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André Camirand MD, Jocelyne Doucet IL
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Montréal (Québec) Canada
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Communications should be sent to:
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| ROBERT M. GOLDWYN, MD |
| Editor Plastic and Reconstructive Surgery |
| 1101 Beacon Street |
Brookline, Massachusetts 02146 USA
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Abtract
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Our profession has not decided if it is better to incise parallel or perpendicular (at an angle) to hair follicles when performing a brow lift or a face lift. 30 patients had one side incised parallel and the other side incised perpendicular to hair follicles. Neither the patient nor the examiners knew how each side was incised.
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By comparing the invisibility, the non linearity, the absence of hypopigmentation and the abundance of hair into and in front of the scar, we got the statistical proof that if we incise perpendicular to hair follicles (to preserve the deep follicles in the proximal flap), scars were better in 95% of cases. .
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Introduction
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When performing a temporal or frontal face lift, plastic surgeons face a dilemma in choosing the incision site.
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An incision made inside the scalp will recede the hairline and widen the temporal area as well as the forehead. An incision made at the hairline will narrow the temporal area and forehead by advancing the hairline thus imparting an aura of youth. However, the latter type of incision should only be undertaken when a perfect scar is expected.
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A temporal incision behind the hairline, in addition to widening the temporal area, will also cause an upward rotation of the hairline in females, worsening the result (1,2) .
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In " Annales de Chirurgie Plastique et Esthétique ", Elbaz and Nataf reported on their treatment of scalp flaps when they inserted dermal grafts containing hair follicles beneath the scar (3) . They claimed that hair grew through the scar. This gave us the idea to use flaps of hair follicles with their associated papillae and advance them under the distal flap of a face lift in order to get some hair to grow through and anteriorly to the scar into the normal epidermis.
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After trying the technique on a small number of patients, we succeeded in making the scars virtually invisible to the naked eye (Photo 1) . Upon viewing our results, some of our colleagues noted that we had rendered the scars almost invisible because we had completely eliminated tension and we had been meticulous with our closures.
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We therefore decided to compare incisions on the same patient: on one side the incision was made parallel and on the other side the incision was made perpendicular to the hair follicles. This set the stage for a meticulous double-blind study where neither the patient nor the examiner knew what surgical procedure was performed on which side of the scalp.
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Ethical consideration
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Both parallel and perpendicular incisions at the hairline produce excellent face lift and frontal lift results in the hands of a competent surgeon. When performing comparative procedures on a single patient there are, in our opinion, no ethical constraints that might inhibit the surgeon and his team. However, each patient involved in the comparative analysis is informed of his or her inclusion in the research program.
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Technique
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It is difficult and always more time consuming to make incisions parallel to the hair follicles. Exceptional precision, necessitating the use of a magnifying lens, is required to follow their constantly changing direction. On the other hand, incisions at an angle (i.e. Perpendicular) to the hair follicles are faster and simpler. In order to preserve deep papillae and the deep part of the follicles the incisions are simply performed with a scalpel beveled between 30 and 45 degrees to the surface of the scalp.
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Because it is extremely important to avoid any tension whatsoever, micro w incisions are used. With micro w incisions at an angle of 45°, there is a mathematical increase in the real length of the incisions (by 41%) without an increase in their apparent length. Minimal tension is therefore decreased by 41% (1-10) . The broken line looks more natural than a straight incision. The scar is both extensible and mobile, and the minimal tension is distributed in an irregular manner. In addition, neovascularization is significantly improved (as in the case of trap doors) (11) .
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The proximal flap is incised in a micro w manner, and the distal flap is excised in a straight line (Fig. 1) . Whereas it is common practice in some regions to expunge the distal flap with a micro w excision, leading to imbrication of the two W's, we have determined that straight line excision of the distal flap produces superior results. Because the length of the stretched distal flap is increased, a micro w excision in this area would only further and excessively lengthen the distal flap.
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Since the length of the proximal micro w is approximately equal in measured distance to the stretched distal straight line, imbrication of the proximal micro w and the distal straight line produces minimal pleating and a perfect, virtually invisible scar (Photo 1) .
Surgical Rationale
During dermabrasion, all of the epidermis is removed as well as a good part of the dermis. Epithelial cells grow from the hair follicles towards the surface to reline the skin. Little if any hair is lost in the bearded area. When the incision is beveled (i.e. perpendicular), a similar phenomenon occurs. This is because the remaining hair follicles and their papillae are eventually covered by a distal flap of biological dressing, part of which is the stratum corneum, a non-viable structure (Fig. 2) . |
| Fig. 1. Shematic drawing: micro W of the incision inside the hairline and linear excision of excessive skin from the distal flap. The linear distal flap is sutured to the W-plastied proximal flap. Both the incision and the excision are done beveling the scalpel, pointing distally. The distal flap will be raised and stretched; therefore, it will be lengthened. The W-plastied of the proximal flap will accommodate the streched and elongated flap. |
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Deeper into the epidermis and dermis, living cells migrate towards the surface at the same speed as those of the distal flap. Under normal circumstances, epidermal cells require 30 days to migrate towards the surface. Following surgical stress or any form of direct trauma they migrate in 3-5 days. They will be accompanied by living follicles as well as hair shafts that migrate towards the skin surface without being destroyed, thereby allowing hair to grow into and in front of the scar.
