Revision Facelift and Neck Lift

Abstract

Facial rejuvenation procedures have become more commonly performed due to an increasing elderly population and greater general public acceptance. As a result, patients are now increasingly undergoing secondary and tertiary rhytidectomies to treat natural aging and/or to correct complications from prior procedures. Revision face and neck lifts are more complex by nature of the procedure and require a comprehensive preoperative assessment for enhanced outcomes. In this review, we discuss the preoperative evaluation, surgical challenges encountered, primary face and neck lift deformities, and their surgical management for patients undergoing secondary face and neck lifts.

Facial rejuvenation procedures have significantly grown in popularity over the past two decades. ¹ With a growing elderly population and an increased interest in facial rejuvenation procedures particularly at a younger age, a greater number of patients are now consequently undergoing secondary and even tertiary rhytidectomies. ²

Facial aging involves a multifactorial progression of morphological changes to the skin, soft tissue, fat compartments, and skeleton. ³ Numerous surgical methods have been employed to correct the aging face, ranging from nonsurgical or minimally invasive techniques to various surgical techniques involving manipulation of the skin and superficial musculoaponeurotic system (SMAS). ⁴ Surgical procedures incorporating the SMAS have demonstrated greater longevity compared with skin-only facelifts. ^{4 5} Most recently, augmentation of deficient facial soft tissues with either a variety of injectable fillers or the use of microfat grafting has been used to address the adverse effects of facial aging.

While primary face and neck lifts have been extensively examined, secondary and revisional facial rejuvenation procedures have not been as sufficiently discussed in the literature. ^{2 6}

Secondary procedures may be performed to treat recurrent skin laxity caused by the natural progression of facial aging and may also be performed to correct many adverse consequences of prior face or neck lifts. As with most operative procedures, less-than-optimal results do frequently occur, and it is incumbent on surgeons who perform these procedures to have the forethought and the ability to correct these issues. Common deformities observed include hairline distortion, ear deformities, neck skin pleats, recurrent platysmal bands, visible and poorly positioned surgical scars, and incomplete correction. ^{7 8} Nonetheless, secondary procedures have been proven to be safe, effective, and reliable with high patient satisfaction. In this review, we will address the indications, preoperative planning, challenges, and management considerations when performing revision and secondary aesthetic procedures of the face and neck.

Preoperative Assessment

A secondary rhytidectomy or neck lift requires extensive presurgical planning to ensure appropriate surgical management and to address patient concerns. It is imperative to review pre- and postoperative photographs of the primary procedure as well as to examine the prior operative report. ^{6 9} An essential element to the preoperative assessment is having an understanding of the motivations for why the patient has returned for a revision facelift. The surgical technique applied can vary based on whether the patient requests a reoperation because of physiological aging, dissatisfaction with a prior rhytidectomy, or a combination of both. Moreover, the surgical technique utilized can also differ depending on the specific outcome that occurred from a previously performed face or neck lift. Was the type of surgical technique performed optimal for the patient's unique presentation? Was the correct operative method utilized but the quality of the procedure inadequate? Was the surgical technique acceptable but with limited postoperative results? These questions provide a framework from which a surgeon can evaluate the patient to offer the most appropriate operative management. ⁶

A comprehensive history and physical examination provide the surgeon with important information unique to the patient during the preoperative assessment. Patients undergoing a secondary procedure are on average nearly a decade older than those who are presenting for their first face or neck lift. ^{10 11} As a result, these patients commonly have greater comorbidities requiring additional medications. A careful assessment of all medications and herbal remedies should be reported due to potential adverse effects such as coagulation abnormalities. The side effects of these medications can result in intraoperative complications including hematoma formation and blood pressure instability. ^{6 7 12 13 14 15} Consequently, these medications should be managed preoperatively to reduce the risk of preventable complications.

Beyond assessing the face via preoperative and postoperative photos, a detailed physical exam is critical. The face and neck must be evaluated methodically by the surgeon. Rohrich et al offered a simple system to assess the face by evaluating midface width, facial length, and facial fullness. Monitoring for asymmetry can more easily help identify differences in these parameters by providing a comparison between both sides of the face. ¹⁶ In addition to these contour-related issues, the position and quality of previous surgical scars, distortion of sideburns and the mastoid hairline, and issues related to contour of the earlobes and helix must be evaluated and considered in the planning process.

