Your Questions
Your Questions
Q: Dr. Eppley, Hello! I’m 46 but I feel like I look 76 years old. I don’t know if a filler or mini facelift would be the answer. I just want to smile without all the wrinkles. I have tried lasers, dermapen and ultherapy. I’ve tried fillers but am not happy with the results. Thank you for your time.
A: You certainly don’t look 76 but I can see your concerns. What you havhe done is prove that nothing short of a surgical procedure would be of benefit. Non-surgical treatments like injectable fillers, energy-devices for skin tightening many other options have their place in facial rejuvenation. But there does come a time when what they can do is beyond their capabilities. Your own experience with them has proven their limitations in anything but the most early signs of aging.
You have reached the point where, if you are going to do anything, it must be surgical which involves skin removal and tissue tightening. And you don’t really want to waste time and money on limited procedures such as many of the so called ‘mini facelifts’. They also have their role in facial rejuvenation but the results they provide will be ‘mini’ and short lived also. What you need is a lower facelift to completely tighten the neck and get rid of the jowls. Ideally this should be combined with laser resurfacing over all other facial areas that are not undermined from the facelift procedure. Anything less will end up with disappointing results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a facelift. I always thought that it would never come to this desire but it has. My goals are to lift my sagging cheeks, reduce the marionette lines some and hopefully ease few wrinkles out of chin. I’m not wanting to look 30… but 55-60 would be nice. I’m going to be making a series of videos of me for my work and the producer wants me to look like a grandma. I would rather look like the kids’ dear auntie. Vanity, vanity….I’ve always known that so I’m good with it.
A: In looking at your three facial rejuvenation goals, they are all exactly what a facelift does NOT improve. A facelift is largely a neck and jowl improving procedure for the lower face. It has not effect at all on the chin, mouth or marionette liens of any significance. It has does not lift the cheeks. Each of your three facial concerns have to be treated by different procedures. Chin skin wrinkles can only be reduced by laser resurfacing, there is no lifting procedure for them. The cheek can be lifted but that has to be done with a cheeklift or midface lift. This is done through the lower eyelid approach so the cheek an be lifted vertically. In some cases, submalar cheek implant can lift sagging cheeks. Your type of deep inverted marionette lines are the most challenging since any type of injectable filler or fat injections will barely make an improvement in them because the line is inverted like a V…this makes it very hard to push out. The best treatment is to excise them and trade-off into a fine smooth line. That would remove them completely but is really done except in older marionette lines that are very deep.
All three of these facial procedures could be performed together and are a lot easier to got through than a traditional facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: D. Eppley, I need advice on a facelift result. I am a 63 year old female, who has lost 125 lbs from gastric bypass surgery over two years ago and had a facelift done two months ago. Sadly, my neck wattle has partially returned and both I and my plastic surgeon are very disappointed. In reading my operative note the facelift technique done was a lower facelift/corset platysmaplasty, lateral spanning sutures in platysma, and SMAS plication, with extremely wide skin undermining.
I am at a loss of what I or my plastic surgeon could have done differently! I don’t want to go back to surgery with the same plan which has already failed once. My plastic surgeon suggested the option of a direct neck lift but I don’t want the visible scar.
Do you have any experience with facelift surgery in massive weight loss patients? Was I asking too much from this operation? I know my skin elasticity is terrible and there is some improvement but not a lot.
A: In my facelift experience with large neck wattle in extreme weight loss patients, the first thing I tell them is that their degree of neck laxity may require a secondary procedure due to rebound relaxation and an inability to adequately reposition all the neck skin up and back. What looks good on the operating room table may be inadequate or does not always hold up well. So plan the surgery as if it is a two-stage procedure.
The second issue is what I do during surgery…you will need a major back cut behind the ears that either extends well into the occipital hairline or goes along the occipital hairline down very low into the posterior neck. This is the only way you can find a place to redrape the neck skin and excise it. In necks like these it is all about incisional location and it is different than a more traditional facelift. This also applies to the anterior incision as well. Because so much skin is being moved, and I don’t want the preauricular tuft of hair to end up way above the ear, I do a blocking incision technique. This is where the incision is made not up into the temporal hairline but around the preauricular hair tuft in a Z-shaped pattern. Good mobilization and redraping of the skin with these incision patterns, will show intraoeratively that the entire ear is completely covered before you make pilot cuts and skin excision. If it is not, then the amount of neck skin redraping will be inadequate.
I would simply plan on doing a secondary facelift with these modified anterior and poster incision locations, doing skin only, and it will be much better than the first time. The reality is that this type of neck skin excess and poor elasticity defies a traditional facelift approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a facelift done while I am in surgery for removal of my thyroid. i would also like to have my breasts lifted. It would seem to make the most sense to do all of these procedures at the same time.
