Your Questions
Your Questions
Q: Dr. Eppley, I am writing because I am concerned about my mother having a facelift. She is 57 years old and I am her 24 year-old daughter. I know lots of people have facelifts but that is them and this is my mother. I am concerned about its safety and I don’t want anything to happen to her. Like me, my brother and sister don’t understand why she wants this surgery. She is a beautiful women who may be aging but still looks good to us. My father just shakes his head but is going along with it. What can I say to talk her out of it?
A: While I obviously don’t know your mother or you, I can share some general comments about ‘older’ people having plastic surgery. Children’s concerns about their parents undergoing some form of face or body rejuvenation is actually very common. Many parents have told me that their children don’t understand or approve of them having elective surgery over something they view as unnecessary. While there may be some understandable medical concerns, most of the apprehension comes from what I often say…’when you don’t have the problem, you don’t see the need’. When one is young and invincible, it is hard to imagine that one day aging and body changes will come knocking. When you develop that sagging neck and jowls or those love handles and stomach that won’t go away no matter what you do, you may have a different perspective on the merits of plastic surgery. I would respect your mother’s desire to look and feel good again for herself. A good self-image knows no age limits. Facelift surgery is very safe and most patients look remarkably recovered in just a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had Restylane and Juvederm injections infrequently over the past 6 years. Two different Dermatologists did them. However even though my results were exceptional at times, the most recent Juvederm treatment seemed lumpy and inappropriately placed. I am hoping a surgeon might have a better result with better knowledge of where the product should be applied. Also, I was wondering about whether very slight eye injections to soften laugh/smile lines would be available? I am 65 years old look 40. I had a mini-facelift 24 years ago and it was the best decision I ever made. Now, however, I would like to also consider a Lifestyle Lift if possible. Less of course is more in the long run, although I am noticing a slight sag under the chin now. Possibly Juvederm or Restylane can smooth that with out changing my facial features. My hope would be to have this all completed in one or two visits as soon as possible. I would like to be treated on first visit as I am very busy with work.
A: While injectable fillers can make some wonderful facial changes, they are not useful for every facial aging problem. They are of little value in the crow’s feet or periorbital line areas as these are very superficial wrinkles. Injections of crow’s feet have a high incidence of irregularities and lumpiness. This is usuallya better area for Botox and fractional laser resurfacing. But it would depend also on how deep the smile lines are. Also injectable fillers will not be able to smooth out loose skin under the chin. This would be better treated by some type of a face or necklift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am confused about the whole facelifting thing. I am 53 years old and am beginning to show it. My neck and jowls are getting droopy and they make me look like a bulldog. I saw one plastic surgeon who said I needed a complete facelift (which I didn’t agree with) and I would need two or three weeks for recovery. Then a second plastic surgeon told me I just needed a ‘tuckup’ (I forget the name that he actually called it but it was something that used the word fast or quick in it) and I would be fine in a week. Why is there such a difference between the two recommendations and what do you think I really need?
A: The concept of facelifts and their variations that have evolved in the past decade can be confusing. Combined with how they are marketed and advertised also lends an almost mystical quality to them. In reality, it is far simpler than what it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually wattles. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version. The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less invasive. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery. A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps around and/or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries.
Between the mini- and full facelift patients lies an almost third category and may well be where you lie. In this facial aging patient, a partial facelift is not enough and a full facelift maybe more than they need. (this may be why you had two ‘different’ opinions.) In this type patient, I use what I call the 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need your help as I have no jawline. My chin is very short, the neck seems to be missing and it appears as I almost have no lower jaw. This gives a profile that I am very self-conscious about. I make every effort so people don’t see me from the side. I know you are an expert in facial surgery based on your writings and patient photos so what do you recommend?
A: Lack of a well defined jawline and neck angle can be due to any one or combination of the following; chin/lower jaw bone prominence, fullness/fat in the neck and loose neck and jowl skin. Most commonly, the combination of a chin implant and neck liposuction can make a dramatic difference in the younger patient who often has a short chin and full neck. In older patients the sagging skin factors in significantly and some form of a jowl or necklift may be needed. There are exception to these two categories, such as the early aging facial patient with a good chin prominence who just needs some neck contouring through a procedure known as submentoplasty. But when someone describes themselves as having ‘no jaw’, this would indicate the problem is more than just one of the three anatomic components that make up the neck angle and jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, are there any good non-surgical treatments for sagging jowls. I am 56 years old and my neck isn’t too bad. But my jowls make me look like I have a bulldog face. I am not afraid of surgery but am worried about the cost and the recovery.
A: Jowling is always a major facial aging concern for many people as they hit 50 years old and beyond. There are some reasonably good treatments for jowls which are device or energy-based approaches. My current preferred approach is Exilis. This is a treatment based on radiofrequency waves which heat up the jowl fat and skin. This causes some fat atrophy and skin tightening. It requires a series of treatments, at least four spaced two weeks apart, to get the best result. While not as effective as surgery, it can make a very visible difference in the right patient who jowls have not developed beyond what a non-surgical approach can treat. The most effective approach, however, is a jowl lift. Your concerns about recovery are excessive when it comes to this tuckup procedure as it is a quick turnaround from the procedure until you are back into your regular routinue. While sugery is never appealing if it can be avoided, solving the problem in a single setting of an hour’s time can change one’s perception of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 19 years old and very thin. But still the skin on my face is very loose. When I pull my cheek and jaw skin towards my ears, my face looks chiseled. Otherwise it looks round and slight chubby. I want to know if a facelift is good for me? If not what I can do to improve my face?
