Your Questions
Your Questions
Q: Dr. Eppley, I am having a rhinoplasty by you later this fall. I was planning on a facelift and breast lift with fat transfer to face and breast. It’s the beginning of a body makeover. I would prefer having you since the surgeons in my area aren’t capable of correcting the nose. Can we do all of the surgery mentioned above, I would really like to do as much as possible.
A: Such combined face and body procedures are often done together and the economy of time, cost and recovery are the obvious reasons why many patients seek to maximize their operative experience. But each patient must be assessed individually to determine if it is the right concept for them. In making that determination the important factors are two-fold; is it safe and is the best result achievable in one combined surgery? From a safety standpoint, 62 years old is perfectly fine for these procedures as long as one is healthy with no major medical problems. (which you are) For your immediate recovery, however, such combination of procedures should only be done if you are observed overnite in the facility. That would be particularly paramount since you are from out of town.
From a procedure standpoint, combining a rhinoplasty and facelift (with or without fat transfers) is very common. The nose is a central facial procedure and the facelift is a lateral facial procedure so one does not affect the other. For a breast lift, however, volume augmentation by fat injections may or may not be affected by the lift. That would depend on what type of lift is being performed and what quadrant(s) of the breast fat may needed to be added. Depending upon your degree of ptosis (sagging) you may only need the Refine internal suspension lift with outward superior nipple lifts. That would allow the maximal volume of fat to be added at the same time. I would need to see some pictures of your breasts to better answer this procedural question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facelift surgery. I am 55 yrs old and have been single for twenty years. I want to finally get to the place were I feel wonderful about me. I do not want to look like a different person with a drastic change. Is it really possible to have the face procedures to look younger/fresher and still be me? Seriously, I hate what I see on TV from even Hollywood stars who have all the financial resources I could not even imagine.
A: Despite what you see from Hollywood celebrities, that is not the way the vast majority of facelift procedures turnout. Unlimited financial resources do not necessarily allow one to make better choices, often the reverse is true. Being able to do anything doesn’t always mean you should. It is also important to understand that those who are in the spotlight on a continual basis face a whole different set of pressures from an appearance standpoint than you and I do. Lastly the face and body standards in Beverly Hills and Hollywood where most of what you see comes from is much different than here in the Midwest. Just walk around those areas and you will see what I mean.
The reality about facelifts and other facial rejuvenation procedures is the opposite of what you think. It is almost never an issue of ‘doing too much’ but can enough results be achieved to make the patient happy. When it comes to facelift procedures, no one ends up looking like a different person. The key is to do the right combination of facial rejuvenation procedures in a judicious manner that makes one look better and younger and not ‘overdone’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m doing fine after my facelift surgery except for one big problem. I have a serious issue with bladder control. I’m constantly feeling the urge to urinate and can expel just small amounts to less than a dibble. It’s been uncomfortable. Any ideas on how to re-regulate this?
A: I am not a Urologist but your after surgery issue is not the first time I have seen it. Urinary retention after surgery in older men is not uncommon, particularly if they have a known or unknown enlarged prostate gland. Usually the problem is treated by the use of a catheter which is passed into the bladder to allow the urine to empty. Initially a one-time (in and out) catheterization is done. But if the bladder fails to continue to empty properly, a catheter may need to be replaced and left in a for a few days. There are no medications that have been proven to be helpful for urinary retention although drugs such as cholinergics and sedatives have been tried with variable results.
You do not want to go for an extended period of time with bladder over distention. Based on your comfort level and how much (or little) urine you are getting out, a visit to the local emergency room may be in order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can you tell based on your extensive experience as a plastic surgeon what is the deal with the Lifestyle Lift? I see their commercials all the time and it just sounds too good to be true. They say nothing about that it is surgery but no cream or laser can produce those kind of results. Is it legitimate or a scam?
A: The Lifestyle Lift is both a tradename and a company that sells a form of a facelift surgery. It is a company that spends a lot of money every year to generate business for its franchisees so to speak. Its most popular TV ad is the one that features Debbie Boone who is the daughter of Pat Boone, a teen idol of many years ago and is still alive. (I just saw him on an infomercial for a whirlpool tub for seniors just this morning)
Like anything that is highly marketed, it is going to attract its share of detractors. While I haven’t done an official poll, I feel confident to say the whole Lifestyle Lift concept is probably not thought of highly by many board-certified plastic surgeons…at the very least for competitive reasons. And there is no question the company has had its share of legal entanglements brought on by a history of aggressive marketing practices.
But all the political and emotional issues aside, the company promotes its facial rejuvenation techniques through licensed physicians who enroll to be a provider in a certain geographic territory. It is surgery and it is a form of a limited facelift. Many of the patients seen in ads clearly have had other procedures done than just the Lifestyle Lift as many facelift patients are prone to need and do.
