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Archive for the ‘facelift’ Category

Male Facelift Incisions

Monday, December 7th, 2015

 

Facelift surgery is the most effective method for reshaping the aging neck and jawline. While many variations of facelifts exist, each with their own advocates, it is clear that there is no single one best way to perform the surgery. The extent of skin undermining, how the underlying SMAS layer is manipulated and what other procedures are done with the facelift, (e.g., fat injections, cheek and chin implants) dominate the talk about facelift surgery. And while each of these maneuvers has their own merits, the most important outcome of a facelift is whether it is detectable as having been done.

The most distinguishing markers of having had a facelift are the incisions around the ear and whether the hairline around them looks undisturbed. Thus the placement of the ear incisions and how the hairline is managed determines whether the facelift is detectable or not. Visible incision placement, wide scars, distorted earlobes and stepoffs in the temporal or occipital hairlines are assured indicators of surgical manipulation and detectability.

While much of a facelift procedure is the same regardless of gender, the one clear difference is in how the incisions are managed. Beard skin and shorter hairstyles are what makes facelift incisions between men and women potentially different. While the retrotragal preauricular incision (behind the tragus in the front of the ear) is the standard for women, beard skin in men requires more thought for the location of this preauricular incision.

Male Facelift Scars Dr Barry Eppley Indianapolis 2Because of the location of the back of the beard hairline near the ear (usually about 1 to 1.5 cms in front of the ear) the choice of either a completely preauricular or partial retrotragal incision influences where the beard skin ends up. The safest way to prevent hair-containing skin from ending up on the tragal skin and inside the ear is to use a completely preauricular incision.This does lose the normal non-hair bearing skin between the ear and the beard skin but at least keeps it off the ear.

older make facelift scarThe other approach to the male facelift incision is to use the same incision as in females. (combined preauricular-retrotragal) This will effectively hide the incision line behind the tragus. But keeping the hair off the tragus is a function of the direction of the undermined skin pull. In men the movement of the skin pull should be largely vertical resulting in some preservation of non-hair bearing skin that ends up being pulled onto the tragus. This is in contrast to a more oblique and posterior skin pull in females who can afford to do so because of their lack of any beard skin.

Besides the aesthetics of the incisional healing around the ears, the placement of male facelift incisions also influences the neck and jawline changes as well. Less dramatic changes in the neck often result in male facelifts because of the care taken to have good incisional healing and displacement of the beard skin onto the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Earlobe Reduction and Facelift Surgery

Thursday, November 5th, 2015

 

A facelift is a very well known facial rejuvenation procedure that has its primary effects on the addressing loose skin and tissues in the neck and jawline. While there are a large number of iterations and varieties of described facelift techniques, they all require incisions around the ears to create their desired effects. While much focus on facelift surgery is on such manipulations as the SMAS or fat grafting, the management of the incision locations and their effect on the ear and the hairine are actually of equal importance.

Facelift Vectors Dr Barry Eppley IndianapolisWhile a debate can be made for whether the facelift incision goes into the ear (retrotragal) or in front of the ear (preauricular), it always goes around the earlobe on its way to behind the ear. One of the key elements of this incision pattern is to not have traction or a downward pulling effect on the earlobe with the raised skin flap to avoid postoperative earlobe distortion. (the so called pixie earlobe deformity)

But another  earlobe consideration before and during a facelift is its size. (vertical length) While facelift surgery will always create a temporary earlobe enlargement due to swelling, a good cradling technique of the skin flap underneath the earlobe from the facelift can also make it bigger. This can be an even be a more exaggerated effect when the earlobe is too large/long before surgery.

Elongated earlobes in women are common as they age due to the weight of ear rings and gravity. While the typical vertical ear length is around 60 to 65mm in women, the elongation of ear size comes from the earlobe with aging. When the earlobe makes up more than 1/3 of total ear size, it is judged as too long.

Faceliftv Earlobe Reduction marking Dr Barry Eppley IndianapolisFacelift Earlobe Reduction result Dr Barry Eppley IndianapolisEarlobe reduction can be performed at the same time as a facelift. The best technique to do so is a helical rim reduction after the completion of a facelift. This allows maximal earlobe reduction to be done without comprising vascular perfusion to the earlobe or disrupting the incisional closure of the facelift incisions.

