Your Questions
Your Questions
Q : I am 49 years old and at least 30 lbs over weight. I am in the process of losing this weight. I want a facelift and liposuction under my chin to help my neck. My second question is about burn scars on the bottom of both of my large toes. These scars cover my toe pad and are up under my toe nails making it very difficult to trim my nails. I have never had a pedicure because I’m too embarassed and scared the clinician will cut into the tissue causing pain and bleeding. What procedure would be used to reduce these scars?
A: One should ideally be within 20% of your weight target before undergoing any facelift/necklift procedure. Most people will lose some weight in the neck with their weight loss, creating more loose skin. You don’t want to do the procedure on the front end of the weight loss as you will end up with more rebound skin relaxation once the weight loss occurs negating some of the hard-earned benefit of the operation. Plus, having the procedure as a ‘reward’ after the weight loss may be more motivating. When it comes to weight loss it is always best to have a definitive but realistic weight target.
Your toe scars are unusual in that they seem by your description to come right up under the nail. (eponychium) I am assuming that your toenails have no problem growing. It is just the thickness of the scar right under the nail edge. I would suggest that dermabrasion (not microdermabrasion) be done to reduce the thickness of the scar. This could remove a few millimeters and reduce the scar hypertrophy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My friend who just had a facelift had a slim face before and it’s even slimmer after the facelift. I am considering a facelift but I don’t want to lose any volume in my face or lose my round face. I think a round face keeps you looking younger. I have that St. Bernard look and is why I want a facelift. Could you explain better the SMAS part of a facelift? I want to have the volume that is now around my mouth back up in my cheeks without having that “alien” look (inverted triangle). That to me is the tell tale sign of a facelift. I want a smoother transition between my cheeks and my lower face and not all the fat in my cheeks. In other words, I don’t want to lose my round face. Would you mind explaining this some more to me please. The best facelifts I have ever seen is when the volume is added to the outside of the cheeks (side closest to ears) making the face wider hence more volume. Is it possible to ask the doctor where to reposition the fat as he marks up my face next week for my nip tuck?
A: A facelift fundamentally works by pulling the skin and the underlying tissues back up along the jaw line and neck towards the ear. In thin faces, tightening these tissues can often make it look even slimmer or more gaunt. That is a simple function of having very little subcutaneous fat between the skin and the muscle. It definitely can give the impression of being pulled too tight even though it really isn’t.
The SMAS part of a facelift is the separation and lifting of the tissue layer between the skin and the muscle. It s usually lifted up in a more vertical direction than the way the skin is moved back. (which is up and back at about 45 degrees) It can help add volume to the side of the face if the SMAS layer has enough bulk. In thin-faced patients, it is quite thin.
In really round faces, a significant slimming effect will not happen after a facelift…even if you wanted it too. It will make the neck and jawline better shaped (which is the lower face) but it will not change what most people interpret as the ‘meaty’ part of the face, the cheeks and side of the face. The change in the neck is what creates the impression that you have lost weight, which is what many people comment on afterwards. (provided they didn’t know you had a facelift)
Indianapolis, Indiana
Q : I am scheduled for a facelift next week. My friend had hers last week. We both go to the same plastic surgeon who is well known. I was shocked today when I saw my friend. It appeared she had been beaten up and looked horrible. Granted it has only been six days but is this normal? When I asked the plastic surgeon about the swelling, he said my friend was still swollen. He does the SMAS lift and pulls the skin as tight as he can knowing that in 3 months it will look normal. Is this routine? I really want a natural look and now am not sure what to do. Please advise. Thanks.
A: Your concern is understandable and let me provide you with this analogy. Facelift results are a lot like getting a haircut. Sometimes in the beginning it looks bad right after, you think it looks good during the middle part of its growth cycle, and then dislike it again once it is too long or outgrown. That is analogous to a facelift because it is not a static result over time.
Meaning…if you have don’t do too much (conservative facelift) then your swelling will be more mild, recovery will be quicker, and your result will look more natural from the getgo…but the result may not last as long. If an aggressive facelift is done, one will have a lot of bruising and swelling (i.e., look awful) and look overdone in the beginning…but will relax into a more natural reesult much later and the results may last a little longer.
As you can see, the facelift operation is balance of how much recovery one can sustain for perhaps a longer lasting result. While everyone wants the best result possible that lasts the longest, the reality is that the initial and short-term recovery period from doing the most aggressive/extensive facelift is not for everyone. Unfortunately, plastic surgeons generally use whatever facelift technique that they prefer on everyone.
Indianapolis, Indiana
Q: I am 58 yrs old and in good health. I have never smoked, drank alcohol or done any drugs. While I am an upbeat person, I have had a difficult past and been exposed to a lot of physical and mental abuse. I just want to have a natural smile. My mouth has always had a natural turn down which makes me appear angry and unhappy. (which I should be because of my past but am not) I can pull my cheeks up at my ears and have a great turned up smile and the jowls disappear. I read about the thread procedure and thought this might be possible for me. Anxious to hear from you.