What turns off most board-certified plastic surgeons is that the Lifestyle Lift is marketed as a new and innovative procedure (I believe ‘break through medical procedure’ is what the ads say) which it is not by any plastic surgery standards. The most novel feature of it is the name as such facelift techniques date back decades in time. Doing the procedure awake and having it done in ‘just over an hour’ is obviously very appealing to patients but that does not necessarily convey that it is a superior surgical result or one that any sustained longevity. Since no scientific study has ever been published on the Lifestyle Lift in terms of its technique or patient outcomes in any professional plastic surgery journal or presented at any plastic surgery meeting, it is easy to understand why many board-certified plastic surgeons are taken back by its claims in its ads.
A prospective patient should view the Lifestyle Lift like having any other consultation from a plastic surgeon. Take in the information, do your research and make your own educated decision about whether it is right for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an appt with you to talk about a limited facelift and upper lip laser resurfacing and a bilateral lower blepharoplastics. I am having these items done to look younger for myself esteem and for my son’s wedding in November. I hope that telling you that bit helps you remember me. I know you are a very busy man. I have a few questions about the upper lip laser resurfacing. Will this be like scar tissue that stays red or white color for life or will my natural face color come back? Also how long will this take to heal? Scale of 1 -10 pain wise ? I am a huge baby when it comes to pain. We mentioned my crows feet and my forehead with like three vertical lines. I wanted gone do they need be resurfaced too if you do these other procedures how much extra would it be?
A: I remember you just like it was yesterday. When it comes to laser resurfacing, the skin is NOT turned to scar or does it remain red forever. There is definitely a ‘pink’ phase of the skin once it heals after the first week but that generally is gone by 4 to 6 weeks later. This would be particularly true in the white Caucasian (Fitzpatrick Type 1) skin that you have.
Most facial procedures, surprisingly, don’t have a lot of pain. Think back to your original lower blepharoplasty procedure years ago and, it may have looked bad, but it was not particularly painful.
As for your crow’s feet and vertical forehead lines, those are best treated by Botox injections. The most economical way to have that done is to have my nurse Lora do it. She is trained by me and provides those injectable treatments at 1/3 less cost than if I did them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having a facelift two weeks from today and want things to go as well as they can. I have read about taking arnica and bromelain supplements to speed healing and make my recovery quicker. Would these be good to take before surgery?
A: These are common non-pharmaceutical supplements for healing that some plastic surgeons endorse and prescribe for surgery including facelift surgery. Arnica is a well-known extract of the mountain lily flower that has been used for decades to prevent or clear bruising related to any form of trauma. Taken one week before and one week after surgery, it helps prevent some of the bruising that will occur as well as speeds its resolution after surgery. Arnica is most commonly used as an oral tablet but can also be applied directly to the bruised site as a topical ointment. Bromelain is an extract in oral or liquid form from the pineapple fruit that has anti-inflammatory properties. It is commonly used for sports injury, trauma and surgery to decrease swelling. Contrary to popular belief, eating pineapple will not increase your levels of bromelain as it exists mainly in the stem of the fruit. My feeling on both supplements is that they do no harm, are relatively inexpensive, and may provide some recovery benefit so I do advise my patients to take them particularly for any facial surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am 82 years old and want to have a facelift. Am I too old for plastic surgery? I stopped smoking 25 years ago and I think I am in pretty good health. I do take blood pressure medication and have a pacemaker.
A: Even though you are not at the typical age of most facelift patients, you can have elective plastic surgery done with several caveats. It would be critical to first talk to your cardiologist and get both their clearance and to find out what type of pacemaker you have. A pacemaker needs to be demagnetized prior to surgery since the electrocautery used during a facelift will cause the pacemaker to malfunction. Whether this is best done in a hospital location or can safely be done in an outpatient surgery center is a judgment for your cardiologist. Your blood pressure must also be under excellent control before a facelift to decrease the risk of a hematoma after surgery. Lastly it would be important to have a type of facelift that produces a good improvement but also limits the surgical time to do it and has a fairly quick recovery. Facelift surgery needs to be adjusted for the unique needs of each patient and, at your age, the need for safety supercedes the degree of facial change.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am confused about all the different types of facelifts. I reading on the internet I have come up with over a dozen types and names of facelifts, some of which seem similar and others very different. Can you help me figure out what is what is facelift surgery?
A: Admittedly, the marketing and promotion of facelift surgery can be very confusing. While there are many naunces/details within a facelift that does differ by plastic surgeon, there are some fundamental concepts that they have in the basic execution of a facelift and in what each individual patient needs. In my practice, I look at three basic types of facelifts and this is how I both allocate time and the charges to do them. It is important to also understand what a facelift is…which is a lower facial procedure that focuses on the neck and jawline.