Earlobe reduction is a simple procedure that adds little extra time to facelift surgery and can help improve its aesthetic results. It requires preoperative awareness of ear size and the awareness of the impact of a facelift surgery on their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

The Liquid Facelift – What It Is and Isn’t

Sunday, September 6th, 2015

The well known procedures of anti-aging facial plastic surgery continue to be debated as to which techniques are best. (e.g., facelift)  And those debates will undoubtably continue for decades to come as the differences in them are often subtle and no matter how it is done it is still a surgical procedure. In contrast, the number of options of non-surgical facial rejuvenation procedures continues with growing numbers of injectable fillers, neuromodulators and skin tightening devices.

liquid facelift indianapolisOne of the most well known but least understood injectable facial rejuvenation procedure is that of the Liquid Facelift. This office-based procedure is an amalgamation of neurotoxins (like Botox, Dysport and Xeomin) combined with a variety of different injectable fillers. (e.g., Juvederm, Voluma) These are often combined with some skin resurfacing tightening procedure like a chemical peel, fractional laser resurfacing or pulsed light therapies. Because it is non-surgical, a Liquid Facelift has next to no downtime, requires no anesthesia and its full effects are evident within days to a week after it is done.

It is touted as a procedure that can take years off the face and can maintain or restore a youthful glow without surgery. While all three techniques (wrinkle weakening, adding facial volume and skin tightening/resurfacing) work synergetically, the back bone of the procedure as the name implies is the injectable filler part. Fillers add volume and with today’s number of injectable filler options exceeding a dozen, the choices are numerous most of which are hyaluronic-acid based. But almost no matter which FDA-approved injectable filler is used, they are all temporary with the exception of one. (Bellacol which contains small plastic non-resorbable beads) It is only question of how long they will last.

The volume effect of the injectable fillers is designed for the midface to add fullness and help create more of a V effect. Whether it really does much lifting can be debated but what it can do is increase cheek and midfacial contours. This can counteract the geometric effect when facial tissues fall (inverted V) and can correct cheek hollows from fat loss. The intent of creating this midfacial effect has led to the Liquid Facelift also being called the Liquid V-Lift.

While the Liquid Facelift has its place in facial rejuvenation, it should not be confused with what a surgical facelift can accomplish. These differences make it critical for patient selection and expectations. While age along is not the only factor, a Liquid Facelift is really for younger patients with early signs of facial aging that do not have a lot of loose skin. Significant jowls and turkey waddles are not going to get improved by an amount of volume addition or superficial skin tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Submandibular Gland Removal in Facelift Surgery

Wednesday, September 2nd, 2015

Creating a much improved neck shape is one of the primary goals of a facelift. (aka lower  facelift or necklift) Manipulating the neck tissues of the skin, fat and platysmal muscle are standard therapies and will create very pleasing changes in the vast majority of facial aging patients. The other structure of the neck that can cause some undesireable neck contour changes is that of the submandibular gland. In some patients a low position of the submandibular gland or submandibular gland ptosis can create an unaesthetic bulge on the sides of the neck. As a s result some plastic surgeons advocate submandibular gland removal for an improved neck contouring result.

submandibular glandsThe submandibular glands are paired structures at the side of the neck that lie above the digastric muscle. They can be felt just below the lower edge of the jaw (mandible) on each side of the neck particulalry if one tilts their head forward. Technically the submandibular glands have two lobes of which the largest is the superficial lobe with the mylohyoid muscle running under it. There is a common duct that drains the gland into the mouth which runs around the back edge of the mylohyoid muscle. While it is one of the major salivary glands it does not produce as much saliva as that of the larger parotid glands.

In the September 2013 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Submandibular Gland Reduction in Aesthetic Surgery of the Neck: Review of 112 Consecutive Cases’. This was a retrospective review of 112 facelift patients in which the submandibular glands were removed over a ten year period. These patients represented around 13% of all primary facelifts done and 25% of secondary facelifts. The vast majority of patients were women. (almost 90%)  Major complications averaged 2% which were due to bleeding. (one patients died) More minor complications that eventually resolved on their own were occurred around 11% including salivary gland leak and facial nerve weakness. (marginal mandibular nerve palsy) No patient reported any permanent dry mouth. problems.

While submandibular gland removal can be done during a facelift through the large skin flap raised,  complications can occur from bleeding, nerve weakness and a salivary leak. These do add to the list of complications from a facelift and indicate their should be a compelling reason for submandibular gland removal for aesthetic purposes. This study is an impressive number of patients who had this complementary procedure as part of their facelifts and provide evidence that, while not a procedure without risk, those risks are fairly low and manageable.

