis). About 1 in 1,000 after deep-plane lifts (PMID 42576065) and about 4 in 1,000 across SMAS techniques (PMID 38283861). It was highest with the SMAS flap technique, which lifts the skin as a separate layer (PMID 30768122). Smoking raises the risk (PMID 6728942). Experience lowers it: in one surgeon's deep-plane series, skin necrosis fell to zero in the later cases (PMID 42385438), and a training-program series had more skin loss in front of and behind the ear (PMID 10890765).
• Hair loss at the temple. Reported after up to about 1 in 12 facelifts; biopsies show shedding from stressed follicles (telogen effluvium) (PMID 15209797). Topical minoxidil used for 2 weeks before and 4 weeks after surgery kept temple hair loss rare, and the one case resolved when minoxidil was restarted (PMID 11991275).
• Pixie ear. Seen in about 1 in 20 earlobe insets (PMID 39013675). With earlobe rotation and the ear-to-bone stitch, ear problems of any kind occurred in about 4 in 100 (PMID 29635413); the method also corrected pixie ear in secondary and tertiary facelifts (PMID 33295958) and improved ear results in Asian deep-plane patients (PMID 41810509).
• Flattened tragus. Prevented with deep anchoring stitches or cartilage shaping during the lift (PMID 16163104, PMID 41972770).

Recovery

• Early scar problems often settle: in a large single-surgeon series, widened temple scars, slow healing and raised scars all resolved without lasting effect (PMID 42380314).
• Silicone placed on the hairline incision at surgery improved scar scores at 6 weeks and at 4 months (PMID 26930341).
• Temple hair shedding after surgery comes from stressed follicles (PMID 15209797); minoxidil before and after surgery is one published way to prevent it (PMID 11991275).
• The final scar is judged at a year or more (PMID 35750195).

Questions to ask a surgeon

• Where will each part of my incision run: temple, front of the ear, earlobe and behind the ear? (PMID 39191413)
• Will my sideburn and temple hairline stay where they are now? (PMID 15692372)
• Will the scar in front of my ear follow the tragus, and how will you keep the tragus from flattening? (PMID 8297574)
• How do you set the earlobe to prevent a pixie ear? (PMID 29635413)
• Does the deep layer carry the lift so my skin closes without tension? (PMID 8427680)
• Will a short incision treat my neck, or do I need the incision behind the ear? (PMID 26890507)
• Can I see your patients' scars at a year or more, photographed from the side with the hair pulled back? (PMID 35750195)

Open questions

• Which incision is best: every technique reports low scar complication rates, and differences in study design keep them from being ranked (PMID 39191413).
• Endoscopic deep-plane lifting through hidden incisions: one surgeon reported no permanent nerve injury and cosmetic revision in about 1 in 20, mostly in the early cases (PMID 40576459).
• Limited-incision facelifts report very low rates of skin and wound problems (PMID 37950895); the twin study suggests the neck is where a short scar gives up the most (PMID 26890507).
• The hairline-preserving temple incision comes from one surgeon with no comparison group (PMID 42380314).
• Scar adjuncts (zigzag closure, botulinum toxin, silicone) rest on small single-center studies (PMID 35697816, PMID 26930341).

Terms

• Tragus: the small cartilage flap in front of the ear canal; incisions run in front of it (pretragal) or along its back edge (retrotragal) (PMID 8297574).
• Pixie ear: earlobe pulled down and forward, stuck to the cheek, after a facelift (PMID 15793461).
• Auricular displacement: the whole ear moved forward and down by closure tension (PMID 11698850).
• Bevelled (trichophytic) incision: incision cut at an angle through hair follicles so hair grows through the scar (PMID 29476262).
• W-plasty: zigzag closure that breaks up a straight scar line (PMID 28837737).
• Hypertrophic scar: raised, thick scar that stays within the incision (PMID 42576065).
• Skin necrosis (slough): loss of flap skin from poor blood supply (PMID 6728942).
• Telogen effluvium: temporary shedding of hair from stressed follicles (PMID 15209797).
• Concha-mastoid suspension suture: stitch fixing the ear bowl to the bone behind it to hold the ear in place (PMID 29635413).
• SMAS: the layer of muscle and fibrous tissue under the facial fat that a facelift tightens (PMID 8427680).
• Facelift stigmata: visible signs that a face has had a facelift (PMID 4083737).

Papers