Level 1 Facelift = Jowl Tuck-up, a true short scar facelift, no neckwork is done (liposuction or otherwise) This is for jowl problems only and would usually be done in someone under 50 years of age. SMAS imbrication by suture is done. Drains are never used. This is the facelift procedure that if one was truly motivated really could be done under local or IV sedation. It would be very similar to the well known Lifestyle Lift . May be called JOWl TUCKUP. It usually takes about 1.5 hrs to perform.
Level 2 Facelift = Semi-full facelift that includes postauricular incisions that usually do not go into the occipital scalp. Neck liposuction is usually done. SMSAS imbrication or flap elevation is done. Drains may or may not be used but are usually not. This is the type of facelift for jowlings and minor neck sagging issues. May be called FACELIFT. It usually takes about 2 hrs to perform.
Level 3 Facelift = Full facelift, extended postauricular and occipital scalp incisions are used with open neck work. There is a full connection of skin flaps between neck and face. Full SMAS flap elevation is always done. Drains are always needed. This is for those who have a major neck problem or concerns. Anyone over 60 or 65 years of age will always need this type of facelift. May be called FULL OR EXTENDED FACELIFT. It usually takes 3 hours to perform.
I hope these basic facelift concepts are helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Not sure what I really need. My forehead has deep wrinkles, I have sagging eyelids, bags under my eyes and jaw line and under chin drooping. Is this a full facelift or what?
A: What you are describing are numerous facial aging changes that are located around the two main areas that bother people the most, the eye area and the jawline/neck region. Unless there is some significant eyebrow sagging, the forehead wrinkles are treated with Botox injections and not surgery. Changing these two aging facial areas require a combination of blepharoplasties (eyelid lifts/tucks) and a neck-jowl lift. This is often interpreted as a ‘full’ facelift but this is not really an accurate description. A facelift is the purest sense of the word really just addresses the neck and jowl area and nothing above the lower 1/3 of the face. You may have interpreted eyelift surgery as part of a ‘facelift’ but they really are a separated procedure that is often done simultaneously for a more complete facial rejuvenation effect.
Please send me some pictures of your face for my assessment and a more individualized answer for your needs.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a craniotomy for an aneurysm over a year ago with radiation. This has left me with many effects from facial nerve paralysis. It has affected my face from the brow the whole down to the neck with a facial droop. I have attached pictures for your assessment. When I lay down my right eye does close which it did not do for quite awhile. The only movement I have on my right temple is a slight lift of the inner tip of the eyebrow. When I try to wrinkle my brow it goes slightly past center but it curves downward. The corner of my mouth was much further down than now. Originally there was no movement at all. I am now able to turn the corner up and the area of movement still seems to be increasing.
A: Thanks for sending your pictures. What they indicate to me is the following:
The frontal branch of the facial nerve is gone which is why the eyebrow does not lift up. As long as the eyebrow has not drifted lower than the opposite normal left side, I would not do any procedure for it. (i.e., browlift)
It is good news that the upper eyelid does now nearly close. As long as it closes completely when you lay down, I would not place a gold weight in the upper eyelid which is the normal treatment for a partial or slow closing upper eyelid.
The lower eyelid, as previously mentioned, needs a procedure which will help it considerably. It needs to be lifted and tightened up against the eyeball. To achieve this more is need to be done than just a traditional lateral canthoplasty. (tightening the lateral canthal tendon at the corner of the eye. That procedure needs to be combined with a fascial sling (harvested from the temporalis fascia) that would be placed from one corner of the eye to the other, much like a clothesline. Together this is the most effective method for lower eyelid tightening and resuspension.
The right face and lower corner of the mouth appears to be in some state of gradual improvement although it is probably not realistic to think that completely normal mouth movement will ever occur. However,, as long as it is improving, I may defer any type of static corner of mouth resuspension until later although that is still up for further evaluation.
The entire right facial droop may be treated with a complete facial resuspension (facelift) on the affected side. That is certainly reasonable to do at anytime. This may be combined with a corner of the mouth lift, both of which will not negatively impact any ongoing facial nerve recovery.
The right temporal area is sunken in due to the effect of the combined craniotomy and radiation, which has caused the temporalis muscle to shrink or atrophy. This is a very common effect from this exact neurosurgical procedure. The temporal area could be built back up using a variety of techniques which would depend on the dimensions of the volume lost. I can not tell exactly from the pictures to give you a better idea on how that would be done yet.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am really interested in a new procedure called “Fractora Firm”. Do you do that and if not, do you know anyone in the state of IN or surrounding states who does? This would be much less costly than a facelift.
A: The procedure or technology behind the Fractora Firm is radiofrequency (RF) energy driven into the skin to creatre a mild firming or skin toning effect. What has caught your attention to it most likely is its recent appearance on the Dr. Oz show. The use of RF and a variety of other energies (ultrasound, pulsed light, galvanic electrical currents, etc) to try and improve sagging skin is not new. Over the past decade there have been a slew of these energy-driven technologies, all of whom capture media attention as they have become available for patient use. They capture the public’s attention due to the widespread concern of sagging facial tissues as one ages and the hope that it will avoid the need for a ‘facelift’.
