Secondary face lift.

Dr. Bernard: The first patient is a 70-year-old nonsmoker who underwent a deep plane face lift about 10 years ago (Figure 1). She wants to see improvement in the jowls, cheek, neck, and jaw line. You will notice that there is some asymmetry of her face. She has had no nerve damage. She has what appears to be a pretragal incision. Given that this is a secondary face lift, how would you approach treating this patient? Dr. Klatsky: She does have facial asymmetry and upper eyelid ptosis. She also looks as if she has some orbital dystopia where the right side of the nasojugal groove is lower than the left. Her asymmetry also reflects into the modiolus, the right corner of her mouth is lower than the left, and she shows more relaxation, at least in the frontal view, on the right. She has either a relaxed platysma or it could possibly be a ptotic submaxillary gland. I am not really concerned with what plane has been dissected. Sometimes we may be fortunate enough to have this information, but many times we simply have no way of knowing. I am concerned , however, with the placement of the incision. The photograph shows an incision anterior to the tragus that is hypopigmented, as well as a little dart near the earlobe that is also white. Most likely, I would approach this patient with a retrotragal incision. If I believed that the hairline would be shifted significantly , I might consider a pre-tricheal (anterior hairline) incision. I cannot tell from this photograph whether the pa-tient's previous incision was within the hairline because her hair covers it. To address her prominent nasojugal fold and raise her malar fat pad, I would use a lower lid approach to a malar pexy, suspending the malar fat pad to the lateral can-thal periosteum. I would also imbricate the SMAS vertically, as well as pos-teriorly and anteriorly near the modiolus. By " selective imbrica-tion " at the level of the modio-lus, I could raise the corners of the mouth and have essentially a double layer of SMAS imbrication. For her neck, without being able to " lay on hands " and see whether the problem is the platysma or the submaxil-lary gland, I can't tell if a submental incision is necessary. The patient's jaw line is not particularly ptotic, so the face lift would probably be more …