Surgical Challenges

By nature of the surgical procedure, a secondary rhytidectomy necessitates a more multifaceted approach when compared with the primary operation. As a result of the previous facelift, there are oftentimes distorted facial planes and tissue rigidity due to scar formation from prior surgical incisions. ^{6 9} Moreover, patients who undergo a secondary operation are significantly older than when they underwent their original procedure, exhibiting poorer skin and tissue quality. It has also been demonstrated that the SMAS layer may be attenuated or thinner. ^{10 13 15 17} This limitation can negatively affect the surgeon's technical options and ability for operative correction of these facial deformities. In this scenario, SMAS plication may be a better option rather than attempting to elevate the thin SMAS layer. ¹³ Additionally, though skin laxity increases with age, the amount of skin resected following the secondary rhytidectomy is typically less than the primary operation. ¹⁰

Scar tissue commonly forms after undergoing any surgery with soft-tissue manipulation such as a face or neck lift. Scars can also migrate to unfavorable positions and can distort normal anatomic structures if the skin flaps are placed under undue tension ( Fig. 1 ). Thus, surgeons must factor in prior scars and incisions when preoperatively assessing the patient. To mitigate the risk of conspicuous facial scarring, it is customary to utilize the original surgical skin incisions when performing the secondary procedure and to excise any additional remaining scars. ^{2 7 9 18} Hatef and Sclafani delineated three exceptions to this rule: unnoticeable or hidden scars; women with pretragal scars and adequate skin laxity who can undergo retrotragal incision placement; patients with evidently, poorly positioned prior incisions who can undergo standard incision with appreciable mobilization of skin area for scar excision. ⁶

Fig. 1.

Early postoperative scarring related to increased tension following a secondary facelift. Stigmata include thinning and hypertrophy of the surgical scars, anterior migration of the preauricular incision, inferior displacement of the mastoid hairline scar, and anterior retraction of the posttragal incision leading to visibility of the external auditory canal ( a ). Long-term outcomes reveal these anatomic distortions even when the incisional scarring improves ( b ).

While a secondary facelift procedure typically contributes to greater technical complexity of the surgery, it can be performed safely with remarkable postoperative results. In fact, Guyuron et al demonstrated that patients were more satisfied with the revisional surgery when compared with the primary operation. ¹¹ Furthermore, the secondary operation displays similar postoperative complication rates to the primary procedure despite its increased difficulty. ²

Our experience involving secondary operations on patients that we have previously treated somewhat contrasts this traditional line of thinking. Given the presence of a thin, yet identifiable scar plane that defines the plane of dissection, we have found flap dissection to be a technically simple and straightforward operative process. Interestingly, the primary rhytidectomy flap demonstrates improved postoperative vascularity due in part to the delay phenomenon. By rendering the tissue ischemic, the flap is capable of forming new blood vessels, which augments the vascularity and thus the survival of the facial and neck flaps upon undergoing a secondary rhytidectomy. ¹⁹

Preoperative Planning

While the facelift is an important component to restoring a youthful face, it can be combined with other procedures to achieve better aesthetic outcomes. This is particularly relevant in patients interested in a secondary rhytidectomy by nature of their older age. Guyuron et al reported that patients who underwent a secondary facelift were significantly more likely to have an ancillary procedure performed compared with their primary rhytidectomy counterparts. ¹¹ It is valuable to remember the quote, “A young face is not an old face with tight cheek skin,” when evaluating a patient. ^{4 20} Stuzin also put it nicely by describing that “facial shaping,” not “face lifting,” is central when assessing the patient preoperatively. ^{16 21} Consequently, utilization of additional procedures to restore volume, recontour the face, and provide a more youthful appearance should be considered during the preoperative visit. ²²

