Short Scar Rhytidectomy Techniques
Drake Vincent, MD, DMD, FAACS
KEYWORDS

Short scar facelift
Face lift
Rhytidectomy
Mini facelift
KEY POINTS

Assessing the quality and quantity of the skin is paramount to achieving good results.

Short scar facelifts can be performed in any plane (deep plane, SMAS, subcutaneous).

Adjunct procedures help improve all types of facelifts (ie, skin resurfacing or volume enhancement due to deflation).

Similar complications exist with short scar facelifts and traditional techniques.

Learn the art of facial cosmetic surgery by understanding descent, deterioration and deflation of the aging face.
Short scar facelift techniques have gained popularity over the
past 15 years for patients who seek facial rejuvenation. The
advantage of reduced morbidity, shorter scars, and less
downtime is very appealing for both the patient and the facial
cosmetic surgeon. In my opinion, the short scar facelift is the
most contemporary facelift and the facelift of the twenty-first
century. Understanding the fundamental principles of facial
rejuvenation is essential to achieving good results with any
facelift technique but is even more essential in achieving good
results with short scar facelift techniques.
A common misconception about short scar facelifts is that
because the incision is short, then the amount of flap dissec-
tion must be short to. When a short scar facelift is performed
properly, the amount of dissection is the same as a classic
facelift except the posterior incision and the most posterior
dissection of the posterior neck is eliminated. Dissection of the
posterior neck can still be accomplished from the retro-
auricular sulcus incision. Dissection in the submental and
lateral areas of the face, as well as plication of the anterior
and posterior platysma, are still the same as in a classic
facelift. Because of the smaller incisions, exposure of the un-
derlying tissue in short scar rhytidectomy is technically more
difficult than a classic facelift and it can be frustrating to
manipulate the superficial musculoaponeurotic system (SMAS)
layer and to achieve hemostasis.
Another misconception about short scar facelifts is that
because the incision is shorter, then the amount of skin
removed must also be less. Actually the amount of skin
removed is essentially the same as a classic facelift except no
skin or hair is removed in the occipital area. In the temporal
and preauricular areas and the area of skin under the ear
lobule, the same amount of tissue is removed for both types of
facelifts (Fig. 1).
Technically, a short scar remains a short scar if the incision
remains in the retroauricular sulcus. Different types of retro-
auricular incision designs exist. Some techniques include a
Disclosures: None.
Vincent Surgical Arts/SwiftLift Surgical Arts Centers, 6710 South
Blackstone Road, Cottonwood Heights, UT 84121, USA
E-mail address: Drakevincent@yahoo.com
Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 37–52
1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2013.11.004
retroauricular sulcus incision and some techniques do not
include a retroauricular incision at all. After performing nearly
1800 short scar facelifts I find it beneficial to drop the incision
in the retroauricular sulcus described by Brandy (Fig. 2).1 The
advantage of this small extension is that it helps tighten the
lower neck tissue and improves treatment in patients with
more severe cervical skin laxity. It also allows better access to
the posterior platysma and makes it easier to deal with dog
ears in the retroauricular area. Initially, I thought dropping the
incision in this area might have negative consequences of poor
scarring or visibility. After evaluating more than 1800 of these
incisions I can confidently tell you that, when done properly,
the incision heals without being noticeable and rarely forms a
hypertrophic or keloid scar (Fig. 3). On the contrary, the classic
facelift incision that involves the posterior temporal hairline
can often heal with a distortion of the hairline with a widening
or hypertrophy of the scar (Fig. 4).
Suspension sutures used in short scar
rhytidectomy
One of the major differences in some short scar facelift tech-
niques is the use of purse-string sutures. Purse-string sutures
for the purpose of lifting the SMAS was introduced by Saylan in
1999.1,2 Multiple other purse-string suture techniques have
then since been introduced. Purse-string sutures create mul-
tiple microimbrications of the SMAS tissue. This leads to a
stable volumetric shift of the subcutaneous tissue of the face.
Purse-string sutures are typically anchored to a stable point on
the face. The overlying periosteum of the zygomatic arch and
the deep temporal fascia have been described as anchoring
points in the S-Lift, QuickLift, and the Minimal Access Cranial
Suspension lift (MACS lift). The suture used for the purse-string
can be nonresorbable or resorbable. Purse-string sutures
create a powerful upward suspension of the desired aging tis-
sue. Although no great studies have shown the impact of the
purse-string suture on the SMAS over time, most likely the
scarring formed by the overlying subcutaneous tissue and the
fibrous adhesions between the microimbrications holds the
newly suspended SMAS tissue in place. This presents one of the
problems with suspension sutures. The use of permanent
oralmaxsurgeryatlas.theclinics.com
38 Vincent

Fig. 1 Typical amount of skin resection during short scar rhyti-

dectomy in the temporal, preauricular, and retroauricular area.