A: In reading your e-mail, by your own description, you have the classic signs of face and jowl laxity. By pulling the skin up by your ears or cheeks, you are creating the classic results of what a facelift can achieve.
Your inquiry regarding a Threadlift suggests that you believe that this may produce a result similar to a facelift or maybe approximately so. Unfortunately, this is not true. While the Threadlift concept has a lot of appeal in the mid-2000s, it is a procedure which has largely disappeared from clinical use. The original ‘threads’ are no longer even manufactured. When an initially popular and marketed plastic surgery procedure ‘disappears’ within five years from when it comes out, that is because it has basically failed to work. Such is the fate of the Threadlift.
Even of the Threadlift procedure was still available, it was never intended for severe facial skin laxity. In other words, it does not sound like it would have worked in you anyway. Some form of a facelift is what you need. Even a limited facelift, or jowl lift, would be better than any form of a Threadlift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like some information about facelifts. Do you do lower face/neck lifts.? How much is the average facelift? Do you have financing for facelift procedures?
A: Very detailed information on facelift surgery can be found on my blog, www.exploreplasticsurgery.com. Just search under facelift and more than 50 articles on various aspects of facelift surgery will come up on the topic. From what a facelift is and its different types, to how it affects the facial aging process and how long they last, and to recovery and postoperative instructions after a facelift are covered in detail in these articles.
The cost of a facelift can range from $5500 to $9500 depending on the type of facelift done. More limited facelifts, like Lifestyle Lifts cost less while more complex full facelifts cost more.
All facelifts are really neck-jowl lifts and affect only the lower third of the face. It is a common misconception that it is a procedure that treats the entire face, from the forehead down to the neck. Many facelifts are done at the samed time as other facial procedures such as blepharoplasty (eyelid surgery), browlift, rhinoplasty and chin augmentation.
The financing of cosmetic surgery is common and many companies offer this service. Plastic surgeons essentually act as referral sources to these companies as both a service and convenience to their patients. One of the most popular is Care Credit although there are many others. Plastic surgeons do not offer the financing directly but provide needed financial information so that you can apply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a brow lift or botox treatment…maybe a facelift. I am 43 years old and I believe I look ten years older. Do you know if I could try one procedure now and then gradually work up to a progressive series of surgeries?
A: The wonderful thing about the many procedures for facial rejuvenation is that both small and big changes can be done. And the procedures can be customized to how much one wants to do, how much one wants to spend, and how much recovery one can allow. Since facial aging is a progressive phenomenon, younger patients will need smaller procedures while bigger changes are reserved for those with more loose skin and wrinkles.
Since you have never had any of these cosmetic procedures before, it is understandable that one often does not know where to start. To ‘put your toe in the water’ so to speak, doing something non-surgical like Botox or injectable fillers is a good way to start. One can venture ‘further into the pool’ with laser treatments and even facelift surgery at a later date. A progressive approach to facial aging treatments is both reasonable and prudent.
Always start with the facial concerns that bothers you the most. To get started, it is helpful to meet with a plastic surgeon and have an educational session about what is appropriate now and what may be beneficial in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a facelift right after this past Christmas. While it turned out great and I wouldn’t change a thing, I forgot to ask my plastic surgeon how long it would last. What is your take on the longevity of facelift surgery? What can I expect to look like five years from now? Will I eventually look like I did right before the facelift?
A: The simple answer is…you will eventually outlive the results of your facelift. In fact, I would argue that is your goal, to be able to live long enough to need some type of tuck-up or secondary facelift. In that answer lies an important truth…facelift surgery is not permanent. Its lack of permanency is because the surgery treats the symptoms of the problem but not the problem itself which is unstoppable aging.
The complex answer is that it is very difficult to predict how long the results of a facelift will last. The rate at which people age is highly variable and depends on the interplay of numerous factors including heredity, sun exposure, stress, smoke and environmental poison exposures and nutrition. The quality of one’s skin, its thickness and elasticity, and the shape and support of the underlying facial bones play a major role in the stability of a facelift result.
The age at which a facelift is done is also an important factor as aging accelerates at different stages of life. As an example, the results of a facelift performed at age 50 can be expected to last longer than the results of a facelift done in a 65 year-old.
But for those that like numbers, on average, most patients will get at least five to seven years of good longevity of a facelift. Some patients make take as long as ten to twelve years to see a significant return of jowling and loose neck tissue again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 65 years old and am extremely bothered by my turkey wattle. I do not look my age except this makes me very self conscious. I want to get rid of it with some type of neck procedure. What do you recommend?
A: Sagging or drooping of one’s neck is one of the most bothersome features of facial aging. While some people would never consider undergoing a ‘facelift’, they want some type of neck procedure to deal with their most troublesome age-related issue.
Aging necks are referred to many uncomplimentary names such as turkey neck and neck wattle. Some people become initially aware of it when they see themselves in profile in a photograph. Others notice it, particularly men, when wearing certain shirts and certainly in a shirt and tie. Others do not like, understandably, that it can be felt to move or flop when turning their head. (in more advanced aging)
Interestingly, some people would consider a necklift but 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 in my Indianapolis plastic surgery practice who actually knew what a facelift really was.