A: It would be hard to imagine under any circumstance that a facelift would be warranted on someone your age. Pulling one’s facial skin back does make everyone’s face look more defined as the bony prominences, particularly the jawline and chin, become more pronounced. But that does not mean that a facelift (neck-jowl lift) is warranted. A facelift’s primary objective and indication is for skin laxity and sagging not to make the face appear more sculpted. (although it can create that secondary effect) You are likely in need of facial procedures that provide enhancement of your facial bone prominences, such as the chin, cheeks or jaw angles. Such facial implants can help create a more defined or chiseled face. But a facelift is definitely not what you need.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, are the various mini- or limited types of facelifts effective and how long will it last?
A: The numerous type of franchised forms of quick recovery facial tuck-ups are well known versions of limited facelifts or a jowl tuck-up procedures. There is nothing magical or unique about this operation or approach. It is a scaled down version of a more complete facelift or a neck-jowl lift. It can be very effective if done well and will get years of sustained improvement which will vary by a patient’s skin type and genetics. It could be anywhere from 5 to 10 years depending upon where one starts and how well one ages. The more relevant question, however, is whether this type of facelift approach is right for you. The vast majority of unhappiness with these franchised named ‘mini-facelift’ is that the patient wasn’t a good candidate. Their facial aging issues were more advanced and they should have had a fuller facelift to get the kind of result that they were expecting. Patients understandably are tempted to choose a facelift operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facelift operation that better fits their actual needs. This is the real issue you should be thinking about.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 74 years old and am really beginning to show my age. I really hate the loose skin on my face and my neck wattle. I have read about a facelift procedure that sounds almost too good to be true.. I like that it is done under local anesthesia and there is little recovery. Do you think that it would be a good choice for me? I have attached some pictures of what I looked like last year at our family Christmas party.
A: These marketed and franchised forms of facial rejuvenation are simply scaled down versions of a facelift. This is typically a “mini” lift of the jowls (primarily) and the neck (secondarily and more limited) that is sometimes performed in the office with no general anesthesia. Understandably this makes it very appealing to some people. But just because it is appealing does not mean it is a good choice for everyone. Whether it can meet your expectations and is worth the cost is a key question for every patient who undergoes limited types of plastic surgery. This is particularly true when trying to improve the degree of facial aging that exists in someone 74 years of age.
You do have a significant amount of loose skin and the very presence of a neck wattle illustrates your degree of facial aging. On the one hand, these mini-facelifts will not produce an ideal result. So if your goal is a smooth and completely uplifted neck and jowl line, you will be disappointed. If, however, you can accept that some improvement is better than none then it may be a reasonable choice.
Rather than getting hung up on a marketed facial procedure, you would be likely better served to consult with a number of plastic surgeons and get a customized approach to your facelift needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting my cheeks lifted. I am 48 years old and my cheeks sag which makes me look sad. My face is plenty full as it is very round. What is the best non-invasive method to lift them up?
A: The first thing that I would tell you is that there is not a non-surgical way to lift up the cheeks. There is almost nothing that I know that can lift any part of the body without some form of surgery. Some doctors may tout that they can lift up parts of your face with injectable fillers and in some small amounts that may be possible for some patients in some facial areas. However, with an already full and round face this injectable approach is likely to make you even rounder…and have no real lifting effect anyway. There are cheek lifting operations but really good results from these procedures come from very careful patient selection. Whether you would be a good candidate or not would depend on seeing some pictures of you. As a general rule, very round and full faces are chcallenges for any lifting operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 48 year old female and have begun to notice some fat under my chin, some jowling and some neck wrinkles. I have had gotten two plastic surgery consultations with differing opinions. One said I needed liposuction of my neck with a submentoplasty and fat injections to the jowls. The other said I needed neck liposuction with a jowl tuck-up. These choices seem so different that I am confused. Both plastic surgeons are board-certified and respected in the community.I don’t know which one is right. Any advice would be appreciated.
A: In reality, both are right and these are just two different options for the same facial aging problem. It is clear that you are what I call a ‘tweener’. Your aging issues are not quite enough for a more extensive facelift (neck-jowl lift) but are more than what liposuction alone can ideally improve. In other words, you have a mild amount of excess skin along the jawline and in the upper neck. As these two options are different in technique, they will also produce different results. I think the right answer for you is defined by how much you want to go through for what result. While neither operation is a big procedure, the liposuction/fat injection approach is less invasive but will not tighten the jowl line as much as a limited facelift with liposuction. (jowl lift) It would help to define what bothers you the most, jowling or neck fat. If it is neck fat go with liposuction. If it is jowling, go with the lift.
Dr. Barry Eppley
Indianapolis, Indiana
Without explanation, everyone seems to know what a neck wattle is. While not seen as an endearing neck ornament as one gets older, this sagging piece of skin and fat is often a source of considerable anguish of one’s appearance.
The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.
The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost thousands of dollars per jar. The other scam is that of neck exercises. If a neck wattle was really due to loose muscles, this approach might have some benefit. But it is loose skin and fat for which the ‘neck gym’ remains no better than those creams in a jar.