sutures can cause palpability of knots and the potential for

long-term infection. Knowing that the face deflates and thins
with time, it only makes sense that the probability of these
sutures having problems after 10 to 20 years is high. Suspension
suture techniques tend to be used on younger patients
receiving facelift and time will tell if we see more problems
with nonresorbable purse-string sutures. On the other hand,
resorbable sutures also can be used. The problem with
resorbable sutures is that the ideal materials, either poly-
glycolide or polydioxanone, should not be used for tissues
requiring prolonged tension. Polyglycolide has only 23% of its
tensile strength at 4 weeks and polydioxanone has 44% at
8 weeks. The question is how long do resorbable sutures need
to maintain tensile strength to prevent movement of the SMAS
tissue when used as a suspension suture in facelifts? When
suspension sutures in the face are placed, a moderate amount
of tension exists in the gathering and lifting of the SMAS layer
and the resorbable suture is losing strength rather quickly. The
ideal suture would retain 100% tensile strength for approxi-
mately 90 days and then completely degrade after the newly
formed fibrous tissue holds the suspended SMAS tissue in place.
I have removed multiple permanent purse-string sutures
months after their placement and have found the SMAS tissue
and skin to remain stable after removal.
Fig. 3 Typical appearance of a retroauricular scar from a short
scar rhytidectomy at 1 year.
Another problem encountered with purse-string sutures is
the gathering of tissue as the purse-string is tightened. As the
suture is tightened, the tissue moves upward but also inward
and outward, entrapping any tissue within the circumference
of the purse-string. Most commonly this tissue needs to be
removed and sculptured to prevent lumps and bumps of the
tissue. If the purse-strings go outside the area of the underlying
parotid gland, then the suture has the ability to also entrap
branches of the facial nerve and cause paralysis. The purse-
strings also have the potential to cause lymphatic congestion
and can prolong the swelling under the surgical flaps. I have
seen both of these complications; fortunately, the complica-
tions are rare and if a facial nerve paralysis occurs, the
treatment is removal of the offending purse-string with

Fig. 2 Small oblique 2-cm to 3-cm incision extending from the

retroauricular sulcus described by Brandy. The 2-cm hockey stick is
made into the Langer lines so that healing is optimized. The pos-
terior incision is 3 cm long and is made slightly above the post- Fig. 4 Postauricular scar of traditional facelift. Notice the
auricular crease. distortion of the hairline and the widening of the scar.
Short Scar Rhytidectomy Techniques
Fig. 5 (A) Frontal and (B) lateral view of poor short scar rhytidectomy candidate and considered a Type IV Vincent short scar
rhytidectomy classification.
potential for recovery. Tonnard and colleagues3 also have re-
ported prolonged swelling and facial edema in the area of the
purse-strings for up to 17 weeks.
The three “Ds” of facial aging
The quality and quantity of the skin helps determine the cor-
rect type of facelift procedure for each individual patient. If
the patient has a significant excess of skin with poor elasticity,
the decision to create longer incisions must be contemplated
(Fig. 5). The ideal patient for a short scar technique should
have mild to moderate skin laxity and good to excellent skin
quality (Fig. 6).
Another very important aspect of facial evaluation is deter-
mining what I call the 3 “Ds” of facial rejuvenation (Table 1).
The first “D” stands for deterioration of the skin. Deteriora-
tion of the skin can be explained by the Glogau Classification (see
Fig. 6 (A) Frontal and (B) lateral view of ideal short scar rhytidectomy candidate and considered a Type I Vincent short scar
rhytidectomy classification.
39
Table 1). Patients with mild to moderate Glogau Classifications
are the best candidates for short scar facelift techniques. To
achieve optimal results, patients with advanced and severe
Glogau Classifications should have some type of aggressive facial
resurfacing procedure before any facelift technique. Patients
having any type of facelift procedure with a severe Glogau
Classification, without first addressing the real problem, which is
the skin quality, are destined for failure. Optimally, these pa-
tients should have either full-face deep CO2 or deep derm-
abrasion at least 3 months before any facelift procedure (Fig. 7).
I have not seen any real dramatic results with the new fractional
or radiofrequency lasers. If anything, I get many unhappy pa-
tients who have had those therapies and they come to see me for
correction of their still sagging jowls and neck.
The second “D” stands for deflation. Deflation of the aging
face has been well documented. Dr Val Lambros studies sug-
gest “that gravity’s role in aging has been exaggerated, and
that the downward migration of facial skin over time is merely
40 Vincent

Table 1 Three Ds of facial rejuvenation

Deterioration Deflation Descent
Glogau I, Mild: Small I, Mild: Early jowls,
Classification: prejowl sulcus, slight cervical
I, Mild: Little slight hollowing skin laxity,
wrinkling of temporal, minimal to no
II, Moderate: periorbital, and platysmal bands
Early wrinkling cheek areas II, Moderate:
III, Advanced: II, Moderate: Moderate jowls,
Wrinkling at rest Deeper prejowl moderate
IV, Severe: sulcus, moderate cervical laxity,
Wrinkling at rest hollowing of minimal
with associated temporal, platysmal bands
cutis laxis periorbital, and III, Severe: Heavy
cheek areas jowls, active Fig. 8 Patient showing severe facial deflation, severe facial skin
III, Severe: platysmal bands, deterioration, and moderate facial skin descent. Example of
Periorbital, significant Vincent Type III classification. Ideally, these patients should have
perioral, cervical laxity or aggressive facial resurfacing before any facelift procedure and
temporal and large obese necks volume replacement.
cheek hollowing

