Segmented scalp peninsula to prevent a raised hairline and misalignment in rhytidoplasty

Introduction: Rhytidoplasty has shown excellent results in the treatment of facial laxity over the years, but in a few cases in which the patient has increased facial laxity associated with high preauricular scalp implantation, we observed elevation of implantation above the root of the helix after flap traction, resulting in an unesthetic facial appearance and marring the surgical procedure. The objective of this study was to demonstrate a surgical technique designed to prevent hairline recession and maintain correct alignment for the facelift. Methods: Of 25 patients who underwent rhytidoplasty, 12 received a segmented scalp peninsula. Descriptive analysis in this group included age, level of scalp implantation, surgical time, elevation of the hairline, necrosis, postoperative hematoma, unesthetic scars, and neuropraxia. Results: We analyzed the results of a segmented scalp peninsula in 12 patients, ranging in age between 41 and 74 years, with a mean of 60 years. The return to usual activities ranged from 10 to 21 days. No unesthetic changes resulted from placement of the hairline on the sideburn in these 12 patients; there was one (4%) case of hematoma, but no case of necrosis or neuropraxia. Conclusion: The segmented scalp peninsula is an easily performed technique, with a low risk of complications and with satisfactory esthetic results. ■ ABSTRACT


INTRODUCTION
Aging is one of the certainties of life that we must face, with the passage of time.The perception of aging and the way we deal with self-image varies among individuals, with different beliefs and behaviors.Surgery has emerged as a tool to freeze time or to regain the youthfulness lost with the uncertainties of life.
Rhytidoplasty has shown excellent results in the treatment of facial laxity since the procedure was described by Charles Conrad Miller in 1907.However, in selected cases in which the patient had increased facial laxity associated with high preauricular scalp implantation, we observed an elevation in hairline implantation above the root of the helix after oblique flap traction, resulting in unesthetic facial appearance and marring the surgical procedure.Our initial intention was to categorize the level of the hairline as high, medium, or low, thus enabling improved prognosis and prevention of elevation of the sideburn.This standardization simplifies learning of the technique, making it teachable and reproducible for medical residents.

OBJECTIVES
Describe and systematize the technique of the segmented scalp peninsula procedure, with the indications and preparation of patients undergoing rhytidoplasty.
Describe a sample of the patients operated on in the past three years using this method.
Demonstrate the indices of recession and misalignment of the hairline.

METHODS
Female patients who underwent rhytidoplasty were analyzed prospectively, with a segmented scalp peninsula performed in the group classified as having a high or medium hairline in the preauricular region between 2011 and 2014 at the Fluminense Plastic Surgery Clinic/Niterói D'or Hospital, Niterói -RJ, and at the University Hospital of Marília -SP.All surgeries were performed by the author.

RESULTS
From March 2011 to March 2014, of 25 patients who underwent rhytidoplasty, a segmented scalp peninsula procedure was performed in 12 (48%), for a high or medium hairline implantation.The age ranged between 41 and 74 years (Figure 5), with an average of 60 years.The return to usual activities ranged from 10 to 21 days.No unesthetic changes occurred with    the implantation of the hairline on the sideburns in these 12 patients; one (4%) patient had an elevation of the hairline implantation above a desirable level because the segmented peninsula was not performed due to a classification error.There was one (4%) case of hematoma with closed suction drainage, which resolved with a manual drain.In one case, a seroma located in the lateral cervical region developed on the 6th postoperative day, and was treated with needle (1.20 x 40 mm) puncture and aspiration, as suggested by Destro et al. 3 .No necrosis, unsightly scarring, or neuropraxia was observed.We optimized the level of standardization of the preauricular hairline implantation as shown in (Chart 1) and illustrated in (Figures 6, 7, and 8).
The patients were divided by hairline level as high (Figures 9 and 10), medium, (Figure 11), or low.

1) HIGH
The lower limit is an imaginary line between the outer corner of the eye and the root of the helix.

2) MEDIUM
The lower limit is an imaginary line between the outer corner of the eye and the beginning of the tragus.

3) LOW
The lower limit is an imaginary line between the outer corner of the eye and the end of the tragus.

DISCUSSION
Castro et al. 4 and Menezes et al. 5 reported optimal analysis of results after the 4 th postoperative month, and    we also adopted this approach.Despite the many publications on rhytidoplasty, few studies describe methods designed to prevent a raised hairline.A raised hairline is unsightly and undesirable in rhytidoplasty, especially in patients with high or average preauricular scalp implantation who do not undergo any technique designed to preserve the level of the sideburn.Professor Pontes introduced the peninsula in 1999 to remedy the problem of excessive elevation of the hairline, as did the compensating triangle described by Neves et al. 6 .Both techniques have demonstrated effectiveness in preservation of hairline implantation, with excellent esthetic results.
This work aimed to systematize the indication for a technique designed to preserve high or medium hairline implantation, regardless of whether the peninsula, compensation triangle, or the segmented scalp peninsula is used.Patients with low scalp implantation have a contraindication to any method of preservation of the hairline.The segmented scalp peninsula is a technique designed to preserve the level of the hairline and alignment to the end of the sideburn, with less scarring.It is one more option, among others [7][8][9][10][11][12][13][14][15] , in facial surgery.
Positive results and satisfactory evaluation by many patients will lead to improvement in techniques, in search of natural and lasting results.

CONCLUSION
The objective of facial rejuvenation surgery is to achieve a fresh and natural appearance.The peninsula, especially as a segmented procedure, fulfills these criteria with satisfactory results.

Figure 1 .
Figure 1.When marking for the segmented capillary peninsula, maintain a circle defining the preservation of a skin segment at the end of the sideburn.

Figure 4 .
Figure 4. Temporal traction with preservation of the hairline alignment at the end of the sideburn.

Chart 1 .
Classification of preauricular hairline implantation.Note: Disregard hairline in the classification.

Figure 6 .
Figure 6.Implantation above the root of the helix, considered high, pre-and post-segmented capillary peninsula.

Figure 8 .
Figure 8.Average implantation of the sideburn, pre-and post-segmented capillary peninsula.

Figure 10 .
Figure 10.Average implantation, previously classified as low, without the peninsula.Note the elevation of the "hairline."Note: Disregard the hairline in the classification.

Figure 11 .
Figure 11.Low implantation, without the peninsula.Elevation of the capillary implantation without compromising the esthetic result, pre and post.