A: It would be hard to imagine under any circumstance that a facelift would be warranted on someone your age. Pulling one’s facial skin back does make  everyone’s face look more defined as the bony prominences, particularly the jawline and chin, become more pronounced. But that does not mean that a facelift (neck-jowl lift) is warranted. A facelift’s primary objective and indication is for skin laxity and sagging not to make the face appear more sculpted. (although it can create that secondary effect) You are likely in need of facial procedures that provide enhancement of your facial bone prominences, such as the chin, cheeks or jaw angles. Such facial implants can help create a more defined or chiseled face. But a facelift is definitely not what you need.

Dr. Barry Eppley

Indianapolis, Indiana

A: The numerous type of franchised forms of quick recovery facial tuck-ups are well known versions of limited facelifts or a jowl tuck-up procedures. There is nothing magical or unique about this operation or approach. It is a scaled down version of a more complete facelift or a neck-jowl lift. It can be very effective if done well and will get years of sustained improvement which will vary by a patient’s skin type and genetics. It could be anywhere from 5 to 10 years depending upon where one starts and how well one ages. The more relevant question, however, is whether this type of facelift approach is right for you. The vast majority of unhappiness with these franchised named ‘mini-facelift’ is that the patient wasn’t a good candidate. Their facial aging issues were more advanced and they should have had a fuller facelift to get the kind of result that they were expecting. Patients understandably are tempted to choose a facelift operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facelift operation that better fits their actual needs. This is the real issue you should be thinking about.

Dr. Barry Eppley

Indianapolis, Indiana

A: These marketed and franchised forms of facial rejuvenation are simply scaled down versions of a facelift.  This is typically a “mini” lift of the jowls (primarily) and the neck (secondarily and more limited) that is sometimes performed in the office with no general anesthesia. Understandably this makes it very appealing to some people. But just because it is appealing does not mean it is a good choice for everyone. Whether it can meet your expectations and is worth the cost is a key question for every patient who undergoes limited types of plastic surgery. This is particularly true when trying to improve the degree of facial aging that exists in someone 74 years of age.

You do have a significant amount of loose skin and the very presence of a neck wattle illustrates your degree of facial aging. On the one hand, these mini-facelifts will not produce an ideal result. So if your goal is a smooth and completely uplifted neck and jowl line, you will be disappointed. If, however, you can accept that some improvement is better than none then it may be a reasonable choice.

Rather than getting hung up on a marketed facial procedure, you would be likely better served to consult with a number of plastic surgeons and get a customized approach to your facelift needs.

Dr. Barry Eppley

Indianapolis, Indiana

A: The first thing that I would tell you is that there is not a non-surgical way to lift up the cheeks. There is almost nothing that I know that can lift any part of the body without some form of surgery. Some doctors may tout that they can lift up parts of your face with injectable fillers and in some small amounts that may be possible for some patients in some facial areas. However, with an already full and round face this injectable approach is likely to make you even rounder…and have no real lifting effect anyway. There are cheek lifting operations but really good results from these procedures come from very careful patient selection. Whether you would be a good candidate or not would depend on seeing some pictures of you. As a general rule, very round and full faces are chcallenges for any lifting operation.

Dr. Barry Eppley

Indianapolis, Indiana

A:  In reality, both are right and these are just two different options for the same facial aging problem. It is clear that you are what I call a ‘tweener’. Your aging issues are not quite enough for a more extensive facelift (neck-jowl lift) but are more than what liposuction alone can ideally improve. In other words, you have a mild amount of excess skin along the jawline and in the upper neck. As these two options are different in technique, they will also produce different results. I think the right answer for you is defined by how much you want to go through for what result. While neither operation is a big procedure, the liposuction/fat injection approach is less invasive but will not tighten the jowl line as much as a limited facelift with liposuction. (jowl lift) It would help to define what bothers you the most, jowling or neck fat. If it is neck fat go with liposuction. If it is jowling, go with the lift.

Dr. Barry Eppley

Indianapolis, Indiana

The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.

The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost thousands of dollars per jar. The other scam is that of neck exercises. If a neck wattle was really due to loose muscles, this approach might have some benefit. But it is loose skin and fat for which the ‘neck gym’ remains no better than those creams in a jar.

Getting rid of that neck wattle requires a necklift, also known as a facelift. There are different varieties of  these lower facial lifting procedures depending upon how the size of the wattle. Smaller or more limited versions are popularly known as Lifestyle Lifts. They are great for jowling but not for the bigger neck wattle. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears and the time of recovery.

 To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck. When needed, the extra recovery is worth the investment.

The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that will last for decades. The tradeoff for this simple wattle eliminator men is a fine line scar down the center of the neck. For men who have beard skin, this scar heals beautifully and may be the procedure of choice in the older male. For women, this potential scar must be considered very carefully.