A: Understandably the concept of combining a facelift, breast lifts and a thyroidectomy would seem to make the most sense from a surgical and recovery efficiency standpoint. And to a large degree it is. However, the hurdles to overcome to put this surgical combination together are substantial. The first is to check with your thyroid surgeon to make sure he/she would be comfortable in doing so. Plastic surgeons are comfortable doing a large number of procedures at the same time, but many non-plastic surgeons are not. Then there is finding the surgeons who are willing to do so and have their schedules find a mutual operative date. Equally, if not more importantly, then there is the cost of trying to do cosmetic surgery in a hospital where the thyroidectomy would almost assuredly have to be performed. The costs of cosmetic surgery, such as lengthy procedures as a facelift, in a hospital are often substantially higher than what they would be in a outpatient or private surgery center. These hurdles are not impossible to overcome but will be challenging. It may be far easier to have your thyroidectomy done first and then the facelift and breast lifts done separately days to a week later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have developed a neuroma after a facelift three years ago.I first noticed it when driving and my shirt collar rubbed against it and it felt as though there was something tickling my right ear. The surgeon treated the neuroma with a steroid shot. Although the numbness and sensitivity went down it was still there. The doctor treated the neuroma two more times without improvement. The numbness extends along my lower right jaw line, upper right neck, right cheek in front of the right ear and the right ear. My surgeon told me he never had a patient with a neuroma that was not treated successfully by injecting a steroid.
I visited another facial surgeon earlier this year. He told me if he did the facial surgery he would recommend treating the neuroma at that time as another facelift. He said he would cut the neuroma off/away from the nerve. He said it might not correct the problem completely and that I might have complete numbness in some of the areas where I now I have this strange feeling in my face.
I am reluctant to have either surgeon cut me since neither has treated a neuroma before. I would appreciate your recommendation concerning my neuroma at this time.
A: Thank you for the detailed descriptions of your after facelift issues. I can make the following comments.
1) While steroids is not an unreasonable approach to an initial treatment of a neuroma, when refractory, others more definitive approaches need to be considered.
2) I have not had a patient develop a neuroma of the greater auricular nerve after a facelift but I have treated several that have.
3) The traditional treatment of a neuroma would be excision and burying the ends of the nerve into the muscle. It is possible, although less likely, that the entrapped portion of the nerve could be identified, excised and the nerve repaired by putting the two ends back together. This would be dependent on being able to find the actual location of the neuroma amidst scar tissue which is usually possible because it is so superficial and its location can be identified externally before the surgery.
4) What will happen to the sensory innervation after any of these possible neuroma treatments is unpredictable…meaning it may get better worse or there be no change. Bring three years out of the procedure makes it a different situation than when done much earlier. Similarly the impact of the neuroma repair plus or minus facelift in your tinnitus is similarly a wild card. Getting it or its exacerbation from a facelift was not a predictable event so what happens with further surgery should not be assumed.
5) Whether you treat the neuroma independent on a facelift or at the same time is personal decision and depends on your motivation for a secondary facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift bit can’t decide if doing it under local or a general anesthetic is best. The use of local anesthesia is appealing as it lowers cost and avoids the risks of a general anesthetic. But I want to be comfortable and have a good experience. What do you recommend?
A: The debate of local vs. general anesthesia for facelift surgery is an historic one and continues to this very day. I have heard it many times and like many chronic debates the issues are not black and white and sometimes the main point of the discussion is overlooked. Let me provide some clarification for you.
The discussion of local vs general anesthesia for a facelift makes the assumption that the facelift part is the same and the only difference is in the level of anesthesia. This is a mistaken assumption and is actually the incorrect question on this issue. The real question is what type of facelift can be done under local vs general anesthesia? As I can assure you the type of facelift obtainable does differ with patient comfort. So the question is what type of facelift does the patient need and does it require general anesthesia to be done in the most through manner possible and with the greatest patient comfort. More complete facelifts that include a lot of neck work usually need to be done under general anesthesia. Smaller or more limited facelifts may be able to be done under local anesthesia with IV sedation. (aka conscious sedation)
One erroneous assumption about anesthesia that is not a general anesthetic is that it costs less. While on the surface that is true. (you do not pay for anesthesiologist’s time) But those cost savings are wiped out as it will take the surgeon more time to do the procedure. For example if it is takes the surgeon 50% more time to do the same procedure under local or IV sedation that could be in less time under a general anesthetic, the surgeon’s charge for doing the surgery can not be the same. One important but often overlooked element in calculating the cost of the surgery is the surgeon’s time. To some degree the surgeon’s charge for doing any surgery is highly influenced by the time it takes to do it. The point being is that it rarely makes good sense to choose a local/IV sedation option vs general anesthetic for many elective cosmetic procedures because you are trying to save money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift and jaw angle implants. Does it make a difference if they are done together or separately? If they need to be done separately which one should be done first? I have already scheduled my facelift but my gut feeling says that the jaw angle implants should be initially done first. My questions are:
1. Since I should have the implants first…how long after should I schedule my facelift?
2. Do you do jaw angle implants and facelift at the same time? (If I decided to have the facelift with the implants).
3. Would submitting pictures help decide which way to go/
Thanks for your help!