It would be a far reach to consider it or any similar technology as a replacement or substitute for what a surgical facelift does. Calling it a non-surgical facelift is a marketing concept not a clinical reality of what actually happens. It is better to think of it as a skin toning or firming method not a sagging tissue lifting method. As a result it is best used on younger patients with early signs of facial aging such as a small amount of jowling or just a little loose neck skin. It is not for someone who has more moderate to advanced facial aging with really evident jowls and a neck wattle. Its success, therefore, is highly dependent on proper patient selection.
What is also not evident on the Dr. Oz show is that Factora Firm requires multiple treatments, usually 4 to 6 treatments spaced a week or so apart, to get the optimal facial toning effect. Thus the cost is not really $300 (as stated on the show and the website) but $1200 to $1800 for a series of treatments. Whether that cost and the effect that it creates is a better value than a ‘facelift’ would depend on the degree of facial aging that one has. If one does not really need a facelift then it is a good treatment that may be worth the cost. If one really needs a surgical facelift, then such treatments are a poor value.
In my practice, we offer a similar non-surgical treatment to Factora Firma using RF energy (Exilis) combined with more superficial fractional laser resurfacing for skin tightening and a mild amount of facial skin lifting. This combined treatment is superior because it combines heating up the underside of the skin (dermis) with a more superficial (epidermis) treatment. This produces the combined effect of skin tightening AND wrinkle reduction. For some patients a more intense single treatment is fine while others may be best served by lighter treatments done in a series.
I would be happy to review any pictures of you to determine whether you are best served by considering a non-surgical RF skin tightening approach or whether something more surgical is more appropriate. While every patient wants to avoid surgery and their associated costs and recovery, most patients would also like to avoid throwing their money away on a treatment concept that never had a chance to achieve what they wanted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had fat from my hip added to the left side of my face. I had a hollow side due to radiation, it’s been about 7 to 8 years since I had this done. And the fat has dropped and looks terrible, what can I do about this? It sticks out and hangs down.
A: You undoubtably had a dermal-fat graft taken to reconstruct the soft tissue atrophy on one side of your face due to the radiation. While dermal-fat grafts are an excellent means of subcutaneous fat reconstruction, they are notorious for ‘sliding off the face’ or falling down to the jowls if they are not anchored securely to the cheek bone and along the zygomatic arch bone. What could be done now is a resuspension of the dermal-fat graft back into the desired position with permanent sutures. This would be very similar to the original procedure to place the graft minus the harvest site. It is, in essence, like a one-sided facelift procedure. It is clear that the dermal-fat graft has taken but it probably developed descent before it completely healed, thus falling down to the jowl line.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a facelift but want a result that really lasts…like the rest of my life. I know that skin and muscle from the neck and jawline have to be lifted and removed and I am fine with that even though it scares me a little bit. But I don’t want to go through that if it doesn’t last a really long time. I have been reading about how stem cells are being used now and some doctors are doing a Stem Cell Facelift. This seems to make a lot of sense because one is not only getting rid of the loose skin but adding something that injects youth back in and can grow new collagen and skin. Is this a procedure that you perform as I am really interested to have it done?
A: The reality is that the use of stem cells in any cosmetic procedure, including a facelift, is both unproven but also illegal. (unapproved by the FDA) Stem cells harvested from patients have recently come under heavy scrutiny by the FDA and such potential cosmetic treatments are now regulated and restricted only to approved clinical trial settings. The widespread marketing of such procedures as Stem Cell Facelifts is now over and you will not hear much about them anymore. Their previous marketing and use was based on the appeal of stem cells and was both unproven and in some cases unsafe. Nobody knows what stem cells will do when transplanted into the body. This is illustrated by a recent report in Scientific American where a women injected with stem cells for wrinkles around the eyes developed bone in her eyelids. This demonstates that the effects of stem cells are not really understood and should be more carefully studied, as they are being done for many other medical condition treatments.
For now you will have to consider a traditional facelift procedure that has long been proven to be both safe and effective with results that last on average 10 to 12 years for many patients.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was interested in knowing if you perform the backlift bra line procedure? I can’t seem to get rid of these backrolls along my braline no matter what I do. I don’t think they are fat but just rolls of skin. I am also interested in a facelift. Can these be performed at the same time?
A: The Braline Backlift is a procedure that I am not only familiar with but have performed numerous times. It is usually done in most cases in the extreme weight loss patient but may occasionally be done in someone of normal weight or has lost a more modest amount of weight. It is an excisional skin and fat procedure which is done along the braline on the back through a double ellipitical excisional pattern. (it is important to not remove tissue across the midline spine due to adverse scarring) It is a tremendously effective procedure for eliminating those pesky back rolls and providing a bit of a ‘backlift’. Think of it as a facelift for the back so to speak. It does result in a fineline scar that sits along the braline, hence the name the Braline Backlift. One has to determine if this scarring is a good tradeoff for the improvement/elimination of the backrolls.