Dr. Barry Eppley

Indianapolis, Indiana

Facelift Surgery Satisfaction

Sunday, August 9th, 2015

 

Facelift Surgery Dr Barry Eppley IndianapolisFacelift surgery is one of the most commonly performed anti-aging facial procedures and certainly one that is historically highly associated with plastic surgery. In the U.S. alone over 125,000 facelift procedures are performed per year. It is felt that a facelift produces a highly satisfied patient given the amount of improvement seen in before and after photographs. While facelifts like any other aesthetic procedure can have complications they are fortunately very low given the excellent blood supply to the facial tissues. A low rate of complications also contributes to higher patient satisfaction.

The few studies that have been conducted on facelift satisfaction have not used rigorous scientific outcome methodology which makes their determinations potentially overstated. One method of quantitating patient satisfaction is using a standardized outcome tool . The FACE-Q is an established validation questionnaire that has been used in aesthetic surgery for assessing patient satisfaction and outcomes for a variety of aesthetic facial procedures.

In the August 2015 issue of the journal Plastic and Reconstructive Surgery an article appeared entitled ‘Facelift Satisfaction Using the FACE-Q’. In this paper the authors reviewed their outcome experience in 53 patients who had a high SMAS facelift technique with submental platysmal plication using the FACE-Q questionnaire assessment. Their results showed that patients had very high satisfaction rates as judged by facial appearance and quality of life parameters. (social confidence, psychological well being and early life impact) Patients felt that they appeared seven (7) years younger than their actual age. Patients were most highly satisfied with the improvement in their nasolabial folds, cheeks and lower face/jawline and secondarily in the appearance of their neck and area under the chin.

In this patient series the authors used one specific type of facelift technique. It is important to realize that there are many different types of facelift methods, each with their own advantages and disadvantages as well as advocates. There is probably no ideal facelift method and the skill and experience of the surgeon is probably more important than any one facelift technique.

Combined Facelift and Chin Implant resultIt is interesting that in this outcomes study that patients saw significant improvement in the nasolabial folds, an area that I always point out to patients that will see little if any improvement from a facelift procedure. Conversely the jawline and neck angle, areas that are perceived as getting the greatest improvements from a facelift, actually were rated lower. This ‘disconnect’ between patient and surgeon perception is interesting and defies an exact explanation. But perception is reality and it is encouraging to note that patients see an effect greater than what one would think.

Dr. Barry Eppley

Indianapolis, Indiana

Combining Laser Resurfacing and Facelift Surgery

Sunday, April 5th, 2015

 

Facelift surgery addresses sagging and loose tissues that have fallen due to aging. To a large degree facelifts are a tissue resuspension method which uses some tissue excision (skin and fat) to create the effect. However, a facelift in and of itself, does not change many of the more superficial lines and wrinkles on the overlying skin. Some wrinkle reduction occurs near the incisions in and around the ears due to the pull of the tissues but more central facial wrinkling remains unchanged.

Laser Resurfacing Face Dr Barry Eppley IndianapolisLaser resurfacing is well known to be the best treatment for superficial lines and wrinkles that we currently have. It is an ideal complement to a facelift as it addresses an aging problem that tissue rearrangement will not improve. Historically it has been often done at the time of a facelift around the mouth area…not only because it addresses a facial area that a facelift does not but also because it is safe do as the skin area treated has not been undermined. (partially devascularized)

In the March 2015 issue of Plastic and Reconstructive Surgery, the article entitled ‘Laser Resurfacing at the time of Rhytidectomy’ was published. Over a fourteen year period the authors performed eight-five (85) facelifts with concurrent erbium laser resurfacing.  Some patients were treated just around the mouth while others had full face treatment. No wound healing complications occurred in the perioral resurfacing group. One patient had moderate hyperpigmentation. There was one case of delayed wound healing and prolonged swelling in the group that had their full face resurfaced. No instances of hypopigmentation or flap necrosis occurred. The overall complication rate was just under 4%. There was a statistically significant difference when comparing number of complications between the facial laser resurfacing area with the full face group potentially being significant. (p = 0.037). Though a significant difference in the number of complications between treatment groups existed, the authors were not able to attribute this exclusively solely to the extentof laser resurfacing.

This paper’s experience as well as that of others shows that, for the most part, simultaneous laser resurfacing and a facelift can be safely performed. The key is that the depth of the laser should not be very deep over the undermined lateral facial skin flaps. The more superficial its depth near the ear, there is little risk of skin flap devascularization.