A: While jaw angle implants and a facelift can be done at the same time, I think it is better to stage them doing the jaw angle implants first followed by the facelift three months later. Jaw angle implants cause a fair amount of swelling in front of the ear and jaw angle area. That swelling would seem counterproductive to the pull of a facelift and would work against what the facelift is trying to accomplish. You do not want to stretch out the very skin and tissues that have just been pulled up. (if the facelift is done before and at the same time as jaw angle implants) While I think the two procedures are complementary (both help create a much better jawline), they just should not be done together and the sequence of the staging (implants before lift) is important.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides. I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag. I’d like a sharper jaw line. I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result. This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up. Thanks for your time.
A: Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.
This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent. (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Twenty years ago, I had a facelift done. Until six months ago, all was well. However, for some time, I have noticed that along my hairline, little “slits: appeared followed by something quite hard. Recently, my face has begun to drop dramatically to the point I’m embarrassed to be in public. The comparative pictures are unbelievable. I have Medicare and Tricare for Life. Is there any possibility insurance would cover the repair or for a new facelift? I’m desperate at this point.
A: Twenty years is a tremendous amount of time to get the benefits of a facelift. Most facelifts have largely degraded and the benefits lost by ten to twelve years after the procedure. I have no idea what the issue is with the ‘slits’ /hard knots in the hairline. Although most plastic surgeons use dissolvable sutures for their facelifts, your surgeon may have placed permanent sutures deep and they may be working their way to the surface after so many years. That would be the only explanation I could fathom for their presentation. No medical insurance is going to pay for facelift surgery. This is a purely cosmetic procedure that is paid for upfront undoubtably just like it was twenty years ago.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift to get rid of my neck sagging and jowls. Is there anything else you see in my pictures that you think would be helpful to create a more refreshed and younger facial look?
A: Thank you for your inquiry and sending your pictures. You would do really well with a lower facelift which will redefine your jawline and reshape the neck. You do have a bit of chin ptosis (roll of tissue on the underside of the chin and a small chin implant would be helpful to eliminate that and add to improvement in the entire jawline appearance. You do have a little extra skin on both eyelids (and just a bit of puffiness of the lower eyelid as well due to fat herniation so doing blepharoplasties at the same time (which is very common) would add to the overall facial rejuvenative effect. Your thinner skin and tissues also makes for a good outcome as these tissues show the effects of facial skin redraping the best as opposed to thicker heavier tissues. It is more common to do additional procedures with a facelift than to do a facelift alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, when I retire I will do a general over-all facial rejuvenation/enhancement and possibly a slight rhinoplasty tune-up/reduction. Probably fairly aggressive because due to my life situation, there is no need to “look like the same person, just well rested”. Now, is there any logical/preferable order in which to do these things? I had a successful facelift several years ago. I can say that I I don’t care if I spend the first three months looking swollen and feeling pain – the end results are well worth it, plus I am just not a whiner. But I thought I might do the rhinoplasty first/separately, so that the follow-on surgeon can correctly judge the amount of change needed with the “new nose”. Thus the question: how much of the facial implant work can be done all at once?
A: Without knowing what you look like or exactly need, I can not give a very precise answer. In general, I routinely perform all facial procures at one time including any implant work and rhinoplasty. How one facial procedure affects another can really be determined before anything is done by computer imaging. But certainly there is no reason you could not do the rhinoplasty first and then three to six months later do the remainder of any facial reshaping procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am two weeks after mini facelift. My tragus is all of a sudden swollen and slightly pulled forward and I can feel it is under some tension. It literally happened almost overnight. My surgeon told me today that the swelling will go down and that the pulled forward tragus will most likely correct itself. When I touch that forward tipped cartilage, I can’t imagine how it will correct itself. Is it really possible that it will?? I’m desperate for an honest answer. And yes, there is a incision inside the ear, and under the lobe and behind. Everything else is healing well except my tragus which is pulled forward and is swollen. Will I need revision surgery? 🙁
A: It is important to realize that healing is often not a linear event. Just because something pops up in the healing process that seems unusual, particularly in the first month, does not mean that something is wrong or will not turn out right. Facelifts of any type takes months to fully heal and six months or longer for all scars to mature and the tissue to feel completely normal.
Having said that a distorted or deformed tragus may settle down and return to normal with adequate healing time. At the least you will need six months to see how it heals. A deformed tragus, however, often is a reflection of too much skin removed in front of the ear or tension not adequately distributed around other areas of the ear. I have seen this to be most common today as many surgeons try to make a mini facelift work when a fuller facelift is really needed with long skin flaps and better tension distribution at the top and behind the ear. Neither the earlobe or the tragus will tolerate much tension at all without subsequent deformation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a “QuickLift” on March 17th 2014. This did not include a submentoplasty however the Doctor did address the platysmal bands during surgery. Photo number 3 is how I looked post surgery 7 days. I was elated. Since then there is now lax skin under my neck along with very slight jowling. (See following emails for photos taken about a week ago) I approached the Doctor and was he agreed I was in need of a revision and wants to do a submentoplasty using a 4 to 5 inch incision. I can’t do it and am hoping for revision with a small incision under my chin. Then I found you. The last thing I wanted to think about was more surgery. I am praying a submentoplasty with a small incision will address the issues. My goal is to look like my early after surgery picture with a firm neck and jowls with a youthful contour. What are your thoughts?