Numerous options exist when considering ancillary procedures to perform, including laser resurfacing and chemical peels. Resurfacing procedures are performed to treat wrinkles, dyschromia, and textural abnormalities. ²² The use of erbium lasers has demonstrated faster recovery times and enhanced outcomes compared with carbon dioxide lasers. Scheuer et al reported that laser resurfacing, in conjunction with the facelift, has a high safety profile with a 3.8% complication rate. ^{22 23} Chemical peels are also performed to address wrinkles and dyschromia. Different agents can be used depending on the depth of skin resurfacing desired. ²² Trichloroacetic acid (TCA) is a commonly applied agent for chemical resurfacing of the face. As demonstrated by Herbig et al, TCA can be combined safely with Jessner's solution for patients undergoing face and neck lift procedures. ²⁴ Consideration must be given to the timing of these procedures and to the areas of treatment, particularly for resurfacing procedures that are “deep” and thus frequently result in permanent hypopigmentation of the affected skin. One should avoid creating demarcation lines that, by definition, occur in patients with higher Fitzpatrick scores, and one should avoid moving demarcation lines to positions on the face that are unfavorable given the skin movement associated with face and neck lift procedures.

The eyes are an integral component of facial beauty and denote youth. Facial aging in the periorbital region is not typically corrected with a facelift and requires additional attention when assessing the patient. To create harmony of the periorbital area with the face and neck, other procedures such as a blepharoplasty or brow lift may be performed at the time of the rhytidectomy. An upper blepharoplasty is performed to restore a youthful-appearing eyelid by excising redundant skin. Though the surgeon should approach each patient individually, the five-step technique for upper blepharoplasty described by Rohrich et al can be reliably used. ²⁵ The ptotic brow can also be corrected with a brow lift such as a temporal brow lift. This method has been shown to be an effective, reliable, and inexpensive technique with high patient satisfaction. ²⁶

The face has five superficial and two deep fat compartments, which lose volume with age. ²⁷ Fat grafting can also be performed in conjunction with the face or neck lift to volumize certain facial regions, thus contributing to a more youthful appearance. ^{28 29 30} Fat grafting serves as a good option as it is readily available, inexpensive, and easily reproducible. ³¹ By incorporating the “lift” and “fill” principle, it has been demonstrated that the surgeon can both recontour the face and address volume deflation of the different fat compartments. ^{29 30}

Deformities and Management

Hairline Distortion

The temporal incision of a rhytidectomy requires meticulous care to prevent significant distortion of the sideburn and hairline ( Fig. 2 ). Aggressive superolateral flap advancement and poor incision design can contribute to their deformity or removal. Traditionally, the temporal incision is placed posteriorly within the hairline to hide the resulting scar; however, this may lead to displacement of the sideburn and hairline. ^{6 9 15} To obviate this complication, the surgeon should estimate the postoperative distance between the lateral orbital rim and the anterior hairline. If less than 5 cm, then the temporal portion of the incision can be placed posteriorly within the hairline; if greater than 5 cm, a pretrichial incision is recommended. ¹⁸ Although a somewhat less “scientific” method of assessment, the general position of the sideburn or temporal hairline can and should be used as a determinant for placement of the temporal incision. If the sideburn is located superior to the root of the helix, the use of a transverse pretrichial incision should be considered ( Fig. 3 ). One can routinely and safely ignore a previous scar within the temporal hairline associated with a prior facelift ( Fig. 2 ). ^{6 32} A beveled incision should be utilized to camouflage the scar and to minimize any additional distortion of the temporal hairline. ³³ This will frequently result in hair growth through the scar, which contributes to the ability to hide and disguise this scar. In the event that the hair-bearing area is severely displaced or absent, hair transplantation may be performed to restore the natural sideburn. ^{2 6 32 34}

Fig. 2.

Patient seeking secondary facelift. A previous preauricular incision extended into the hairline resulted in significant elevation and distortion of the sideburn, resulting in an unnatural appearance ( a ). Pre- and postoperative results following a secondary facelift procedure. The previous temporal scar was ignored and a transverse temporal incision was used to avoid further elevation of the temporal hairline and sideburn ( b ).

Fig. 3.

