facelifts and browlifts: amelioration of scars...jury, surgery, dermabrasion or incision. under such...

Facelifts and browlifts: Amelioration of scars

André Camirand MD, Jocelyne Doucet IL

Chirurgie Esthétique et Plastique, Montréal, Québec

As a person ages, the hairline recedes at the frontal and

temporal regions. The brow lowers, and the hairline re-

cedes; the resulting wide forehead gives the face a cadaveric

look. In the temporal region, the distance between the brow

and temporal hairs increases, ageing the face. Any incision

behind the hairline increases these distances and further ages

the patient. This is true for coronal, endoscopic and facelift

incisions made behind the hairline. However, a hairline inci-

sion (a few millimeters behind the hairline) can reduce the

width of the forehead or temporal area, and the resulting

abundance of hair can give a look of youth. However, one

must know how to exploit this alternative by obtaining less

noticeable scars. We explain how to produce less obvious

scars and provide examples of what can be accomplished.

In the literature, there are examples of physicians who

have improved bad scalp scars by grafting hair follicles con-

taining dermal grafts under the epidermis of healed scars (1).

These grafts allow the hair growing through the epidermis to

camouflage the scars. Some surgeons improve hairline scars

by grafting hair. If grafts work, it is expected that flaps will

work even better.

A top surgeon once suggested that bevelling incisions to

preserve the deep follicles of the proximal flap would result

in hair growing through and anterior to the scars. This sur-

geon meant that the skin should be incised with a bevel paral-

lel to the hair follicles so as not to injure any follicles. The

surgeon was misunderstood, and the incision was instead

bevelled to contain cut hair follicles in the proximal flap, so

that they would grow under the distal flap and in front of the

scar (Figure 1). As a result, the facelift and browlift scars

were dramatically improved (Figure 2).

Can J Plast Surg Vol 7 No 1 January/February 1999 27

PAPERS & ARTICLES

Correspondence and reprints: Dr André Camirand, 12245 Grenet

Street, Suite 112B, Montreal, Quebec H4J 2J6. Telephone 514-745-1360,

fax 514-745-5906, e-mail [email protected]

A Camirand, J Doucet. Facelifts and browlifts: Amelioration of scars. Can J Plast Surg 1999;7(1):27-34.

In facial rejuvenation, the hairline must be advanced mostly in the frontal and temporal area. The resultant abundance of hair gives

an illusion of youth. A method of incision to produce excellent hairline scars is described. Elimination of tension and proper

bevelling of the incision facilitate hair growth through and anterior to the scars and make them inconspicuous.

Key Words: Browlift, Facelift, Facelift incision, Facelift scars, Hairline incision

Lifting facial et frontal : Amélioration des cicatrices

RÉSUMÉ : 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.

Figure 1) Incision perpendicular to the hair follicles

Camirand and Doucet

28 Can J Plast Surg Vol 7 No 1 January/February 1999

Figure 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

Anatomically, the skin is composed of the epidermis and

the dermis, which lie over the hypodermis. The epidermis is

composed of many layers of cells: the stratum germinativum,

the stratum spinosum, the stratum granulosum and the stra-

tum corneum, which lies at the surface of the skin. The cells

that make up the lower layer, the stratum germinativum,

grow towards the skin’s surface and finally loose their nu-

cleus to become a dead protective layer called the stratum

corneum, which eventually sheds to be replaced with

younger cells. This migration takes approximately 30 days

under normal circumstances. However, the normal cycle is

greatly accelerated under certain circumstances, such as in-

jury, surgery, dermabrasion or incision. Under such circum-

stances the cycle may last from three to four days instead of

the usual 30 days.

With dermabrasion of a man’s cheek, the epidermis and

part of the dermis are eliminated. With a proper physiological

dressing such as Vigilon (Bard Home Health Division, New

Jersey) the skin re-epithelializes within three days. Also, be-

cause of the healing and inflammation, the local temperature

increases and the beard grows faster than usual. This acceler-

ated growth may be due to the same mechanism that is re-

sponsible for the accelerated migration of the cells from the

stratum germinativum to the skin’s surface in three days to

become the stratum corneum. With dermabrasion, removing

the superficial part of the skin does not prevent the underly-

ing hair from growing to the surface. Men continue to shave

after a dermabrasion.

MATERIALS AND METHODSAn incision is made approximately 2 to 3 mm within the hair-

line (2-16), anteriorly at an angle of 30° to 45° to the proxi-

mal scalp (Figure 1). As the excessive skin is excised from

the distal flap, it is incised with at least as much bevelling.

This is imperative because hair will not grow through fat or

hypodermis.

A micro W incision (Table 1) is made to increase the real

length of the incision of the proximal flap by 45% (Figure 3)

without increasing its apparent length, because a straight line

is the shortest distance between two points. As the distal flap

is pulled closed, the length of the distal flap is increased. As

Facelifts and brow lifts: Amelioration of scars


Figure 3)Mathematical formula demonstrating that aW incision with a

45°angle can lengthen the scar by 41%

45

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TABLE 1Advantages of W-plasty

1. Increases the real length of the proximal scar by 40% without in-

creasing the apparent length

2. Decreases tension by 40%

3. Facilitates closure because the distal flap stretches by 30% to 40%

because of the pull, resulting in no pleating and no dog ears

4. Multiple hinges allow the scar to be mobile and stretchable with

motion or facial expression

5. Improves neovascularization, as in Z-plasty, with less edema

6. Different tension and different points of the scar result in a more

natural appearance

7. Breaks the hairline, resulting in a more natural appearance

(the hairline is never linear)

the distal flap is excised, the incision should not be W-pla-

stied because this further increases the length of the distal

flap, which is already lengthened by stretching (30% to 40%)

when tension is placed on it. The surgeon should try to suture

skin edges of the same length to prevent pleating and obtain a

better closure (dog ears, when present, persist and must be

avoided).