A: While I do not have any idea as to what you looked like before your Quicklift, the neck problem that you now have is excessive skin and prominent platysmal bands. This has occurred for one main reason…you had excessive neck skin initially and the Quicklift has merely unmasked this issue. (and maybe even made it worse) As the neck was defatted by liposuction (which I assume you had done) the hope was that your skin would shrink back down and tighten and no formal neck work would be needed. That unfortunately has not happened.
What I know unequivocally is that no form of a submentoplasty, regardless of the incision size, will significantly improve your neck. The only method to get your neck like you would like (smooth neck and jawline) is to do the one thing that you have tried to avoid from the beginning…a formal lower facelift. Anything less will be a waste of surgery and money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 62 years old and I had a facelift done six weeks ago. I still have very dense numbness on both sides of my face which goes as far forward as my cheeks and straight down to and under my neck as far forward as my chin? Is this normal and, if so, when will it go away?
A: When performing a facelift, the skin is raised up extensively to access the SMAS layer and well as to remove lax face and neck skin. Anytime the skin is undermined the tiny nerves that supply feeling to it are cut. This will result in numbness of the overlying skin that will persist for some time after surgery. Most if not all of the feeling will return but it will take time to do so. The return of feeling will begin in the most medial skin areas near the chin and nose and will work its way slowly back towards the ear. This is a process that will take months, often as long as six months to achieve maximal sensation return. In some patients they will be a small area of permanent numbness that may remain right in front of the ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am searching for a facelift opinion. I know you are an expert so I would value your opinion. Can a facelift correct this droopy mouth and marionette lines? I have lots of sag and volume loss. My skin seems firm with good elasticity but aging and gravity does take its toll. Is a long lasting correction possible? There are so many options for facelifts these days I don’t know which is the right one. Every doctor seems to have their way to do a facelift and they all claim their way is the best. I will only be able to financially do this once, so I’m looking for the best information to get the best outcome for me.
A: You are correct in that there seems to be many ways in which facelifts are done. And any time there are so many ways touted to do something you can be assured that there is no one single best way to do it. Nor does one facelift method work best for everyone as today’s facelift patients range anywhere from 35 to 85 years old…and simple logic would indicate that the facial aging concerns and anatomy amongst patients are quite different.
Facelifts fundamentally differ in three ways, extent (incisions and dissection), degree of SMAS manipulation and adjunctive procedures done at the same time. Putting together all these areas is what makes facelifts different and customized for each patient. But what does make them somewhat similar and serves as the basic elements of a facelift are the amount of skin flap dissection and SMAS redraping. With significant marionette lines and a droopy mouth, it is clear that you need a fuller type facelift with long skin flaps as opposed to a short scar or more limited type facelift. (e.g., Lifestyle Lift) SMAS manipulation is handled differently by various plastic surgeons but suffice it to say that extensive redraping of it is needed. Such manuevers are needed to help get rid of the marionette lines and improve the jawline and neck.
What a facelift will not do is correct droopy mouth corners. As a result, a separate small procedure will be needed with your facelift that directly treats this problem…a corner of a mouth lift.
When it comes to a ‘lasting correction’, it is important to understand that a facelift essentially buys time. It is not a permanent procedure and its effects will last years, perhaps 8 to 10 years, but eventually some or much of the correction will be lost. Facelifts help reverse the clock but they can not stop it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 56 yrs. old and have developed 2 vertical lines between my brows. They make me look mad or mean. My face has also started to sag. I have the saggy vertical lines from sides of mouth to chin and the sides of my mouth are starting to turn down. I use to have beautiful lips and they are looking thinner and I have vertical lines from smoking. I have always had a high forehead plus I had 40 stitches in my head from a car wreck years ago and my hair never grew back over the scar. I nose is slightly crooked and is showing more now. My face needs refreshed.
A: Many of your facial concerns are very common and there are a variety of surgical options for substantial improvement. I could give you a more detailed description of what they would be if I could see a few pictures of you. Just by description I am envisioning the needs to be a lower facelift (of some type), possible upper and lower lip advancements/lift with corner of the mouth lifts, possible hairline lowering with glabellar muscle excision for the vertical lines, scale scar revision and possible rhinoplasty. As you can see there are a lot of good options here and the issue is just how to put a surgical plan together that will optimize your face and give the most refreshed facial result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the difference between the composite facelift using the subSMAS spaces and your technique? Do you make those incisions inside the ear cartilage behind the tragus? Can you please explain the differences between the Deep Plane facelifts? I am basically looking for the most invasive change/longest lasting facial rejuvenation change.