Getting rid of that neck wattle requires a necklift, also known as a facelift. There are different varieties of these lower facial lifting procedures depending upon how the size of the wattle. Smaller or more limited versions are popularly known as Lifestyle Lifts. They are great for jowling but not for the bigger neck wattle. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears and the time of recovery.
To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck. When needed, the extra recovery is worth the investment.
The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that will last for decades. The tradeoff for this simple wattle eliminator men is a fine line scar down the center of the neck. For men who have beard skin, this scar heals beautifully and may be the procedure of choice in the older male. For women, this potential scar must be considered very carefully.
Q: Dr. Eppley, I am 54 years old and am interested in getting a facelift, rhinoplasty, and blepharoplasty surgery. I’m trying to achieve a more youthful look, less sagging, and not so tired looking appearance. I have attached some pictures of me so you can show me by imaging what the results may be like.
A: Thank you for sending your pictures. Here is some imaging for the following procedures; a facelift (neck-jowl lift) and a rhinoplasty.You could get a really significant improvement in your neck wattle as it is a large amount of loose hanging skin. That would dramatically change your neck-jawline profile. It is interesting as to why you have such a large amount of hanging neck skin even though it appears you are relatively thin. Perhaps you have lost a lot of weight ?? Regardless a full facelift will remove inches of skin from the neck and tighten up the entire jawline.
From a nose standpoint, you tip is wide and thick and turns down slightly. There is also a small bump higher up on the nose. A full rhinoplasty would take down the bump, shorten and narrow the tip with some lifting and narrow the size of the nostrils. This type of nose change at your age changes the structure of the nose and makes it look smoother and more refined, a look that has a more youthful quality.
The combination of these two procedures, as the imaging illiustrates, would make significant rejuvenative changes to your overall facial appearance
As an addendum, I did not do nor is it possible to do realistic blepharoplasty computer changes. It is clear from the pictures that you have some extra eyelid skin that can be removed as well as some herniated fat from the lower eyelid. Your lower eyelid shows no significant skin excess, however, other than a few millimeters. Together, this type of upper and lower blepahroplasties will make you look less tired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 59 years old with a younger looking face and body but an old, wrinkly neck. My neck does not match the rest of my face or body and makes me look old. From what I’ve read, a direct necklift may work to improve the appearance of my neck but would be of interest to me since it may cost less but I’d like to know what you think. I have attached some pictures which shows my wrinkly saggy neck.
A: Thank you for your inquiry and sending your photos. You have a most unusual amount of neck aging compared to that of your face. And the direction of your neck sagging is mainly horizontal and not vertical. Many men develop so called turkeynecks which are largely a vertical skin sagging problem. This is the typical direction that direct neck lifts treat which is a vertical neck skin removal with some minor horizontal skin removal at both ends of the vertical excision.
Your neck, however, shows a substantial amount of horizontal skin laxity as seen by your many horizontal neck wrinkles. This indicates that a direct necklift for you must have a different excisional pattern. Using your horizontal neck wrinkles, two to three inches of neck skin can be removed across the width of the neck keeping the final scar in a horizontal neck wrinkle line. The only question is whether a vertical component to the skin excision needs to be done as well. I can not tell that from your photos since your face is tilted upwards in the photos you sent which may artificially make any neck wattle look better than it really is.
There is also the option of a more traditional facelift approach which will also work very effectively as well, albeit with more recovery and expense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had in orthognatic surgery several years ago for a bad bite that gave me a lot of problems with my teeth and pain in my jaws every morning. While the surgery went fine from a technical standpoint (my bite is better) it left me with a very bad look. I think it is because he made some mistakes with repositioning the masseter muscle as my face shrunk on the sides and left me with a lot of loose skin. This makes me look 10 years older then my age. I’m now 50 and I look older. I am used to always looking much more younger than I am. I’m very unhappy and I don’t think normal lifts of skin will help because what is missing is underneath, it needs to be filled in. I need deep tissue filling not just stretching the skin. Here are some photos for you to see what I mean.
A: What I see on the photos is lack of jaw angles and loose jowl and neck skin. The jaw angles actually appear both high and indented or concave. I think the jaw angle issue is a result from your orthognathic surgery but it was not a mistake by the surgeon. Mandibular osteotomies involves elevating the masseter muscles off of the bone to perform them. There is no such thing as having to reposition them during the surgery as they simply fall back into place. But what can happen is muscle atrophy/shrinking from the trauma of the surgery and I believe this is what you have experienced. Because of the lack of a jaw angle, you would benefit by small lateral augmentation style of jaw angle implants. This could be combined with a limited neck-jowl lift (facelift) to create a more youthful jawline and nek appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can a lower jaw setback be combined with a lower gfacelift during the same procedure? Have you yourself done this before?
A: The technical capability of performing a combined orthognathic procedure, like a mandibular setback, with a facelift is certainly possible. The need for it is so rare, however, that it would be hard to a surgeon that had ever done it together. There are several reasons for its rarity. By definition, a facelift would be done in an older patient while orthognathic surgery is usually done in a younger patient. Thus, the mainstream population of each procedure are at diametric ages. There is also the consideration that the type of surgeon that performs these procedures are quite different. Most maxillofacial surgeons have little or no training for facelift surgery and most plastic surgeons have little or no training in orthognathic surgery. While plastic and maxillofacial surgeons certainly can work together and coordinate these surgeries, most plastic surgeons would probably prefer to defer the facelift to a later date due to swelling considerations.
