Scientific Forum
Continuing Medical Education Examination—
Facial Aesthetic Surgery
Avoiding Hairline Displacement:
A “High” Flap to Eliminate Transverse
Retroauricular Scars
Daniel Marchac, MDa; Marc Vandevoort, MDb; David Fisher, MDc; and Pedro
Meneses-Imber, MDd
Learning Objectives:
The reader is presumed to have a broad understanding of plastic surgical procedures and
concepts. After studying the article, the participant should be able to:
1. Review the surgical anatomy of the temporal scalp area.
2. Evaluate a surgical approach to the periauricular area that minimizes visible postoperative scarring.
Physicians may earn 1 hour of Category 1 CME credit by successfully completing the
examination based on material covered in this article. The examination begins on page
194.
Background: Hiding the scars and avoiding hairline displacement are crucial in performing face lift surgery.
Objective: We review temporal and retroauricular flap techniques aimed at avoiding
hairline displacement.
Methods: We introduce a new “high” retroauricular flap, used since 1997, which avoids
the usual transverse retroauricular scar.
Results: The objective of maintaining the hairline has been achieved with this incision.
Conclusions: To diminish hairline displacement and retroauricular scars in face lifts, the
temporal rotation flap and the retroauricular flap with and without a “high” skin flap
are used.
From a private plastic surgery practice in Paris, France,a a private
plastic surgery practice at H. Hart
Hospital, Roeselare, Belgium,b
Children’s Hospital, Toronto,
Ontario, Canada,c and a private
plastic surgery practice at Hospital
de Clinicas, Caracas, Venezuela.d
Accepted for publication March 12,
1999.
M
Reprint requests: Daniel Marchac,
MD, 130, rue de la Pompe, 75116
Paris, France.
inimizing the sequelae of rhytidectomy is of paramount importance. Too often,
patients return to the consultation room saying they look younger but complaining of unwanted postsurgical sequelae. Three of these particularly undesirable signs are (1) elevation of the temporal hairline; (2) a step in the postauricular
hairline; and (3) a noticeable and sometimes hypertrophic horizontal postauricular
scar.1,2 We present our techniques to overcome these tell-tale signs that indicate an
“operated-on face”3,4 and introduce the use of a new high retroauricular flap.
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Figure 1. The triangular subtemporal full-thickness resection described
by Rees.5 He resects an additional triangle (A) at the upper part to
avoid a dog-ear. Reprinted with permission from Rees T, Aesthetic
Plastic Surgery, 1980, p. 603. Courtesy of WB Saunders, Philadelphia,
PA.
Temporal Rotation Flap
To elevate the temporal hair in front of the ear, Rees5
proposed in 1980 performing a horizontal triangular
resection below the temporal hairline in cases of secondary face lifts (Figure 1). Since 1983 we have modified
this approach by performing a rotation flap that enables
lowering of the hairline and keeping the deep dermo-fatty
layer to improve the blood supply of the tip of the hairbearing flap.
After the deep layer work has been repaired (superficial
musculoaponeurotic system elevation,6 plication, lipectomy), the key stitch of the skin flap is placed at the posterior tattooed dot and sutured to the cartilage of the
anterior part of the helix. One can then position the temporal flap by use of proper tension and determine at
which level the horizontal part of the hairline will be. In
cases of a low hairline, this can be acceptable, and a simple adjustment is made. In most cases, whether it is a primary or secondary face lift, the hairline is too high, and a
downward rotation will be made to place it back into
normal position. The fold created by the downward rotation helps to determine the width of the excisional triangle. The upper portion is at the limit of the temporal hair,
disregarding the short and sparse hairs often seen below.
The lower line of the incision usually starts 5 mm above
the preauricular key stitch. The anterior angle of the triangle should stay in the horizontal area where the hair
grows downward and should not extend anteriorly.3,4 In
this triangle a deepithelialization is performed with a
number 15 blade, and the edges are approximated with
inverted subcutaneous 5-0 Vicryl® fast absorbable suture.