There is no problem combining the Braline Backlift with a facelift at the same time.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I always felt I had too much skin in my neck and as you can see from my pictures I have no jaw line and I must have too many platysma muscles causing me to have this large oversized neck. I have the neck of a 80 year old and have had this since I was 19. If you look at my high school year picture it is not too bad but for some reason after I hit 20 my skin just got more and more loose in my neck. It just sucked. Which is why I can never wear a hat as all you see is my multiple chins. I hate the fact that I have this old man neck and have had it all these years. If I gain an ounce its always in my neck and face. Just fyi, I’m 5'10 and 219lbs. My BMI or fat percent when I am training regularly is 19 which is not bad. But when I slack off it’s between 25 to 30. I really just want too get rid of all this loose skin and for once in my life be able too wear a hat!!! Does it take long too recover since I am embarassed and don’t want anyone to know. Have you seen this Lifestyle Lift advertisement? Would that help? Thank you so much for looking into this for me, greatful for your time. From a guy with too many chins.
A: The problem is your neck is not just loose skin or 'too much platysma muscle' (such a thing doesn't exist), it is a combination of anatomic factors including loose skin, subplatysmal and supraplaytsmal fat, a high hyoid bone and a mildly recessive chin. The one thing you absolutely don't want to do is the Lifestyle Lift. That would be a waste of money for you because that is an operation that is too small and inadequate for your neck problems. That is really a limited form of a facelift that is good for jowling problems but is inadequate for you neck concerns. What you really need is a neck-jowl lift combined with chin augmentation with aggressive work in the submental/subplatysmal area. (all part of what is more commonly called a facelift) That is the only approach that will have any chance of making a significant change. Do not waste your time or money searching for other solutions that appear simpler and easier…because they will not work for your anatomic neck problem.
When you look at recovery from this type of operation, it is going to take two or three weeks to look pretty good again and you feel comfortable out in public. So it is a commitment on your part to make this change. Yours is not a neck problem that will be fine in a few days or a week after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can you tell me anything about the Lifestyle Lift? Their commercials look great but I am skeptical. What is it that they do, is it surgery and how long will the results last?
A: Just like hamburgers and coffee, facelifts today are also a franchise business. The Lifestyle Lift is the most well known due to their large national advertising efforts and having been around for over ten years. While it often is not obvious in their commercials and advertisements, it is surgery and it is all based on a variation of small facelift. The other thing that is not obvious for their advertising is that many of the patients have had more than just a Lifestyle Lift to get the results that are shown.
There are numerous types of what I call franchised forms of so-called quick recovery facial tuck-ups which aare well known versions of limited facelifts or jowl tuck-up procedures. There is nothing magical or necessarily unique about the underlying procedure. They are all scaled down versions 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. I suspect the results could last anywhere from 3 to 7 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-facelifts’ is that the patient wasn’t a good candidate for it. 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 rejuvenation operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facial rejuvenation procedure(s) that best suit their needs. Like all cookie-cutter approaches, it works well for some people but not for others. Like any consult with a plastic surgeon, be educated, do your homework, and get different opinions.
Q: Dr. Eppley, I am a plastic surgeon in New Mexico and need your thoughts on a facelift patient that I did six months ago. She is a 65 year-old woman that I did a full facelift on. Despite pulling and getting her as tight as I could, she is now left with some loose residual skin in the neck. She nor I want to go through another facelift procedure and I doubt very highly I could get her neck to get any better by this approach. Do you have any suggestions.
A: For residual loose central neck skin after a facelift, one option is either a submentoplasty or a direct neck lift. A direct necklift is always more effective if she is willing to accept a fine line central enck scar. A good direct necklift option for this lady is what I call the Zipper Necklift. It is just a running w-plasty from the submental crease down to a low horizontal neck crease no lower than the thyroid cartilage. (never go as low as into the sternal notch area) By the pictures you can see it is just a running w-plasty excision/closure. The key is the markings. Halfway between the submental and thyroid cartilage pinch the loose skin together and mark it. That will be the point of the widest arc of excision. Then make a vertical ellipse from top to bottom but make the lines INSIDE your previous pinch mark. Then mark your running w-plasties going to the outside of that mark. Excise full thickness skin and fat right down to the platysma muscle. Then you can sew the platysmal muscle together from submental to thyroid cartilage like never before. Close the skin with 4-0 or 5-0 Vicryls for the dermis and 5-0 or 6-0 nylon for the skin. Ointment or glued on tapes is the only dressing. They will have virtually no pain and very minimal swelling and bruising. This will be the sharpest neck angle that you have ever created! The w-plasty concept is to prevent a straight line scar contracture which is greater in women than men because men do a daily scar treatment….shaving. (microdermabrasion)
There are different variations of the direct necklift and the most common is the ‘candelabra’ pattern which adds horizontal excisions at the submental and thyroid cartilage areas. But given that your lady has already had a facelift, she may only need more central neck tissue excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 63 year-old female who just recently had a facelift. Because I am thin, I really had no fat just loose kin in the neck and jowls. Now that I have gotten the skin tightened up, how can I keep the facelift in place? I have read about a lot of things such as Thermage, Ultherapy, Exilis and others and, while they sound good in theory, I have read and been told that they don’t work for a lot of people. Some have said that the only really effective method of skin tightening is through collagen regeneration using a fully ablative CO2 laser. But laser resurfacing of the face can be associated with long-term pinkness of the skin. What do you recommend?