A facelift incision may be placed transversely in a pretrichial fashion along the temporal hairline ( red ) or may be followed into the hairline ( green ) depending on the position of the sideburn. The incision continues along the root of the helix and then may proceed in a pretragal ( red ) or posttragal ( purple ) fashion. This is then continued around the ear lobule and postauricularly onto the concha and then high across the mastoid ( dashed red line ). The incision may stop there for short-scar facelifts or may continue either into the hairline ( yellow ) or along the occipital hairline ( red ). (Authors maintain copyright privileges to artwork.)

Similar to distortion of the temporal hairline, improper design of the posterior hairline incision can result in displacement of the occipital hairline. This defect is commonly referred to as a “step-off” deformity or superior hairline displacement ( Fig. 4 ). ³⁵ In addition, areas of alopecia within this scar can lead to unfavorable results, which are particularly obvious in males or in females who frequently wear their hair up in a ponytail. Scar widening along the posterior hairline incision can also result in an unfavorable aesthetic appearance even when the incision is appropriately positioned. This can occur as a result of a poorly undermined flap that is mostly suspended utilizing skin as opposed to the deeper tissue structures. ¹⁵

Fig. 4.

This patient's hairline is shifted superiorly after her facelift and a significant hairline step-off is seen ( a ). Correct incision placement and proper realignment of the occipital hairline does not create such a step-off ( b ).

Continuity of the postauricular incision either into the posterior scalp or along the occipital hairline requires a thorough assessment of the patient to reduce the risk of displacement ( Fig. 3 ). If the surgeon deems that less than 2 cm of postauricular skin will be resected, then the incision should be carried into the posterior scalp; but if the surgeon expects that more than 2 cm will be excised, the incision should continue along the occipital hairline to prevent the step-off hairline deformity. ¹⁸ Again, having a discussion with the patient as to how they wear their hair may influence this decision, even when a limited amount of skin will be resected. To correct a displaced occipital hairline or significant scarring, the surgeon should widely undermine the cervical flap and perform a lateral platysmaplasty to release any tension present along the previous scar and to amend any existing deformity. ³² Scar resection, flap advancement-rotation, and layered closure can also help restore the natural contour of the posterior hairline. ^{6 9} If the patient is presenting for a tertiary procedure and already has two scar incisions within the occipital region, the incision should be placed either along or above the superior incision and sufficiently undermine the tissue to remove both scars. ³² Again, it behooves the surgeon to also bevel the incision to reduce postoperative scar definition. ^{7 15 32 33}

Tragal Deformity

Loss of proper tragal positioning and effacement of a natural pretragal depression are common complications witnessed following rhytidectomy, rendering the most refined facelift noticeable to the observer. ³⁶ These deformities occur as a result of either poor incision design and/or excessive tension on the skin following closure. ^{6 9 37} If significant tension is present, the tragus may migrate anteriorly with pronounced separation from the auricle and an exposed auditory canal, which is termed as the shotgun ear deformity ( Fig. 5 ). ^{6 7} For the most part, this type of deformity is associated with the use of a posttragal incision rather than a pretragal incision. Unless there is excessive tension on the facial skin flap at the time of closure or if skin necrosis occurs in this area, this deformity can be generally be avoided by the use of a pretragal incision.

Fig. 5.

A “shotgun” ear deformity. The tragus is distorted anteriorly resulting in loss of the pretragal crease and a visible external auditory canal. When severe, it can appear as though one is looking directly into the external canal.

Ramirez et al described their methodical approach to preventing this deformity when performing a facelift. ³⁶ To construct the pretragal concavity where none exits, the fascial attachments to the tragal cartilage must be separated within the preauricular region. This will allow the facial flap to settle into this relative concavity, thus maintaining an acceptable aesthetic appearance in this area. To achieve a well-defined, thin tragus, the facial flap that is created should be appropriately defatted, generally to the level of the deep dermis. To further define the pretragal depression, the base of the tragal flap is fixed to the designed preauricular depression with sutures. ^{3 6} Frequently transcutaneous horizontal mattress sutures can be placed and tied at the base of tragus at the level of the external auditory canal. To correct this complication during a secondary procedure and prevent further distortion, any tension should be displaced superior to the helix and within the postauricular area 2 to 3 cm above the external auditory canal. ^{9 13} Otherwise, the surgeon should follow a similar technique utilized for performing a primary rhytidectomy. If there is insufficient skin to redrape over the tragus, a triangular skin flap can be designed superior to the tragus and rotated 180 degrees for coverage. ¹³ The use of a pre-, inter-, or retrotragal incision is highly surgeon-dependent, though a pretragal incision is commonly utilized to prevent additional tension or anterior displacement. ^{6 7 8 18 32} A surgeon may choose to perform a retrotragal incision in women who present with pretragal scarring and sufficient skin laxity; however, the same should not be performed in men to prevent incorporating facial hair into the tragus. ^{6 7 8}