The superior and posterior edges of the temporal flap are
then readjusted. Because of the downward rotation, it is
often unnecessary to excise any additional hair-bearing
scalp (and that is why we initially perform an incision
parallel to hair follicles, where we incise the temporal
flap). Suturing is performed without tension with 4.0
Vicryl® fast-absorbable sutures in the hair-bearing portion
and 6.0 Prolene® interrupted sutures on the plicated lower
area. The fullness created by the deep-layer plication has
always rapidly subsided, and the use of fibrin glue
(Tissucol, Immuno) helps to flatten and adjust the temporal area. The same approach is used when an endoscopic
forehead lift is combined with a cervicofacial lift.7,8
The Retroauricular Flaps
The incision is vertical from about 4 cm from the helical
root and then becomes horizontal at about the level of
the anterior frontal hairline. The undermining of the flap
is extensive, first in the hairy portion, as deep as possible,
to avoid exposing and damaging the hair follicles. It continues subcutaneously up to the lateral canthus, superficial to the orbicularis muscle, and rejoins the preauricular
undermining (Figure 2). A tattooed ink dot is placed
behind and in front of the preauricular incision at the
level of the anterior extremity of the anthelix of the auricle. This usually corresponds to the level of the horizontal temporal hairline.
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The goals are to avoid a step in the retroauricular hairline and a transverse scar in the mastoid skin when the
ear is small or this bald area is wide. Since 1983 we have
used a retroauricular scalp flap to avoid the hairline step.
Starting from the auricular lobule, the retroauricular incision is placed within the sulcus and turns horizontally
across the mastoid area at a level corresponding to the
maximum width of the external ear, usually at the level
of the crus helix, slightly below the anterior key stitch
(Figure 3). The incision is continued horizontally for
about 4 cm and then turns inferiorly at a right angle for
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A
B
C
Figure 2. Temporal rotation flap. A, The skin incision in the temporal area extends vertically from the helical root and then is continued horizontally
at the level of the frontal hairline. In most patients the lower border of the temporal hair-bearing area is at the level of the helical root. B, The cervicofacial flap is retracted superiorly and posteriorly. The third key stitch (3) is placed at the level of the helical root. Note that the temporal hairline is displaced cephalad. A posteriorly based triangle is designed. The upper edge is placed along the lower border of the temporal hairline. The lower edge is
then drawn from the anterior limit of the upper line to a point within 2 to 3 mm above the level of the helical root. This area is deepithelialized (mottled shading). Adequate mobilization of the temporal area allows caudal rotation of the temporal flap, and the edges of the triangle are closed primarily. This returns the lower border of the temporal hair to the level of the helical root. The excess skin is trimmed (dotted shading). Only a limited
resection is required from the top of the temporal flap. C, The incision is closed without tension.
A
B
C
Figure 3. Retroauricular flap. A, The postauricular incision runs in the postauricular sulcus. At the level of the tragus, the incision then extends transversely and posteriorly across the glabrous retroauricular skin, crossing the hairline into the mastoid and occipital hair-bearing scalp. Posteriorly the
incision turns inferiorly for a distance of 1 to 2 cm. B, The cervical flap is retracted posteriorly and superiorly, the line of pull along the direction of the
postauricular sulcus (black arrow). The first key stitch (1) is placed at the level of the crus helix. The short inferior limb of the retroauricular flap allows
for anterior and superior rotation of the hair-bearing portion of the scalp. Superior and anterior traction is placed on the flap, with the line of pull along
the direction of the posterior hairline (white arrow). This maintains the continuity of the posterior hairline without producing a step-off. A second key
stitch (C, 2) is placed at the hairline. The excess skin is trimmed (dotted shading). C, The incision is closed. Anterior to the hairline, adjustments must be
made for minor length discrepancy that exists between the upper (short) and lower (long) skin margins. Any wrinkling will disappear rapidly.
about 1.5 cm. Ink dots are tattooed on the ear, hairline,
and flap to allow measurement of displacement and facilitate reapproximation of the natural hairline. The entire
flap is undermined as deeply as possible above the mastoid and cervical aponeuroses.
When the cervical undermining has been completed, we
evaluate the retropositioning of the cervical flap, and in
primary cases, a 0.5-cm strip of skin is usually taken
from the upper border of the flap, with a careful exten-
Avoiding Hairline Displacement: A “High” Flap
to Eliminate Transverse Retroauricular Scars
sion around the lobule. In secondary cases we remove
only the scar.
The backward displacement of the cervical flap is evaluated and a 4.0 Maxon® suture is placed at the tattooed
key point “1” (Figure 3, B). A measurement of the displacement is made.
The next step taken is to reconstruct the hairline by an
upward and backward displacement of the hairy portion.