A: Let me provide you with some further comments and my experience with composite acelifting since this is a topic about which you have inquired.
I do not claim to have originality or unique experiences with extended SMAS or sub-SMAS facelifting or composite facelift procedures. The principal motivation of a composite facelift is to bring a rejuvenative effort to more of the midface rather than just the neck and jowl areas. In other words, extending the lifting efforts to more of the central face area. A true composite facelift, in the purest sense of the term, works below the SMAS layer around the cheek, buccal fat pad and deep to the nasolabial fold area. The theory behind such a central dissection is that there is volume descent of the midfacial fat pads which has certainly been shown to be true by anatomic studies. This is not an area that any of the more traditional forms of facelifting strive to reach and treat. By dissecting the fat pad out and lifting and securing it vertically, midfacial descent of tissues is improved.
While this dissection can be done, and a few surgeons certainly tout it, more widespread experiences have been that the risk of injury to the buccal branches of the facial nerve, prolonged operative times, substantial and sustained edema and recovery and the sustainability of the midfacial results do not justify this type of effort in most patients. Other than a very few surgeons, the documented and proven long-term results simply do not justify that effort. The risk of buccal nerve injury, even if temporary, is very real and unsavory for any patient who sustains it.
If it is midface rejuvenation that one is striving for from a deep plane approach, there are more effective and less risky methods that can be combined with a good SMAS dissection. (e.g., subperiosteal midface lift through an eyelid approach)
Thus one should not confuse longevity of a facelift necessarily with the deepest plane approach. There is only so much one can do with the SMAS layer and the intent of a deep plane technique is not necessarily one that ensures a more sustained result because of its extensive SMAS manipulation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been reading about various types of facelifts and have a couple of questions and comments.
Questions:
1) Will he be tightening the muscles beneath the skin as well as cutting away skin?
2) Where will the fat injections go? I don’t want to look like Kim Novak did at the Oscars this year—so bloated my head seems too large for my body.
3) Can you send me pictures of previous facelifts you has performed on other people?
Comments:
1) I am not wanting to look 25 or 30 but to go back 10 to15 years would be nice.
2) I’ve attached 4 pictures of what I looked like from 1985 through 2005. I hope you’ll be able to get me back to 2000.
A: In answer to your queries:
Questions:
1) The only muscle that is tightened in a facelift is the plastysmal muscle in the midline of the neck. The SMAS layer on the sides of the face, which lies above the muscle, is lifted and tightened.
2) The only place fat injections go are in the nasolabial folds and the cheek pads.
3) There are many before and after pictures of facelifts on my website.
Comments:
1) Most facelift patients do turn the clock back by about p to 12 years. But it is important important to understand that a facelift only affects the neck and the jawline…and has not affect on the mouth area. To affect other areas of the face, other procedures needs to be added to areas such as the eyes and mouth. It is a common misconception that many people confuse a facelift with a more comprehensive total facial rejuvenation of which a facelift is just a part of it.
2) Whether you can get back to what you looked like in 2000 depends on an understanding of exactly the facial areas you want to improve and what procedures you want to do to get there.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I lost of a lot of weight and my face is asymmetrical. I have small jowls and not sure if I need a facelift or just a necklift and if face implants would be an alternative to a facelift. I want to look prettier and have a long, narrow face with high cheek bones but hollow cheeks underneath and nasolabial folds. I have tried to have my own fat injected into the nasolabial folds but it does not last very long. I also have very thin skin. Would you recommend a regular face lift or a smart lift? Thank you
A: In looking at your face and objectives, I see three procedures that would be simultaneously beneficial. Higher cheekbones are only going to be obtained by cheek implants. While chin or chin-prejowl augmentation is not a substitute for what some form of a facelift can do, a small vertically lengthening chin implant can help the jowls somewhat but more importantly contribute towards a longer more narrow face. Facelifts go by many names and their name sometimes indicates the extent of the procedure. You need more of a jowl lift type procedure which often carries the name of short scar facelift, Lifestyle Lift, Smartlift etc. Regardless of the name it is designed primarily to lift and eliminate the jowls. When done together with the chin augmentation your jawline should be fairly smooth.
Improving the nasolabial folds is difficult and fat injections, while worth a try, are rarely successful. The only technique that I have found consistently effective are dermal-fat grafts which are essentially autologous implants but they require a harvest site to use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 63 year old female who is interested in a direct neck lift but am concerned about the scar that will result. I have had two facelifts but each one has failed to really improve my neck like I want. I have been recommended now to have a direct neck lift because they say there is no more loose skin to tighten. I value my face and neck very highly since I had double mastectomy years ago and never had any type of reconstruction. What is your advice about the direct neck lift scar?