tissue. Likewise, if the main problem of the aging facial patient

an illusion. The real culprit, the study found, is the loss of
volume underneath the skin.”4 Regardless, if the real culprit is
deflation, you should never overlook the first “D” for deterio-
ration of the skin. Giving a patient volume without restoring
the quality of the skin first is a recipe for disaster, especially if
the patient’s primary reason for facial aging is deterioration.
Deflation can be apparent with temporal hollowing and sunken
periorbital areas and the cheeks (Fig. 8). Volume replacement
can be achieved with alloplastic implants, fat grafting, or some
kind of filler.
The third and final “D” stands for descent. Descent of the
facial skin can be seen in the brows, nasolabial folds, jowls,
and especially in the submental area and lower neck (Fig. 9).
The key here is that in most cases, I believe descent of facial
tissue is really a problem of the first two “Ds.” If the primary
problem of the aging facial patient is poor skin quality or
deterioration of the skin, then you will see descent of the
is deflation, you can also see descent of the tissues.
In my opinion, the art of facial cosmetic surgery is learning
to decipher what percentage of each of these 3 “Ds” your
patient has before you decide to perform any type of facelift
procedure. After you have decided on the amount of each of
the 3 different “D” percentages of each aging face, you can
then come up with a treatment plan. For example, a patient
will present to your office for a facelift, when in reality all the
patient really may need is an aggressive resurfacing procedure
and volume modification (Fig. 10). In this particular situation,
I would look at the patient’s face and say “60% of her aging is
deterioration of the skin, 30% of her aging is deflation, and

Fig. 7 Patient showing severe deterioration of facial skin, severe

deflation, and severe descent of facial tissues. Example of Vincent
Type IV classification. Ideally, these patients should have aggres- Fig. 9 Patient with severe descent of lower face and cervical
sive facial resurfacing before any facelift procedure and volume tissues. Example of Vincent Type IV classification. Poor candidate
replacement. for short scar rhytidectomy.
Short Scar Rhytidectomy Techniques 41

Fig. 10 (A) Frontal and lateral views of patient with Vincent Type IV classification before aggressive full-face CO2 resurfacing and fat
grafting to the face. (B) Frontal and lateral views 12 months after procedure showing improvement of deterioration of facial skin and
correction of severe deflation of the face. Note the persistent severe cervical skin laxity.

maybe only 10% of her problem is descent.” Her treatment plan
consisted of a first-stage surgery with deep full-face CO2 and
approximately 30 mL of harvested lateral thigh fat grafted to
her face. The second stage would be 3 months later, with a
lower face and neck lift with possible relasering of stubborn
wrinkles and a second fat-grafting session to the face. She was
so happy with her first-stage results that she never came back
for her facelift. Only after or possibly at the same time, should
some patients have a facelift until the other 2 “Ds” have been
treated. Most of all my patients with short scar facelift receive
some form of resurfacing and volume procedure either before
or at the same time as the short scar facelift. Rarely will
42 Vincent

I perform a short scar facelift by itself. It is for this reason
I believe my short scar facelifts have such a high satisfaction
rate. A study I performed and presented at the American
Academy of Cosmetic Surgery Annual Meeting in January of
2010 showed a short scar facelift 5-year satisfaction rate of
higher then 90%.4 These results were compared with Owsley’s
satisfaction rates5 at 5 years for a traditional type of facelift
and were found to be statistically very similar.
Each surgeon used a different technique, including Daniel
Baker performing his short scar facelift on one of the twins.
Follow-up at 1, 6, and 10 years showed no significant differ-
ence in results and longevity. Most patients are very happy with
less-invasive techniques, and the fact that more deeply inva-
sive techniques have not really shown better results has
motivated more and more facial cosmetic surgeons to explore
less-complicated techniques.

Short scar rhytidectomy techniques and evolution S-lift

Friedland6 has divided the history of rhytidectomy into 4 gen- In 1999, Saylan2 of Dusseldorf, described the preexcision of
erations during the twentieth century. skin in the preauricular area in the shape of an “S.” The S-lift
is a short-scar, short-flap, facelift technique that uses limited
First generation: up to World War II undermining so he could place 2 purse-string sutures in the

Skin lift only SMAS. The purse-string sutures were placed in the SMAS in the

Subcutaneous dissection with variable undermining shape of a U and O (Fig. 11). The S-lift combines the advan-
tages of a limited incision and dissection with the advantages
Second generation: 1970e1975 of SMAS microimbrication and manipulation. Saylan’s2 contri-

Subcutaneous dissection, skin lift, and superficial bution to the technique involved the effective use of purse-
plication string sutures microimbricating the mobile SMAS and the
extended supraplatysmal plane to the fixed periosteum of the
Third generation: 1970e1980 zygomatic arch. In the S-lift, the permanent 2e0 braided nylon

SMAS and platysmal flaps vertical U-shaped and oblique O-shaped purseestring sutures

Subcutaneous dissection with more extensive defatting pass through the superficial musculoaponeurotic system and
are firmly anchored to the deep tissues overlying the zygo-
matic arch. Skin redraping is at a 45 angle to the horizontal
Fourth generation: 1990s
axis with minimal skin tension.4 The purse-string sutures sup-

Subperiosteal lifts
port the advanced tissues, resulting in minimal tension on the

Subplatysmal surgery
flap and incision. Saylan2 also discussed the need for platysmal

Composite rhytidectomy
plication and closed lipoplasty of the neck at the same time.
The disadvantage of this technique is that the amount of
Fifth generation: present and twenty-first century
subcutaneous skin dissection is limited to the preauricular area

Subcutaneous undermining
and does not release the 4 main facial ligaments (Fig. 12).

