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Dr. Barry Eppley

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Archive for the ‘facelift’ Category

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

Short Scar vs Full Incision Facelift

Sunday, June 5th, 2016


Facelift surgery is far from a homogenous procedure. Since its introduction over one hundred years ago there have been a large number of facelift techniques used, all claiming some aspect of superiority in either results or recovery. Despite claims from many surgeons, little scientific evidence exists that supports the superiority of one facelifting technique over another.

Short Scar Facelift Indianapolis Dr Barry EppleyShort Scar Facelift Dr Barry Eppley IndianapolisA very popular facelift technique that has emerged in the past decade or so has been the short scar facelift. This facelifting method places no incisions on the back of the ear. Besides the elimination of any postauricular scarring and more limited dissection, it also has an associated quicker recovery. While popular amongst potential patients, many plastic surgeons believe that a short scar facelift does not produces limited and subpar neck improvement.

In the June 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘A Comparison of the Full and Short-Scar Facelift Incision Techniques in Multiple Sets of Identical Twins’. Using four sets of identical twins and one set of identical triplets, different types of facelift surgery were performed in a randomized with the first born twin undergoing the more complete full incision facelift. Short (one year) and long-term (five years) patient photographs were assessed. No difference was found at one year but at five years the full incision technique showed superior and more sustained neck results.

The differences between facelift techniques is very hard to compare because of a wide variety of factors of which the most noteworthy is anatomic and genetic dissimilarities between patients. Only in genetically identical patients at the same age using the same surgeon and the same surgical techniques could real facelift comparison be done. Such a study would seem impossible…until this study appeared in print. While the patient numbers in this study are understandably low, their results have value nonetheless.

What this study shows is what most plastic surgeons believe…that a full incision facelift more effectively improves the aging neck. The larger amount of undermining is the reason for the neck improvement and its sustained improvement several years later.

This study is not a condemnation of the short scar facelift. Rather it supports that patient selection is the key for any type of facelifting technique. If one does not have significant neck issues and the jowls and a deepening nasolabial fold are the main concerns, then a short scar technique is fine. But if the neck is an important part of the patient’s concerns also then a full incision technique would be preferred.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Facelift

Monday, May 9th, 2016


Background:  Just like women, men have concerns about facial aging and undergo surgical procedures to improve their appearance. While men do have have facial rejuvenation procedures in the numbers that women do, they have surgery which historically is often later when the aging face problems may be more advanced.

There are numerous characteristics that separate men from women in undergoing facial procedures and facelift surgery is no exception. The key difference in this procedure in the presence of beard skin and the location and density of the hairline around the ear incisions. Keeping beard hair out of the ear and not making visible scars that stray far from the shadow of the ear are key considerations in surgical planning.

Case Study: This 47 year-old male presented after having had a ‘necklift’ by another surgeon. He had scars behind his ears but none in front of his ears. The scars behind the ear were low and back along the occipital hairline. He noticed no significant improvement from this type of necklifting operation.

Male Lower Facelift result side view Dr Barry Eppley IndianapolisUnder general anesthesia, he underwent a more traditional lower facelift approach using a  preauricular incision as well as his existing incisions behind his ears. A submental incision was also added to address the central neck area.

Male Lower Facelift result oblique view Dr Barry Eppley IndianapolisMale Lower Facelift result front view Dr Barry Eppley IndianapolisHis one year after surgery results showed sustained improvement in his neck and jawline that looked natural. His surgical experience shows that neck and jawline improvement really can’t be achieved with incisions that are limited to just behind the ear. It is an appealing approach but without tissue undermining in front of the ear that permits an anterior axis of rotation, the neck and jawline can not really be improved.

Male Facelift ScarThe preauricular incision in the male facelift, while usually healing quite well, will shorten the distance of the non-beard skin area in front of the ear. This is unavoidable ut not usually detectable by most people.


1) The interest of most men in treating facial aging is in the neck and jowl sagging that develops

2) The male facelift usually uses a preauricular ear incision to avoid displacement of the beard skin onto the ear tragus.

3)  Men seek a natural facelift result which has nearly undetectable scars and a smooth and non-tense skin appearance across the lower face and neck.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Type 1 Facelift

Saturday, February 20th, 2016

Background: Aging affects faces at different rates but the overall effect is the same. The face slowly sags with skin hanging over the jawline and the neck tissues becoming loose. Because facial aging occurs differently, the type and extent of its treatment should also differ.