With all of that being said, a mandibular setback and a facelift can be done together. The question is not whether they can be done together but whether they should. While each operation poses a ‘surgical opportunity’ to do additional procedures, you want to make sure that the patient can still get a result that would be comparable if either procedure was done alone. Surgical opportunity should not be more important than an outcome. In that regard, I would have to know more about how much mandibular setback is needed and the proposed technique (sagittal split ramus osteotomy vs vertical oblique osteotomies) and the degree of neck and jowl sagging that exists. Then I could answer the question better about whether such a combination is a good idea.
Dr. Barry Eppley
Indianapolis, Indiana
Catching a glance in the mirror or looking at a picture and seeing those sagging jowls and a droopy neck can be a troubling finding. It often seems like it came out of nowhere. I have yet to see a person find this discovery charming. While hope lies in that some magic cream or laser treatment will make it all go away, deep down inside we all know it isn’t true. (but we can dream can’t we?)
When it comes to that loose jowl and neck skin, everyone wants to avoid the dreaded word…facelift. While most people are unaware that a facelift is really just a necklift, everyone would agree that they would like as little surgery as possible. While the fears and recovery surrounding a necklift are largely overstated, one really hopes that they can get by with a ‘minimal’ procedure. This understandable apprehension has led to the nationwide branded selling of facelift surgery.
The best example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. I have seen many patients who know the name, but don’t really know what it is. Promising to turn the clock back at least ten years and look recovered in just a few days, its catchy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, and perhaps not an oversight, nowhere in their advertising does it even suggest that it is real surgery. Many prospective patients only become aware that it is surgery when they actually visit a company facility.
What is a Lifestyle Lift? While sounding new, it is really quite old and has been practiced by plastic surgeons for decades. It is a scaled-down version of a facelift, a ‘mini-facelift’ if you will. Sometimes called a tuck-up facelift, a secondary facelift, or a jowl lift, it is a limited operation that best improves those sagging jowls with a little tightening of the neck. The operative word here is a ‘little tightening of the neck’. If you have a neck wattle or turkey neck, this is not the right procedure for you.
Because it has an appealing name, the Lifestyle Lift has created a number of name knock-offs, including the Swiftlift and even the Lunchtime Lift to name just a few. Most of these are surgeons who have jumped on the naming and marketing bandwagon and have given their version of a limited facelift its own name. There is no real difference in the procedure or in whom it is or is not most beneficial.
Because it is heavily marketed and the internet exists, the Lifestyle Lift has its share of critics. Much of this has to do with trying to make an individualized custom operation into a factory line retail product. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a full facelift.
Facelifting is not an operation that should performed the same on everyone. Nor does having a catchy name mean it leads to better results or a quicker recovery. Many plastic surgeons offer similar limited types of facelifts that just don’t have a branded name, but that doesn’t make them any less effective or useful.
Dr. Barry Eppley
Indianapolis
Q: I had a SMAS facelift earlier this year in February. I also had my eyelids done as well. I have several problems from this surgery. My eye opening is smaller than before and one of my lower eyelids is hanging down. In addition, you can not tell that I have had a facelift. It doesn’t look different or improved at all. The Dr. said he will not redo it. Will I have to get a complete facelift again? Do you do redos?
A: Anytime there is an outcome that does not meet a patient’s expectations, it is important to determine why. There are only two fundamental reasons; there has been a complication that mars an otherwise acceptable result or there has been a fundamental miscommunication between the doctor and the patient as to what to expect afterwards. Having one lower eyelid than hangs down or is pulled away from the eyeball after surgery is known as ectropion. That is a postoperative complication that can occur after a lower blepharoplasty. If it is a small amount of ectropion and it is not that far out from surgery, then time and patience are acceptable for now. But since it is four months after surgery and there is still some noticeable lower eyelid malposition compared to the other side, revisional lower eyelid surgery may be needed. Why you see no result from your facelift is another matter. That would be an unusual outcome given the nature of how a facelift is performed. I think you need to go back and discuss your results with your original plastic surgeon. Most likely what he said was that he would not revise or redo your surgery at just 4 months after surgery. A different answer may be forthcoming with more time and if your lower eyelid ectropion persists. Only after you have given the original surgeon ample opportunity to come to a mutually acceptable decision should you pursue an outside opinion for revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 45 years old and have been frustrated with the appearance of my jowl area. I am interested in improving that part of my face. I want to learn more. What is the recovery/healing time? Can anything go wrong during procedure? Thanks
A: Sagging of the jowl area is a natural part of aging and is often the first area of the face to fall. Provided that the neck is not also sagging, and it often isn’t early on, a modified or limited type of facelifting procedure is used. Known by a variety of branded and marketed names, which imply rapid recoveries and minimal interruption in your lifestyle, it is a jowlift or a mini-facelift. Because it is a scaled down version of a facelift, it is a much shorter procedure to undergo and the recovery is likewise much quicker…like in the one week range. Recovery in this limited type of facelift is largely social in how one appears. (bruising, swelling) Other than the typical surgical risks of bleeding, infection and adverse scarring, there is nothing else that can go wrong of any significance. None of these risks have I ever seen in this jowl lift procedure.