A facelift is primarily a necklift. The type of facelift determines how much improvement in the neck is obtained. A limited facelift (aka Lifestyle Lift) has a minor effect on neck sagging and is best for just minor neck problems. It is primarily a jowl changing procedure. A full facelift is a powperful changer of the aging neck. The differerence 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 occipital scalp. It is the pull from behind the ear that changes the neck. You can demonstrate this quite simply with your fingers in front of a mirror. A manuever that many patients with aging faces have done regularly.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am tired of looking older. My jowls are getting bigger and my neck is starting to really sag. I hate to consider the thought of a plastic surgery procedure like a necklift but I am going to have to do something in the near future. I don’t mind getting old per se, I just don’t want to look old! I have read that there are different types of facelifting procedures. How do I know which one will work for me?
A: A facelift is a plastic surgery operation that changes the lower third of the face, the neck and jowls only. So it is a good match for the jowl and neck issues which bother you. Like many plastic surgery procedures, there are different ways to do them and they come in different ‘varieties’. No one type of facelift is right for everyone. Your plastic surgeon must ‘match the solution to the problem.’
Fundamentally, a full facelift changes both the neck and jowls and is best for someone whose primary problem is their neck. The jowls get improved as well and get swept alone in the changes that occur far away in the neck. The mini-facelift, aka Lifestyle Lift as called by some, changes the jowls primarily and a little bit of the neck. Any limited improvement in the neck is the result of the changes that have occurred in the jowls. The mini- or limited facelift is best for someone whose primary concern is in their jowls. Since jowling proceeds any significant changes in the neck, one can appreciate why a limited facelift is for younger people who have less signs of facial aging.
Another way to think about it is by looking at the incisional pattern around the ears. Mini-facelifts have use an incision that runs into and around the front the ear. Pulling upward from there only impacts the jowls primarily. A full facelift uses incisions in front of and behind the ear. By moving tissue upward from behind the ear, excess neck skin can be worked out to be cut off behind the ear.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m a 62 year old female interested in widening a narrow face with a chin/jaw widening implant that would also help with jaw lifting and mild jowls. Is this possible for someone my age?
A: It is unusual for a female at any age to desire a wider lower face. This is almost always a male procedure for the obvious reason of making the jaw line more prominent to create a masculinizing effect. It would be particularly rare, and the first time in my Indianapolis plastic surgery experience, to have an older woman make that request.
I suspect that the real reason for this request is to help improve the classic signs of facial aging which is that of jowling, loss of the jaw line, and neck sagging. While it is true that jaw line enhancement at the chin and even more posteriorly at the jaw angles can help fill out a lower face, I question whether the effect would be significant enough to achieve your goals.
While I will have to see your pictures, it is possible that chin and jaw widening in combination with a limited or tuck-up facelift may create a more ideal result. Widening and lifting along the jaw line is a diametric movement of soft tissues that will usually result in a better outcome than either procedure done alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am inquiring about the correction of a pixie ear deformity from a previous face lift done two years ago. I have read about so I know what it is. How did this happen and how can it be corrected. My ears really look funny and that is not a good look for someone 55 years old!
A: The pixie ear is a well known earlobe deformity that can occur after a facelift. It has been described for decades and, while once more common, modern facelifting techniques have largely eliminated this problem.
While folklore pixies are usually cute and even beautiful, they often have distorted facial features. One of those is the elongated earlobe, hence the name pixie ear deformity. If a facelift is pulled up too much (undue tension), there will be some secondary pullback of the tissues later due to gravity and wound relaxation. Since a facelift incision goes around the ear, the earlobe at the lower end of the facelift incision can show how much the tissues have pulled back down. Because the earlobe is the only portion of the ear that is not supported by cartilage, it can easily be pulled downward months later as tissues settle. Since this is a well recognized potential problem, plastic surgeons strive to keep the tensions point on the scalp areas above and behind the ear and not on the earlobe. It is also helpful to not try and pull a facelift so tight.
Correction of the pixie ear is relatively simple. The earlobe can be detached and restored to its normal shape. This will leave a small residual scar below the earlobe but it can be done in the office under local anesthesia. If it has been years and some jowl or neck relaxation has occurred, one can undergo a simple tuck-up facelift and restore the earlobe shape. By relifting some small amount of loose facial skin, there would be no visible scar below the earlobe as it is tucked back up underneath.
Dr. Barry Eppley
Indianapolis Indiana
As people age, two of the most noteworthy and bothersome facial changes is what occurs along the jaw line and neck. These two changes are usually progressive, first comes the jowls then goes the neck. Like wax melting off of a candle, cheek skin and fat begins to slide off of the face creating those fleshy droopy folds at the jaw line known as the jowls. Recent research also indicates that it is more than just gravity that causes jowls, it is the shrinking of facial fat as well.
