Preserving The Natural Pretragal Depression After Rhytidectomy
Lior Heller, MD, Oscar M. Ramirez, MD, and Keith M Robertson, M.D.
Stigmata of face lift surgery are one of the main concerns of the esthetic surgery patients.
Failing to preserve the natural look of the tragus and the pretragal depression can betray
the best and most innovative rejuvenation procedure. A relative simple technique to
preserve the pretragal depression has been applied to all the patients that underwent
rhytidectomy in our practice.
The standard face-lift incision we use extends from the sideburn in a slightly curvilinear
fashion to the root of the helix and then down into the marginal tragal area ( endotragal)
and around the earlobes retro-auricularly. The amount of subcutaneous dissection is
tailored to the specific needs of each patient. After completing the subcutaneous
dissection and before closing this incision the component added to recreate the pretragal
depression includes separation of the SMAS fascia attachments from the cartilage in the
preauricular area. Then this fascia is sutured over the anterior SMAS with several
interrupted 5-0 Prolene sutures to exaggerate the creation of a preauricular groove.
The skin tragal flap is deffated and a thin flap is achieved. The pretragal depression is
further defined by anchoring with the anchorage of one or two 5-0 Prolene suture from
the deep surface of the base of the tragal flap (usually the fatty layer) to the depression
created in the preauricular area. These sutures also help to decrease the tension on
the incision line and decrease the chances for a widening of the scar. Caution is advised
to avoid too thick of a bite on the base of the flap which may occasionally produce an
indentation or compromise the vascularity of the tragal flaps. The rest of the periauricular
cutaneous flap is inset in two layers. The dermal layer is anchored to the preauricular
fascia with interrupted 5-0 Prolene sutures and the epidermal layer is sutured with a 5-0
Prolene continuous suture after segments of skin are trimmed based on the skin laxity.
Beginning from the ear-lobe area and continuing in the posterior auricular area closure is
also done in two layers.
Any face lift incision should preserve the anatomic details of the ear, hairline and
pretragal area and at the same time be "invisible" to the casual observer. Several points
of concern regarding the periauricular incision have been previously mentioned: wide
hyperthrophic or hypopigmented scars, especially in the preauricular area, hidden or
buried tragus, loss of pretragal definition and deformed ear lobe. There is a continuous
debate in the literature whether a better aesthetic result can be achieved with a pretragal
incision versus an endotragal incision. The endotragal incision is in reality a "marginal"
tragal incision however the main advantage of this incision is the fact that is almost
invisible. However the advocates of the pretragal incision mention the following points as
negative features of the endotragal incision:
1) loss of the natural cheek/ear interface and sulcus because of the difficulty to recreate
the subtle crease that is normally present in the skin just anterior to the ear,
2) tragus distortion to a more anterior orientation due to tension on the sutures pulling
the tragus
3) exposure of the external auditory canal as a result of the tragal distortion that
removes the protective hooding effect that the tragus normally has in shielding the
external auditory canal.
A technique that takes advantage of the hidden location of the endotragal incision and
preserves or recreates the natural pretragal depression as well as diminishes the tension
on the suture line could be ideal. The active creation of the pretragal sulcus during
rhytidectomy eliminates this factor from the equation of decision making regarding the
location of the tragal incision. Sutures between the pretragal fascia and the SMAS as well
as the anchoring sutures between the base of the pretragal flap and the subfascial
depression created in the preauricular area absorb some of the tension applied to the
cheek skin flap and diminish the tension in the line of sutures. Closure of the suture line
is done in two layers except the tragus. The tragal flap is further more left long enough to
redrape without tension. The sutures located under the petragal cutaneous flap enable the
skin incision to heal under condition of minimal tension and the result is a fine line of
scar without widening or hypertrophy.
With this small addition to the facelift technique the natural look of the pretragal
depression is preserved and a more discrete endotragal incision can be used. In the last 5
years we implemented this technique we good results in more than 300 patients that
underwent rhytidectomy. The addition of this component to the operation didn't elongate
the operative time and only minor complications were observed. These were two cases of
partial necrosis that healed with secondary healing and two cases of indentation that
required release under local anesthesia. No widening of the incision line was reported. In
two cases loss of the pretragal definition were observed. These were due to probably
disruption of the deep layer support.
Preservation of the natural look in the tragal and pretragal area was mentioned by the
patient as a positive point. From our perspective the preauricular area looked more
natural and without noticeable scars or the stigmata of a facelift surgery.
Conclusion: We suggest that the addition of this simple technique to rhytidectomy
help to preserve the natural pretragal depression and avoid one of the most visible
postoperative stigmata frequently observed after face lift. In addition it helps to locate the
tragal incision in the endotragal area by this achieving a more discrete incision.