The good thing about this jowl lift operation is that it is a solution that is well matched to the size of the problem. Jowling is a relatively minor facial aging issue and therefore it does not need a major operation for its improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested, I think, in some fillers, Botox and perhaps a partial facelift. What I would like to achieve is a firmer jawline, reduce my crow;t feet and just have a refreshed look. I am attaching some pictures for you to review and give me your recommendations. Thanks!
A: Thank you for sending your pictures. I have done some imaging looking at firming up your jawline. You hve the typical jowling the comnes with aging and this also creates a prejowl indentation as the jowl sags. That is best corrected by a lower facelift (neck-jowl lift) and adding in a small chin-prejowl implant to bring the chin out slightly (yours is a little short) and filling in the prejowl deficiency. The combination of these two makes for a smooth jawline. At the same time, I would place some fat injections in the nasolabial folds (lip-cheek grooves, parentheses) as this is the best ‘filler’ to use when you have are doing a facelift as it is the only filler that potentially can be more permanent. Botox for the crow’s feet can be done either during a facelift or anytime in the office. Just for the sake of one additional suggestion, I have also imaged a rhinoplasty by doing some nose narrowing and lifting the tip a little as this can also have a rejuvenating effect as one gets older.
These computer images will help you think more about what can be done for a refreshed look.
Dr. Barry Eppley
Indianapolis Indiana
Q: I want to thin out my face and am thinking of having a facelift to initially tighten my skin and then my cheekbones (zygomas) cut and narrowed. The reason I am considering zygomatic reduction and face lift is to first “trim” excess skin for maximum tightening of the jowls, nasolabial region, cheeks and neck. Then narrow my face with zygomatic reduction, perhaps including the arch and the zygomatic body itself. I was hoping to improve skin definition below zygomatic arch and angularity of the jaw first, than schedule second surgery afterwards. Do you think it is a good plan for my case? Thank you kindly.
A: While I don’t have the advantage of looking at your facial pictures, I think your plan is fundamentally fine but it is planned in reverse. You want to do any skeletal or underlying foundational surgery first. The reason being is that such surgery causes a fair amount of external swelling which will stretch any tightened skin, potentially reversing some of the effects of any skin tightening procedure. Maximum tightening of the jowls cheeks and neck (facelift) should, therefore, be done after the bone foundation has been treated.
When considering zygomatic reduction, it is important to know if it will produce much of effect. This can be assessed by locally at plain film x-rays, particularly a submental and/or a water’s view. These simple films give a visual assessment of how significant the curve is on the zygomatic arches. That will have to be ordered through a hospital or any free-standing x-ray facility where the appropriate equipment exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I am looking the best procedure for diminishing marionette lines, over lips, and most importantly, droopy skin on the neck. What do you recommend?
A: In reading your question, I am going to assume that you mean marionette lines that start at the corner of the mouth and hangs over the corners. (hence the phrase ‘over lips’) When you combine those aging facial features with droopy neck skin, you are talking about a combined neck-jowl problem. Heavy marionette lines that hang over the mouth corners indicates that there is likely some jowling and skin that is falling forward and down…the reason thaty most marionette lines exist. While I obviously have not seen any pictures of you nor have examined you, all of these aging facial issues point to one and only one effective treatment option…some version of a neck-jowl lift. The key issue is the droopy neck skin. Nothing short of this type of a tuck or lift can change a loose neck skin issue. This is often combined with a corner of the mouth lift to get rid of the overhang, a small little procedure done at the corner of the mouth. This will most effectively get rid of the loose neck skin, ‘over lips’ and decrease the depth of the marionette lines.
It would be helpful to see some facial photographs or come in for an evaluation to confirm this potential recommendation. These are common facial aging problems where patients are often searching for some ‘simple’ or non-surgical approach where such treatments do not really exist. You want to avoid wasting money on any non-surgical treatments that really have no hope of making a substantive difference…and there are lots out there that sound good but don’t work very well.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 52 years old and have myasthenia gravis. I had a thymectomy 23 years ago and currently have very minimal symptoms. I am interested in reducing the appearance of aging, especially in the neck and jowls. Is the IGuide or another minimally invasive procedure recommended for patients who have myasthenis gravis? If not, what are my options to improve my appearance?
A: Having the condition of myasthenis gravis (MG) poses potential issues for anesthesia for surgery but not for the surgery itself. You are likely interested in minimally invasive facial surgery because of its often association with local anesthesia and potential avoidance of general anesthesia. What you want to avoid with any form of anesthesia is a myasthenic crisis. This occurs when the muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring a respirator for assisted ventilation. This is most likely to occur in those MG individuals whose respiratory muscles are weak. This does not appear to an issue for you whose has minimal symptoms. Nonetheless, it is best to avoid any form of general anesthesia particularly for elective cosmetic surgery.
The IGuide neck procedure, a more limited type of necklift (e.g., Lifestyle Lift) or both done together are procedures which are effective in individuals with early to moderate neck aging issues. Whether any of these are good procedures for your neck and jowl concerns can only be determined by doing an assessment of some photographs. They can be very successfully performed under local anesthesia supplemented by either oral or light intravenous sedation.