The appearance of jowls will eventually occur in everyone with enough time. Jowling creates an undesireable change in facial shape, making it wider and more rectangular in the lower face which is characteristic of an older person. It also causes a distinct disruption of a smooth jaw line from the chin on back, which is characteristic of a more youthful appearance.
Jowl correction is generally part of a facelift procedure. This is done during a facelift by either trimming the jowl fat, suturing the jowl fat back up to a higher level, or some combination of both of these manuevers. Facelifting is a relatively common procedure as evidenced by the 95,000 performed in the U.S. in 2009 according to the American Society of Plastic Surgery.
When only jowls are present and the neck has minimal loose skin, a different variation of a facelift can be done. Scaling back the ‘size’ of the facelift procedure can very effectively eliminate those troublesome jowls. Known by a wide variety of different names, the limited or downsized facelift tucks up the hanging loose jowls with very minimal recovery. Unlike a traditional facelift where incisions are made in front of and on the back of the ears, the jowl facelift only uses a fine incision in the front. The lack of any significant recovery is noted by the different names that are used to describe it, such as Lifestyle Lift, Swiftlift and EZ Lift. Expect one week for the significant recovery period of some mild swelling and bruising.
One of the great advantages of a jowl lift or ‘short scar facelift’ is that it also addresses a common facelift fear, that of looking unnatural. Few patients that I have ever met want to look like they have had a facelift. These procedures have no risk of that ever happening as they deliver a more subtle and less dramatic result. One will never look have that windwept or overdone look as, by definition, the procedure is more limited.
Q: I have an inherited double chin that makes me look twice my 46 years of age. Can you make it disappear so I can look younger ??
A: A ‘disappearing’ act is what we do a lot of in plastic surgery. Whether it be liposuction, chin implant, facelift…or some combination….it certainly can be made to ‘vanish.’ I know that your double chin makes you look older….but I doubt if it makes you look 92!
When patients refer to a ‘double chin’, this means there are at least two and sometimes three rolls of skin if you include the chin as one of the rolls. The double chin is often the result of the combination problem of a full neck and a short chin. In the younger patient, this can be improved by doing chin augmentation and neck liposuction at the same time. When you move two different things in opposite directions, the result becomes greater than when only one is done alone. In an older patient with more loose skin, this diametric action may require chin augmentation and a facelift to get the neck going back and up as the chin comes forward.
If the forward position of the chin is adequate, then the neck alone can be treated. Again, age and the amount of loose skin determines whether liposuction (good skin) or some version of facelift (bad skin) is needed.
Correction of a double chin is highly effective plastic surgery adventure and can make for a dramatic difference in one’s appearance.
Dr. Barry Eppley
Q: Dr Eppley I have had my lower eye bags and lids done and also had a MAC facelift with liposuction to my neck all at the same time. I now have two eyelids that are different and am not pleased with the result of my lower neck. I went back to see the surgeons yesterday and they said they would have to do the two eyelids again but can’t do the neck any better. I am 65 years old and after reading your article about a low horizontal neck lift I wonder if this is would nto work for me. That procedure has given me hope but I can’t trust my previous surgeons to do it.
A: The MAC facelift, like all forms of limited facelifting, is a great procedure for the right patient. The right patient for it is one that doesn’t have a significant neck problem or a lot of loose neck skin. These limited facelifts are primarily jowl reducing/smoothing procedures with some minor improvements in the neck area. Those improvements are helped through the use of neck liposuction, but the key to getting a good result is that the neck skin must not be too loose.
When one has a more significant neck issue, a full or more traditional facelift procedure is more appriopriate. This is a much more powerful neck procedure. One of the problems with these limited facelifts is that they get used in patients that really should have had a more complete necklifting procedure. As a result, they can often be disappointed with the neck result. I suspect this is what has occurred in your case.
Once can always have a secondary more complete facelift done to improve your neck result. Having had a MAC facelift does not preclude that. Saying that ‘no more can be done’ suggests to me that they are either unwilling or incapable of doing a more complete facelift procedure.
A low horizontal neck lift is always an option and certainly is simpler and easier than reverting to a complete facelift. As long as one can accept a fine line scar in a low neck crease, this could be an option worth considering. That could even be done local anesthesia.
Dr. Barry Eppley
Q: As I am getting older, I don’t like my neck which is getting looser and lower. I think I may need a facelift but am scared to death to go through it and it will likely cost more than I have. I have read and seen pictures about the Lifestyle Lift and that really interests me as it doesn’t look like surgery is needed and the results are great. Do you think that will work for me?
A: As we age, the very common signs of facial aging is in the development of a saggy neck and jowling. These loose facial skin issues are exactly what a facelift treats, contrary to what many patients believe that a facelift is.
Facelifts can be done in a variety of ways but fundamentally there are two types, limited and full. For smaller neck and jowl issues, a limited facelift can be a very good rejuvenative procedure. For larger neck wattles and jowls, a full facelift is often needed to get the best result.
The Lifestyle Lift, a tradename and franchise approach to delivering cosmetic facial surgery, is a variation of a limited facelift. Many patients have commented to me that they did not think it was surgery based on the ads and the TV commercials. But a Lifestyle Lift is surgery and can be combined with a wide variety of other facial procedures and injectable treatments. Usually a combination of ‘small’ procedures can collectively create a significant facial improvement.