A: The reality is that nothing can keep a facelift ‘in place’ forever as surgery does not stop the effects of time and gravity. But there are certainly things to do to help slow down the process. Skin tightening and collagen rebuilding would be the correct approach after a facelift and, for many, should be considered maintenance therapies. There are numerous enery-based devices for skin tightening and you have named a few of the most well known. I do think they do have some benefit even if it is not the same for every patient as each person’s skin is different. In my practice, I currently offer Exilis and BBL (Skin Tyte) as methods of skin tightening maintenance after a facelift in which a series of treatments (usually 4) could be once a year. If appropriate based on how many skin wrinkles one has, light laser resurfacing is also a good choice and can be done with the other skin tightening treatments. Just don’t have any deep laser treatments but more regular lighter ones. That will avoid the prolonged redness and recovery. These treatments will not stop the aging process completely and more tissue sag is to be eventually expected but it will slow down the process and maintain the facelift result much longer. Also don’t forget basic preventative measures for skin aging which includes avoidance of excessive sun exposure, no smoking, a stable weight and a good daily skin treatment regimen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if it is possible to have two procedures done at the same time. I want my ears tucked and a mini face lift or a limited lift done. Thank you.
A: Both an ear pinning (otoplasty) and a facelift can be done at the same time under certain cirucmstances. The key to whether these can be performed together is what type of otoplasty and what type of facelift is being planned. In a traditional full facelift there is an incision along the back crease of the ear. This would be lower than the incision traditionally used for an otoplasty which is higher up on the back of the ear. Many plastic surgeons may justifiably feel uncomfortable having two paralleling incisions along the back of the ear due to intervening skin survival concerns. So an otoplasty may not be recommended at the same as a full facelift. In a limited or mini-facelift, the incision on the back of the ear is more limited or not used at all. So an otoplasty can always be performed at the same time as a mini-facelift.
When an otoplasty is done with a facelift there will be some greater and more persistent swelling of the ear but this is an eventual self-solving issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lower face lift done along with neck liposuction. The doctor did a skin only lift and pulled it to the side and incisions were made by ears and in back of hairline. He redid 4 months later because it was not correct. It is better but I think my cheeks need pulled up, more like a vertical lift. I feel like my cheeks are hanging down by bottom of face. I have already invested $8,000 into this and wondered if I could now just have some vertical pull in cheek area?
A: A facelift (aka neck-jowl lift) never changes or rejuvenates the cheek area on its own in most cases unless a more extensive procedure was done. A neck-jowl lift moves sagging tissues obliquely back towards the ear while sagging cheeks require a more vertical lift as you are aware. However, in looking at your pictures I can not see a great benefit for such a procedure in you. A cheek or midface lift is a very technique-sensitive procedure to do since it often involves incisions along the lower eyelid and there is always the risk of lower eyelid malposition/sagging afterwards. Therefore, one should have a compelling reason to do the procedure. Cheek lifts can also be done endoscopically with a combined incision in the mouth and in the temples in more mild cheek sagging cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a facelift and have consulted with three different plastic surgeons. From these consults, I got two different basic opinions. One option was a more traditional facelift with incisions in front of and behind the ear. The other approach presented was a mini facelift with an incision mainly on the front part of the ear. I am leaning towards the mini facelift but am just not sure which way to go.
A: The decision between a mini- or a full facelift can be a difficult one for some patients. Understandably, the concept of a mini facelift is more appealing in the hopes that ‘less is really the same’. But the reality is less is…less in most cases. Therefore do not get catch up in the benefits of smaller incisions and less recovery because the differences between these two types of facelifts are not as great as patients are lead to believe. Two or three weeks after surgery the incision and recovery issues will have no significance and all you will care about then is the result. The important question is what do you hope to be achieved. If jowling is your major aging concern then any of the smaller facelift versions will likely be satisfactory. If your neck is the biggest concern then a fuller version of a facelift will be more satisfactory.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a facelift with lipo done two years ago. While the result has overall been very good, I am unhappy with the appearance of my neck under the chin area. I’ve included a few photos so you can get a better idea of my situation. When I don’t lift my chin or move my head things look good, but moving my head or chin around creates a really unattractive situation that distracts from the very nicely done lower facelift. I am thinking these are muscle bands that need to be swen together to fix it. What do you think?