Dr. Barry Eppley
Indianapolis, Indiana
The development of a droopy neck and saggy jowls is loved by few…and is the bane of many women and some older men. Much can be found that promises to improve it from creams, exercises, laser and light therapies, and even the occasional clothespin approach. But we all know deep down inside that such hope only benefits the manufacturers and sellers of these products…and the only lifting that gets done is usually from your wallet.
While surgery is the only effective option for that loose neck and jowl skin, everyone would like to have as little surgery as possible and avoid hearing that dreaded word…facelift. While the fears surrounding a facelift are largely unfounded, people would certainly like to avoid that consideration if possible. This facelift phobia has led to the emergence of the concept of the branded selling of facelift surgery.
The most well-known current example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. Promising to turn the clock back at least ten years and look recovered in just a few days, its snazzy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, nowhere in their advertising does the company suggest it is actual surgery. Somehow the concepts of surgery and lifestyle are incongruous. I have seen numerous patients who have visited their facilities and were surprised to learn that it was actually an operation that requires some recovery and a temporary change in their lifestyle.
In reality, the Lifestyle Lift is an operation that is decades old and is practiced by most plastic surgeons. This ‘mini-facelift’ operation has now cloned many spinoffs including the Swiftlift and Weekend Lift to name just a few. Often touted as being innovative and original by the advertising surgeon, the names suggest that getting a fresh, younger look is really easy…or at least is quick for the surgeon to do.
Like many things that are heavily marketed, the Lifestyle Lift has its share of proponents and critics. An internet search will quickly bare that out. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a fuller or more complete type of facelift.
Facelifting is not, nor should be, an operation that is performed the same on everyone. ‘Mini-facelifts’ are best reserved for patients with earlier signs of aging, not advanced problems such as turkey necks. A catchy name does not necessarily make the procedure novel or unique. Many plastic surgeons offer similar type facelift procedures that just don’t have a branded name, but that doesn’t make them any less effective or useful.
Dr. Barry Eppley
Indianapolis, Indiana
Turkey and Thanksgiving go together like no other holiday and food combination. While there is no evidence that it was ever actually served at the first pilgrim’s festival, it became a mainstay shortly thereafter. While many will anxiously await for their share of the turkey this holiday, whether it is a leg, breast or stuffing, no one aspires for the turkey neck.
This fleshy fold of hanging skin, known as the neck wattle in the bird, appears in people as well. While in turkeys it occurs mainly in the male, in humans the turkey neck is not gender specific. As we age, the appearance of one’s neck often becomes a bothersome issue. The loss of a once smooth jaw line and a shapely neck shows the effects of gravity and time. Catching one’s profile in a picture can sometimes be disturbing…who is that older person with such a floppy neck?
While creams and other potions do much to alleviate’s one’s pocketbook, the turkeyneck is otherwise a surgical problem. Forget about non-invasive options or ‘lunchtime’ type procedures. These simply will not work for the dangling neck no matter how they are marketed or hopeful one is. For the full neck with good skin, and if one is young enough, good results can be had with liposuction alone. But when the skin is loose and floppy, fat removal alone with only make the neck skin more loose and floppy.
If you can grab a wad of neck skin and fat between your fingers, then some form of a facelift procedure is what is needed. Using the term facelift can be confusing as this procedure often conjures up images of extensive surgery from the forehead down to the neck. In reality, a facelift is really a neck and jowl operation and does not affect the face above the jaw line. It is a poorly named procedure and the term necklift would more accurately describe it than calling it a facelift. It is really less extensive and easier to go through than most people actually think.
When it comes to facelifts (aka necklifts), there are numerous options.Which one is best for any particular person is determined by how much loose neck skin one has. Some jowling and a little loose neck skin may only need a limited facelift. (often called the Lifestyle Lift) If there is a lot of loose neck skin, then the more complete facelift is really needed. This is a powerful neck changer and can produce some really dramatic results. For those that want the least invasive amount of surgery but with a dramatic change, the turkeyneck can be directly cut out in a procedure appropriately called the direct necklift.
The turkeyneck is not a desired culinary item on the bird and many people don’t like it on themselves either. While year round turtlenecks are always an option, a little skillful carving may be a better solution.
Dr. Barry Eppley
Indianapolis, Indiana
The association of turkey and theThanksgiving holiday goes back for over three hundred years. While there is no real evidence that it was ever served at the first pilgrim’s festival, it became a mainstay shortly thereafter. While many people will anxiously await for their share of the turkey this holiday, albeit a leg, breast or otherwise, nobody aspires to have a turkey neck.
This well recognized fleshy fold of hanging skin, known as a wattle in the bird, appears in people as well. While in turkeys it occurs mainly in the male, in humans the turkey neck is not gender specific. For some, the neck is often one of the biggest areas of concern as one ages. The loss of the once smooth jaw line and a more well-defined neck angle are telltale signs of the effects of gravity and time. The turkey neck is just an advanced stage of neck aging as it eventually flops from side to side in the older patient.