The limited facelift approach has been around for a long time, dating even back to the early part of the 20th century. It has re-emerged in popularity today because younger patients are seeking facial improvements. They don’t want to wait until they need a complete facelift and have such a dramatic change. Plus, they want to maintain a more youthful appearance as they are in their prime work years. About half of the facelifts I now do are of the limited variety because it fits many patient’s age, lifestyle, and budget.
When you see a good before and after picture of a significant facial change, you should know that is not possible without some form of surgery. There is no magical cream, laser, and other ‘magic’ that can create what a facelift operation can do. We all would like there to be but it does not exist. Remember a basic plastic surgery rule…’small changes require only small procedures, big changes come from big procedures.’
Dr. Barry Eppley
Q: I am a male and am interested in the direct neck lift and want to know more about it. I don’t want a complete lift and think this may be my answer. How much of a scar remains visible and will it last a long time. Also, do you tighten the muscles and remove some of the fat?
A: The direct necklift is an alternative to a facelift for a select number of men and women that are interested in getting rid of their neck wattle. A facelift works out excess neck and jowl tissues by chasing them back towards the ears and placing the scars there. A direct necklift cuts out the neck wattle directly, placing the scar right down the middle of the neck. It is a highly effective procedure that produces neck results that are just as good, if not better, than what a facelift can do particularly in men.
In the direct necklift, not only is skin removed but fat and muscle tissues are changed as well. With the skin cutout, the underlying fat is removed as well right down to the muscle. The split platysma muscle is widely exposed with the overlying tissue removed. Because of the excellent visibility, it can be sewn together from under the chin right down to the thyroid cartilage with superb tightening achieved.
The direct necklift is not for everyone but for just a select few patients. In my Indianapolis plastic surgery practice, I reserve it primarily for older men (55 years and older) who either do not want to undergo a facelift or have a very poor hair pattern and density around their ears. The occasional woman is done but they are almost universally 65 years and older and are choosing the direct necklift vs a facelift because of its lower cost.
The obvious issue with a direct necklift is the scar. Generally these scars are quite thin and the only widening that occurs in them is in the middle of the neck where the tension is the highest. For this reason, I usually place a z-plasty scar orientation in this area to avoid hypertrophic scarring there. I have performed no scar revisions on them to date which speaks to patient acceptance of their final aesthetic appearance.
Dr. Barry Eppley
Q: I am interested in the direct neck lift and want to know more about it. I dont want a complete lift and think this may be my answer. How much of a scar remains visable and will it last a long time? Do you tighten the musles and remove some of the fat during the procedure?
A: A low hanging neck, or wattle as it is sometimes unaffectionately called, is a concern for both male and female patients particularly as they get older than 55 or 60 years of age. The traditional and most method of treating these neck concerns is a conventional facelift. In this procedure, the loose neck skin is moved back from the central part of the neck up and backwards and then trimmed off, putting the scar in a near invisible location in and around the ears.
When one doesn’t want to go through a facelift procedure, due to either lack of good hair around the ears or the expense and recovery, the direct necklift may be a reasonable alternative option. Because it cuts the wattle out directly, it leaves a vertical scar running down from under the chin to just below the adam’s apple. Both skin and underlying fat is removed and the platysma muscle is also tightened, which is both easy and very effective due to the wide open exposure. It is a simple operation with very little recovery, minimal swelling and bruising and virtually no pain other than some neck tightness.
The issue is the scar which is why it is not for everyone with a neck wattle, particularly younger patients and most women. It is largely an older male procedure as many men do not have good hairlines and are interested in going through a smaller less drastic procedure. Neck scars in men tend to do fairly well as they have thicker beard skin and do an unintentional but helpful scar treatment daily, known as shaving or microdermabrasion. But for the right older female who has less of a scar concern, it can make a dramatic neck difference.
The scar down the neck can be done several ways, either as a straight line, a straight line with a central Z, or a running w line. (like a pinking shear cut) I have used them all and the choice of which scar pattern is used is based on skin quality and the tightness of the closure. Most scars will become fine white lines that are very acceptable. Scar revision is always possible also but is not commonly needed in my experience.
Dr. Barry Eppley
While the way and the changes that a face undergoes as it ages may not have changed since time began, the treatment of it has. Facelift surgery used to be an extensive operation largely because it was done on older people. (who needed a lot of work!) In a generation past, most people (primarily women) underwent a facelift when they retired, rewarding themselves for a lifetime of work and when they can most afford it.
But today’s approach to facial aging is different and reflects changes in both society’s attitudes and plastic surgical techniques. People now want to age less obviously and remain youthful appearing in middle-age as they participate in the ever competitive workplace. As a result, facelift surgery has adapted to these needs becoming less invasive and suited for less severe signs of aging that exist in the 40 and 50 year-old ages.
