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Archive for the ‘facelift’ Category

Case Report – Correction of Pixie Ear Deformity by Secondary Facelift

Saturday, December 9th, 2017

Background: The surgical origin of a facelift is what transpires around the ears. Making skin incisions around and in (retrotrgal) the ear creates the access needed to both mobilize and reposition loose skin but also to treat the deeper tissue layers. Closing a facelift is about bringing the shape of the ear back out through skin excision and layered tissue suturing.

While much thought and discussion gets into whether and how the SMAS is manipulated in a facelift, incision placement and closure around the ear is often overlooked or taken for granted. One of the underlying principles in removing and redraping facial skin around the ear is to avoid any tension on the lower half of the ear. Since the earlobe contains no supportive cartilage, it is susceptible to being stretched if the skin that is reattached to it is under any tension.

Such elongation of the earlobe after a facelift is known as the pixie ear deformity. While this is a well known term to describe this type of ear deformity, actual pixie ears have elongation of the upper third of the ear and not the lower third. But that issue aside, the vertical lengthening the earlobe and the stretching of the scar around it represents an undesired form of tissue expansion of a once smaller earlobe.

Case Study: This 62 year-old female had a facelift twelve years previously. As time had progressed she ha lost the benefits of the facelift and was in need of repeat jowl and neck reshaping. One aspect of her original facelift she didn’t like was how it make her ears look. Shortening and reshaping the earlobes was a necessity for her next facelift.

Under general anesthesia her original facelift and submental incisions were used to perform a secondary facelift with SMAS flap resupension.. As part of the procedure the skin beneath the earlobe was cradled up against the ear cartilage and the earlobes shortened and reattached to it.

While more minor forms of the pixie ear deformity may be treated by release and vertical skin closure, this will not be effective when the earlobe lengthening is more than 50% of its original length. (unless one can accept a long vertical scar extending down from the earlobe) Wide re-elevation of the facial skin flaps is needed (secondary facelift) for a complete correction with hidden scars.


1) The ear is intimately involved in any facelift procedure.

2)  The earlobe contains no cartilage and is susceptible to being elongated after a facelift if any skin tension is placed on it.

3) The severe pixie earlobe deformity is most effectively corrected by a secondary facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Limited Facelift Concept

Monday, October 9th, 2017


Background: One of the most recognized anti-aging facial procedures is that of the facelift. While commonly recognized it is not commonly understood by the public. Many misconceptions exist about this operation from how it is performed, its immediate and long-term facial effects and to who may even be a good candidate for it.

The facelift procedure has been around for over 100 years and its medical name, rhytidectiomy or the removal of facial wrinkles, speaks to its age. In its original use it was designed to remove wrinkles from the face by cutting out skin in front of the ear or temple area. The operation has certainly evolved since its inception, due to improved anesthesia and surgical techniques, and it has become as much about repositioning of lax facialk tissues as it is about cutting them out.

Despite the evolution of the modern day facelift and its myriad of technical maneuvers within the operation, there are still some basic components to it. The extent of skin flap elevation in the face, how the SMAS layer is managed and how much central neck work is done allows for the facial procedure to be divided into three types or levels whose application depends on the extent of the patient’s aging facial tissues.

The limited or mini-facelift, aka level 1 procedure, has become popularized under a variety of marketing names. Because it is a more limited operation it has become promoted for its quicker recovery, shorter operative times and execution under more limited anesthesia methods. By definition such intra- and postoperative sequelae occur because the operation is less invasive. Less surgery is done, thus making everything about this type of facelift ‘less’ even including cost.

Case Study: This 45 year-old female wanted to reverse some adverse changes that had occurred in her neck and jawline. She had developed some jowls as well as some neck skin laxity occur with some platysmal banding.

Under general anesthesia, she had a limited facelift performed with short skin flaps raised in front of the ear and down into the neck but did not extend to the central neck. A short SMAS flap was raised with suture suspension. A submental incision was made to release and tighten the platysmas bands. Her six week results show a smoothing of the jawline and an improved neck angle.