A: As I always say to patients with difficult scar choices, the only way to be sure of having no regrets is to never have the scar in the first place. In listening to you, I just don’t see that the scar no matter how it is done is every going to truly be acceptable. And you don’t merely want to tradeoff one problem for another and then just dislike your neck for a different reason. The only way any form of a direct neck lift would even be acceptable to any patient is when they can unequivocally say that the scar is absolutely better, no matter how it looks, than what it is a substitute for. This is clearly not the case for you. As a plastic surgeon I would certainly not be comfortable placing a scar in an aesthetic operation when the patient is very equivocal about its trade-off. This is magnified in you who now values the importance of how their face and neck looks as a some form of ‘compensation’ having lost other body parts.
On a different note and tact, I would question why none of your facelifts could not adequately address this neck issue. That is very uncommon/rare in my experience. I suspect this is a technique issue and thus I would question the statement of ‘ there is no more loose skin that can be tightened’. You may merely have reached the limits of what your surgeon can do. I would not take that as gospel that further neck improvement can not be obtained by a facelift approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do I need a facelift to correct my chin sagging after being burred? I had a procedure done three months ago where the surgeon burred under and shortened the chin. It was done intra orally and the lower chin and my face is slack and looks like there is a protrusion. In other words it still looks like I have a double chin despite everything. I am not sure which procedure I need but I did include pictures. Also could a slight buccal fat removal be done in conjunction with this?
A: Intraoral chin reduction is almost always associated by loose chin skin afterwards and often fails to make a big improvement in the amount of chin projection. A submental approach to your chin reduction would be more effective. Whether this is addressed only by a submental tuck (submentoplasty) or would be rolled into a lower facelift would depend on where you see the area of improvements needed and whether you want the whole jawline tightened. It is not crystal clear in the pictures and the real test would be what happens when you bend your head down and where the skin rolls appear.
When referring to the buccal area, there is the area right below the cheekbone (the true buccal fad pad area) and the area that lies much lower near the mouth and jowl area known as the perioral mounds. (which is often confused with being the buccal area) I believe you may be referring to the perioral mound area by description and in the pictures. Perioral mound liposuction can be done in conjunction with any submental chin tuckup or facelift procedure
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a lot of facelift questions for you. Which ‘full facelift’ technique do you offer? Do you offer the deep plane composite facelift technique with a 80% vertical pull and 20% lateral pull? I see on your website that most of your pulling is towards the ear. Doesn’t this result in a ‘wind pull’ ‘done’ appearance? The vertical pull seems to be more natural. And using the deep plane technique to offer a longer lasting result by accessing the the premasseter space, to lessen the jowl, and the labiomandibular fold?
A: Facelift surgery comprises a large number of techniques that can principally be broken down into incisional locations, skin flap undermining, SMAS management, platysmal muscle manipulation, method of fat removal and/or fat volume replacement. Any facelift procedure and its results and longevity is really a symphony of how these parts are put together that can really be different for each patient. Rarely do two facelifts have exactly the same anatomic components. I would submit that each and everyone of these parts have a role to play in the outcome and no one component alone is responsible for how a facelift result will look or how long it will last. There is also the other important variable which is the patient themselves…how extensive a procedure do they want, how much recovery and swelling can they tolerate and what is their budget.
But since you have ask about the SMAS component of a facelift I will address that issue in detail only as it relates to results and longevity. Manipulation of the SMAS layer in a facelift can be done by numerous methods including suture plication with no undermining to extensive undermining with a SMASectomy and plication. (what you are partially referring to with the term deep plane) While some manipulation of the SMAS has proven benefits over none at all (a simple subcutaneous facelift) it is has never been conclusively proven that deeper methods of SMAS undermining produce a more natural result or last longer than lesser degrees of SMAS undermining. It would theoretically seem like it would, and it may well be, but proving it (other than some surgeon’s touting it as so) is another matter. Its proof would be difficult as it would require one type of facelift being done on one side of the face and another on the other side in a series of patients.
It is also important to understand the movement of the SMAS layer and the overlying skin may and often are different. Since the skin and SMAS are commonly separated, their tissue movements are usually in slightly different vectors. The SMAS layer can be done in a completely vertical direction (when it is plicated) or in a more superolateral direction when it is undermined and repositioned. Likewise the skin layer can be similarly moved in these directions. Both the SMAS and skin layers are moved in varying degrees of superolateral movements. There is no such true lateral repositioning in either the SMAS or the skin layers. This is probably where you have gotten the phrase ’80% vertical and 20% lateral’, demonstrating that tissue relocation in a facelift is a combined superolateral translocation of tissue that is directed primarily towards the ear and the lower temporal region.
When it comes to what makes a facelift look natural, it is not an issue that is caused by one facelift technique being better in that regard than another. All facelift techniques, big or small, can make for an unnatural result. It is most significantly influenced by the ‘artistry’ of the plastic surgeon…not overlifting or overpulling any tissue layer and in how the incisions and hairline are managed around the ears and the temporal hair-bearing region. (e.g., more vertical directions of skin movement will move the hairline up higher unless that is factored into the incision design.
