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Archive for the ‘facelift’ Category

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.

Highlights:

  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.

cw-jaw-angle-implants

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.

Highlights:

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.

Highlights:

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.

Highlights:

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


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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