SMAS (plication and SMASectomy)
Other disadvantages include the use of a permanent suture and

Short scar, S-lift, Minimal Access Cranial Suspension
need for future removal and the occasional problems with the
(MACS) lift
lumpiness often seen because of the “bunching and lumpy”

Suspension sutures
effect of the purse-strings. My experience with this technique

Fat grafting and fillers
often brought patients back at 1 year with complaints of
relapse, concerns with lumpiness in the preauricular skin area
In 1995, a group of 4 renowned surgeons (Baker, Hamra, for 4 to 12 weeks, and occasionally palpability of the suture
Ramirez, and Owsley) operated on 2 sets of identical twins. requiring removal.

Fig. 11 (A) Example of S-lift incision and skin resection. (B) Example of U and O purse-strings. (C) Example of skin tightening at a 45
angle that is in a superior and posterior direction. (Copyright ª Dominic A. Brandy, MD, Pittsburg, PA.)
Short Scar Rhytidectomy Techniques
Fig. 12 The main facial retaining ligaments of the face. Most
early purse-string short scar facelift techniques do not release the
zygomatic and mandibular facial retaining ligaments and in the
author’s opinion is a major reason for early relapse. (From Barton
FE Jr. Aesthetic surgery of the face and neck. Aesthet Surg J
2009;29(6):449e63; with permission.)
Simple MACS lift and the extended MACS lift
In 2002, Tonnard and colleagues3 described a modified S-lift
technique similar to the S-lift and created a mini-lift designated
as the minimal access cranial suspension lift (Fig. 13). The
theory to facial aging in the MACS Lift is that aging occurs in
mainly a vertical direction. The goal of the MACS Lift is to shift
facial volumes and skin in a purely vertical vector upward.
Therefore, restoring volume to the midface and cheeks and not
Fig. 13 Typical placement of 3 purse-string sutures, area of
undermining, and incision for MACS Lift. (Copyright ª Dominic A.
Brandy, MD, Pittsburg, PA.)
43
placing horizontal traction on the face causing flattening which
is often seen in classical facelifts.4 The MACS Lift would theo-
retically provide more fullness to the face rather than flatten it.
If necessary, submental liposuction is performed first.
In the simple MACS Lift, an inverted L-shaped incision is
made from the inferior portion of the auricle along the pre-
auricular crease, turning anteriorly along the inferior aspect of
the sideburn. A subcutaneous skin flap is dissected to extend
5 cm anterior to the incision, superiorly to 1 cm above the
zygomatic arch, and inferiorly to the angle of the mandible.
Using either a Prolene or Mersilene suture, a pretragal purse-
string suture is anchored in the deep temporalis fascia. The
suture continues inferiorly in a narrow U shape, incorporating
the SMAS overlying the parotid gland and ending in the pla-
tysma at the angle of the mandible before returning to the
starting point 1 cm anterior to the first leg of the suture. A
second, more O-shaped, purse-string suture is then placed in
the same location on the deep temporal fascia as the first su-
ture at an angle of 30 to the vertical. This suture, once placed
under tension, should elevate the jowls and marionette
grooves. The skin is then elevated superiorly, and excess skin is
excised. The skin is then closed without tension. The ear lobe is
repositioned as a transposition flap to avoid the superior pull of
the skin.
In the extended MACS Lift, a third malar loop purse-string
suture is used, anchoring to the deep temporal fascia under-
neath the orbicularis oculi and medial to the frontal branch of
the facial nerve. The loop has a narrow U-shape and is oriented
obliquely downward and medially toward the malar fat pad.
The extended MACS Lift has an extra effect on the nasolabial
fold, the midface, and the lower eyelid.
The disadvantages of the MACS Lift are its difficulty to treat
patients with severe neck laxity and patients with type 3 and 4
Glogau Classifications. The problem with pure vertical vectors in
my experience is that “sweep deformities” tend to occur in
patients with poor skin quality. Other potential problems were
lumpiness from the purse-strings and, if permanent sutures are
used, the possible need for removal and palpability of knots.
I often saw patients coming back with relapse within a year.
I attributed this to the fact that the 4 main facial ligaments were
not released and repositioned in a higher position on the face.
QuickLift
In 2004, Dominic Brandy described his first short scar facelift
single O-shaped purse-string technique in what he called the
QuickLift (Fig. 14). He used a 2e0 braided nylon purse-string
suture anchored to the zygomatic arch, which then dropped
down to grab the platysma and SMAS.1
In 2005, Brandy then published his double purse-string
QuickLift. Two oval-shaped purse-strings are placed in the
SMAS. The advantages of the double purse-string technique
allows for less deep tissue bulging; a much stronger plication
effect; improved tightening of the neck, jowl, and midface;
and, last, a backup suture if the first purse-string pulls through
the SMAS.4
Brandy’s QuickLift technique also brought out 2 new very
important aspects of maximizing the short scar facelift.
Because Brandy had extensive hair restoration training, he
thought about the hairline and distortion commonly seen in
traditional and other short scar techniques. The first important
point was the superior aspect of the incision extends up to the
most anterior aspect of the temporal peak, but does not alter
the temporal hairline. It is important that a 45 bevel be used
44
Fig. 14 (A) Example of the comparisons of the amount of undermining with the QuickLift, S-Lift, MACS Lift and a Traditional Facelift. (B)
Example of the vector of skin advancement in the Quicklift. (C) The newest version of the Quicklift showing the triple purse-string suture
technique. (Copyright ª Dominic A. Brandy, MD, Pittsburg, PA.)
where the temporal scalp meets the temporal skin so that hair
will grow through and anterior to the scar 3 months later. The
temporal aspect of the incision allows for better handling of
dog-ear formation at the temporal region while additionally
creating some smoothing at the lateral midface, and peri-
orbital region. The second important change was a 2-cm
hockey-stick incision, dropped about one-third of the way up
the postauricular sulcus that follows the Langer lines, at the
posterior earlobe crease with 5 cm of increased inferior-pos-
terior undermining with a Burrow Triangle formation prevent-
ing posterior dog-ear formation and a greater smoothing effect
of the neck region. This configuration also allows for greater
superior advancement of the flap with a better smoothing
effect to the skin inferior and posterior to the earlobe.
The disadvantages of the QuickLift that I found were similar
to all the other purse-string suspension suture techniques. The
“mushrooming” effect of the SMAS inside the purse-string
caused lumps and the use of permanent sutures caused prob-
lems with need for removal with the palpability of knots.
Vincent
Another potential problem, I felt, was the problem with
relapse due to not releasing and repositioning the major facial
ligaments.
S-Plus lift
In 2010, Steven Hopping7 introduced his S-Plus lift technique,
which combines the limited incision of an S-lift with 2 SMA-
Sectomies, purse-string suture imbrication of the lateral pla-
tysma, SMAS, and malar soft tissue suspension. Hopping
described 2 SMASectomies before placement of the purse-
string sutures, thus eliminating the bunching effect of the
tightened purse-string. One of the main differences in the
S-Plus Lift was that the S-Lift was a “short-flap,” SMAS plication
procedure, whereas the S-Plus lift with its midface extension is
a “long-flap,” SMAS imbrication rhytidectomy.8 The difference
with the S-Plus lift and the MACS Lift was the removal of the
SMAS and an imbrication instead of a plication of the SMAS.
Both lifts use the placement of 3 purse-string sutures.
Short Scar Rhytidectomy Techniques 45