Any ‘limited facelift’ technique is, by definition, a limited version of its more complete form. What makes it easier in every aspect is that it is less surgery. While that may seem obvious it it important for patients to understand that, while everything about the operation is appealing, it will not create the same result as its much larger form. It works best when the operation is matched to the anatomic problem. For patients with greater neck sag, jowls and overall tissue descent, this operation will not meet one’s expectations. In short a limited facelift is not a full facelift.


  1. A facelift is a variable operation whose extent is based in the aging anatomy that it needs to treat.
  2. A limited or mini-facelift is usually defined as a procedure that does not include the full neck dissection and/or has limited skin flap elevations.
  3. Most more limited facelifts are best done ion younger patients who have earlier rather than advanced signs of facial aging.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Retrotragal Facelift Incision

Tuesday, June 27th, 2017


The facelift is one of the most common of all facial rejuvenation procedures. While there area a myriad of methods to perform it with various technical maneuvers that can seem bewildering to the patient, the most basic part of it remains the incision around the ears. While perhaps not the most technically challenging part of the operation it is certainly the most visible.

No matter how well the ‘inside’ of the facelift procedure is performed, poor incision placement, adverse scarring and hairline displacements/distortions will be an aesthetic detraction. These external markers can often be how a facelift is judged and is an understandable preoperative patient concern.

The basic facelift incision around the ear is often called preauricular or retrotragal. This refers to the incision on the front of the ear which represents a part of the total facelift and just a minor portion of its total incisional length in most cases. But it is the most visible part of the incision and thus its aesthetic importance.

In almost all women and in many men the facelift incision will be placed in a retrotragal fashion. The incision will go inside or behind the cartilage bump (tragus) as it crosses this part of the ear. Otherwise the rest of the incision runs in the natural face-ear junction around the ear and up and back into the hairlines. Such placement hides part of the incision and helps break up scar tension on it due to its non-linear course. (this is an example of such an incision several weeks after surgery.

These type of facelift incision usually heals quite well and as discretely as one would hope. This is because it is not only hidden but because it is closed with no tension after the excess skin is removed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facelift with Jaw Angle Implants

Sunday, April 16th, 2017


Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.

While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.

Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period.  Good compression facial dressings during the first few days after surgery is very helpful in this regard.

Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.

Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.

Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.


  1. Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
  2. Creating a more defined jaw angle builds up the back part of the jawline.
  3. Most jaw angle enhancements in aging require a vertical jaw angle implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Liquid Facelift vs Surgical Facelift

Sunday, April 9th, 2017


Rejuvenation of the aging face can be done by a variety of treatment strategies. This is no better illustrated than in the differences between the traditional facelift, that has been around for over one hundred years, and the more newly marketed ‘liquid facelift’.

The traditional or truly surgical facelift works by removing excess skin and tightening the underlying layer of tissues in the neck and along the sides of the face. It remains the gold standard in surgical facial rejuvenation because it treats the primary cause of droopy necks and sagging facial tissues. Its effects can be dramatic albeit surgical with all the risks and recovery that goes with the process.

The liquid facelift has emerged as a result of the widespread use of synthetic injectable fillers which explains it as a more recent treatment offering. Adding volume under the skin through a wide variety of filling techniques and materials remains the backbone of how it works. By plumping up the skin from the jawline to the cheek and even up into the brows the skin is pushed outward and to some degree upward. This plumping effect is what creates any amount of a facelifting effect and is done so in a non-surgical fashion as an office procedure without recovery and minimal downtime.

The liquid facelift has evolved into many variations that differ based on each physician’s own protocol. These can include mixing the injectable fillers with fat or platelet-rich plasma. (PRP) Various topical therapies are often done at the same to treat the overlying skin such as Botox injections, laser resurfacing, chemicals peel and microneedling.

