Short-Scar Face Lift: Operative Strategies and Techniques

Short-Scar Face Lift: Operative Strategies and Techniques Edited by Patrick L. Tonnard and Alexis Verpaele. Pp. 450. Quality Medical Publishing, St. Louis, Mo., 2007. Price: $365. In the 1980s and 1990s, face lift procedures were increasingly invasive and aggressive. No plane of the face was considered off limits to dissection and traction. Endoscopic surgery was new, and concepts of fill were not yet generally appreciated by plastic surgeons. We are now in an age of minimalism, where simplicity, technical ease, and short recovery times are major considerations of treatment.FigureDrs. Tonnard and Verpaele have made a significant contribution to the face lift world in popularizing and codifying what they call the minimal access cranial suspension, or MACS, lift, which they defined in their first volume and enlarge upon in this second, multiauthored volume. Many of the well-known names in short-scar lifts are contributors, Baker, Jewell, Nahai, and Roberts among them. As befits its name, the book does not limit itself to minimal access cranial suspension, though a good deal of the book is a re-demonstration of the extended MACS lift. Other fixations, including formal superficial musculoaponeurotic system (SMAS) dissections and SMASectomy, are also discussed. The question of which method of SMAS fixation is best remains unanswered, as the results look very similar. A long and perceptive concluding chapter by Thomas Roberts III discusses the use of volume alterations in the face. A DVD is included that illustrates a MACS lift and the vertical suture plication of the posterior platysma. Multiauthored books are notorious for being uneven in quality, but most of these chapters are well written and well illustrated. The book has excellent production values, and as a hopeful sign of the times, the photography, although not perfect, is better than that in most facial cosmetic surgery volumes. One of the strengths of the book is the quality of the images, which allow the reader to see what is treated and what is not and how common cosmetic problems have fared with the techniques. Another strength of the book lies in its detailed intraoperative photographs and clear artist’s depictions of the techniques. Someone new to practice could follow the basic steps of the procedure and do a reasonable job on the faces that fit the operation. It is not the place of a reviewer to insert personal prejudices, but one can make observations based on experience. The editors make much of the verticality of the lift, and though it is true that the preauricular skin shift is vertical, it is easy to see in their photographs that when markers such as moles are present on the face, they shift in the familiar superoposterior direction, not vertically. This does not detract from the quality of the results, which are lovely in the faces that best fit the operation. The short-scar face lift with suture elevation is an excellent procedure for some patients, but it is not a separate and unique operation. A technique very much like it was described in the 1920s. In a broad sense, it is a face lift operation from which the posterior approach to the neck has been removed and more vertical skin vectors of closure substituted. The majority of the necks presented here were fairly easy, consisting of lax skin that improved with the surgery. One wonders if the more complex necks seen in many practices will similarly improve. A vertical preauricular vector in skin types with many pores and preexisting wrinkles is not well tolerated, as even with no skin tension in the closure, wrinkles and pores may be seen to drape up the face to the ear. In many of the patients presented in this book, one can see folds at the base of the ear as well. The verticality of the skin pull necessitates a temporal hairline incision, which becomes more visible the more superiorly it is made. Even with revisions, the scar is forever and one should be sure that one is getting a good trade-off for it. This is not an approach for all patients, as the authors all mention. The secret to any face lift technique is patient selection. I think the book would be improved by showing a series of patients who are not candidates for a short-scar lift and explaining why. Inexperienced surgeons would be able to see which patients should not be “short scarred” without having to find out for themselves. It is reasonable to have some concern that in the competitive world of cosmetic surgery, the formulaic simplicity for the surgeon and the perceived easier recovery for the patients make this an easily marketed operation, and its easy marketability may leave some patients undertreated or with difficult-to-treat secondary skin deformities. This book belongs in the library of physicians interested in the surgical treatment of the aging face. Both new and experienced practitioners will find something to learn and upon which to reflect. Val Lambros, M.D.