Fig. 15 Baker type I: ideal candidate. (From Baker DC. Minimal incision rhytidectomy (short scar face life) with lateral SMASectomy:
evolution and application. Aesthetic Surg J 2001;21(1):14e26; with permission.)

The advantage of the S-Plus lift is the use of resorbable 2.0
vicryl purse-string sutures and the removal of the bunching
SMAS that caused lumps inside the tightened purse-strings. The
S-Plus lift helped address more moderate to severe midface
laxity and pronounced nasolabial folds. S-Plus lift also brings
out the advantage of the long flap and release of the facial
retaining ligaments.
The disadvantage of the S-Plus lift was that the use of purse-
string sutures was still problematic but the idea of using a
resorbable suture for the purse-string helps eliminate the need
for possible future suture removal and palpability of the knot.
Short scar lateral SMASectomy
Daniel Baker6 performed his first short scar facelift in 1990. In
1992, he started using the concept of SMAS manipulation and
suspension by describing the lateral SMASectomy. The problem
with extensive SMAS dissection was that the facial nerves were
in jeopardy of injury and the SMAS thinned anterior to the
parotid gland, making it easier to tear. For this reason, Baker
concluded that an extensive SMAS dissection was not war-
ranted in most patients and offered very little long-term
benefit compared with SMAS imbrication or plication.9 How-
ever, Baker realized that submental dissection and lateral
dissection with medial platysmal plication was required in most
patients with severe cervicofacial laxity.
Baker also presented a classification system for candidates
for short scar rhytidectomy (Figs. 15e18, Table 2). Baker’s
classification system addresses the descent and deterioration
of the aging face but does not include the deflation or volume
loss of the aging face. Therefore I prefer using the Baker classi-
fication with the addition of the Modified Glogau Classification.
In addition to the Baker classification (see Table 2), I have
added the Vincent Short Scar Rhytidectomy Classification
to help further identify ideal patients for short scar rhytidec-
tomy (Table 3). The Vincent classification helps further identify

Fig. 16 Baker type II: good candidate. (From Baker DC. Minimal incision rhytidectomy (short scar face life) with lateral SMASectomy:
evolution and application. Aesthetic Surg J 2001;21(1):14e26; with permission.)
46 Vincent

Fig. 17 Baker type III: fair candidate. (From Baker DC. Minimal incision rhytidectomy (short scar face life) with lateral SMASectomy:
evolution and application. Aesthetic Surg J 2001;21(1):14e26; with permission.)