The other issue to consider with laser resurfacing in the facelift patient is its impact on recovery. The laser injury to the skin causes greater swelling and a more difficult first few days after the procedure when done in a full face manner. When done only around the mouth this is less of a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Lifestyle Lift Company Suspends Business Operations

Monday, March 9th, 2015

 

Lfestyle Lift procedureThe Lifestyle Lift is a fairly well known cosmetic procedure due to extensive marketing and long-term branding efforts. It represents one of the few plastic surgery operations that has become ‘franchised’ and turned into a medical commodity of sorts. This is very different and much more difficult than what occurs with drugs and devices which by definition are already packaged and priced. What started out as selling a procedure (Lifestyle Lift) eventually morphed into creating a nationwide chain of plastic surgery centers.  It was hard to overlook them, both physician and patients alike, due to their heavy promotions in magazines and TV ads.

On March 2, 2015, the Lifestyle lift company abruptly shut down the majority of its businesses. Speculation abounds as to why and the company has not explained its reasons, other than bankruptcy, or whether it may eventually reorganize and re-emerge. One can only assume that the cost of doing business (marketing) surpassed its revenues for too long.

Lifestyle LIftWhatever may be the outcome of the Lifestyle Lift ‘story’, it shows how tricky packaging and selling an elective operation can be when done on a grand scale. The premise of the Lifestyle Lift was initially based on offering a mini-facelift operation done under local anesthesia as an office procedure at a discount price. The typical prices for these operations were often about half of that offered by many plastic surgeons and certainly far less than a ‘full’ facelift. In addition, the operation promoted a quick recovery and minimal downtime. Their ads were compelling with the before and after results shown although many questioned whether a mini-facelift alone could produce such results.

The appeal to prospective patients was obvious…low cost, little recovery and results that showed (and indirectly promised) a facial rejuvenation outcome that was almost too good to be true. For some patients good results were almost certainly obtained but there is no denying that there was also a significant contingent of patients who were either unsatisfied and with some that developed actual complications. Whether their rate of complications was higher than that of other facelifts will never be known.

The Lifestyle Lift saga illustrates that it is hard to create and sell a ‘one operation fits all approach’  when it comes to treating facial aging. The effects of time, gravity and the environment on the face are highly variable. Many patients are drawn to a mini-facelift, due to recovery or budget, when they really need a more extensive facial rejuvenative effort. As a result they can be easily sold and are ripe for disappointment when their mini procedure fails to deliver a maximum result. Like in all of plastic surgery patient selection and education is paramount and that can easily be overlooked when trying to make production numbers.

Dr. Barry Eppley

Indianapolis, Indiana

Facelifts in Weight Loss Patients

Tuesday, February 3rd, 2015

 

There are many bodily changes that take place when one loses a lot of weight and they are well recognized as general skin and soft tissue sag. But the face is not immune to weight loss changes. It creates equal issues of volume loss and sag resulting in a droopy deflated face and obvious turkey neck deformities. In young patients this effect makes them look older and saggy while in older patients it just makes them look even older even though they have dramatically improved a significant medical problem. (their weight)

The treatment of the weight loss face and neck is largely a lower facelift. This is the only way to redrape the loose skin over the neck and jawline. But the weight loss patient also suffers from volume deflation in such areas as the cheeks and temples. This makes weight loss facelifts unique and with slightly different considerations than many of the typical facial aging patients.

In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Face Lifting in the Massive Weight Loss Patient: Modifications of Our Technique for This Population’. Twenty two weight loss facelift patients (15 women, 7 men) were retrospectively reviewed. The average of the patients were around 52 years old with average body mass indexes of 26. Most (near 90%) had noticeable volume loss in the midface and nasolabial folds, 60% has perioral volume loss and over 80% had platysmal bands. For their facelift techniques, 90% had some form of SMASectomy and all patients received fat grafting. The average amount of fat grafting was over 20mls.

This paper highlights techniques that can improve facelift results in weight loss patients. These include extensive fat grafting the cheeks and aggressive SMAS manipulations with sutures to resist the pull down effect of heavy skin. The SMASectomy involves an oblique excision of redundant SMAS which parallels the nasolabial fold and extends from the cheek down to the jaw angle.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Submental Rebound Relaxation After Facelift

Tuesday, December 16th, 2014

 

Background: A facelift is one of the most well known but also misunderstood of the anti-aging facial surgical procedures. Besides the frequent misinterpretation of what a facelift really is, there is also the confusion added to it by the marketing of many ‘franchise’ forms of facelifts which promise big changes with limited recovery. Numerous other minimally invasive to non-surgical types of lifts created by fillers and energy-based devices add to the mix of ‘facelift’ options.