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Even if hair follicles grow anteriorly to the scar by only a fraction of a millimeter, the scar will not be visible because of the presence of hair. Again, it should be emphasized that the closures must be perfect. There must be no tension whatsoever on the skin. This prevents the formation of large collagen-laden ischemic scars that would otherwise in turn prevent the growth of hair follicles, their hair shafts and papillae.
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It is also important to remember that melanocytes are extremely vulnerable to tension and ischemia, thus hypopigmentation may be another undesirable consequence.
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| Fig. 2. Beveled lift incision: proximal flap (on left) contains deep hair follicles, and the distal flap (on right) will serve as a biological dressing, allowing the hair follicles to grow into and anterior to the scar. |
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By following the principles of perpendicularity, perfect closure and minimization of dermal tension, many patients show absolutely invisible scars (Photo 1) . While both procedures are excellent, the advantages of perpendicular incisions are significant. The aesthetic and medical prognoses are superior, as evidenced by positive results on follow-up.
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| TABLE 1 - Examiner Scores |
Patient
No. |
Perpendicular
side* |
Scores for pigmentation, nonlinearity and nearby pilosity** |
| Examiner 1 |
Examiner 2 |
Examiner 3 |
Examiner 4 |
| 1 |
Right |
3,2,3 |
3,3,3 |
3,3,3 |
3,3,3 |
| 2 |
Left |
3,3,3 |
3,3,3 |
3,3,3 |
3,3,3 |
| 3 |
Right |
3,3,3 |
3,3,3 |
3,3,3 |
3,3,3 |
| 4 |
Left |
3,2,3 |
1,1,1 |
2,2,2 |
2,2,2 |
| 5 |
Left |
1,1,1 |
1,1,1 |
1,1,1 |
1,1,1 |
| 6 |
Right |
3,3,3 |
3,3,3 |
3,3,3 |
2,2,2 |
| 10 |
Left |
3,2,2 |
1,1,1 |
1,1,1 |
1,1,1 |
| 13 |
Left |
1,1,1 |
1,1,1 |
2,2,2 |
1,1,1 |
| 17 |
Right |
1,1,1 |
2,2,2 |
1,1,1 |
2,2,2 |
| 18 |
Right |
1,1,1 |
1,1,1 |
1,1,1 |
1,1,1 |
| 19 |
Left |
1,1,1 |
1,1,1 |
1,1,1 |
1,1,1 |
| 20 |
Right |
1,1,1 |
3,3,3 |
3,3,3 |
3,3,3 |
| 21 |
Right |
1,2,1 |
2,2,2 |
3,3,3 |
3,3,3 |
| 22 |
Left |
1,1,1 |
1,1,1 |
1,1,1 |
1,1,1 |
| 23 |
Left |
1,1,1 |
1,1,1 |
1,1,1 |
1,1,1 |
| 24 |
Left |
1,1,2 |
3,3,3 |
3,3,3 |
1,1,1 |
| 25 |
Right |
2,2,2 |
3,3,3 |
3,3,3 |
3,3,3 |
| 26 |
Left |
2,2,2 |
1,1,1 |
3,3,3 |
1,1,1 |
* Side on which the incision was done perpendicular to hair follicles.
** Scores by each examiner for pigmentation, nonlinearity and nearby pilosity, respectively,
Possible scores: (1) the left scar is better than the right scar; (2) both scars are comparable; (3) the right scar is better than the left scar.
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Evaluation
These preliminary results have encouraged us to design a rigorous double-blind protocol in which a sample of 30 patients* undergoing frontal lift or face lift will have randomly assigned left-side vs. right-side and parallel vs. perpendicular incisions to determine which technique is superior. The parameters to be measured are: invisibility of the scar, non linearity of the scar, absence of hypopigmentation and abundance of hair into or in front of the scar.
* Of the 30 patients, only 18 were eligible for the study.
The photographs show only the scars of a specific patient so the patient cannot be recognized by the personnel evaluating the scars. Two nurses and two secretaries are the evaluators. Each person is experienced in cosmetic plastic surgery and have a good knowledge of scars.
