The science and anatomy of facial aging serves as the foundation for tailoring management options in facial rejuvenation.1,2 Although many of the principles in restoring a youthful facial appearance apply universally, certain characteristics unique to the male patient must be addressed to achieve a safe, consistent, and natural appearing result (Table 1).3–6 Male face lifts consistently account for approximately 10% of the total number of face-lift procedures performed annually in the United States.7 However, application of the same technique and management used in a woman would yield a feminine, insufficiently rejuvenated, and potentially dangerous result in a man. The following article and associated video demonstrate the senior author’s (R.J.R.) principles, technique, and finesse for performing the male face lift.
Table 1. -
Male Face-Lift Principles
| Thicker skin |
| Heavier, flatter brow |
| Facial hair patterns |
| Less prominent malar eminence |
| Central face fat atrophy |
| Deeper nasolabial folds and more prominent descent of the jowl fat pad |
| Excessive neck skin laxity, platysmal banding, and cervical fascial laxity |
| Skin vascularity, blood pressure stability, and hematoma risk |
PREOPERATIVE MARKINGS
Facial markings are tailored to distinguish the areas to be treated. This also serves as an opportunity to review the surgical plan with the patient. [See Video 1 (online), which demonstrates the preoperative markings for the male face lift.]
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FACIAL ANALYSIS
The facial analysis is performed at the time of consultation and repeated on the morning of surgery. Aging characteristics in the upper, middle, and lower thirds of the face are systematically identified and addressed. Special attention in men is directed toward periorbital, central face, jawline, and neck aging.3 [See Video 2 (online), which demonstrates facial analysis of the male face.]
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SURGICAL TECHNIQUE
Facial Fat Grafting
Facial fat grafting in men is focused on the deep nasolabial and malar compartments to correct the disproportionate volume loss in the central face.8 The zygomatic arch is avoided in men to prevent a feminine appearance.3 The volume of fat grafted is based on the preoperative analysis and ranges from 10 to 25 cc per hemiface.9 [See Video 3 (online), which demonstrates fat grafting to the male face.]
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Five-Step Upper Lid Blepharoplasty
Upper lid blepharoplasty is performed to remove excess skin and rejuvenate the brow with fractionated fat.10 In the male patient, it is important to perform a conservative skin excision, leaving at least 1 cm from the lateral edge of the incision to the brow.3 [See Video 4 (online), which demonstrates male eyelid rejuvenation finesse.]
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Five-Step Lower Lid Blepharoplasty
Conservative transconjunctival fat excision during lower lid blepharoplasty is performed to remove bulging retroseptal fat. Lateral retinacular canthopexy is often performed in men because the lateral retinacular ligament is often weaker and more attenuated than in women.3 A 5-0 nonabsorbable braided suture is used in men. A skin pinch excision is performed before the final step of blending the eyelid-cheek junction with fractionated fat.11–13
Face-Lift Incisions
Male face-lift incisions need to be designed to be well hidden, respect facial hair patterns, and address neck skin laxity.3 Before making the incisions, the face is infiltrated with approximately 150 cc of a 1:400,000 epinephrine, superwet solution in the subcutaneous plane.14 The incisions start with a concave-convex incision parallel to the root of the helix, which is continued inferiorly to the tragus. A separate intratragal incision is made. If hair-bearing facial skin is pulled on to the tragus, the hair follicles can either be excised immediately, or the patient can have delayed laser/electrolysis treatment to ablate the follicles. The incision is continued around the ear-lobule junction, staying 1 mm off the ear lobule. The incision curves onto the postauricular surface and turns in to the hairline at the auricularis posterior.14 [See Video 5 (online), which demonstrates surgical technique of the male face lift.]
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Face Dissection
The face is dissected in three zones to avoid injury to underlying vital structures. These zones are delineated by lines tangent to the alar base, ear lobule, and body of the sternocleidomastoid muscle.15 Dissection of the male face tends to be more fibrous and produces a thicker, well-vascularized flap. Considering the higher incidence of postoperative hematoma in men, perioperative blood pressure should be aggressively controlled and events causing acute hypertension (ie, vomiting) should be avoided.3
Submental Dissection
Men typically present with a greater degree of neck skin laxity, platysmal banding, and cervical fascial laxity as compared to women.3 Incision in the submental crease for medial platysmal plication is indicated for medial platysmal bands smaller than 2 cm. This is performed in the majority of male patients presenting for face and neck rejuvenation. Concurrent supraplatysmal fat removal and inferomedial platysma myotomy are performed to improve cervical definition.16 Finally, the lateral platysmal window is routinely performed to further define the jawline.17
Superficial Musculoaponeurotic System Manipulation
The mobile superficial musculoaponeurotic system (SMAS) is manipulated with either a SMASectomy for patients with a wide face or SMAS plication in patients with a narrow face. Horizontal orientation of the SMASectomy or plication is used in patients with a long face, whereas a more oblique vector is used in patients with a short face.15
Skin Redraping
After meticulous hemostasis, the postauricular skin is redraped in a superior vector. In male patients, aligning the posterior hairline is particularly important because a misaligned hairline is conspicuous with shorter hairstyles.3 Anterior to the ear, the skin is redraped in a more lateral vector. Superior to the root of the helix, the incision should not extend past the infratemporal hairline. Deep layer closure and conservative skin excision ensure a tension-free closure anteriorly at the root of the helix, posteriorly at the apex of the postauricular incision, and at the lobule.14,15
Skin Resurfacing
At the completion of the procedure, skin resurfacing can be performed safely in the perioral area, central face, or full face. The modality and depth of treatment is determined by the extent and location of rhytides, dyschromia, and/or actinic damage.18,19 [See Video 6 (online), which demonstrates a perioral augmented 35% trichloroacetic acid peel.]
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CONCLUSIONS
Detailed understanding of the science and anatomy of facial aging specific to men is imperative to achieve favorable outcomes in male face lifting. [See Video 7 (online), which demonstrates early postoperative results of a male face-lift patient.] Adherence to the principles, technique, and finesse of male face lifting allow for the procedure to be performed safely, consistently, and with natural results (Fig. 1.)
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Fig. 1.: Frontal view preoperative (above, left) and 1-year postoperative (above, right) photographs. Lateral view preoperative (center, left) and 1-year postoperative (center, right) photographs. Oblique view preoperative (below, left) and 1-year postoperative (below, right) photographs.
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PATIENT CONSENT
The patient provided written informed consent for the use of his images.
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