A: Thank you for sending your pictures. Here is some imaging for the following procedures; a facelift (neck-jowl lift) and a rhinoplasty.You could get a really significant improvement in your neck wattle as it is a large amount of loose hanging skin. That would dramatically change your neck-jawline profile. It is interesting as to why you have such a large amount of hanging neck skin even though it appears you are relatively thin. Perhaps you have lost a lot of weight ?? Regardless a full facelift will remove inches of skin from the neck and tighten up the entire jawline.

From a nose standpoint, you tip is wide and thick and turns down slightly. There is also a small bump higher up on the nose. A full rhinoplasty would take down the bump, shorten and narrow the tip with some lifting and narrow the size of the nostrils. This type of nose change at your age changes the structure of the nose and makes it look smoother and more refined, a look that has a more youthful quality.

The combination of these two procedures, as the imaging illiustrates, would make significant rejuvenative changes to your overall facial appearance

As an addendum, I did not do nor is it possible to do realistic blepharoplasty computer changes. It is clear from the pictures that you have some extra eyelid skin that can be removed as well as some herniated fat from the lower eyelid. Your lower eyelid shows no significant skin excess, however, other than a few millimeters. Together, this type of upper and lower blepahroplasties will make you look less tired.

Dr. Barry Eppley

Indianapolis, Indiana

A: Thank you for your inquiry and sending your photos. You have a most unusual amount of neck aging compared to that of your face. And the direction of your neck sagging is mainly horizontal and not vertical. Many men develop so called turkeynecks which are largely a vertical skin sagging problem. This is the typical direction that direct neck lifts treat which is a vertical neck skin removal with some minor horizontal skin removal at both ends of the vertical excision.

Your neck, however, shows a substantial amount of horizontal skin laxity as seen by your many horizontal neck wrinkles. This indicates that a direct necklift for you must have a different excisional pattern. Using your horizontal neck wrinkles, two to three inches of neck skin can be removed across the width of the neck keeping the final scar in a horizontal neck wrinkle line. The only question is whether a vertical component to the skin excision needs to be done as well. I can not tell that from your photos since your face is tilted upwards in the photos you sent which may artificially make any neck wattle look better than it really is.

There is also the option of a more traditional facelift approach which will also work very effectively as well, albeit with more recovery and expense.

Dr. Barry Eppley

Indianapolis, Indiana

A: What I see on the photos is lack of jaw angles and loose jowl and neck skin. The jaw angles actually appear both high and indented or concave. I think the jaw angle issue is a result from your orthognathic surgery but it was not a mistake by the surgeon. Mandibular osteotomies involves elevating the masseter muscles off of the bone to perform them. There is no such thing as having to reposition them during the surgery as they simply fall back into place. But what can happen is muscle atrophy/shrinking from the trauma of the surgery and I believe this is what you have experienced. Because of the lack of a jaw angle, you would benefit by small lateral augmentation style of jaw angle implants. This could be combined with a limited neck-jowl lift (facelift) to create a more youthful jawline and nek appearance.

Dr. Barry Eppley

Indianapolis, Indiana

A:  The technical capability of performing a combined orthognathic procedure, like a mandibular setback, with a facelift is certainly possible. The need for it is so rare, however, that it would be hard to a surgeon that had ever done it together. There are several reasons for its rarity. By definition, a facelift would be done in an older patient while orthognathic surgery is usually done in a younger patient. Thus, the mainstream population of each procedure are at diametric ages. There is also the consideration that the  type of surgeon that performs these procedures are quite different. Most maxillofacial surgeons have little or no training for facelift surgery and most plastic surgeons have little or no training in orthognathic surgery. While plastic and maxillofacial surgeons certainly can work together and coordinate these surgeries, most plastic surgeons would probably prefer to defer the facelift to a later date due to swelling considerations.

With all of that being said, a mandibular setback and a facelift can be done together. The question is not whether they can be done together but whether they should. While each operation poses a ‘surgical opportunity’ to do additional procedures, you want to make sure that the patient can still get a result that would be comparable if either procedure was done alone. Surgical opportunity should not be more important than an outcome. In that regard, I would have to know more about how much mandibular setback is needed and the proposed technique (sagittal split ramus osteotomy vs vertical oblique osteotomies) and the degree of neck and jowl sagging that exists. Then I could answer the question better about whether such a combination is a good idea.

Dr. Barry Eppley

Indianapolis, Indiana

When it comes to that loose jowl and neck skin, everyone wants to avoid the dreaded word…facelift. While most people are unaware that a facelift is really just a necklift, everyone would agree that they would like as little surgery as possible. While the fears and recovery surrounding a necklift are largely overstated, one really hopes that they can get by with a ‘minimal’ procedure. This understandable apprehension has led to the nationwide branded selling of facelift surgery.

The best example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. I have seen many patients who know the name, but don’t really know what it is. Promising to turn the clock back at least ten years and look recovered in just a few days, its catchy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, and perhaps not an oversight, nowhere in their advertising does it even suggest that it is real surgery. Many prospective patients only become aware that it is surgery when they actually visit a company facility.