Fig. 18 Baker type IV: poor candidate. (From Baker DC. Minimal incision rhytidectomy (short scar face life) with lateral SMASectomy:
evolution and application. Aesthetic Surg J 2001;21(1):14e26; with permission.)

Table 2 The Baker classification system

Submental,
Candidate Cervical Skin Submandibular Platysmal
Type Age Jowling Laxity Fat Micro-Genia Bands Misc
I: Ideal Early to late 40s Early signs Slight þ/e þ/e e Good cervical
skin elasticity
II: Good Late 40s to late Moderate Moderate þ þ/e e
50s
III: Fair Late 50s, 60s, Significant Moderate þþ þ/e þ (on Some 2ary
early 70s animation) rhytidectomy
IV Late 60s and 70s Significant Poor þþþ þ/e þþ Deep cervical
creases
Data from Baker DC. Minimal incision rhytidectomy (short scar facelift) with lateral SMASectomy; evolution and application. Aesthetic Surg J
2001;21:14e21.
Short Scar Rhytidectomy Techniques 47

Table 3 Vincent short scar facelift classification

Baker Candidate
Type Deterioration Deflation Descent Vincent Classification Type and Recommended Treatment
Baker I: Ideal Glogau I Mild Mild Vincent Type I
Ideal: Submental liposuction (SML), skin flap, chin implant if needed,
plicate anterior platysma if indicated
Baker II: Good Glogau II Moderate Moderate Vincent Type II
Good: SML, long skin flap, chin implant if needed, volume replacement,
plicate anterior platysma if indicated
Baker III: Fair Glogau III Severe Severe Vincent Type III
Poor: CO2 skin resurfacing and fat grafting 3 mo before facelift, consider
traditional incision and if short scar then drop small oblique
retroauricular incision and plicate anterior platysma if indicated
Baker IV: Poor Glogau IV Severe Severe Vincent Type IV
Poor: CO2 skin resurfacing and fat grafting 3 mo before facelift, consider
traditional incision and if short scar then drop small oblique
retroauricular incision and plicate anterior platysma if indicated

short scar rhytidectomy candidates by incorporating skin exposing the posterior aspect of the platysma. Typically, a
deterioration, facial deflation, and skin descent. Patients with 1-cm to 3-cm resection of posterior platysma is completed
Baker type I classification but a Glogau IIIeIV classification, depending on the degree of cervical laxity and SMAS laxity.
should have aggressive facial resurfacing before any facelift Exposure of the posterior aspect of the platysma allows for
procedure. resection of the posterior platysma and resuspension to the
auriculotemporal ligament of Furnas. This key point of sus-
My operative overview and technique for short scar pension on the posterior platysma puts maximum traction on
rhytidectomy the cervicomental angle. Labbé and colleagues9 showed that
the aging neck and platysma occurs in an oblique direction
In 2005, I did my first short scar facelift. I found most patients mainly downward and anteriorly. The amount of resection and
with mild, moderate, and even severe skin laxity to be very tightening in this region can be customized to each individual
happy with their results. I mainly reserved the double and patient. When resecting the SMAS, it is important to stay
triple purse-string short scar facelift technique for patients superficial to the parotid-masseteric fascia to avoid facial
with mild to moderate skin laxity and type I and II Glogau nerve injury and parotid parenchymal injury. In patients pre-
Classifications. Although I felt the double and triple purse- senting with strong platysmal banding and banding at rest,
string techniques with extended skin undermining had I prefer anterior platysmal plication or a corset platysmaplasty.
decreased the amount of early relapse compared with the In general, patients with severe cervical laxity and pla-
S-lift, patients still had the same problem of lumpiness in the tysmal banding at rest require an anterior platysmal tightening
preauricular skin area for 4 to 12 weeks and occasional procedure in combination with the submental dissection
palpability of the suture, requiring removal of the purse-string connecting to the lateral dissection for proper redraping of
or knot. For the reasons outlined previously, I abandoned all
suspension purse-string techniques in 2009.
In 2009, I started using the lateral SMASectomy for all my
short scar and traditional style facelifts. Since using this
technique, I have had much fewer revisions due to relapse.
There is no more need for occasional removal of a permanent
suture or a palpable knot. I also started using a resorbable 4.0
PDS continuous running suture from an inferior to superior
direction to close the SMASectomy. The inferior to superior
direction allows me to raise the anterior mobile SMAS to join
the posterior fixed SMAS in a mostly posterior and superior
direction (Fig. 19). The SMASectomy can be tailored to any
type of face by removing SMAS in the direction of needed
rejuvenation (Fig. 20). Changing the shape and the amount of
SMAS resection in the SMASectomy allowed me to precisely
tailor the SMAS lifting procedure in the midface and also the
posterior platysma. Most commonly, I use a lazy S-shaped
resection of SMAS with the superior resection at the level of Fig. 19 Tightening of the lateral SMASectomy with a continuous
the zygomatic arch parallel to the nasolabial fold. The lazy running 4.0 PDS in an inferior to superior direction. The more
S-shape then continues over the tail of the parotid, staying movable anterior SMAS is tightened in a posterior-superior direc-
anterior to the ascending great auricular nerve branches, tion to the more fixated posterior SMAS.
48
Fig. 20 Example of the shape of the lateral SMASectomy that is
resected. Different amounts of resection can be performed in the
areas that need the most tightening. Typical amounts of resection
are from 1 to 4 cm of SMAS.
skin. These patients also can be technically more difficult when
dealing with dog ears and loose skin. For this reason,
I recommend dropping a small 2-cm to 3-cm oblique incision
from the retroauricular sulcus. Preoperatively, I use a posterior
vertical skin-pull test to help evaluate patients who benefit
from the small oblique incision dropped from the retro-
auricular sulcus (Fig. 21).
After the SMAS plication is complete, the plication and the
remaining SMAS tissue is trimmed with facelift scissors and
smoothed with the cautery tip on coagulate mode. I call the
sculpturing of the fat and SMAS tissue with the cautery tip lip-
osculpting. I will spend a considerable amount of time with this
step until I feel the underlying layer is completely smooth and all
contours look acceptable. Once this step is complete, I establish
hemostasis and prepare for arrangement of the skin flap.
The skin-flap closure must be done with minimal tension on
the incisions. The direction of pull in the temporal area is
approximately 60 to 70 . The pull on the retroauricular skin is
mainly completely vertical (Fig. 22). A Burrows Triangle exci-
sion is performed in the area of the retroauricular sulcus.
Closure is performed with a deep 4.0 PDS and a 5.0 fast-
absorbing gut for final skin closure. Drains are very rarely used,
but I do routinely use a 14-gauge angiocatheter at the base of
Fig. 21 Example of posterior skin vertical pull test to evaluate
posterior cervical skin laxity.
Vincent
Fig. 22 Example of vertical direction of skin pull in the retro-
auricular sulcus region.
each skin flap (Fig. 23). If a submental dissection is performed,
then 2 angiocatheters are placed at the base of the submental
flaps on each side of the hyoid area. These catheters are then
removed the following morning. Very little pressure is applied
with the surgical dressings and no Coban or tight wraps are
used. Typically a fluff of gauze is used with a Velcro neck strap
the night of surgery.
Almost all face procedures are performed under intravenous
sedation with a propofol drip, ketamine, fentanyl, and versed.
If multiple facial procedures are being performed, then gen-
eral anesthesia is often used.
Complications
Complications in short scar facelifting are similar to compli-
cations seen with classic rhytidectomy. However, although the
type of complications reported in short scar versus traditional
scar rhytidectomy are similar, the percentage of complications
in short scar rhytidectomy has consistently been shown to be
less. This includes complications of hematoma, seroma, skin
necrosis, and facial nerve paralysis. Because in most short scar
facelift techniques the amount of skin and SMAS dissection is
reduced, and in purse-string techniques there is no deep SMAS
dissection, it makes common sense that less surgery results in
fewer complications. The real question: is less really more? If
Fig. 23 Example of 14-gauge angiocatheters used overnight for
drainage after surgery. Catheters are removed the day after
surgery.
Short Scar Rhytidectomy Techniques 49