Facelift Vectors Dr Barry Eppley IndianapolisBut moving beyond what constitutes a facelift are other important concepts such as the results and its short and long-term effects. Patients often ask how long a facelift lasts with  an understanding that it is not a permanent result. Like the onward march of time, aging will continue and the results of most facelifts will eventually be lost. (perhaps not completely but some of its effects will surely dissipate)

The most noticeable change will be in the neck and it should be divided into a short-term and a long-term change. The long-term change is obvious and refers to when one may return to what they looked like before the surgery. Estimates vary and no one number can factor in all the patient variables but the time frame of 8 to 12 years is often quoted. But a potential short-term change is often overlooked…a phenomenon known as rebound relaxation.

Case Study: This 65 year-old female wanted to improve her sagging neck and jowls. While the upper portion of her face had similar aging changes, these were not of concern to her. She stated that she did not look this way until about ten years ago when it started.

Necklift result Dr Barry Eppley Indianapolis side viewUnder general anesthesia, a full lower facelift was performed including neck defatting, platysmal plication and SMAS imbrication. Enough skin was mobilized back up over the ears that the entire ear had to be cut out from the mobilized skin redraping during closure.

Necklift result Dr Barry Eppley Indianapolis oblique viewNecklift result Dr Barry Eppley Indianapolis front viewAfter a full recovery, she had a great result with a fairly sharp cervicomental angle and no evident loose neck skin. When seen at six months after the procedure, she still had a very significant change but there had developed a small amount of loose skin or banding in the submental region under the chin. This was not an aesthetic concern to her not did she want anything done about it. She felt she had aged an ‘additional six months’ since the surgery.

Almost no matter how ‘tight’a facelift may be done, the ability of the result to hold is partially dependent on the elasticity of the skin. To no surprise, older aged skin has lost a lot of elasticity and will exhibit some relapse or skin relaxation afterward. This is usually seen in the submental region which is most distant from the point of pull of a facelift.(ears) These submental changes are not aging but a secondary skin relaxation phenomenon which is not usually seen until three to six months after surgery. Sometimes it does not become evident until about one year after the procedure. A submentoplasty procedure can be done to ‘touch up’ the facelift result and attacks this problem through direct skin excision.

Case Highlights:

1) A lower facelift works by a combination of removal and repositioning with the skin part being the most visible.

2) The vast majority of facelift patients want a natural looking result that is not oevrpulled or has a ‘windswept’ look.

3) Every facelift, no matter how much tissue removed, will undergo some degree of submental relaxation in the first six months after surgery. This should not be construed as recurrent aging or failure of the facelift. A secondary submentoplasty may be needed for optimal neck correction.

Dr. Barry Eppley

Indianapolis, Indiana

Combining Facelift, Cheek Implants and Laser Resurfacing for Total Facial Rejuvenation

Monday, November 3rd, 2014

 

When most people think of facial rejuvenation undertandably the thought a facelift emerges. But contrary to popular perception, a facelift only addresses the lower third of the face. While smoothing out the neck and the jawline provides a youthful improvement, it does not address the middle of the face. Even if it could pulling the middle of the face outward would produce an unnatural distortion and is rarely the answer to midface rejuvenation.

Loss of facial volume and removal of tissue support is a well recognized mechanism of facial aging. Thus volume restoration is a very useful approach to helping to reverse midface deflation. This can be done by either malar/submalar implants or fat injections and there are advocates for each approach. Implants tend to produce a more consistent augmentation method that is stable long-term.

Neither a facelift or the addition of volume restoration to the midface will improve the texture of the skin. Chemical peels and laser resurfacing are the known effective approaches for smoothing out fine wrinkles and improving the look of the skin.

A more complete facial rejuvenation approach would include all of these elements from a facelift, midface augmentation and skin resurfacing. In the September 2014 issue of the American Journal of Cosmetic Surgery, an article appeared entitled ‘Total Face Rejuvenation: Simultaneous 3-Plane Surgical Approach Combined With Ablative Laser Resurfacing’. In this paper, a retrospective review of 21 female patients (age 58 to 71 years old) undergoing combined extended-SMAS facelift, mid-ace augmentation with implants, and full-face ablative laser resurfacing by a single surgeon was done. None of the facelift skin flaps suffered any healing problems. The skin healed (re-epitheliazed) within ten days and makeup was able to be worn again within two weeks. One hematoma occurred as well as one implant infection. This study showed that all three facial procedures can be performed at the same time.

It has been historically thought that combing certain procedures, such as laser resurfacing and a facelift, runs the risk of skin loss and other healing problems. But this study shows what has been known now for some time that combining multiple facial rejuvenation procedures is not only safe but necessary in most cases to have the best results. As long as the laser resurfacing is not done too deep over the raised skin flaps of the facelift, a negative effect of skin and incisional healing does not occur.

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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