The other differentiating factor is the large amount of temporal scalp skin removal as described with minimal preauricular skin removal.
Dr. Menkes has performed approximately 50 of these short incision facelifts in the past two years.
Different incisions, different results
Dr. Menkes is an assistant professor of dermatology at Stanford University School of Medicine, Stanford, Calif., and he practices at Orchard Creek Medical Center in Mountain View, Calif. He described his procedure at the recent annual meeting of the American Society of Dermatological Surgery, here.
"It's a short incision that actually starts in front of the ear and is then carried out into the scalp, not the hairline. I'm able with this short incision to elevate a considerably large cheek and neck flap," Dr. Menkes says.
"The top of the ear is the extent of the vertical portion of the incision. But the temporal scalp portion being in the hair itself allows for a strong vertical lift with an invisible scar. I think many surgeons believe they will get hair loss if they are actually removing hair-bearing scalp skin, but we have not had any such problem," he adds.
Cheek flap modification
The other important difference in Dr. Menkes' short incision lift is the cheek flap itself. This cheek flap dissection incorporates a three-staged approach best described as 2 cm of skin followed by 5 cm to 6 cm of superficial SMAS plus skin, followed by skin only. In other words, the mid-portion of the cheek flap incorporates some SMAS and is a "thick" flap. Most short incision facelifts rely on a skin-only flap, he points out.
His unconventional approach, Dr. Menkes says, allows for both an SMAS plication - which occurs in many lifts - and the use of superficial SMAS suspension sutures that elevate the skin-SMAS portion of the cheek flap up to the temporal scalp. At the level of the mandible, the flap extends onto the neck and can be extended medially all the way to the midline.
"It is very important to note that this neck portion of the flap is very thin and is entirely superficial to the platysma. Once the cheek and neck flap is completed, I do a fairly standard deep SMAS plication using four or five interrupted 4-0 nylon sutures, emphasizing primarily a vertical vector," he tells Dermatology Times.
"In a lot of traditional lifts, I believe there is too much emphasis in an oblique or even horizontal vector of plication resulting in an unnatural looking result," he adds.
After the standard SMAS plication, two suspension sutures - usually 2-0 Prolene - are used to elevate the cheek flap vertically. These are attached to the deep portion of the temporal scalp incision, he explains.
"Finally," he says, "temporal scalp skin is removed so the skin suturing in the scalp with 3-0 nylon achieves a lot of vertical lift."
Very little skin is removed from the preauricular incision so the skin closure here is under very little tension, and therefore the resulting preauricular scar will not spread and will be less likely to become hypertrophic.
SMAS and skin suspension
Suspending the SMAS and the skin together differentiates Menkes' facelift from most mini-facelifts, the doctor points out.