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The delta short scar facelift is intended for patients with mild to moderate facial aging that is characterized by malar descent, deepening of the nasolabial fold and early jowling. The best candidates have good skin quality without excessive skin redundancy. This is best tested preoperatively by simulation of the intended result. If repositioning the malar fat pad results in excessive periocular bunching, then a temporal brow lift may be added. If there is bunching beneath the ear, then the patient would be better treated with a full scar technique. Proper patient selection is critical to achieving a natural result.

The marking are made in the seated upright position. The malar fat pad is repositioned to its ideal location, and the skin is marked with an X. This provides the landmark for the volume augmentation, which is accomplished by SMAS plication and autologous fat grafting.

The procedure begins with the administration of local anesthetic. Fat is harvested and prepared for immediate injection. The fat is then used to treat the deficient areas. Fat is routinely placed along the infraorbital rim, cheek, nasolabial fold and geniomandibular groove. It is our practice to complete the fat grafting prior to the rhytidectomy.

The skin is opened with a pretrichal incision following the side burn and extending along the root of the helix. The incision then shifts to the tragal edge for improved ear definition and ends just posterior to the earlobe. A subcutaneous flap is then elevated ending just over the mobile SMAS in the cheek, and inferiorly over the platysma below the angle of the mandible.

The Delta plication is then marked in methylene blue. The base of the delta is obliquely oriented parallel to the fold. The superior or horizontal limb lies just inferior to the zygomatic arch, and the vertical limb runs parallel to the ear over the parotid gland. The size of the delta design is variable and is determined by grasping the mobile SMAS and elevating the tissues to the desired correction. The plication begins medially by anchoring the malar fat pad to the malar periosteum. This single deep suture imparts an immediate correction and is the foundation of the midface rejuvenation. Next, the SMAS plication proceeds along the oblique limb using interrupted sutures. The lower SMAS is rotated superiorly and medially and secured to the upper marking. With this maneuver, both the jowl and platysma are elevated. This results in a profound contour improvement in the lower face and neck. The inferior most sutures secure the platysma to Lorre’s fascia to prevent distraction of the ear. The plication is then over sewn with a running suture. Further subcutaneous dissection is usually required to release any adhesions. The skin is then redraped with modest tension in a superiolateral vector, similar to other short scar techniques, with the key suture placed at the superior aspect of the preauricular incision. The redundant skin is then conservatively excised and closed under minimal tension. A light compressive dressing is then applied. Post-operatively the patients have minimal bruising, and swelling is usually resolves within a week.

Variations include the full length postauricular incision when the loose skin in the neck extends below the level of the thyroid cartilage. This extra skin needs to be resected and cannot be accommodated in the preauricular incision only. Very commonly we do a full length low division of the platysma starting 5 cm below the mandibular border in order to avoid the marginal mandibular nerve. The muscle can be divided only from laterally or with a combination of a submental dissection when platysmal bands need to be plicated. We then use two anchoring sutures from Platysma to Lore’s fascia laterally and the other from the medial low cut edge of platysma straight back to the SCM fascia. This combination of sutures has given us predictable aesthetic angles in the neck. The submandibular gland can be partially resected through either a medial or lateral approach.

Your guest editor of this issue of Plastic Surgery Pulse News, Dr. Al Cohn, asked me to contribute a short piece on Incorporating Overseas Volunteerism Into Your Practice. Dr. Cohn is my practice partner and when he did a fellowship with me years ago, we often talked about this topic so it is with great pleasure that I have the opportunity to put a few of my thoughts into this article.

Medical professionals and, in particular, plastic surgeons have skills which can readily be utilized in many parts of the world. Fortunately, most plastic surgery procedures require very little in the way of sophisticated instruments or modern technology. As a result, outstanding plastic surgery is being practiced all over the world and creative minds are at work in even the least developed parts of the planet. The problem, of course, is that too few qualified individuals are available to serve remote areas where resources are scarce and poverty is pervasive. But how does one incorporate volunteerism into a busy practice?

I was introduced to the concept of overseas plastic surgery in the late 1950’s when my dad who was the first plastic surgeon in Minneapolis was approached by a family practice friend of his to travel to India to work with local surgeons and staff cases of reconstructive plastic surgery for a few months. With an ophthalmologist colleague, they did hundreds of cases together with the young doctors in the Santal Mission in Mahulpahari, India. Even though I was only nine years old, I could tell that he returned from that experience forever changed by what he had seen and done.