Pixie Ear Deformity

The pixie ear deformity is caused by removal of excess skin and improper utility of SMAS-based techniques, resulting in significant skin tension along the lobule. ^{15 32} The sulcus between the lobule and cheek is lost, and the lobule appears tethered to the cheek. ⁷ The earlobe is displaced caudally and anteriorly and is characterized by lengthening of the attached cephalic segment and shortening of the free caudal portion. ^{6 38} While numerous surgical methods exist to correct this deformity, avoidance of this complication entirely is most prudent. ⁹ One can choose to overrotate the earlobe superiorly during inset to account for caudal migration; however, more success has been described anecdotally via splitting of the distal SMAS and placing the earlobe between the two separated ends with anchorage to the mastoid periosteum. ^{6 39} Adequate skin laxity and minimum tension during closure are also essential components to preventing the deformity. The pixie ear has been reportedly corrected via wedge excision, triangular excision, and earlobe redesign. ^{6 9 40 41} Our preferred method of correction is simply to partially inset the lobule anteriorly and posteriorly, thus leaving a 4- to 5-mm open area at the caudal portion of the earlobe. This open area is allowed to heal secondarily and results in upward turn of the lobule and a more aesthetic, less tethered appearance ( Fig. 6 ). It should be noted, however, that the basic principles of scar resection and tension reduction on skin flaps remain the same. The surgeon should also attempt to transfer tension to the SMAS and/or platysma if possible. ³²

Fig. 6.

An attached “pixie” earlobe has a very unnatural appearance ( a ). There are numerous techniques described for correction of this condition. We utilize a technique involving surgical release and allowing a portion of the previously attached boarder to heal secondarily. This results in an upswing of the medial border and improved appearance ( b ).

Neck Skin Pleats

A paucity of information exists regarding the revision of neck deformities. Skin pleating, or lateral skin folds, results from skin laxity as part of the natural aging process. ⁴² They can also present in a secondary rhytidectomy and neck lift patient due to inadequate excision of neck skin at the time of the primary procedure. It has been reported that utility of a limited incision via the minimal access cranial suspension technique has demonstrated higher rates of neck laxity, neck pleating, and periocular pleating. This can be particularly evident in a patient with a bulky neck who undergoes liposuction alone or simply due to inadequate correction of excess skin. ⁴³ The surgeon can reduce the risk of this deformity by performing the traditional facelift procedure and ensuring that sufficient skin is excised and the skin around the neck is adequately pulled. For patients who present with lateral skin folds during the preoperative assessment, surgical management involves re-elevation of the neck skin flap, removal of excess skin, and redraping skin appropriately by extending incision as needed.

A relatively simple office-based procedure is quite effective in correcting residual skin excess following either a facelift or isolated neck lift procedure. This is performed under local anesthesia and utilizes incision at the mastoid hairline, postauricular sulcus, and extends anteriorly to the base of the tragus. A facelift flap is elevated to the midportion of the lateral neck with the dissection extending superiorly approximately 3 to 4 cm superior to the mandibular border ( Figs. 7 and 8 ). Plication of the SMAS is also performed along the anterior border of the sternocleidomastoid, which contributes to the correction of the excessive anterior neck skin and vertical banding. The skin is advanced posteriorly and anchored at the height of the mastoid in the usual fashion. Barbarino et al also discussed the isolated stork lift procedure for correcting vertical and diagonal lateral neck folds and reported 100% correction with high patient satisfaction in the postoperative period. ⁴²

Fig. 7.