The facelift remains as the definitive treatment of the lower face. While many different non-surgical treatments have been described and are available for lower facial aging, they all fall short of what the facelift operation can do. No non-surgical treatment can lift and tighten loose face and neck skin like removing and tightening facial tissues can do.

The fundamentals of facelift surgery are largely the same regardless of the method used. But the extent of the procedure can be altered to be less extensive based on either treating less severe forms of facial aging or doing a ‘repeat’ or secondary facelift.

Case Study: This 55 year-old female had some loose skin along her jawline and neck that she wanted gone. She was very thin and had little subcutaneous fat just about anywhere on her face and body.

Female Lower Facelift result side view Dr Barry Eppley IndianapolisFemale Lower facelift result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, she had a type 1 facelift performed. In this type of facelift, a short skin facelift flap is raised from around the front and back of the ear to the level of the nasolabial fold and to just shy of the center of the neck. The deeper SMAS layer is plicated upward by a horizontal row of sutures below the zygomatic arch and a vertical row in front of the ear. The skin is redraped, excised and closed in the traditional manner around the ear.

Female Lower Facelift result front view Dr Barry Eppley IndianapolisThe type 1 facelift is a more limited facial rejuvenation procedure based on the extent of the facial aging pattern. It goes by many different names (Lifestyle Lift, Quicklift, mini facelift, Light Lift, Featherlift etc) and within each one lies subtle technique differences. But they all share the more limited dissection approach and are best used when the extent of facial aging is also more limited.


1 The type 1 facelift may also be called a mini-facelift or a jowl tuckup procedure.

2) The early signs of facial aging can be corrected by a short skin flap and SMAS plication.

3) The this type of surgical facial rejuvenation procedure has a very rapid recovery and one can look very socially acceptanle at one week after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Pixie Ear Deformity Correction in Small Earlobes

Saturday, February 20th, 2016


pixie ear deformityThe Pixie ear deformity is a well described adverse after effect from a facelift.  It is seen as an aesthetic postoperative anomaly where the lower portion of the earlobe is attached to the side of the face without a notch at the earlobe-face junction. In short, the earlobe looks pulled down. It is caused by a variety of issues including over aggressive elevation and removal of skin, lack of deeper tissue support and poor management of the earlobe during closure of facelift incisions.

A variety of surgical techniques have been used to correct the pixie earlobe deformities. These include a V-Y release and elevation of the earlobe and redoing a portion of the facelift to get the skin to sit up higher under the earlobe. The V-Y release, although very effective, results in visible scars below the earlobes. Re-doing a portion ofmthe facelift is unappealing given the extent of the procedure.

In the Online First edition of the July 2015 issue of Annals of Plastic Surgery, a case report was published entitled ‘A Novel Method for Correction of the Hypoplastic Pixie Earlobe Deformity: V-Y Advancement Flap and Dermofat Graft’. The authors describe a novel technique method for the correction of pixie ear deformity in patients with small ear lobules. Rather than  re-doing the facelift and tucking it up under the earlobe, the reverse approach was used.  The small earlobe was expanded by a V-Y advancement skin flap on the back of the earlobe. A dermal-fat graft was inserted under the skin of the advanced flap to prevent retraction. In essence the pixie ear lobe deformity was camouflaged by making the earlobe longer. This is done while making no scars on the front or the bottom of the earlobe. This allows for a natural appearance of the earlobe to be attained.

While the pixie earlobe deformity after a facelift can be treated by numerous methods, the small earlobe presents the opportunity to use a reverse approach from the traditional re-rotation of the facelift skin flaps. It is inherently more stable to bring the earlobe down than it is to pull the skin on the sides of the face up.

Dr. Barry Eppley

Indianapolis, Indiana

The Type I Facelift

Sunday, January 10th, 2016


When people think of facelift surgery, they usually envision an extensive and a one procedure fits all type of operation. But the reality is that not all patients have the same type of facelifting procedure as facial aging affects different ages and people in various degrees. Because of these variable age-related effects,  facelifts can be categorized into three basic types based on the extent of tissues needed to be manipulated during the procedure.

The extent of skin flap elevation, what type of neck procedures are done and the type of SMAS manipulation are what separates the three basic categories of facelift surgery.