The deep plane composite facelift is unique amongst facial rejuvenation techniques because it basically does not separate the skin and the SMAS layer once beyond the anterior border of the parotid gland. Once the tissue plane is elevated, the entire composite of tissues is then lifted and secured. This composite tissue unit will always have a more vertical direction of relation, because if it does not, the amount of change would be minimized because the skin is attached to the SMAS layer throughout the flap. The deep composite facelift takes the longest to perform, has the greatest risk to injury of the buccal facial nerve branches, and will have a longer recovery due to prolonged swelling. Its best benefit, in my experience, is that it is the ‘safest’ facelift technique in smokers and others that may have compromised healing as the blood supply to the overlying skin is not disrupted by making a completely separate tissue layer from the SMAS.
Facelifting in men offers several unique considerations. The vector of tissue lifting in men has to be as vertical as possible since any significant lateral movement will result in having to workout tissue excesses behind the ear, risking a longer and more visible scar into the occipital hairline. Moving the sideburn higher is overcome by merely growing out the beard skin to drop the hair level back down. (which is why it is advised that men grow longer sideburns before the procedure) Too much of a lateral movement will also risk placing the beard skin closer to or on the tragus of the ear which is obviously undesirable. (although this can be prevented regardless of tissue movement by the location of the incision) Men are also unique facelift patients as their tolerance for a lot of swelling and prolonged recovery is not typically very high.
As you can see, facelift surgery is a myriad of assembled parts. While it is understandably convenient to label them as certain types, each facelift technique has varying influences on the outcomes, recovery and risk of complications. One facelift type is neither completely superior nor applicable to every patients’s facial aging needs and concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the Quicklift procedure for my aging face. Can you tell me if this procedure works and whether it would be good for me?
A: When someone inquires about highly marketed and franchise type facial rejuvenation procedures like the Quicklift or Lifestyle Lift, the first question I always like to ask is what has drawn one to these type of facial surgeries. The answers are almost always going to be because promote a quick to minimal recovery, lower cost or avoid the use of a general anesthetic. While there may be some truth to all of these claims, that is only so because they are ‘minimal’ type facelifts that are limited in the extent of surgery and thus limited in the kind of result that can be achieved with them. This is fine as long as one has the type of facial aging problem that is likewise not extensive and would respond well to this approach. There is considerable unhappiness with these types of facelifts and that is because often the patient’s problem exceeds what the operation can do under the circumstances in which it is being provided.
As a result, it is important to know the degree of one’s facial aging concerns to see if there is a match or whether a different type of facelift would be more appropriate. This can easily be done by sending me a few pictures for my assessment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How feasible would it be for a healthy 70-year-old female to undergo a “turkey neck, jowl, eyelid” lift? I’m on Medicare and a fixed income.
A: Feasibility for any type of facial rejuvenation procedure(s) (such as a lower facelift and eyelid lifts) is determined by two factors. First, age is really an irrevelant issue as long as one has good health. There are many 70 year old and older patients that very successfully undergo these procedures without any problems. The oldest patient I have ever done for a facial procedure (necklift) was a 92 year-old man! So as long as you are healthy and have laboratory studies which are normal, your age is not a limiting factor for the surgery. Secondly, there is the affordability of the procedure. These are plastic surgery operations not covered by Medicare. As such, they must be paid for as an out of pocket expense up front before the surgery. These costs would be affected by what type of lower necklift and how many eyelids are being done. For most patients at any age, the cost of the surgery is usually the determining factor of feasibility. I would need to see some pictures of your face to determine what the feasibility numbers would be for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to know which its a better choice between a facelift or laserlift. My concern is since my face is thin and non-fat, its more sagging skin around my jaw line and a little on my neck. I don’t know if the laser will really tighten my skin or cutting it will produce a better result.
A: While I don’t know what your face looks like and the degree of jowl and neck sagging that is present, it is fair to say that any form of a so called ‘laserlift’ pales in comparison to what a real surgical facelift can do. All so-called non-surgical ‘facelift’ technique only produce a mild amount of skin tightening that is very temporary at best. Regardless of the device used, its results are extremely modest and are best reserved for those patients whose skin laxity issues are so slight that the consideration of any form of a facelift is premature. Think of non-surgical facelift methods as a delaying tactic to push back by a few years the need for surgical improvement. In short, non-surgical facelifts are not a substitute for even the most minor form of a surgical procedure. Be aware that facelifts today have evolved so that they are done in minor to major forms depending upon the amount of jowl and neck work needed. They range from simple jowl lift procedures to more extended neck-jowl lifts. Often the debate between non-surgical vs surgical facelifts comes down to a decision between non-surgical skin tightening and a jowl lift. (level 1 facelift) For the economic investment and duration of effect, the far better value is almost always the surgical facelift hands down.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a middle-aged man who have been considering elective surgery for a long time. Due to my temple hollowness, I have had injectables (Radiesse, Sculptra, fat) in the area for long time, but with very limited effect and minimum duration. I am looking now into a more permanent solution, like temporal implants. On the other hand, due to my “sad look” a lateral brow lift has been offered to me several times, however, do you think that correcting the temples could fill up the area around the orbital contour or a lateral brow lift could still be needed? If so can both procedures be done together? My separate question to you is to whether a facelift could be performed at the same time as the one or the two procedures discussed above. Thank you in advance for your reply.