The W-plasty creates a multitude of hinges that make the

scar mobile and more inconspicuous with facial motion and

expression.

Increasing the length of the incision by 45% inevitably re-

duces the tension by 45% and furthermore improves 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

Camirand and Doucet


Figure 4) Incision perpendicular to the skin Figure 5) Incision parallel to the hair follicles

Figure 6) Top left Browlift scar following an incision parallel to the hair follicles. The scar is linear and devoid of hair clinically and histologically

(Bottom left). Top right Browlift scar following incision maintaining cut follicles in the proximal flap. Bottom right Histology of the scar shows the

presence of hair in the scar

is reduced because W-plasty, as with Z-plasty, reduces the

‘trap door’ phenomenon and facilitates neovascularization,

which is believed to occur because bevelling of the incised

blood vessels increases the diameter of the cut vessels and

capillaries.

At the venous level, where pressure is low, the calibre of

vessels increases and venous return improves; the same

situation occurs in the capillaries. Increasing the calibre of ar-

teries lowers the pressure locally and improves the local he-

modynamic equilibrium.

It is very important to bevel the distal flap. The distal stra-

tum corneum behaves as a biological dressing, allowing the

proximal flap hair to grow for a few days as it is sheds off.

In the proximal flap, the cut hair shafts in the stratum spi-

nosium, the stratum granulosum and the stratum germinati-

vum do not stop growing because they are cut. On the

contrary, they migrate towards the surface more rapidly than

usual as the opposite cells of the distal flap migrate at the

same rate, which is faster than the usual rate due to the surgi-

cal stimulus.



Figure 7) Top left Before rejuvination of the face.Top rightAfter rejuvination of the face.Bottom leftHair is beginning to grow through and anterior

to the incision sixweeks after the browlift operation.BottomrightThreemonths after the operation, the scar is invisible because of the presenceof hair

Tension (Table 2) should be avoided because the local

ischemia interferes with the cellular response, and the result-

ing scarification is unesthetic. Contamination and infection

also interfere with the normal healing process. If the wound

is not reapproximated very well, it will never be comparable

with one that is meticulously sutured, even if plenty of hair

grows anterior to the incision. Cauterization and laser should

not be used near the hair follicles because they can destroy

the follicles and the melanocytes; this would cause a hairless

and hypochromic scar.

Tension on closure is improved by removing the excess

cervical fat, by extensive undermining beyond the osseocuta-

neous ligaments of Furnas (17), by putting tension on the su-

perficial musculo-aponeurotic system and platysma and by

using key points in front and behind the ear for facelifts. For

browlifts, the tension is applied to the galea.

The different cellular layers of the epidermis of the distal

flap should be sutured opposite to the equivalent cellular

layers of the proximal flap. The closure must be meticulous.

Because scalp hair, temporal or frontal, grows anteriorly if

the incision is made perpendicular to the skin’s surface, the

hair shafts that grow into and in front of the scar are incised

(Figure 4). However, if the incision perpendicular to the hair

is bevelled (Figure 1) (at an angle to the scalp surface), many

more hairs grow through the distal flap and camouflage much

more of the scar. In a double-blind study, incision perpen-

dicular to the hair shaft was compared with incision parallel

to the hair follicles (Figure 5). An incision made parallel to

the hair follicles, although resulting in a acceptable scar, was

linear and regular compared with an incision made perpen-

dicular to the hair follicles. With the latter incision, the hair

grew anterior to the scar, which was invisible and nonlinear;

the hairline was more anterior, and it was not possible in

some cases to see any sign of a surgical scar. The abundance

of hair was confirmed with a biopsy (Figure 6) from both ap-

proaches on the same patient. Hair was seen in front of the

scar from the perpendicular incision but not in front of the

scar that resulted from the incision parallel to the hair shaft.

As shown in Figure 7, hair grows through and anteriorly to

the incision after six weeks. Three months after the opera-

tion, because of the abundance of growing hair, the scar be-

comes invisible as shown in Figures 7-9. These photos not

only demonstrate good scars but also demonstrate that a good

clinical result can be obtained without much tension on the

skin.

CONCLUSIONSProperly bevelling incisions at an angle to the hair follicles of

the scalp can allow the hair to grow through and anteriorly to

the scar.

Camirand and Doucet


Figure 8) Facial rejuvination showing inconspicuous scars in the tem-

poral and postauricular area

TABLE 2To improve facelift or browlift scar

� Bevel the incision properly

� Bevel the distal flap equally

� Avoid tension by

� removing excess subcutaneous fat

� extensive undermining beyond the osseocutaneous ligaments of

Furnas (17)

� applying tension mostly on the superficial musculo-aponeurotic

system and platysma

� using W-plasty incision

� Avoid contamination

� Avoid laser or cautery, which can destroy hair follicles and

melanocytes and cause local ischemia and scarification (hairless and

achromic)

� W-plasty the proximal flap only (not the distal flap)

� Ensure closures are meticulous



Figure 9) Invisible scars in the temporal and postauricular area after a facelift operation

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Camirand and Doucet


facelifts and browlifts: amelioration of scars...jury, surgery, dermabrasion or incision. under such...

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