What is a Lifestyle Lift? While sounding new, it is really quite old and has been practiced by plastic surgeons for decades. It is a scaled-down version of a facelift, a ‘mini-facelift’ if you will.  Sometimes called a tuck-up facelift, a secondary facelift, or a jowl lift, it is a limited operation that best improves those sagging jowls with a little tightening of the neck. The operative word here is a ‘little tightening of the neck’. If you have a neck wattle or turkey neck, this is not the right procedure for you.

Because it has an appealing name, the Lifestyle Lift has created a number of name knock-offs, including the Swiftlift and even the Lunchtime Lift to name just a few. Most of these are surgeons who have jumped on the naming and marketing bandwagon and have given their version of a limited facelift its own name. There is no real difference in the procedure or in whom it is or is not most beneficial.

Because it is heavily marketed and the internet exists, the Lifestyle Lift has its share of critics.  Much of this has to do with trying to make an individualized custom operation into a factory line retail product. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a full facelift.

Facelifting is not an operation that should performed the same on everyone. Nor does having a catchy name mean it leads to better results or a quicker recovery. Many plastic surgeons offer similar limited types of  facelifts that just don’t have a branded name, but that doesn’t make them any less effective or useful.

Dr. Barry Eppley

Indianapolis

A: Anytime there is an outcome that does not meet a patient’s expectations, it is important  to determine why. There are only two fundamental reasons; there has been a complication that mars an otherwise acceptable result or there has been a fundamental miscommunication between the doctor and the patient as to what to expect afterwards. Having one lower eyelid than hangs down or is pulled away from the eyeball after surgery is known as ectropion. That is a postoperative complication that can occur after a lower blepharoplasty. If it is a small amount of ectropion and it is not that far out from surgery, then time and patience are acceptable for now. But since it is four months after surgery and there is still some noticeable lower eyelid malposition compared to the other side, revisional lower eyelid surgery may be needed. Why you see no result from your facelift is another matter. That would be an unusual outcome given the nature of how a facelift is performed. I think you need to go back and discuss your results with your original plastic surgeon. Most likely what he said was that he would not revise or redo your surgery at just 4 months after surgery. A different answer may be forthcoming with more time and if your lower eyelid ectropion persists. Only after you have given the original surgeon ample opportunity to come to a mutually acceptable decision should you pursue an outside opinion for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

A: Sagging of the jowl area is a natural part of aging and is often the first area of the face to fall. Provided that the neck is not also sagging, and it often isn’t early on, a modified or limited type of facelifting procedure is used. Known by a variety of branded and marketed names, which imply rapid recoveries and minimal interruption in your lifestyle, it is a jowlift or a mini-facelift. Because it is a scaled down version of a facelift, it is a much shorter procedure to undergo and the recovery is likewise much quicker…like in the one week range. Recovery in this limited type of facelift is largely social in how one appears. (bruising, swelling) Other than the typical surgical risks of bleeding, infection and adverse scarring, there is nothing else that can go wrong of any significance. None of these risks have I ever seen in this jowl lift procedure.

The good thing about this jowl lift operation is that it is a solution that is well matched to the size of the problem. Jowling is a relatively minor facial aging issue and therefore it does not need a major operation  for its improvement.

Dr. Barry Eppley

Indianapolis, Indiana

A: Thank you for sending your pictures. I have done some imaging looking at firming up your jawline.  You hve the typical jowling the comnes with aging and this also creates a prejowl indentation as the jowl sags. That is best corrected by a lower facelift (neck-jowl lift) and adding in a small chin-prejowl implant to bring the chin out slightly (yours is a little short) and filling in the prejowl deficiency. The combination of these two makes for a smooth jawline. At the same time, I would place some fat injections in the nasolabial folds (lip-cheek grooves, parentheses) as this is the best ‘filler’ to use when you have are doing a facelift as it is the only filler that potentially can be more permanent. Botox for the crow’s feet can be done either during a facelift or anytime in the office. Just for the sake of one additional suggestion, I have also imaged a rhinoplasty by doing some nose narrowing and lifting the tip a little as this can also have a rejuvenating effect as one gets older.

These computer images will help you think more about what can be done for a refreshed look.

Dr. Barry Eppley

Indianapolis Indiana

A: While I don’t have the advantage of looking at your facial pictures, I think your plan is fundamentally fine but it is planned in reverse. You want to do any skeletal or underlying foundational surgery first. The reason being is that such surgery causes a fair amount of external swelling which will stretch any tightened skin, potentially reversing some of the effects of any skin tightening procedure. Maximum tightening of the jowls cheeks and neck (facelift) should, therefore, be done after the bone foundation has been treated.

When considering zygomatic reduction, it is important to know if it will produce much of  effect. This can be assessed by locally at plain film x-rays, particularly a submental and/or a water’s view. These simple films give a visual assessment of how significant the curve is on the zygomatic arches. That will have to be ordered through a hospital or any free-standing x-ray facility where the appropriate equipment exists.

Dr. Barry Eppley

Indianapolis, Indiana