Incision placement ( red ) and extent of flap elevation ( blue ) for revision “mini-facelift.” This is performed under local anesthesia allowing plication of the neck SMAS and the lower facial SMAS. (Authors maintain copyright privileges to artwork.)

Fig. 8.

Preoperative ( a, b ) and postoperative ( c, d ) results following an in-office “mini-facelift.” Improvement of both the anterior neck and the jowl area can be achieved using this technique.

Platysmal Bands

Platysmal banding is considered one of the earlier signs of recurrent aging following a primary rhytidectomy and neck lift. ⁹ Patients will classically present with one or two vertical bands along the anteromedial aspect of the neck. ⁴⁴ The surgeon should individualize the approach to treating patients with platysmal bands, as some will have thin bands, while others more protuberant depending on the bulkiness of the muscle. ⁴⁵ Patients who initially present with platysmal banding and those who present with recurrence or insufficient correction are typically managed in a similar fashion. Conservative subcutaneous and submental defatting should be performed initially to appropriately assess for the extent of platysmal banding. ⁴⁵ Midline plication of the platysma may then be performed for correction of medial platysmal bands through several methods. ^{46 47 48 49} Guyuron et al established the vest-over-pants technique, which has been performed to improve neck contour. ⁵⁰ Pioneered by Feldman, the corset technique involves use of a continuous suture connecting the medial borders of the platysma along almost the full vertical length of the neck. ⁴⁸ If significantly hypertrophied, horizontal cuts can be made along the medial borders of the platysma prior to performing the corset platysmaplasty. ⁴⁵ It is important to account for scarring; therefore, wide undermining of the tissue may be required to bring the platysmal edges together. ⁴⁴ In addition to platysmaplasty, partial transection of the caudal platysma can and should be performed to help mitigate the risk of recurrence of this deformity and decrease tension along the superiorly repositioned SMAS. ^{13 44} Alternatively, lateral platysmal window suspension can be utilized if other surgical interventional modalities prove inadequate. The platysmal window is a safe and efficient technique that obviates injury to the great auricular nerve, a complication observed in neck lifts. ⁵¹ Interestingly, Trévidic and Criollo-Lamilla showed that platysmal bands may form as a result of increased platysma muscle activity as opposed to skin laxity and muscle relaxation. Consequently, a proposed surgical option could include platysma denervation. ⁵² If platysmal bands recur, surgeons can inject botulinum toxin to help camouflage their appearance. ⁴⁴

Midline ridge deformity may appear following a corset platysmaplasty from a prior neck lift. To prevent this complication, the surgeon should utilize a continuous suture and advance the suture along the length of the neck three times to optimally contour the area. ⁴⁸ If the patient presents with a midline ridge for a secondary neck lift, the corset platysmaplasty can be performed to cover the defect. In the presence of significant scarring, it should be resected and the platysma undermined enough to reperform the platysmaplasty.

Cobra Neck Deformity

The cobra neck deformity presents with hollowing within the submental region between the digastric muscles. ^{8 9} This surgical complication results from scarring and the formation of a depression due to overly aggressive submental liposuction and defatting. ^{7 8 9} To prevent this deformity, the surgeon should assume a more conservative approach for fat removal. ⁷ Additionally, the liposuction cannula should be directed away from the undersurface of the skin to prevent unnatural contouring from adherence of the dermis to the underlying muscle. Postoperatively, the patient may also benefit from massage to the area and triamcinolone injections. ⁸ Fat grafting is the treatment of choice to restore volume and improve contour to the submental region when a patient presents for a secondary procedure. It should be performed at least 6 to 12 months after the primary procedure to allow appropriate healing. ^{8 31} The surgeon should be adept in the process of selecting a donor site, harvesting and processing the fat, preparing the recipient site, and injecting the fat grafts. ³¹ Alternatively, corset platysmaplasty with sufficient undermining of the tissue and redraping of skin can be performed to correct the cobra neck deformity or other complications related to unnatural submental skin contouring. ⁶