While year round turtlenecks are an option, it is otherwise a surgical problem. Forget about non-invasive options or ‘lunchtime’ type procedures. These simply will not work for the turkey neck no matter how they are marketed. If the neck and jowls are made up mainly of fat with good skin, as usually occurs in the younger patient, then good results can be had with liposuction alone. But when the skin is loose and floppy, fat removal alone with only make the neck skin more loose and floppy
If you can grab a wad of neck skin between your fingers, then some form of a facelift procedure is what is needed. Using the term facelift can be confusing as this procedure often conjures up images of extensive facial surgery throughout the whole face. In reality, a facelift only effects the neck and jowl area and will do nothing for the face above the jaw line. It is a poorly named procedure and a facelift should be called a neck-jowl lift. It is really less extensive and easier to go through than most people actually think.
In actuality, there are only two types of facelifts… limited and full. Which one is best for any particular6 person is determined by the amount of loose neck skin that one has. If the loose neck skin is not extensive, a limited facelift may be enough as this lifts the loose jowl skin a lot and the loose neck skin a little. If there is a lot of loose neck skin, then a full facelift is really needed. This is the most powerful neck procedure and can produce some really dramatic results. The differences between the two are how much of an incision is needed around the ear and the number of days of recovery needed. (even though the recovery is really about how you look or a social issue, there is next to pain at all for either)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I have a question regarding my face since it has gotten thinner after a facelift. I had a facelift last summer after losing 45 pounds. My plastic surgeon said he took four inches of skin out of my neck. However I did lose my round face because my cheeks are more sculpted now due to loss of volume. While I like the change it is a weird look for me because I have always had a round face since I was just a kid. I never had sculpted cheeks even at a normal weight. I used to get carded well in my 30’s because of my baby face. So there is some merit to having volume. It is weird for me to see my cheekbones as opposed to my puffy cheeks. I almost feel like I look older without my round face. So my question to you is it possible to add some volume in my lower cheeks BELOW the cheek bone to get my “baby face” back. What would you suggest? I can send pix if you want me to. Thanks for your advice.
A: There is no doubt that between having a facelift and undergoing considerable weight loss, one can end up with less facial volume. This is usually most manifest around the cheek areas when it occurs, specifically in the area below the cheeks known as the submalar area. I prefer to call this area the submalar triangle as it is a soft tissue area that has the configuration of an inverted triangle and has no underlying bony support. That is why it suffers the greatest indentation or hollowing on the face with fat loss…it has no underlying bony support so it sinks in.
There are several ways to build out the submalar triangle. The simplest is to replace what is lost through fat injections. Fat is both natural and easy to harvest through liposuction and its injection is not ‘invasive surgery’. Its downside is that its survival is not always predictable. The other is to use a specific submalar implant which sits on the underside of the cheek bone. This will build out the upper part of the submalar triangle but not the lower area near the corner of the mouth. The total submalar area can also be built out by the insertion of onlay dermal grafts. Using part of your old facelift incision, allogeneic dermal grafts (human dermis out of a box) can be cut and laid underneath the skin to add a soft natural volumetric fill. The dermal grafts will integrate and become part of your natural tissues.
As you can see there are a variety of submalar augmentation options. Which one is right for you depends on which approach offers the simplest, most natural, and predictable outcome.
Dr. Barry Eppley
Indianapolis Indiana
For those who don’t know, the “wattle” is that fleshy fold of skin hanging down from the neck or throat. While not seen as an endearing piece of anatomy as one gets older, it is quite common in birds be it the pelican, common rooster or a Thanksgiving turkey. While it may be cute in a bird and makes it identifiable as a species, I have found no human yet that finds it flattering. Common amongst men and women alike as they get older, this sagging piece of skin and fat is often what bothers them the most about their aging face.
The wonderful world of digital cameras and cell phones have helped some people discover their neck wattles by seeing themselves in side view in a picture. Men make the discovery when wearing certain shirts and often feel it ‘flopping’ around when they move their heads. (swinging a golf club seems to bring on this sensation)
The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.
The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the manufacturer and seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost hundred to thousands of dollars per jar. (wrinkles are one thing, wattles are quite different) The other hopeful but unsuccessful effort is that of neck exercises. If the loose neck was primarily due to muscle looseness, this approach might have some benefit. But for the skin and fat that has become loose and is sliding off the face into your neck, the ‘neck gym’ remains more theoretical than useful. Neck exercising will have about the same benefit as it would for lifting the sagging breast or those eyebrows that just keep getting lower.
While many people would consider having a necklift, they wouldn’t dare undergo a facelift.This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same. I have found only a handful of patients who have ever actually known what a facelift really was. A facelift is really a necklift. But facelifting comes in two varieties which differ based on how much improvement in the neck is needed. A limited facelift (popularly known as a Lifestyle Lift or jowl lift) is great for jowling but not so much for the neck wattle. For small neck wattles, a Liftstyle Lift combined with liposuction in the neck may just do the trick. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck.
The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that hasn’t been seen for decades. The price for this most effective and simplest of wattle solutions is a fine line scar down the center of the neck. For the beard skin of men, this scar heals beautifully and may be the procedure of choice in the older male. For women, the location of this scar must be thought about carefully to determine if this is a good trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, Can you tell me how to get rid of my pesky double chin? It bothers me tremendously. I am only 43 years old and my neck looks twenty years older! I am too young to look like this. I am at a good weight and haven’t been able to shake these two chins off no matter what I do. What do you recommend?