Besides the common misconception of what a facelift really, most people perceive that it is a highly invasive procedure that requires a long recovery. These two perceptions are tied together under the belief that a facelift is a ‘scalp to neck’ lift. In reality, a facelift only changes the lower third of the face…a neck and jowl improvement. It does not change the mouth, cheek, eye or forehead area. These require separate and often combined procedures with a facelift to create a complete facial makeover. When one understands the more limited scope of what a facelift is, it becomes less scary and intimidating.
Facelifts have evolved into two different types, complete and limited. The difference is in the amount of neck improvement that is obtained. Since many younger patients have more jowling than sagging neck issues, the limited facelift has become widely used. The surge in the number of facelifts has been because of this scaled down version and accounts for at least half of all facelifts now performed.
The popularity of the limited facelift can be seen by the numerous marketing approaches taken by both plastic surgeons and franchises alike. Catchy names that imply the ease of recovery, such as Swiftlift and SimpleLift to name a few, are used to differentiate this technique from that of the historic facelift perception. Promoting surgery under local anesthetics, one hour procedure times, and a few days of recovery, it can make it seem that it is hardly surgery at all. I have seen numerous patients initially seen at these franchise establishments and they were surprised to find out it was an actual surgical operation.
But limited facelifts are real surgery, even if it isn’t the same as an extended full facelift. It can become a more extensive procedure if combined with other facial aging treatments such as eyelid tucks (blepharoplasty)or browlifts, which is quite common. The concept of several smaller operations at a younger age is a sound maintenance approach that may make the need later for a full facelift unnecessary.
Limited facelifts, however, are not just for the young. For the older patient, who may really need a full facelift for the best result but does not want it, the limited facelift offers moderate improvement with less recovery and costs.
Contemporary plastic surgery is about adapting the operation to the magnitude of the problem. The limited facelift is a great illustration of that principle.
Dr. Barry Eppley
The mere mention of the word ‘facelift’ is to many people a frightening concept that is best avoided. Beyond implying surgery, images of ‘perpetual surprise’, ‘wind-tunnel’ and ‘unnatural’ come to mind. It is these very misconceptions and fears that have led to a surge of procedures that have become broadly known as non-surgical facelifts.
Cleverly marketed as appealing improvements known as ‘lunchtime facelifts’ and ‘liquid facelifts’ , these facial procedures are hopefully performed in a doctor’s office with a combination of Botox, injectable fillers (such as Juvaderm and Radiesse), and light and laser treatments. They are tremendously appealing precisely because they are not surgery, and involve no scarring or downtime. And they are based on a recently appreciated anatomic understanding of facial aging which is that of volume deflation (loss of fat) and not just sagging tissues alone. ‘Re-inflation’ of the face is the result of these treatments, even if it is only temporary (there are no permanent injectable fillers).
Under the guise and enthusiasm of anything that is pain and recovery-free being better than a real facelift, a patient inquired about the ‘new’ Y-facelift published this past weekend in New York Times Sunday Magazine. Buried in the center pages of this magazine was a story entitled ‘Houston, We Have Facelift’. Reading this story got me thinking about everything that is both good and bad about the non-surgical facelift ‘revolution’.
The concept: Developed by a dentist who claims to have taken four years to develop this approach, the Y-facelift involves filling the face with large volumes of injectable fillers, molding it around with one’s fingers, and then treating the skin with radiofrequency treatments to tighten it. I am not sure what the Y means but some filling out of the face is most certainly achieved, without surgery, for a subtle improvement.
The bad:. It may be shocking for some that everything in New York isn’t always better (although always twice as expensive) and the New York Times Style magazine does not carry the same scientific clout, for example, as the New England Journal of Medicine. Cosmetic procedures are fraught with a common problem- marketing that frequently gets way ahead of proven science. This practice is so prevalent that doctors and companies alike have learned that appearing in Allure, Cosmopolitan and other beauty magazines with exaggerated and unfounded claims drives business better than a scientific discourse in any medical peer-reviewed magazine. (and much easier to get published) Even the pharmaceutical industry has this figured out which is why almost one-third of television ads today are for some prescription drug. The bottom line is the ‘Y-Lift’, while based on a few known plastic surgery procedures, is an unproven amalgamation which most likely benefits the treatment provider more than the recipient.
What matters: The debate between non-surgical or surgical facelifts can be debated ad nausem. Both may be appropriate for any patient under the right circumstances. The practitioners of both will hotly contest each one’s merits. But the non-surgical boom of cosmetic procedures speaks to an important issue that is rarely discussed…value. What does one get for what one pays? The non-surgical Y-facelift retails between $4,000 and $8,000 for results that will last one year, maybe slightly more. The price of non-surgery, when looked at long-term, is frequently more than that of actual surgery…with results that are not nearly as long-lasting.
There are many factors that go into deciding what is the best facial rejuvenation procedure. Never forget that the concept of value in plastic surgery, like any other retail purchase, is extremely important. But the medical merits of such procedures should not be determined by what is written in a trendy magazine whose sole intent is newsstand and ad sales, not satisfied and happy patients.