The liquid facelift is usually best done on younger patients who have the early signs of aging and often serves a ‘bridge’ until a surgical facelift is needed when one is older or is ready for a more invasive procedure. It is not an advised primary treatment for older patients with significant loose tissue in the neck or on the sides of the face. This is where a traditional facelift is indicated and produces far superior effects and is a better return on one’s investment. Patients that have had a traditional facelift that needs some maintenance treatments, however, may be good candidates for a liquid rejuvenative approach.

Like any form of a facelift, none produce permanent effects. They treat the symptoms of aging but do not cure the fundamental problem. Any facelift that removes tissue and/or resuspends it will have results that persist for years. Liquid facelift have far shorter facial rejuvenative effects often limited to the duration of the injected filler material. (one year or less for many injected fillers)

Dr. Barry Eppley

Indianapolis, Indiana

Great Auricular Nerve Branches in Facelift Surgery

Saturday, March 25th, 2017


Greater Auricular Nerve in Facelift SurgeryThe most common injury that occurs from a facelift is to the greater auricular nerve. This is a large sensory nerve comprised of fibers from C2 and C3 spinal nerves that supplies sensation to the ear and the skin over the parotid gland and mastoid process. It is located across of the sternocleidomastoid muscle where it ascends parotid gland where it bifurcates into anterior and posterior branches. It is this location of the nerve that makes it susceptible to injury during the raising of the facelift skin flap.

The classic teaching in facelift surgery to avoid injury to the greater auricular nerve is to identify the McKinney point. This point represents the location of the nerve trunk which is 6.5 cms below the ear canal on the sternocleidomastoid muscle. Further delineation of the nerve distribution was described by Ozturk with a 30 degree angle from the Frankfort horizontal plane which outlines the region of nerve distribution. Staying right under the skin and above the fascia over this area will avoid inadvertent nerve injury.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery an article appeared entitled ‘What Is The Lobular Branch of the Great Auricular Nerve? Anatomical Description and Significance in Rhytidectomy’. In fifty cadaver dissection the lobular branch of the greater auricular nerve was dissected out. Various measuremenst were taken to the ear, SMAS and mastoid process. Greater auricular nerve diameter was measured. The branching pattern of the nerve and the location of the branches within the Ozturk 30 degree angle were documented.

Lobular Branch Greater Auricular NerveThe lobular branch existed in all specimens and was distributed to three regions. In the vast majority of the time (85%), the lobular branch was located inferior to the antitragus, in the remaining specimens it was located inferior to the tragus. The path of the lobular branch can be determined before surgery by making two vertical lines from the tragus and antitragus down to the McKinney point. The lobular branch ascends within this marked region. These markings provide guidance to avoid injuring the lobular branch during facelift flap dissection and SMAS elevation.

Dr. Barry Eppley

Indianapolis, Indiana

Male Facelift Strategies

Saturday, February 4th, 2017


According to annual statistics from the American Society of Plastic Surgeons over 100,000 facelift procedures were performed in the U.S. last year. Roughy 10% of them were done in men. While many of the reasons for having a facelift and the surgical techniques used to perform it are not gender specific, there are some distinct differences between men and women in the surgery.

In the February 2017 issue of the journal of Plastic and Reconstructive Surgery, a paper was published on the topic entitled ‘The Modern Male Rhytidectomy: Lessons Learned’. The authors discuss eight (8) key issues that they feel make for a successful male facial rejuvenation result. These include: 1) thicker facial skin 2) stronger flatter brow bones, 3) hairline patterns, 4) less prominent cheekbones, 5) central facial fat atrophy, 6) deeper nasolabial folds and more prominent jowling, 7) loose neck skin and plastysmal banding and 8) higher risks of hematoma. Their recommendations for management of the male facelift patient are based on a twenty year experience with 83 patients.