Years later in 1973 , prior to starting medical school, I had the chance to spend about four months working with Dr. Daniel Gruver in a small mission hospital in the San Blas Islands off of Panama among the Kuna Indians. I had enough OR experience from working in hospitals and surgical research labs that I was able to assist him on everything from snakebites to cholecystectomy—an experience that solidified my interest in surgery. Ironically, Dr. Gruver always wanted to be able to learn cleft lip repair even though he was only trained in general surgery. Ultimately, when the Panamanian dictator Noriega assumed power in Panama and Dr. Gruver was forced to leave, he got a plastic surgery residency with Dr. Ralph Millard in Miami and became a plastic surgeon making numerous trips back to the San Blas Islands over his lifetime.

Fast forward to 1987 and I had only been in practice at UAB in Birmingham, Alabama, about two years. Our very first fellow, Dr. Brian Windle, called me to ask if I would be willing to accompany him on an Operation Smile mission to Naga City, Philippines. Of course, my immediate reaction was that I was not only too busy to leave but felt uneasy about the volume of cleft lip and palate surgery that would be required to really be a solid team member. After three more convincing phone calls, I was persuaded that I was REALLY needed and that experienced cleft surgeons would make sure I was up to the task and that we would be learning from each other every step along the way. For the first time, I saw how local surgeons with huge cleft experiences could teach me ways of handling problems effectively and I could also offer ideas that might be of help to them. This was a TEAM EFFORT with members from all over the world working side by side to create a better life for children we had just met for the first time. I was hooked! This was the essence of plastic surgery and the very basis of medical and surgical care in a place of great need.

Since 1987, I have made dozens of trips to various places around the world and I credit Bill and Kathy Magee for having the vision to create Operation Smile. This organization makes it possible for medical teams made up of members from all over the world to provide care in places that express the desire for help. This is a key feature of all successful plastic surgical volunteer organizations—they must incorporate the local medical community who request the help and are willing to pitch in and work hand in hand for the benefit of those in need. That means “in country” funding as well as developing a local Op Smile infrastructure. Lasting success can never be achieved if a short range view is taken where doctors from the US sweep in like “knights in shining armor” to sprinkle some surgery here and there without regard or respect for the culture of the people they seek to help.

• Start Early. Don’t put it off like I tried to do! I think it is best to pick an organization that has already solved many of the problems such as instruments, equipment, and supplies. Additional hurdles are licensing, customs, hospital cooperation and support, as well as anesthesia, nursing, and getting the word out to patients in need. Mature organizations such as Operation Smile have already worked all of this out and determined which destinations make the best partners. Additionally, funding may be available to offset at least some of your costs such as transportation and lodging. Don’t expect luxury and don’t think of it as a way of underwriting your vacation. You will work hard but the rewards are rich.
• Think of ways in which you can mobilize the resources of your community to help support your involvement. All of us have patients and friends who would love to be involved with projects that they can personally connect with. To be able to contribute substantially to the organization you are involved with creates sustainability that will last beyond your personal involvement.
• Make it a priority to make at least one trip a year or every two years. Plan ahead and involve your office staff, family, and patients in preparing for your trip. They want to feel part of “making a difference” in the world. Further, they will make sacrifices at home to allow you to travel overseas.
• Take advantage of opportunities to become as highly trained as you can. Operation Smile has a variety of educational tools to learn cleft lip and palate techniques that work well in more primitive settings. Avail yourself of spending time observing or assisting cleft lip and palate experts in your community if you are not doing those cases yourself. Remember that the medical communities in developing countries resent having marginally competent plastic surgeons learning on patients who deserve excellent care. The days of going overseas to gain experience on poor populations are long gone and never should have occurred to begin with. The best organizations try to maintain a standard of care at or exceeding that which we have in the United States. You can expect to be proctored initially to make sure you are operating at the established standard before being allowed to operate independently.
• Stay in good health and good shape! Operating in developing countries is physically grueling especially when trying to get as many patients on the operating room schedule as possible. You can plan to get started early every day and work late. When the operating schedule is complete, postop rounds need to be made to make sure everyone is doing well. It is NOT a vacation, so plan to take extra days either before or after the mission to travel if you wish—and there are so many wonderful places to visit in developing countries so take advantage of being close by.
• Above all, keep your patients safe. I don’t think that undertaking complex reconstruction such as burns or microsurgery is wise unless your team is specifically going over to do this type of surgery and is prepared to take care of those patients until they are out of the hospital. The last thing you want is to precipitate a major complication or death. So concentrate on doing procedures which will have maximum impact for a child or family with minimum amount of risk.

As I look back on my career in plastic surgery, the time that I have spent overseas doing mission work ranks at the very top of the list of worthwhile activities. Some of my very closest friends in plastic surgery are those whom I have had the good fortune of working side by side with during mission trips. Gradually, I have developed wonderful friendships with people around the world. Although it is a well known cliché, I know that I have received far more than I have been able to give. As long as I stay healthy and technically competent, I will continue to be part of the world community of volunteer plastic surgeons.