Incisions and Evidence
The Surgical Reality of Facelift Scars

When I started learning about plastic surgery as a medical student, I thought it was simple: surgeons would operate, patients would heal, and there would be no sign that anything had been done. The goal was to leave no trace.

Thirty years later, I still believe the same thing. We should not leave any sign that surgery was done.

But even now, I see skilled surgeons at conferences describe procedures that leave obvious scars on a patient’s face. Some make cuts in front of the hairline or straight down the sideburn. Others leave large scars on the chest after breast surgery. In Birmingham, the humid weather means patients can’t always cover up with scarves or turtlenecks. They need their skin to heal well. It is possible to restore facial structure without making cuts in visible places. You just need to know the anatomy.

What dictates a facelift incision?

A facelift incision is a careful cut that lets the surgeon reach the deeper layers of the face, like the SMAS. The best place for this cut is hidden in the hair and along the natural lines of the ear, so there is no visible scar on the cheek.

At A Glance

The Sideburn Compromise

Many patients come to my office worried about looking too tight or pulled after surgery. They are afraid of the wind-swept look. This problem almost always starts with a poorly placed incision.

Why do some surgeons cut through the sideburn? It gives them quick and easy access. By making a straight cut down the side of the face, they can remove a lot of skin and sew it back together quickly. But this comes at a high cost for the patient: it changes your natural hairline.

The area of hair just in front of your ear is called the temporal tuft. If a surgeon cuts in front of this area and pulls the skin back, hairless cheek skin ends up where hair should be. This ruins the sideburn and leaves a clear, unnatural line. You might have to use makeup or certain haircuts to hide it for the rest of your life. There is no medical reason to accept this outcome.

The Tragal Pathway

We use a specific, hidden path for the incision and do not change the hairline.

For our extended deep plane facelift, the incision begins above the ear and stays hidden in the hair. It then goes down and passes behind the tragus, which is the small cartilage flap in front of your ear canal. The tragus naturally hides the scar. Some surgeons cut in front of it because working behind the cartilage takes more care, but we keep the incision hidden inside the ear structure.

Next, the incision curves under your earlobe and follows the natural crease behind your ear, called the post-auricular sulcus. It then moves back into the hairline behind your ear.

You can wear your hair in a ponytail, and no one will see any marks. Even if your body heals in a way that the scar is not perfectly flat, it will still be hidden in the shadows and out of sight.

Tension and Biomechanics

Hiding the incision is only part of the challenge. If the surgical method stretches the skin, a hidden scar will not help.

This is the main problem with the superficial 'mini-lift.' If the surgeon pulls the skin tight to lift the muscle and fat, the skin pushes back. The body senses this tension, and the incision takes all the stress. Because skin is elastic, too much tension stretches the collagen fibers, turning a thin scar into a wide, flat, white one.

We change where the tension goes. In an extended deep plane facelift, we work deep under the skin, below the SMAS layer, and release the retaining ligaments. We also go under the platysma muscle, sometimes freeing it near the collarbone. This lets us move the deeper facial tissues upward and anchor them to strong, stable facial fascia.

The deep muscle layer holds all the tension, so the skin is not stretched. We lay the skin back over the new foundation and remove any extra. With no tension on the outer closure, the incision heals as a barely visible line.

The Unfixable Mistake

You cannot fix a bad surgical plan by healing well. Once a sideburn is cut, it cannot be undone.

One patient had trusted our practice for years. We talked about her facelift and planned everything carefully. But my schedule was full, and she did not want to wait. She decided to go to another provider nearby.

I did not see her again for a year. When she came back, her impatience showed on her face. She had a large, bright white scar around her sideburn and up into her temple. The other surgeon had removed too much skin to make her face look tight. The tissue was thin, and her hairline was gone.

She sat in the exam chair, pointed to the obvious scars, and asked, "Can you fix this?"

I had to be honest with her. "No. You can't."

You cannot put back skin that has been removed. Once the tissue has healed in the wrong position, it cannot be fixed.

The Endoscopic Rule

This rule applies to every part of the body. We do not leave visible scars.

For brow lifts, we do not make a long cut across the top of the scalp. Instead, we use a small camera and make tiny cuts hidden in the hair. We lift the tissue off the bone without leaving any visible marks on the forehead.

The same idea applies to breast surgery. I do not understand why some surgeons still make cuts on the chest for breast augmentation. It is not needed. We use an endoscope and make a small cut in the natural fold of the underarm. When your arms are down, the scar is hidden. We do the whole procedure from the inside.

The Consultation

Your anatomy determines the surgery, but your surgeon’s technique decides your long-term results.

If you have a facial rejuvenation consultation and the provider suggests making a cut around your sideburn or in front of your ear, it is best to look for another surgeon. You do not have to accept visible scars to improve your facial volume. Contact Core Plastic Surgery for an evaluation. We will plan your surgery to restore your features without leaving obvious signs of surgery.