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A
B
C
D
E
F
G
Figure 4. High retroauricular flap. A, The postauricular incision runs along the length of the postauricular sulcus, turning posteriorly and then along the
posterior hairline. At the level of the tragus, the incision then extends transversely and posteriorly, crossing the hairline into the mastoid and occipital
hair-bearing scalp. Posteriorly the incision turns inferiorly for a distance of 1 to 2 cm. B, The cervical flap is retracted posteriorly and superiorly, with the
line of pull along the direction of the postauricular sulcus (black arrow). The first key stitch (1) is placed at the level of the tragus. The short inferior limb
of the occipital portion of the flap allows for anterior and superior rotation of the hair-bearing portion of the scalp. Superior and anterior traction is
placed on the flap, with the line of pull along the direction of the posterior hairline (white arrow). A second key stitch (C, 2) is placed maintaining the
continuity of the hairline without any step-off. The excess skin is trimmed (dotted shading). C, The high retroauricular flap is inset after some anterior
rotation. There is no tension in this portion of the flap, which is somewhat redundant. The incision is closed. Any wrinkling will resolve over time. D,
Note the tattooing at the level of the curs helix. E, The key stitch has been placed at point 1. F, An upward movement will recreate the hairline alignment
by suturing at point 2. The superior flap is adjusted without any tension. G, The suture is performed with intradermal running sutures and fine interrupted
stitches. Note a retroauricular fold resulting from the rotation that usually subsides on its own.
The dotted point helps to realign the hairline with a very
moderate hair-bearing scalp excision in the lower portion, with the right angle incision becoming nearly
straight. Because of this upward movement, there is a dis-
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crepancy in the mastoid skin area between the posterior
and anterior edges. This skin is thin, and the skin folds
created by this upward displacement will quickly subside
after suturing.3,4 Suturing is performed with fast-
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Figure 5. Postoperative view of a female patient 4 months after a procedure with the high retroauricular flap.
Figure 6. Postoperative view of a female patient 6 months after a procedure with the high retroauricular flap.
absorbable 3-0 Vicryl® in the hair and a 5-0 Prolene®
intradermal stitch in the skin area, completed by a few 60 interrupted sutures.
base of the flap is very wide, it is possible to remove the
upper limit of the flap behind the ear to get rid of these
folds. When the pedicle is not very wide, it is better to
accept the folds, because they will diminish with time
(Figure 4, G).
The High Retroauricular Flap
Since early 1997 we have also used a high retroauricular
flap in certain cases. To avoid the mastoidal horizontal
scar when the ears are small or when the non-hair-bearing retroauricular area is wide, we combine this high
retroauricular flap with the previously described scalp
flap, which restores the hairline (Figure 4). The same
design as for the previous flap is marked at the same
level, but instead of turning the incision horizontally
across the mastoid skin, we follow the retroauricular sulcus up to the limit of the glabrous area and then turn
down to follow the hairline until a horizontal scalp incision is reached. This can be performed only if the width/
length ratio is not smaller than 1:1 (Figure 4, A-D).
The skin flap is carefully raised in continuity with the
scalp flap, keeping it as thick as possible. At the time of
readjustment, the cervical flap is pulled backward and
first sutured at the level of the tattooed ink landmark
behind the ear, marked “1,” as previously described
(Figure 4, B and E).
The hairline is then realigned, and an incision is made
along the hairline on the flap up to the point where the
lower hairline joins the upper hairline (Figure 4, C).
When this point is sutured and the scalp is adjusted, we
carefully adjust the high skin flap, avoiding any tension
(Figure 4, F). An excess of retroauricular skin is created
by the upward movement of the skin flap. When the
Avoiding Hairline Displacement: A “High” Flap
to Eliminate Transverse Retroauricular Scars
Results
We have used the temporal rotation and high retroauricular flaps since 1988.3,4 This series represents patients
who underwent operation between February 1997 and
November 1998 and focuses on the use and complications of the high retroauricular flap. A total of 190 face
lifts were performed (180 women, 10 men). Of these,
116 were primary, 63 were secondary, and 11 were tertiary. Temporal flaps were used in 96 cases, high retroauricular flaps in 28, and 13 patients had a combination of
these. Almost all of the high retroauricular flaps were
performed as part of a primary face lift, and all combined
cases were primary.
Complications were limited to partial superficial or fullthickness partial flap losses or to redundant retroauricular skin folds. Distal superficial partial skin loss occurred
in five patients and healed without further complication.
Two full-thickness partial flap losses were noted, both in
smokers whose flaps had relatively narrow pedicles.
Persistence of retroauricular skin folds was seen in six
cases. Only two patients desired a revision, and these
were performed on an outpatient basis with local anesthetic. The resulting scars have always been of excellent
quality (Figures 5 and 6). The objective of maintaining
the hairline has been achieved.
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cated again, associated with various maneuvers to
diminish detectability.9 We use precapillary incisions in
patients who need a significant skin excision and who
already have a receding hairline as a result of previous
surgery. Smokers with fine, fragile hair are also candidates for precapillary incisions. In our experience these
scars are unpredictable; some are hardly visible on one
side yet visible on the other side, even though they are
done in exactly the same way with identical care and
precautions.