The type I facelift is known by many names such as a mini facelift, short scar facelift, MACS lift, Lifestyle Lift, and Quicklift to list the most commonly used terms. The basic components of this limited facelift is a shorter postauricular and temporal incisions, absence of any neck work (other than liposuction) and a SMAS plication technique. In essence it is a smaller operation that is designed to treat smaller facial aging problems.

One of its fundamental features is that the raised skin flap does not extend into the neck. And any neck skin flap raised does not connect with that of the side of the face. With a lesser extent of skin flap undermining the amount of skin tightening is limited

Limitred Facelift (Quicklift) results right oblique view Dr Barry Eppley IndianapolisLimited Facelift (Quicklift) results side view Dr Barry Eppley IndianapolisA type I facelift can be used for younger patients who have the early signs of aging such as the development of jowls and some initial neck sag. They do not have significant neck skin sag nor obvious platysmal banding. There is loss of a smooth jawline due to downward drift of the skin from the side of the face.

Female Lower facelift result oblique view Dr Barry Eppley IndianapolisFemale Lower Facelift result side view Dr Barry Eppley IndianapolisA type I facelift is also done as a secondary or tuck up facelift years after a primary facelift. To help maintain the facial and neck results from a prior procedure, maintenance sin tightening will eventually be needed.

One of the beneficial features of a smaller invasive operation is that many adjunctive anti-aging procedures can be combined with it. Full face fractional laser resurfacing and TCA chemical peels can be safely done for skin rejuvenation and wrinkle reduction. Fat grafting and facial implants for facial soft tissue volume and skeletal augmentation can provide facial feature enhancements at the same time as achieving a smoother jawline and an improved neck shape.

Because a type I facelift is less invasive the recovery associated with it is also shorter. One can usually look pretty good at just 7 to 10 days after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Facelift Incision Planning

Thursday, January 7th, 2016


Incision planning and execution is one of the most overlooked aspects of facelift surgery. While patients may get caught up in the details of whether and how the SMAS is manipulated, for example, facelift incisions actually are more crucial to a successful outcome and the long term satisfaction from a facelift. Visible scars or changes to the hairline are the most frequent source of patient dissatisfaction which can mar an otherwise good facelift result. An unaltered hairline that permits patients to have the freedom to wear their hairstyle as they choose and near invisble often separates the good from the ‘bad’ facelift result.

There are three key techniques in planning facelift incisions. These include anterior hairline management (preauricular tuft of hair and sideburn) and preauricular and postauricular incision placement.

Every patient, both female and male, has a different width and location of the lower end of the sideburn (in females it is called the preauricular tuft) as it extends downard of the superior attachment of the helix of the ear. For a low sitting sideburn (1 to 2 cms below the ear), the preauricular incision can extend upward in a curved design into the temporal hairline. This will allow for some slight upward and backward translocation of the hairline but not excessively so. As long as the hairline is lifted no higher than the level of the attachment of the ear, it will still look natural. The curved temporal portion of the incision will resist scar contracture and an obvious line of alopecia.

If the sideburn is naturally at the level of the ear, then the incision must be made along the bottom edge of the hairline. This will allow the cheek and lateral facial tissues to be lift without changing the sideburn location. This is what is referred to as a hairine blocking incision.

female facelift incision dr barry eppley indianapolisMale Facelift Scars Dr Barry Eppley Indianapolis 2For the rest of the preauricular incision down and around the earlobe, there has been an historic debate between a pretragal or retrotragal placement. Some facelift techniques, like that of the Lifestyle Lift or Quicklift, teach an incision that stays in front of the tragus. But I think most plastic surgeons would agree today that an incision placed on the back edge of the tragus provides better scar camouflage as that portion of the incision is inside the ear. The pretragal approach may be good for those patients that have a lot of hair in front of their ear (most men) where you don’t want to carry hair back onto the tragus with the skin lift.

On the back of the ear, the postauricular incision should be placed a few millimeters onto the back of the ear so that the final scar line will settle into the actual sulcus and not outward onto the mastoid skin. At some point the incision must move away from the back of the ear towards and into the postauricular hairline for any significant neck skin translocation to occur. This is best done at the level of the tragus as the distance from the postauricular hairline and the shadow of the back of the ear gets closer at this point. Many facelift patients do not need an extended incision into or along the postauricular hairline unless there is a large amount of neck that needs to be moved back. In these cases the incision is carried back back into the postauricular hair rather than following the hairline down into the anterior neck.

Proper incision placement, while not the only important part of a facelift, makes the operation look natural with good scar camouflage and unaltered hairlines.

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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