patients are satisfied with their results and minimal compli-

cations exist, then yes, less is more, but if patients are
returning sooner than later for revision facelift surgery and are
unhappy with their long-term results, then the answer to the
question is no.
Regardless of the facelift technique, I will not operate on
patients currently using nicotine. A minimum of 4 weeks of
nicotine cessation is required before their facelift procedure.
Any nicotine-dependent patients who present for a facelift
consultation are shown previous examples of facelift compli-
cations related to nicotine (Fig. 24). Showing these examples
has dramatically improved compliancy with nicotine cessation
before their procedure. The other thing it has done for the
patients who cannot stop smoking is they no longer consider
having a facelift and do not try to fool me and still have the
procedure done without disclosing their continued nicotine
use. Measurement of cotinine, a primary metabolite of nicotine
that has a half-life of 16 to 18 hours and that can be detected
in urine (urine NicAlert [Craig Medical Distribution, Inc, Cali-
fornia, USA]), saliva (saliva NicAlert), or serum, provides a
reliable means of determining smoking status and other to-
bacco product use, but allows detection of exposure only
within 2 to 3 days.
Because the short scar rhytidectomy I perform consists of a
long skin flap and the frequent use of submental dissection with
or without platysmal plication, the complication types and rates
are similar to other published traditional facelift techniques.
One main difference, however, is that the small oblique retro- Fig. 25 Devastating complication with patient who had facelift
auricular scar in a short scar facelift hardly ever requires revi- procedure and full-face CO2 resurfacing at the same time. After
sion due to irregularities, hypertrophy, or widening of the scar. this procedure, I no longer will resurface the facial flap at the
I prefer to not combine full-face CO2 resurfacing with any same time as the facelift procedure.
type of facelift because of the potential devastating compli-
cations with skin necrosis (Fig. 25). Staging the procedure al-
lows for a more aggressive resurfacing in the area of the flap