Their  surgical technique consists of the following: 1) tumescent infiltration of low dose epinephrine solution into both sides of the face and neck, 2) concentrated fat injections into the deep malar fat pads and nasolabial folds from inner thigh fat, 3) retrotragal preauricular incision with either hairline or temporal extension with retroauricular hairline extension, 4) thick skin flap elevation to maintain hair follicle survival, 5) anterior submental platysmaplasty, 6) lateral facial SMASectomy and plication, 7) neck and cheek skin flap lateral vector of elevation, and 8) prolonged use of postoperative drains.

Blood pressure management is a major issue in the male facelift patient as many men have either inadequately or undiagnosed high blood pressure. Hypertensive medications were continued up to the day of surgery as well as after surgery. A clonidine patch or 0.2mg were administered the morning of surgery. During surgery either Labetolol or Hydrolazine was given IV as needed. Postoeprative restrictions were placed on strenuous activities for several weeks after surgery.

Using this protocol 83 male facelifts were performed with an average age of 59 years old.  One-fourth (25%) of the men had a known history of hypertension. Hematomas occurred in 6% of the patients and were all diagnosed within 24 hours of the surgery. All were treated in the operating room

Male Facelift Scars Dr Barry Eppley IndianapolisOne of the key technique differences in the male facelift patient is managing the hairline through incisional placement. The classic teaching is that the perauricular incision should be placed in front of the ear in a skin crease. But this can result in a visible scar in front of the ear or a prominent color mismatch.. A retrotragal incisional placement  produces a better color match. Carrying the incision from the root of the superior helix in a horizontal fashion through the sideburn hair avoids any issues of temporal scarring and hair loss. The postsuricular incision is placed right into the ear sulcus and is backcut at the level of superior concha before trailing down along the edge of the occipital hairline.

A successful and natural looking male facelift requires good incisional placement in and around the ears, preservation of as many hair follicles as possible, central face re-volumization and hypertensive management to avoid hematomas.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Older Female Jaw Angle Implants

Saturday, January 7th, 2017


female-strong-jawline-dr-barry-eppley-indianapolisBackground: The strength of the lower jaw is a known favorable feature for a male. But it has become increasingly desired and requested for women as well. Partially spurned on by various well known celebrities and actresses’ jaw shapes, younger women are seeking stronger jawlines as well.

An important part, and until recently overlooked, of a well defined jawline is the jaw angles. When patients refer to a ‘stronger jawline’ they are usually referring to the jaw angle area. A well defined and prominent jaw angle is one that is clearly seen from the front view and often creates more of a V-shape to the jawline. While once considered more masculine, a female with more prominent jaw angles are now seen as youthful and atractive.

One unexpected but favorable effect of jaw angle augmentation is that it provides a lift along the jawline. Making a stronger jaw angle requires increased soft tissue coverage. This recruits tissue from the neck to cover the increased bony prominence. This can have a favorable effect in the older patient who has developed loose skin along the jawline and posterior neck.

Case Study: This 61 year-old female was to undergo a variety of facial rejuvenation procedures. One of her requested procedures was jaw angle augmentation. She wanted more defined jaw angles and v-shaped jawline. She previously had a facelift.

female-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, she had medium widening jaw angle implants placed through posterior intraoral incisions. The implants were placed under the masseter muscle, snuugly fitting up against the existing bone angle posterior and inferior contour.


A more sharply defined jaw angle has both a jawline reshaping effect and a lower facial rejuvenative influence in older patients. Even in the older female patient who has already had a facelift, a stronger jaw angle adds to a rejuvenated jawline.


1) Jaw angle implants add shape and definition to the back part of the jaw/lower face.

2) Females are having an increased interest in the shape and definition of their jawline.

3) In older females a stronger jaw angle can fill out loose skin and give a bit of a facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facelift with Earlobe Reduction

Sunday, December 18th, 2016


Background: Facelift surgery is one of the most recognized of all the facial rejuvenation operations. There are a lot of misconceptions about what a facelift is and what it can accomplish. But at its fundamental core it improves the lower face by relocating loose skin from the neck and jowls up and back towards the ear where it can be removed with more hidden incisions around the ears.