Dr. Barry Eppley
Facelift surgery is one of the top five requested procedures in plastic surgery. Despite its popularity, it remains as the most misunderstood of the known plastic surgery operations. Almost everyone thinks that a facelift is a total makeover of the face, from the scalp down to the neck. In reality, it only treats the lower third of the face, the jowls and the neck. Therefore, it is a much less extensive operation to go through than one thinks, with a smaller than anticipated recovery as well. Facelifts are often combined with other facial procedures as well such as blepharoplasty and browlift.
In this edition of the Doc Chat radio show, Dr. Barry Eppley discusses many aspects of facelift surgery, demystifying the operation and providing insight into what it can and cannot do. In discussion of facelift surgery, Dr. Eppley interviews a husband and wife, both of whom had different facelift operations. The wife underwent a traditional full facelift, the husband underwent a direct necklift. Hear what they have to say about their experiences and the learn from actual patient experiences what facelift surgery is all about!
In running across a copy of Nora Ephram’s best selling book by the same title, I could not help but think how many times I have heard this very phrase from patients. While we are long past Thanksgiving, some may still be thinking of turkey in a different light…that of their ‘turkey neck’.
Many people want to improve the appearance of their neck without having to resort to a facelift. Getting rid of a neck wattle would return them to a younger look and be able to wear ties, turtlenecks or jewelry more comfortably. The fear of a facelift is a near universal one. Whether one feels that they are too young or too old for surgery, do not have time for any significant recovery or cannot afford it, many potential patients are drawn to any procedure or method that offers an alternative.
Some fuller necks or neck wattles may benefit from targeted treatment just to the neck. Such neck rejuvenation, known as submentoplasty, only works on the neck removing fat and tightening muscles. No incisions are around the ears are needed unlike traditional facelift surgery.
As we age, definition and smoothness under the chin and along the jaw line is lost. This occurs due to fatty deposits, weakening muscles and the appearance of loose skin. This results in the obliteration of a sharp neck angle, where the neck and chin meet. Often this just becomes a straight line angling obliquely down from the chin to the lower neck.
Neck skin is different from the rest of facial skin. It generally has much more elasticity and can actually contract or shrink upward after being released from the underlying muscle and fat. Given that the neck skin lies on the underside of the chin, many would think that it would fall downward and hang more after being released. But this does not generally occur unless one’s neck skin is paper thin.
The submentoplasty procedure is done through an incision under the chin. First, fat removal in the neck is done with liposuction. This is followed by midline platysmal tightening and wide freeing of the neck skin from the muscle. Whether liposuction alone or the complete submentoplasty procedure is needed will depending on the age of the patient and the quality and amount of loose neck skin that is present.
Younger patients (less than age 35), who generally have more skin elasticity and have a skin wattle because of too much fat underneath the skin, usually just need liposuction only. Middle-aged patients (ages 35 to 55) have fat deposits also but in addition have a loose or split plastysmal neck muscle and skin. This requires the full submentoplasty method of treatment. Older patients (age 55 and over) almost always need extensive neck recontouring and a facelift is needed where loose skin is actually removed.
In my Indianapolis plastic surgery experience, I have found that adequate neck rejuvenation for many patients requires some version of a facelift. But age is a key factor in determining the suitability of a submentoplasty. In patients under age forty-five, about half of them can get good results with a submentoplasty and avoid a facelift. Over the age of forty-five, however, that number drops to less than one in ten. And over the age of fifty-five that numbers drops to essentially zero.
While submentoplasties are a primary treatment for certain neck issues, it can also be used as a secondary tuck-up after a facelift. Some facelifts, particularly with really saggy necks, will often get some rebound relaxation in the submental region which is furtherest from the point of skin pull way back at the ears. A submentoplasty allows further neck refinement when the results of the facelift begin to relax.
Dr. Barry Eppley
The plastic surgery treatment of the aging face often involves a facelifting surgery. A facelift is one of the top ten cosmetic procedures performed in the United States. Despite its frequent performance and its recognition by the public, it is a procedure that is usually misunderstood.
The most common misconception of a facelift is that it does very little for much of the face. It is a procedure that has its impact on the neck and jowl areas. The rest of the face is untouched by the operation. While other procedures are often done with it, such as eyes and brows, these procedures are not part of the a traditional facelift operation. A facelift should more properly be called a necklift or a neck-jowl lift.
Another misconception about facelifts is what is actually lifted. Everyone understands that face and neck skin is lifted and moved back, but what goes on underneath the skin layer is a frequent point of misinterpretation. Patients often ask me if I am going to lift and tighten the ‘muscles’. From an anatomic standpoint, lifting the facial muscles is an impossibility. Most facial muscles are attached tightly to the underlying bone and moving them would not only be very difficult but would not have any postive benefit. There is only one muscle that is often tightened in a facelift and that is the platysma muscle in the neck, which is often separated due to aging. It is never lifted per se but it is tightened in the middle, from the chin down to the adam’s apple, to help sharpen the neck angle.