A: Temporal implants would be the only effective treatment option with your type of temporal hollowing. Your thin facial tissues have little fat and this explains why any type of injectable filler, including fat, can persist. Subfascial temporal implants will provide a permanent result by muscle augmentation. Temporal implants will not lift up the tail of your brows, n matter the size. That will require a temporal browlift, best done in men through a transpalpebral approach using an endotine fixation device. A facelift can certainly be done at the same time with careful placement of the incisions around the ears.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if I had maxillofacial surgery, would a chin implant and mini facelift be out of the question for me? Does having had the facial/jaw bones being worked on exclude the possibility of having implants placed on top of the bone or the outer skin lifted like in a facelift?
A: Any type of a facelift and chin implant can be done on someone with a prior history of orthognathic surgery, whether it was a LeFort 1, mandibular advancement/setback or genioplasty or any combination of them. What is done down at the bone level has no impact on the adjustments of the facial soft tissues along the jawline or on the side of the face. A chin implant can also be done over a previous sliding genioplasty even though there may be some more scar or tissue adhesions around it. To illustrate this point, it is not rare in my experience to place facial implants at the same time as having orthognathic surgery or to do a second stage after orthognathic surgery to place them. Given that the bone is at a completely separate layer than the skin or the SMAS tissues, there is no impact on having any type of a facelift later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a necklift question. I want to know why you can’t just make an incision behind the ears and pull the skin up. When I pul the skin back along my jawline all my wrinkles disappear. This seems like such a simple thing to do so why is a necklift not done this way?
A: You are basically describing how a necklift (lower facelift) is done. There are variations of where the incisions are placed around the ears and whether the deeper tissues are manipulated and tightened . When you use your fingers to create a ‘facelifting’ effect, here is the trick to see where the incisions must be placed. First, the finger traction test must be done right next to the ear not more forward along the jawline as that creates a false result with too much of a change. The fingers must be placed from where the point of pull actually comes from by the ears. Secondly, put your fingers in front of the ear as well as behind the ear and do the lifting. You will see that a far more effective change occurs in both the jowls and neck when the pull is done from the earlobe and upward. This indicates that all effective lower facelifts must have an incision along the front of the ear to create an adequate skin movement. How far the incision goes on the back of the ear is determined by the severity of the neck sagging problem. In short, you can not have an effective lower facelift by an incision limited to just the back of the ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facelift or facial rejuvenation but just not sure what. Not sure what procedures I would need to get rid of wrinkles, sun damage, and acne scars. I have attached some pictures of my face so you can see how bad I look.
A: In looking at your face, one of the fundamental problems is the large amount of loose skin which is contributing to the appearance of so many wrinkles. Rather than the loose skin just hanging off the facial bones, some people like you have it just pile up on the face. This also makes the acne scars look worse.
With this underlying skin problem, there are two fundamental approaches to take for your facial rejuvenation. The ideal approach would be a two-stage treatment consisting of a first stage lower facelift and browlift to get rid of much of the loose skin and to tighten the face. Then a second stage could be done of a full face laser resurfacing or deep chemical peel to smooth out more of the smaller wrinkles and lessen the acne scars as well. Such skin resurfacing can not be done at the same time as the facelift due to healing concerns of the skin.
The second approach, not as ideal, is to just do the facelift or the laser resurfacing. Both are beneficial and would provide some significant benefit by themselves without the other. But the result would not be the same as if both were done. If one had to choose just one, skin tightening provided by the facelift would be the best choice as the one treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had three prior facelift efforts and none have been effective at giving me an upward look to my face that crrently looks pulled down. It’s been recommended to me that a MACS lift might help pull upwards somewhat without involving the same incisions around the ears from the 3 previous facelifts. (I’ve been told that opening previous incisions could be risky.) Does a MACS lift have to include opening up the previous incisions around the ears or could it somehow be done otherwise. I am trying to get rid of my ‘hound dog’ look to my mouth and the deep creases above my lips.
A: Having had three prior facelift type procedures, it should be obvious by now that any type of facelifting effort is not going to improve the central aspect of your face. That is simply not where the pull from facelifts have their effects. Facelifts never improve sagging around the mouth and deep nasolabial folds. Thus, not type of MACS lift or any other variation of a facelift that uses the ears as the location for the direction of pull will work. Your prior facelifts have not failed because they did not improve these central facial areas as they have donen a good job with your neck and jawline which is where they work teh best. You are going to need to consider other more direct procedures such as corner of the mouth lifts, midface lift or even direct nasolabial fold excision to get this part of your face looking as rejuvenated as the jawline and neck.
Dr. Barry Eppley
Indianapolis, Indiana