Fig. 24 Patient 1 week postoperatively after short scar rhytidectomy. Patient was, unknown to me, currently smoking a pack of
cigarettes a day before and after procedure. Her husband told me she was smoking on the way home from her surgery.
50
and better long-term results and stability of the facelift.
Patients with moderate to severe deflation can be treated
concurrently with most facelift techniques. Patients with
severe descent of facial tissues (significant jowling, large pla-
tysmal bands, and severe cervical skin laxity) are poor candi-
dates for short scar rhytidectomy.
Results
At the annual American Academy of Cosmetic Surgery meeting
in 2011, I presented my results from a retrospective analysis of
463 short scar rhytidectomy patients. These results were
compared to Owsley’s retrospective analysis and satisfaction
survey involving 89 patients who had traditional rhytidec-
tomy.10 Owsley’s results were published in the Journal of
Plastic and Reconstructive Surgery in 2010. When patients
were asked if they were happy with the incisions created by
their facelift, the patients who received short scar rhytidec-
tomy had an 87% satisfaction rate compared with a 72%
satisfaction rate among the patients who received a tradi-
tional facelift incision. The other important factor was that at
4 years postoperatively, 81% of the patients who received
short scar rhytidectomy were still moderately to completely
happy with their facelift results compared with 83% of patients
with the traditional facelift who were still moderately to
completely happy with their results. These results help
reconfirm that patients are happy with their short scar rhyti-
dectomy long-term results when a long flap with closed sub-
mental lipoplasty or extended submental dissection with or
without anterior platysmal tightening was used.
Fig. 26 Picture on left shows area of skin to be undermined and approximate location of triple purse-strings. Picture on right shows area
of skin to be undermined and location of lateral SMASectomy.
Vincent
Summary
After performing more than 1800 short scar rhytidectomies,
I have learned that the short scar technique certainly has
limitations. Being in private practice for more than 8 years,
I have been able to evaluate the long-term results of my
facelifts. I rarely perform my short scar technique on Vincent
type III or IV patients anymore. Almost always I will perform
full-face CO2 resurfacing 3 months before any facelift with or
without volume replacement. Men also present problems with
early relapse and tend to have very stretchy skin that creates
problems with dog-ears.
The primary advantage of short scar rhytidectomy is the
scar. Because the scar is limited to the retroauricular sulcus,
the patient can wear a pony tail without visible scars. The
small extension from the retroauricular sulcus is rarely
noticeable; however, the posterior aspect of the classic face-
lift incision is almost always noticeable to some degree. The
other advantage is that, on average, a short scar facelift is
30 minutes faster. The classic posterior extension takes about
15 minutes longer to dissect and close. The reduced amount of
dissection in the posterior neck reduces morbidity and im-
proves recovery time.
The disadvantages of the short scar facelift are difficulty
treating patients with severe wrinkling (Glogau III, IV), severe
cervical skin laxity, and large obese-necked individuals
requiring aggressive removal of Preplatysmal and subplatysmal
fat. Exposure of the underlying tissue in short scar rhytidec-
tomy is also limited, thus making it much more difficult than
classic facelift techniques to control hemostasis and perform
SMAS techniques.
Short Scar Rhytidectomy Techniques 51

No facelift technique has really shown to be the very best, morbidity, shorter recovery times, and reduced risk of poten-
and all good techniques rely on a basic theme of manipulating tial scarring are evolving in the twenty-first century. As the
the underlying SMAS (Fig. 26). It is clear, however, that the baby boomer population increases over the next 20 years, so
trend for more minimally invasive techniques with less will the number of facelifts being performed (Fig. 27).

Fig. 27 (A) Frontal before and after of patient who had short scar rhytidectomy, full-face CO2 resurfacing, and fat grafting. (B) Lateral
before and after of same patient in (A).
52 Vincent

References 6. Baker DC, Hamra ST, Owsley JQ, et al. Ten year follow up on the
twin study. Presented at Annual Meeting of the American Society of
Aesthetic Plastic Surgery. New Orleans (LA).
1. Brandy DA. The QuickLift: a modification of the S-lift. Cosmet
7. Hopping SB. Minimally invasive face-lifting: S-Lift and S-Plus lift rhy-
Dermatol 2004;17:351e60.
tidectomies. Oral Maxillofac Surg Clin North Am 2005;17(1):111e21.
2. Saylan Z. The S-lift: less is more. Aesthetic Surg J 1999;19:406.
8. Friel MT, Shaw RE, Trovato MJ, et al. The measure of face-lift
3. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial
patient satisfaction: the Owsley Facelift Satisfaction Survey with a
suspension lift: a modified S-lift. Plast Reconstr Surg 2002;109:
long-term follow-up study. Plast Reconstr Surg 2010;126(1):245e57.
2074e86.
9. Labbé D, Franco RG, Nicolas J. Platysma suspension and plas-
4. Brandy DA. The QuickLift: a modification of the S-lift. Cosmet
tysmaplasty during neck lift: anatomical study and analysis of 30
Dermatol 2004;17:351e60.
cases. Plast Reconstr Surg 2006;117:2001e7.
5. Lambros V. Aligned image transformations and facial aging. Pre-
10. Vincent D. Retrospective analysis of 800 short scar facelifts. Pre-
sented at the Annual Meeting of the American Society for Aesthetic
sented at the Annual Meeting of the American Academy of
Plastic Surgery, in Los Angeles, California, 2001.
Cosmetic Surgery. 2011.