Statistical Analysis
For each patient, the incision parallel to the hair follicles was compared to the incision perpendicular to the hair follicles. Such an evaluation was very difficult since it required a qualifying judgment which induced, by definition, some subjectivity. In order to minimize this problem as much as possible, three criteria of evaluation were established: i) the absence of hypopigmentation; ii) the non-linearity of the scar; and iii) the presence of pilosity within and in front of the scar. Each of the four examiners judged the pair of scars according to these three criteria and assigned a score of 1 to 3 for each of the three criteria: |
| Fig. 3. Three months postoperatively. A hairline incision for a brow lift. The scalpel was beveled perpendicular to the hair follicles to constrain deep hair follicles in the frontal or proximal flap. Plenty of hair grew through and in front of the scar, rendering it invisible. |
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| Fig. 4. Appearence 2 1/2 years after a brow lift. On the left side of the patient (to your right) the incision was made perpendicular to the hair follicles. The scar is less visible because it is less linear and hair grows in front of the scar. |
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| Fig. 5. Appearance 10 months after a brow lift. The incision on the right side (to your left) was beveled to preserve the deep part of hair follicles in the proximal flap. The scar is less linear and less visible than the one on the left side (hair grows through and in front of the scar) |
Score 1. The lift scar is better than the right scar
Score 2. Both scars are comparable
Score 3. The right scar is better than the left scar
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A score for each scar was obtained from each of the four examiners based on the category chosen, and the final score for each scar corresponded to the mean of these four scores. This mean value can reasonably be considered as a continuous one.
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The difference between the mean scores for the perpendicular incision and the parallel incision was studied using a paired analysis. Since this variable did not follow a normal distribution, the data were analyzed by a nonparametric approach, the Wilcoxon signed rank test.
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Results
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The difference between the means of the final scores of the perpendicular incision and the means of the final scores of the parallel incision was 0.82 ± 1.33 (X ± STD), p = 0.0304. From these data, it can be affirmed , with a confidence level of 95%, that the incision perpendicular to the hair follicles is more aesthetic than the incision parallel to the hair follicles.
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| Fig. 6. (above, left) On the right side of the patient, the incision was done to preserve the deep hair follicles in the proximal flap. A lot of hair grows through the scar. On the left side of the patient, there is no hair growing through the scar and the scar is hypochromic. (above, right) A tattoo was required to improve with some success the scar on the left side of the patient. (Below, left) The histology of the scar from the right side of the patient demonstrating the hair growing through the scar and penetrating to the surface. (Below, right) Histology from the scar on the left side of the patient showing the presence of pigment (tatoo) and the absence of hair. |
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Conclusion
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We have proved beyond any doubt that by beveling our frontal and face lift incisions (incising perpendicular to the hair shaft) we preserve the deeper part of hair follicle in the proximal flap and this hair will grow into and in front of our scars. This is confirmed by comparing biopsies from both approaches (Photo 4) . The closure must be meticulous and without any tension.
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P.S. The pictures chosen were not from our best results but chosen because of the presence of hypochromic demonstrating the presence of hair in the scar. Better scars are to be expected.
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References
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P.S. The pictures chosen were not from our best results but chosen because of the presence of hypochromic demonstrating the presence of hair in the scar. Better scars are to be expected.
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- Camirand, A. Amélioration des cicatrices de lifting temporal et frontal. Ann. Chir. Plast. Esthet. 36: 3, 1991.
- Camirand, A. Improvement of the scars of temporal and frontal face lifts. In Mosby Yearbook of Plastic Surgery, ed. McKinney, P., 1993.
- Elbaz, J.S., Nataf, J. Etude critique des transplantations du cuir chevelu et propositions d'une optique.
Ann. Chir. Plast. Esthet. 21: 199, 1976.
- Camirand, A. How to improve face lift scars. VII Congreso Iberolatinoamericano de Cirugia Plastica, Carthagène, Columbia, 1988.
- Camirand, A. How to improve face lift scars. Franco-American Congress, Paris, June, 1989.
- Camirand, A. How to improve face lift scars. X Congress International Society Aesthetic Plastic Surgery, Zurich, 1989.
- Camirand, A. How to improve face lift scars. Canadian Society of Aesthetic Plastic Surgeons, Toronto, 1989.
- Camirand, A. Advanced facial contouring and how to improve face lift scars. San Diego, 1991
- Camirand, A. X Congress of the International Confederation for Plastic and Reconstructive Surgery, Madrid, 1992.
- Camirand, A. Brow Lift in Aesthetic Surgery in the Male. Marshac, D., Solomon, M.F., Granick, M.S., eds., a textbook in press.
- Grab and Smith. Plastic Surgery, 4th Edition. P. 58, 1991
- Connell, B.F. et al. The forehead lift: Techniques to avoid complications and produce optimal results. Aesth. Plast. Surg. 13: 217, 1989.
- Connell, B.F. Eyebrow and forehead lifts. Male Aesth. Surg. 22: 243, 1982.
- Bossé, J.P. Personal communications, 1992.
- Connell, B.F. Personal communications, 1992.
- Papillon, J. Personal communications, 1992.
- Perras, C. Personal communications, 1992.
- Regnault, P. Personal communications, 1992.
- Kerth JD, Toriumi DM. Management of the Aging Forehead (Northwestern Univ, Chicago; Univ. of Illinois, Chicago) Arch Otolaryngol Head Neck Surg 116: 1137-1142, 1990.
- Kerth JD, Toriumi DM. Management of the Aging Forehead. Year Book of Plastic, Reconstructive and Aesthetic Surgery,
p. 216-219, 1993.
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