Another solution is the zig-zag incision described by
Guyuron,11 following the horizontal part of the temporal
hairline and then ascending vertically behind the hairline.
We use it occasionally in patients who are smokers, have
thin hair, or are elderly. We hesitate to use this incision
in younger patients because the revisions are more difficult and a rotation flap is impossible because of the anterior scar. Elevation of the temporal scalp carries a risk of
hair loss, which is minimized by a deep and atraumatic
dissection and an absence of tension exerted during
suturing. Occasional hair loss may be observed, but the
hair grows back, with the exception of an occasional borderline slough that can be observed in smokers.
A
B
In the retroauricular area, the precapillary incision has
very rare indications for us, because we have observed so
many widened and whitish scars. It is only when an
extraordinary amount of skin must be removed that we
would consider this approach; otherwise, we would perform our usual intracapillary incision. Realignment of the
hairline is not always possible. In cases of very extensive
resection (7 cm retroauricular) or in secondary face lifts,
we are obliged to accept a moderate step. The high
retroauricular flap carries a risk. It is a random flap, and
the length/width ratio must be respected, as we have
learned. Therefore it should not be used when the hairline is close to the ear.
C
Figure 7. A, There is a wide retroauricular glabrous area in this patient.
The base of the flap will be wide. B, After adjustment, with no tension
above the key points 1 and 2 (see Figure 3, C). C, There is no visible
transversal scar; the scar follows the hairline without any tension.
Discussion
In the continuous effort to improve results and to minimize sequelae of face lift procedures, the preservation
of hairline and concealment of scars play an important
role.1,2,9,10 In the temporal region, precapillary incisions
have been used for many years and periodically advo-
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The best indications for the high retroauricular flap
(Figure 7) are (1) young age, (2) small ears, (3) large
glabrous mastoid area, (4) hairstyle exposing the ears, (5)
male patient, and (6) no previous transverse scar (therefore primary face lifts). Male patients do not usually
require a temporal rotation flap because the beard is in
continuity with the temporal hair. This is not always
true, however, and the hair implantation should be
examined carefully. Occasionally there are only a few
hairs in the preauricular area, and a temporal rotation
flap may be indicated.
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Regarding the retroauricular area, with the usual short
male hairstyles that provide greater visibility around the
ear, the continuity of the hairline and attention to the
quality of scars become even more important. In the
absence of contraindications (especially a narrow pedicle), the high retroauricular flap and realignment of the
hairline are routinely performed.
Conclusions
After 16 years of using the rotation temporal flap and
elevation retroauricular flap, the goal of diminishing the
sequelae of the face lift in terms of preserving the hairline
has been approached. The fact that these flaps are reproducible in cases of secondary and tertiary face lifts is also
of great importance. With the high retroauricular flap,
we are able to further conceal the signs of surgery. Use of
this flap is particularly indicated for young patients with
small ears and a recessed retroauricular hairline. ■
References
1. Franco T. Face-lift stigma. Ann Plast Surg 1985;15:379-85.
2. McKinney P, Maywood B. Camouflage of the postauricular scar in
rhytidectomy. Plast Reconstr Surg 1982;69:352-5.
3. Marchac D. Préservation de la ligne chevelue dans les liftings cervicofaciaux par double lambeau de rotation temporal et retroauriculaire. Ann
Chir Plast Esthét 1992;37:519-24.
4. Marchac D. Preservation of the hairline in face lifts by double temporal
and retroauricular flaps. Plast Surg Tech 1995;1:217-22.
5. Rees T. Aesthetic plastic surgery. Philadelphia: WB Saunders, 1980.
6. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS)
in the parotid and cheek area. Plast Reconstr Surg 1976;58:80-8.
7. Marchac D, Sandor G. Face lifts and sprayed fibrin glue–an outcome
analysis of 200 patients. Br J Plast Surg 1994;47:306-9.
8. Marchac D, Ascherman J, Arnaud E. Fibrin glue fixation in forehead
endoscopy: evaluation of our experience with 206 cases. Plast
Reconstr Surg 1997;100:704-12.
9. Camirand A. Amélioration des cicatrices de lifting temporal et frontal.
Ann Chir Plast Esthét 1991;36:215-7.
10. Connell B. Surgical techniques of cervical lift and facial lipectomy.
Aesthetic Plast Surg 1981;5:43-50.
11. Guyuron B. Modified temple incision for facial rhytidectomy. Ann Plast
Surg 1988;21:439-43.
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to Eliminate Transverse Retroauricular Scars
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