The layer underneath the skin that patients misinterpret as muscle being moved is actually a different tissue altogether. Between the skin and the muscles is a layer of tissue known as the SMAS. This is an acronym for a more anatomic name but for simplicity of understanding think of the SMAS as another layer of skin underneath. This layer can be raised up off the muscles and resuspended up higher on the face. The combination of SMAS and skin tightening together generally makes for a better facelift result that may last somewhat longer.
There is great controversy in plastic surgery about how to most effectively deal with the SMAS during the facelift operation. Many facelift surgeons tout their own techniques and may even have their own names for their ‘type’ of facelift based on their version of SMAS manipulation. While SMAS management in any form of a facelift is a plus, there is no proven superior method of what to do with it. If one single SMAS facelift technique was genuinely best, we all would be using it.
In a facelift, the underlying tissues that are manipulated is the SMAS layer not muscles. SMAS tightening does usually make for a better facelift result that is more durable. However, time and aging will eventually outlast any facelift result no matter how it is done. And the overall goal for most patients is to ultimately outlive their facelift result….or at least I would think so.
Dr. Barry Eppley
The greatest misconception about facelift surgery is that it does very little for what most people think of as their face. A facelift is really a neck and jowl lift, changing only the lower third of the face or the neck. Facelift surgery is also not a ‘one size fits all’ operation. Facelifts come in a variety of variances that are customized to the each patient’s specific problems. Subtle differences in each facelift do make each one a little unique.
Despite many nuances in each patient’s facelift surgery, they are done in fundamentally two ways or types, limited and full. The differences lie in how much work is done in the neck area.
Limited facelifts affect mainly the loose skin in the jowls with some minor effect on the neck. Often neck liposuction is done as part of the procedure. This type of facelift has become popularized by different surgeons and companies that implies its simplicity and ease of recovery. Despite these name differences, they are are essentially the same operation. It is a good procedure for those who have early to moderate signs of face (neck and jowl) aging. The recovery is quick, one week or so, and in my Indianapolis plastic surgery practice the limited facelift makes up about one-half of all facelifts that I do.
A full or traditional facelift is an extension of the full facelift. More skin is undermined in the neck and the platysmal muscle is often sewn together as well. It is reasonable to think of a full facelift as about twice that of a limited facelift. The surgery is twice as long, the amount of work done is about double. This is a better procedure when one is older and the facial (neck and jowl) aging process is more advanced. If you have significant loose skin in the neck, then a full facelift is probably needed.
One of the fears that many patients have is that a facelift involves a lot of pain, swelling, and an extended recovery. In reality, this is simply not true. One of the main reasons people think this goes back to a basic misunderstanding of what a facelift really is. (it does not involve any operations above the mouth…..while many other facial procedures can be done with a facelift, they do not count as a facelift) Isolated facelifts are much easier to go through than most imagine. Even a full facelift takes only slightly longer than a limited one.
Unfortunately, the fear of what a facelift may entail after surgery prevents some people from even considering this very effective procedure. Once I explain in detail the type of facelift a patient may need and what is really involved to go through it, these fears subside and the process to get what one wants is no longer so daunting.
Dr. Barry Eppley
Due to the marketing and appeal of a facial rejuvenation procedure called the Lifestyle Lift, many people have at least heard of it. A scaled-down version of a facelift, the Lifestyle Lift is not unique or new but is actually a common procedure performed by many plastic surgeons. Todays trend toward less invasive plastic surgery and beginning facial rejuvenation earlier has led to the marketing of an otherwise routinue facial procedure.
Unknown to most, the Lifestyle Lift is a branded name and is a blended marketing and service approach to delivering minimally invasive facelift surgery. In essence, it is a franchise approach to selling surgery with office locations in 22 states. (the closest office to Indy is in Cincinnati)
While there is nothing wrong with that concept, the Lifestyle Lift company was recently fined $500,000 in New York where its corporate headquarters is located.. The attorney general there has settled complaints against the company as it has admitted that it used its employees to pose as satisfied customers in online ads. Apparently the company ordered employees to write positive reviews of the Lifestyle Lift on message boards and other internet forums to appear as unsolicited testimonials and endorsements, thus violating consumer protection laws. (proving once again that www. really means the wild wild west…believe at your own risk!)
While the company and the way it operates may have some deceptive marketing practices, the actual operation however is still a sound one. The limited facelift or short scar facelift (a.k.a Lifestyle Lift) is very popular and highly successful. It is a scaled down version of a more extended facelift into which many other smaller facial procedures can be added as well.
Younger patients today want to treat jowl and neck sagging early rather than wait until it looks worse. Therefore, their facial concerns are less severe and they do not need a full facelift operation. The limited facelift is often combined with other smaller procedures (e.g., Botox, injectable fillers, laser resurfacing, neck liposuction, eyelid tucks) to create an even better overall result without extending one’s recovery. Older patients (who really do need a bigger operation but do not want it) can still get a simpler and less invasive operation that will provide some real improvement. (although less than that from a full facelift) This usually fits their financial situation and allows them to have surgery that they can afford with a recovery that fits into their work or leisure schedule.
Dr. Barry Eppley