Anterior Neck Irregularity and Deformity

A submental approach to the anterior neck with contiguous elevation of the cervical skin flaps from side to side has its advantages and indeed its own disadvantages. This degree of flap elevation allows for correction of platysmal banding, excision of excessive anterior neck fat, and possibly greater correction of redundant neck skin. Unfortunately, there are potential unfavorable outcomes of such an approach that do not occur when the anterior neck skin is not part of the facelift/neck lift dissection. The majority of these complications relate to excessive scarring and adherence in the region of the central anterior neck. This can lead to significant irregularity and deformity of the anterior neck, which is difficult to correct secondarily. Frequently, attempts at re-elevation of the skin flap and recontouring of this region result in less-than-optimal outcomes and persistent deformity. External ultrasound therapy and steroid injections have been found to be of limited utility in these patients. As such, patients can be left with a significant aesthetic deformity in this area, which is quite noticeable and troubling for these individuals.

We have adopted a methodology for treating these significant neck deformities in patients who have failed conventional surgical correction. While typically reserved for male patients with disproportionately excessive neck skin, a direct excision via a T-Z-plasty can be used to address this condition. ⁵³ This relatively simple procedure can be performed in the office setting using local anesthesia ( Fig. 9 ). A submental transverse incision with a vertical midline extension is used and encompasses the inferior extent of the involved deformity. Flaps are elevated laterally in the facelift plane and the excess, irregular skin and underlying scar are excised. A small Z-plasty is placed at the level of the anterior neck break and measures no greater than 1 cm in length. Postoperative scarring has been found to be minimal and the aesthetic results quite acceptable, particularly in elderly patients with thinning skin.

Fig. 9.

This patient underwent multiple revisions attempting to correct an anterior neck deformity following primary facelift. The skin was densely adherent to the underlying platysma and demonstrated significant irregularity ( a ). A direct excision using a submental and vertical midline approach was utilized ( b ), resulting in improved contours and acceptable scarring ( c ).

Lateral Sweep, Joker Lines, Commissural Distortion

In addition to the above-discussed complications, other commonly observed deformities include the lateral sweep, joker lines, and commissural distortion. The lateral sweep deformity occurs when the primary rhytidectomy flap is positioned along a lateral vector under tension, and the remaining superior portion of the cheek is undercorrected. Over time, the undercorrected area descends faster over the corrected lower portion of the cheek, resulting in the characteristic appearance. ^{6 9 54} Lateral sweep is revised and generally prevented by utilizing a more superior vector. ^{6 54} The cross-cheek depression deformity, also known as joker lines, commonly presents with a slight indentation near the oral commissure that exaggerates as it tracts laterally toward the ear. Joker lines are more likely to appear in patients who have prominent malar bones and submalar hollowing. ^{2 6 9 55} Lambros and Stuzin state that the facelift only unmasks these facial features that were always present. ⁵⁵ Cross-cheek depression is more apparent following SMAS manipulation and skin tension in the vertical direction. To surgically repair this deformity, reduced lateral release of the SMAS and skin in addition to a more lateral vector of pull is recommended. Alternatively, volumetric filling of the depression can be performed in the event that the patient does not want to undergo an additional operative procedure. ⁵⁵ When cross-cheek depression manifests in conjunction with commissural distortion, it can produce an unsightly appearance. ⁶ Consequently, a thorough preoperative assessment is imperative to manipulate the SMAS and skin along the appropriate vector.

Conclusion

Secondary face and neck lifts have risen in popularity as a result of a growing elderly population and increased interest in facial rejuvenation procedures. Patients may seek a secondary face or neck lift procedure due to the natural aging process, prior surgical complications, or a combination of the two. Secondary procedures demonstrate more challenges not typically observed in primary procedures. Due to the complex nature of their presentation, patients must undergo meticulous preoperative assessment by the operating surgeon. Several unfavorable face and neck deformities may need to be addressed as a result of previous surgical procedure. Correction of these surgical complications requires a good understanding of the anatomy and morphological features of the face and neck. While these deformities can be difficult to revise, thorough preoperative planning can help the surgeon to deliver excellent and reliable postoperative outcomes with high patient satisfaction.

Funding Statement

Funding None.