But within a facelift procedure are many moving parts consisting of different maneuvers. These include such techniques as various SMAS manipulations, liposuction, fat grafting, implants and laser resurfacing. All of these are complementary procedures to either enhance the facelift result or improve its longevity. Fat grafting and laser resurfacing offer very helpful skin rejuvenation benefits, something a facelift alone does not to.

One uncommon but very helpful addition to a facelift is that of earlobe reduction. Some patients have fairly large earlobes which is a common finding with aging. Since the facelift incisions go in and around the ear it is a good time to consider a simultaneous earlobe reduction.

Case Study: This 68 year-old female wanted to improve her facial appearance and get rid of her sagging neck. She has spent much of her life being a sun worshipper/tanner which was reflected in her leathery type skin and numerous brown spots. She also had fairly large earlobes.

mvfacelift-frontUnder general anesthesia she had a full lower facelift with SMAS flap elevation and plication. During the closure of the facelift incisions a inferior helical rim earlobe reduction was performed. She went on to have in office laser resurfacing treatments six weeks after surgery.

mvfacelift-resultlong-earlobe-facelift-result-side-viewHer four month result showed a much improved neck and jawline as well as earlobes that were smaller than before surgery.

facelift-earlobe-reduction-result-side-viewfacelift-earlobe-reduction-result-side-view-copyThe relevance of earlobe reduction as part of a neck lift is that they often can appear larger afterwards. At the least earlobes will always develop a lot of swelling after surgery since the lymphatic drainage of the ear is partially disrupted by the near circumferential facelift incision. In ears that are marginally large the earlobe can appear enormous in the first few weeks after surgery. When in doubt even the marginally enlarged earlobe should be reduced.


1) A traditional facelift is a lower facial procedure that addresses the jawline and neck.

2) A lower facelift can be combined with simultaneous laser resurfacing or it can be done shortly after for an even better rejuvenative result.

3) An earlobe reduction can also be done at the same time as a facelift to ensure that they do not even look bigger afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Cheekbone Reduction and Facelift Surgery

Monday, July 25th, 2016


Cheekbone reduction is a common facial skeletal procedure done for aesthetic purposes in Asians. It is not done exclusively in Asians, as many different ethnic groups can have wide cheeks, but the vast majority are.

One of the main risks of cheekbone reduction is sagging of the attached soft tissues. This can be avoided by how the osteotomy is done and with good bone fixation. But in older patients who are already predisposed to loose cheek tissues this risk becomes magnified. It has been suggested that the risk cheek sagging can be prevented by combining a facelift procedure with cheekbone reduction in older patients. This can help create an oval and youthful midface.

In the August 2016 issue of the Annals of Plastic Surgery an article was published entitled ‘Reduction Malarplasty With Face-Lift for Older Asians With Prominent Zygoma’. In this clinical series over 20 older Asian women had a combined cheekbone reduction facelift procedures for their prominent zygomas and aging faces. The cheekbone reduction was done using an L-shaped osteotomy pattern. The facelift was performed in a usual fashion. All of the patients recover successfully with any major complications. The prominence of the cheekbone and sagging midface tissues were improved and the natural midface contour was preserved. Near one hundred percent satisfaction with the improved midface shape as well as rejuvenation of midface was achieved.

The most important aspect of this paper to me is that the performance of a facial skeletal osteotomy and a soft tissue suspension does not work against each other. In other words, the swelling from the cheekbone reduction does not stretch out the facelift result. This would have been my concern and it is good to read that this does not appear to occur.

There was no doubt that the facelift would provide a protective function against any cheek sagging. This is a useful combination of facial procedures to restore the youthful and proportionate facial relationships in older Asian patients. Or for any cheekbone reduction procedure done in an older patient regardless of their ethnicity.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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