A: In looking at your pictures, I don’t think that the vertical bands you are seeing in your neck are platysmal muscle edges. Notice that there are numerous ones not just two isolated long parasagittal bands. I think what you have is a ‘skeletonization’ effect. This means the there is very little neck fat between the skin and the muscle which can lead to adhesions and scar contractures in the neck which are vertical in orientation and almost always occur primarily in the submental area. They are most evident when the chin is raised and the neck stretched upward. This is prone to occur in thin women when the neck is aggressively liposuctioned as part of the submental management of their facelift. There always needs to be some fat left on the skin otherwise adhesions will result. The question then becomes as to how to manage that issue as further muscle plication may not be the ultimate answer. In my experience, re-elevation of the involved skin (adhesion release) and possible muscle plication if needed is the best approach. In an ideal world, some fat would be put back or a dermal graft placed as an interface between the skin and the muscle but I would go with the simpler skin flap elevation/adhesion release initially.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 57 yrs. old woman with sagging jowls and a double chin. My jowls started sagging when I was just 38 yrs. old. I’m very self conscience of this. I need your help so I can wear my hair up again and look my age.
A: Everyone ages differently and some, by genetics, environmental or weight changes, age much sooner than others…or at least looks older sooner. (in theory we all age similarly at the molecular level) The combination of jowls and a double chin is a revealing description because it speaks to the amount of tissue sagging that is present. This means that only a full lower facelift will be effective and no more limited or minimally-invasive neck and jowl procedure will be effective. A full lower facelift means a neck and jowl procedure that removes fat from the neck, tightens the platysma muscle, redrapes excess skin and removes it from the jowls and neck. This is done through incisions around the ears that ultimately lie behind the tragus in the front of the ear and in the crease of the back of the ear. The true success of a lower facelift in your case is when you feel comfortable wearing your hair back in a ponytail or up again. Based on my experience, you had better prepare yourself by getting new ponytail ties and other items to hold your hair in a bun…as you are going to need them!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 55 year old women who is a little overweight. At 5’4” and 190 lbs, I wouldn’t call myself fat just above my ideal body weight. The reality is that this weight is very stable and have been relatively the same weight for almost 20 years. I exercise and eat reasonably and this is just the way it is. I am fine with that as I am otherwise healthy. My face has always been al little plump but otherwise firm until the past few years. I have noticed that there is some jowling that has appeared along the jawline but the real problem is my neck. It has gone to hell in the proverbial hand basket. It has gotten so droopy and saggy that I know it is time for some type of necklift. My question is am I too fat to get any benefit from such a procedure?
A: Your question is a good one and would be a lot more relevant when you were younger. But as you have gotten older, enough though it sounds like you have a rounder fuller face, the skin in the neck has begun sag. This sagging is the result of the skin stretching and loosening, no longer being able to support the weight of the fat it contains. While I would have to see pictures of your neck to be certain, many females with similar situations and face shapes actually get great benefit from neck reduction/tightening. Until proven otherwise, it may be that you may get a greater benefit from a necklift than someone who is thinner with less loose skin. It would make sense to delay your facelift if you were planning on losing weight but that clearly is not the case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am coming for a facelift and chin augmentation from out of the country and have a visa to travel to the U.S. But my wife does not so she can not accompany me there. How do you handle the arrangements for after surgery care in patients in my situation?
A: Almost every male patient that comes from afar to my practice comes alone. This is actually common and we are very familiar with handling such a situation. Postoperative care would be provided by either staying overnite in the facility or we arrange to have one of our nurses take you back and stay with you the first night after surgery in our hotel. Being from out of town and having a facelift (and being a male), staying overnite in the facility would be the more ideal postoperative scenario. Once the drains and hear dressing are removed the next morning, you will be in a better situation to be by yourself the next day after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 55 year-old woman who would like a facelift to remove jowls and improve droopy neck. I also would like my nose done as the tip seems to keep getting lower as I age. (is it really growing at my age?) The question I have is the timing of the nose surgery and the facelift. Should they be done separately or together? If separate, should the nose be done before or after the facelift? My thought would be after because it give my surgeon a better idea to do the nose based on the new way my face looks.
A: You are correct in your impression that the nose is getting longer and ‘growing’. It does not actually grow per se but the tip of the nose does fall as the ligaments weaken. As the tip falls downward the nasal length increases and the nasolabial angle decreases. This means that a very simple tip rhinoplasty to elevate the tip and open up the nasolabial angle can be quite rejuvenating to how the face looks.
