Q: Dr. Eppley, I had an unfortunate fat graft and if englarged my masseter muscle (among other things). I am looking to reduce the masseter area surgically. I do not think that botox will help as some of the bulk is fat. I was told that it was placed UNDER the masseter. Do you know or can you suggest any local maxillofacial drs that could help me with this? I am worried about nerve damage. I also had too much fat along the lower jaw and it looks like jowling. What are your thoughts on smart lipo type procedures? I had regular liposuction to try to fix this with no positive improvment at all. Thank you for your informative website and any advice you can give me.
A: Given that you had liposuction of the masseter/jowls with no improvement, this would indicate that the fat is not in the subcutaneous space (of which you have already mentioned) and therefore no form of liposuction will work. This means then that the fat is either under the masseter muscle, in the masseter muscle or a combination of both. I would think it would be very difficult to get all the fat under the masseter muscle and some of it is likely in the muscle as well. Thus removal would require an intraoral submasseteric approach to get access to the fat. There is no risk of nerve injury in doing so so that should not be a concern. The only issue, in my mind, is how much fat could be removed from this approach and whether any masseter can or should be taken if there is not much fat visible in subperiosteal/subfascial plane. One way to really know where the fat is is to get a high resolution MRI of the masseter area. That would give a good idea beforehand of the success of such a procedure. The jowling fullness is another issue and, if not improved by liposuction, may have to consider some form of a jowl lift for improvement.
I can not give you any recommendations for any local doctors that may perform such procedures as I would think it would be very uncommon and may even make most uncomfortable.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 45 year-old female and I have concerns about my jaw line. I have attached some pictures and we would like to have your opinion on what would be some treatment options. I would like to have a return of firmness to my jawline.
A: In regards to early onset jowling/laxity, there are two basic options depending upon how one wants to approach the problem. From a non-surgical standpoint, there is a slew of energy-based devices out there that do create some degree of skin tightening/fat reduction for minor degrees of jowling. Devices such as Exilis, Ulthera and Thermage all drive energy into the dermis of the skin to heat it up creating some new collagen production and a tightening effect. Given Melinda’s good skin thickness and minor amount of jowl softening, you could argue that she is an ideal candidate for this non-surgical device approach. Its negatives are that it requires a series of treatments to get the desired effect, usually four separated by a week or two between them, and it is indeterminate how much improvement can be obtained. While I find these devices effective, it is best to view these treatments as a delaying manuever or bridging step to an eventual surgical treatment. For some patients, it may put off the ‘inevitable’ for years. Remember that you don’t cure aging, you just temporarily improve it. As a surgical approach, a very simple and easy jowl tuck-up can provide an immediate improvement that will surpass what any device can do. This one-hour tuck-up with less than a week social (appearance) recovery is a common facial rejuvenation procedure today as people seek earlier treatment for their jowls and neck issues than ever before. It is really just a miniature or microform version of a lower facelift.
In conclusion, either jowl tightening approach is perfectly valid and the choice depends on what result someone wants and what they want to do to get it.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question concerning my “puppet” lines around my mouth that get infected often. Are some type of injections a reasonable answer to this problem? Thank you.
A: What you refer to as puppet lines are technically known as marionette lines. That is the groove area that develops as the face and jowls fall forward with aging against the fixed skin of the chin. They extend downward from the corner of the mouth to the jaw line. There are multiple treatment options for marionette lines, depending upon how severe they are. For mild to moderate depth marionette lines, injectable fillers may be a reasonable option albeit a temporary one. For moderate to deeper marionette lines, injectable fillers are not very effective at effacing them. Options include a jowl lift (mini-facelift) which really treats the cause of the problem or direct excision of them which may be a reasonable option in the older patient who does not want to undergo any form of a jowl lift. I would need to see a picture of your mouth or face to give you a more definitive answer.
You can always try injectable fillers first as they are easy to do in a few minutes in the office setting. An injectable treatment will prove, one way or the other, if it is effective. Whether that is ‘reasonable’ ultimately comes down to an issue of cost. Is the depth of the marionette lines worth that gamble? That is where seeing a picture of it will help.
Dr. Barry Eppley
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
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
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