A: The ‘double chin’ appearance comes from two upside down hump areas. The first is the chin, which everyone has, but in the double chin patient it is often short or set back. This can make it appear that it is part of the neck when it should be a more distinct forward prominence of the jaw. The second hump or sag is the soft tissue of the neck. This may be just a lot of fat but is usually mixed in with some loose skin as well. This is particularly so in older patients who may have overall neck skin laxity. Given your relatively young age, I would envision that the anatomic composition of your double chin is a bony chin shortness and a collection of fat with some mild amount of loose skin in the neck.
Therefore, correction of your jaw and neck contour could be done by a combined chin augmentation and neck liposuction. It may also be beneficial to do a little neck muscle (platysma) tightening at the same time to get the best neck angle. I doubt if you need any removal of skin at your age and we would rely on the natural skin tightening that occurs after liposuction in good quality skin.
Dr. Barry Eppley
Indianapolis, Indiana
This advertising phrase has been used countless times in the world of cosmetic surgery. I usually just gloss over it and write it off as exuberant advertising. After all, very few things in life of any value can really be obtained in just five minutes…even a good cup of coffee takes almost that long to get. But seeing this phrase as the main topic on the cover of a major magazine of good reputation made writing about it irresistible.
The concept of the ‘5 Minute Facelift’, beyond the slathering on of alleged beauty crèmes that ‘really work’, relates to the contemporary use of injectable fillers. Not to be confused with Botox (which paralyzes small areas of facial muscles) which is also injected, fillers add volume to the face underneath the skin. Most commonly used for the lips and the facial parentheses (a.k.a. lip-cheek grooves), it has become more widely used for many other areas of the face. Since one’s face is known to lose fat as we age, plumping up the face with fillers can have some rejuvenative effect. Inflating the face pushes out the skin and accounts for the claims of ‘making wrinkles disappear instantly’.
The allure of the 5 Minute Facelift, however, must be looked at more closely to see if it is real. The five minute part for any injectable treatment is not exactly accurate. Since placing the material requires multiple needle sticks, most people would prefer to take a little longer…if they could be numbed up for it. Getting good local anesthesia before having your face injected is appealing to just about everyone. As I always say…nobody ever says they are too numb. (or conversely, can I have just a little more pain?) While the actual injections may only take five or ten minutes to do, the preparation for it is much longer.
Time is not important, however, if the procedure does what it promises. I’ll bet most people would be willing to spend several hours if it would take away five or ten years in such a short period of time. Does plumping up the skin really achieve a facelift? Not by what most people would consider a facelift to be. While inflating a hot air balloon will lift it, such a phenomenon does not really occur in the aging face. While some areas of the facial skin can be made smoother and little volume added to the cheeks and lips, those falling eyebrows, heavy eyelids, or jowls and sagging neck will not be improved. A few wrinkles may be better but calling that a facelift is more than just a bit grandiose.
But for the sake of argument, let’s assume that the 5 Minute Facelift was really possible. Would it be a good idea? If you were going to an event or wanted any improved look for a few months, then it is clearly better than any surgical alternative. When viewed from the perspective of value, however, it is not a good investment. The volume of injectable fillers needed and their cost could easily be several thousand dollars. For a treatment that lasts six months or less (there are no permanent injectable fillers) that money would be better saved and eventually invested in a surgical facelift which is proven to last many years.
The 5 Minute Facelift, also called the Liquid Facelift, sounds too good to be true because it is. It undoubtably appears on magazine covers because it makes you instantly grab it off the rack and turn to the article. Injectable fillers have been a revolutionary facial treatment for adding small areas of temporary plumping. But to say they can lift a sagging face is like that hot air balloon…over plumped and soon to be lost in the horizon of hope.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I am 3 weeks post SMAS facelift and necklift. I had a friend who had her facelift months before me. She was very thin and her face looked too tight to me (really pulled along the jaw line). I have a round face despite losing 50 pounds with very sagging neck and jowls. I read where you wrote that a facelift will not get rid of a round face. I know know you were right. My dilemma is that it almost appears that I had nothing done. My round face is still….round.
My plastic surgeon says my neck looks like an 18 year olds neck. I am extremely pleased with that and it is tight as a drum. I feel like my face is tight and a little lifted only on the sides near the ears. I still have loose skin around my mouth. Is this normal? Does the SMAS facelift not address the nasolabial folds? I am very disappointed after spending 11k. What should I do now? Should I address this with my plastic surgeon? He proclaims a “natural” facelift is one that is not too tight or pulled. It may be too natural for me.
A: My first comment is that it is only three weeks from your facelift. When you are living it that seems like an eternity. However, when it comes to facial swelling you still have a ways to go. I would not pass final judgment until three months after your surgery.
That being said, you appear to have a mismatch between expectations and the anatomy of a facelift. You actually have exactly what a facelift can achieve…a nice tight neck and jawline. That is all that an isolated facelift can achieve, no more and no less. It does very little to nothing around the mouth area (nasolabial folds and mouth corners) as they are too far away from the point of pull. (which is around the ears) This is a frequent point of expectation and subsequent disappointment if patients are not properly educated from the beginning. In reality, a facelift is a neck procedure and does little for what most patients believe in their ‘face’.
This also explains why a round face can never be changed from a facelift. The source of the round face is not what is treated by a facelift. The round face is largely a function of the size and thickness of the facial bones, muscles and fat layers.
Dr. Barry Eppley
Indianapolis, Indiana