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Archive for the ‘facelift’ Category

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

Concepts of Facelift Surgery

Tuesday, January 5th, 2016


The natural looking facelift result is the most important goal to most patients that consider or undergo the procedure. Few patients want to look like they have had a facelift or look excessively pulled. (windswept look) Patients desire to set the clock back so to speak and look like a more youthful version of themselves. Having scars that are well hidden and not easily observed by even hairdressers is part of the natural look. Patients are also interested in the time of recovery and may even choose a lesser operation so they can resume normal activities sooner.

Facelift Indianapolis Dr Barry EppleyHaving performed many facelifts over the past twenty years, I have made numerous observations that impact how I perform a facelift today and how I qualify patients for the procedure. One has to look past the marketing names and the hype surrounding many cleverly named facelift procedures to determine what type of procedure they are actually having done.

Since patients today present for facelift surgery at a wide range of ages, their skin quality and looseness and their hair characteristics (density, position and hairstyle) all impact in how the facelift is performed. Generally patients have three main areas of concern about their aging face although in younger patients not all may be present. These include a loose neck with a double chin or neck bands, the development of jowls and lack of a smooth jawline and the appearance of nasolabial fold and marionette lines. Facial wrinkles are also of concern although less than the three previously mentioned concerns.

In discussing facelift surgery with patients, it is extremely important to point out what it does not do as much as what it can do. Patients will often lift up on their cheeks and say this is the change they want. Or because of some social stigmas about having a ‘facelift’, they lift up and back on their neck and say this the change they want but are definitely not interested in any type of ‘facelift’. One of the great misconceptions about this form of facial rejuvenation is that it will lift up drooping mouth corners or remove lip lines. These common misconceptions must be dispelled during the initial consultation as any misunderstanding about them will lead to an early disapppointment after surgery when the swelling has subsided.

The facial aging changes determines the type of facelift that the patient needs. Not every patient needs the exact same type of operation to get a good result. In my experience facelift surgery can be broken down to three basic types based on the amount of surgery needed. These types differ based on the degree of skin undermining (short or long flaps), the type of SMAS manipulation (lateral face) and how the plastymal muscle is treated. (neck)  A In short, a Type 1 facelift is primarily a jowl effacing procedure, a Type 2 facelift treats both the jowls and the neck while a Type 3 facelift is for the extensive turkeynecks or the very heavy neck.

Dr. Barry Eppley

Indianapolis, Indiana

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

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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