There are arguments to be made on both sides of that discussion either combining or separating a facelift and rhinoplasty. In reality, it is not necessary to look at the ‘new’ face afterward to figure out how to change the nose via rhinoplasty surgery. Therefore, I have found it best to combine the procedures for the benefits of one single surgery and recovery and lower costs. In addition, a rhinoplasty is a central facial surgery while a facelift is a lateral or side facial surgery. One does not really impact the other when it comes to facial appearance changes or swelling and bruising. Put together, however, the combined facelift and rhinoplasty procedure can have quite a rejuvenating impact on the aging face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a facelift about six weeks ago. This was a very traumatic experience for me. While my jowls and neck got better, my nasal folds and turned down corners of the mouth did not. They initially looked good while I was still swollen but that has now all gone away. This is very disappointing since this was one of the main reasons I had the operation. I feel like a wasted my money as my jowls and neck were not that bad.
A: This is a common misconception and occurs either as a result of inadequate education during the consultation or a failure to understand what a facelift does best on your part. Because the tissue pull of a facelift occurs from around the ears, it has the least effect on anything far away. The mouth area is the furtherest point from the ears on the face, thus deep nasolabial folds or a downturned corner of the mouth will ultimately remain unchanged. It is just biomechanically impossible to substantially change the center of the face from back in the hairline. This is an issue that has frustrated facelift surgeons for years and many techniques have been tried, few with much success. This is why adjunctive techniques are often done with facelift that address the mouth area directly, like fat injections and a corner of the mouth lift. These can be at the time of a facelift or afterwards as may be desired in your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a healthy 65 year-old women with a large turkey-like hanging directly under my chin as well a bit of jowls. When I pull the skin back at the jaw angle/ear area, I see a great change and I look like myself again…like I did 20 years ago. What type of necklift is this? I do not feel like a need a facelift but just a necklift.
A: The turkeyneck is a common problem and there are many people who have this pessky aging issues but are happy with the rest of the face…or at least it does not look as bad as the neck and jowl area. This hanging neck skin must be treated by moving it up and backward to hidden incisions around your ears where it can be removed and invisible scars left in its wake. Your perception of a facelift is common with the belief that it is a top of the scalp down to the neck procedure, which it is not. A true isolated facelift only treats the lower 1/3 of the face, exactly where your concerns are. As a result, it is a much simpler and easier procedure to go through than most patients envision. Your proof that this is the correct procedure is evident by the presurgical facelift ‘test’, pulling up and back around the ears and jaw angles creates the desired neck and jowl changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 45 year-old female and I have concerns about my jaw line. I have attached some pictures and we would like to have your opinion on what would be some treatment options. I would like to have a return of firmness to my jawline.
A: In regards to early onset jowling/laxity, there are two basic options depending upon how one wants to approach the problem. From a non-surgical standpoint, there is a slew of energy-based devices out there that do create some degree of skin tightening/fat reduction for minor degrees of jowling. Devices such as Exilis, Ulthera and Thermage all drive energy into the dermis of the skin to heat it up creating some new collagen production and a tightening effect. Given Melinda’s good skin thickness and minor amount of jowl softening, you could argue that she is an ideal candidate for this non-surgical device approach. Its negatives are that it requires a series of treatments to get the desired effect, usually four separated by a week or two between them, and it is indeterminate how much improvement can be obtained. While I find these devices effective, it is best to view these treatments as a delaying manuever or bridging step to an eventual surgical treatment. For some patients, it may put off the ‘inevitable’ for years. Remember that you don’t cure aging, you just temporarily improve it. As a surgical approach, a very simple and easy jowl tuck-up can provide an immediate improvement that will surpass what any device can do. This one-hour tuck-up with less than a week social (appearance) recovery is a common facial rejuvenation procedure today as people seek earlier treatment for their jowls and neck issues than ever before. It is really just a miniature or microform version of a lower facelift.
In conclusion, either jowl tightening approach is perfectly valid and the choice depends on what result someone wants and what they want to do to get it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 52 year-old female and am interested in reshaping my chin. I have always been bothered a bit by the squareness of my chin which is a bit unfeminine.with aging But now that I have developed some jowling, it makes my face look more square. I want to get my chin reshaped to a more narrow appearance and then have a facelift afterwards. How would this be done and how far apart should the chin reshaping and facelift be? I have attached some pictures and have done a ‘homemade’ facelift by pulling up on my skin so you can see the squareness of the chin better.
A: Thank you for sending your photos. Your homemade facelift shows the exact location of the squareness of your chin. Now that I know the location of bony excess, that would be best reduced by an intraoral approach given that it is fairly anterior. It would be reshaped by a saw technique, taking off the wings of the chin. I have done an image showing its reduction result, more can be done but this is a good starting point for discussion. Given its very anterior location and away from the plane of dissection of a facelift, I see no reason why the two procedures could not be done at the same time. The distal tightening effect of the facelift would help any soft tissue slack/swelling that would occur from the chin ostectomy/reshaping.
Dr. Barry Eppley
Indianapolis, Indiana