We all are aging even as you read this. It is inevitable, it exists all around us, and it is part of everyday life. You might say it is an integral and, maybe even an essential, component of the human condition. As a plastic surgeon, trying to improve or reverse the symptoms of aging is part of our everyday work. This makes us a student of aging and hopefully an astute one.

Recent studies into facial aging has brought new insights into how it happens for many people. Historically, it was believed that faces aged by falling or the descent of facial tissues. Thus the emergence of facelifting operations. Facial and neck skin was moved in an opposite direction to that which the tissues fell, forward and downward. For some patients, there is no doubt this descent is the primary reason that their faces look older as some faces do look better when the skin is lifted and pulled tight. But this is not completely true for everyone.

It is now been shown that volume loss or fat atrophy plays a significant part of what ages many faces. Today’s widespread use of injectable fillers, including fat, is the offspring of this new facial aging understanding. Interestingly, this may have been recognized over a hundred years ago when the first injectable facial fillers were used. Injecting paraffin into facial hollows was done before the turn of the century but was abandoned due to predictably high complications and infections. Synthetic fillers and fat have now emerged as the modern-day version of this old facial aging treatment concept…with more predictable results and much more limited side effects.

As part of this volume loss aging concept is the influence of one’s facial weight. Some faces are fat even when they are older and others are more thin. Usually this facial weight does correlate with one’s body weight and habitus but not always. Heavier faces have thicker skin and they wrinkle less but their heaviness leads to deeper nasolabial folds and marionette lines and ‘meatier’ sagging jowls and necks. Less heavy faces have thinner skin and develop a much larger number of wrinkles particularly around the eyes, forehead and mouth. But they do not develop large amounts of sagging neck and jowl skin until they are quite advanced in years. In essence, fat faces fall while thin faces deflate. For most people, however, their aging is a mixture of varying ratios of falling and thinning.

This new paradigm shift in facial aging understanding allows for dual and often intertwining roles for tissue lifting and volume addition. This is most relevant for those patients in their 40s and 50s where the aging process is not severely advanced and may be visually slowed to a greater degree. More limited facelifting procedures combined with volume enhancement with fat injections can be very effective and not associated with long recovery times.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The  most recognized signs of facial aging is sagging and loose skin.  Therefore, the use of facelifting techniques and other soft tissue suspension procedures have been the foundation of any facial rejuvenation treatment program.  But recent published and presented research in plastic surgery in the past few years has shown that the underlying bone structures over which the soft tissue sags is a contributing cause as well. Bone resorption along facial bony prominences occurs  as well and this contributes to the falling tissue process. As the soft tissues slide off of the face with aging, that process is accentuated by loss of bone structure.

Bone loss with aging has been shown to occur amongst most facial bones. Many studies support these facial findings including changes along the jaw line. Jaw resorption is well known to occur with tooth loss (edentulism) and this is the result of loss of alveolus or the top part of the jaw bones. Recent work has shown, however, that the basal part of the lower jaw changes as well. This area of the jawbone was previously thought to be unaffected with aging.

From a recently presented study from the University of Rochester, new insights have been provided by studying facial CT scans. Researchers used a computer program to measure the length, width, and angle of the lower jaw bone and compared the results for different age groups. CT scans allow for more accurate tmeasurements than traditional jaw x-rays.  Their study shows that he angle of the jaw increases markedly with age, which results in a loss of definition of the lower border of the face. Jaw length and a decline in jaw height also decreases significantly in older age groups.

Since the jaw is the principal support for the lower face, its shape and size affects the overlying soft tissues. As the size of the jaw decreases with age, the soft tissues of the lower face and neck also loses support. This loss of bony volume may contribute to sagging facial skin, decreased chin projection, and loss of jawline definition. As jaw volume decreases, soft tissue of the lower face has less support, resulting in a softer, oval appearance to the lower face and sagging skin, which also affects the aging appearance of the neck.

This raises the question of the role of facial augmentation as part of the rejuvenation strategy to the aging face. Augmenting or increasing the size of facial bones can only be done with implants. The influence of a chin implant with a facelift is a well recognized combination that produces a very noticeable improvement. Is its effect a function of improved chin projection or the appearance of a large jaw bone overall? Would other enhancements of the jaw be equally beneficial? Is jaw angle augmentation (the back end of the jaw) as beneficial as that of the front?

One bone change that I have seen that is particularly advantageous is inferior border augmentation. This can be particularly useful in men. Vertical lengthening of the chin and back along the edge of the jawline adds vertical facial height. This expansion  of jaw volume speaks to exactly what this recent study has shown. No current off-the-shelf implants exist for this application but it would be a useful addition to the current array of available facial implant styles.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

While more women than men undergo facelift procedures, men still make up about 15% to 20% of the facelift population. Men are almost exclusively bothered by a ‘neck waddle’ and usually consider a facelift at an older age than women when this waddle is more significant.

One of the keys to facelifting in men is not too overdo it. I have see many men who have had a facelift and they look a little unnatural at best and some even look more effeminate. I am certain this is not what they were seeking from the procedure. A subtle improvement for men is much better than an overdone dramatic one. Men, understandably, are particularly skiddish about being known as having had a facelift.

 
From a planning and technical standpoint, the male facelift patient differs from the female in one significant way….hair. Both the amount and style of scalp hair and the presence of beard skin changes several aspects of the operation. The placement of the incisions and their eventual obscurity is of critical importance. Like all facelifts, the first and most important goal is to have scars that are difficult to find. No matter how great the neck and jowl result is, or how long the result may last, poor and visible scarring will make that all irrelevant. I have yet to find a patient who wants to advertise that they have had a facelift. (although some results that you have seen scream that they have!)

 
Men have beards which provide both an advantage and a disadvantage. The upward-disappearing sideburn that can occur in women with a facelift (the tuft of hair in front of the ear gets higher) is not an issue for most men. When their existing sideburn gets higher after surgery, they simply start shaving lower regaining the lost sideburn. Most men should even start before facelift surgery in growing longer sideburns so they will be at a normal level after surgery. The diadvantages are that the incision in front of the ear must stay…in front of the ear. It can not be placed partially inside the ear as in women (known as retrotragal) because beard skin will drawn up into the ear which is both a nuisance and not natural looking. In addition, because of the direction of pull behind the ear in a facelift, some beard skin will end up behind the ear necessitating shaving this area. As long as men are advised of this possibility and after surgery requirement, I have not seen it to be a problem.
One final thought on male facelift results…..men do not usually get a particularly dramatic result. Their skin often stretches more than a woman’s making it difficult (and unnecessary) to create a super sharp neck angle. They are also prone to more settling or some ‘relapse’ after surgery due to their thicker heavier skin. As already mentioned, however, men are usually not interested in spectacular changes but prefer less obvious ones. This may be the most important key to the male facelift patient.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As we age, most people will develop lower eyelid prominences otherwise known as lower eyelid bags. Ini addition to the excess skin thaty develops, a big part of these bags is caused by fat coming out from underneath the eye. In plastic surgery, we call this ‘herniated orbital fat’ which has alway been believed to be caused by the weakening of the tissue that runs between the eyelid and the underlying rim of orbital bone. (known as the orbital septum) Much like a hernia, this support tissue becomes weak and allows some of the fat which wraps around the eyeball to come protruding out. As a result, lower eyelid surgery (lower blepharoplasty) has traditionally involved removing this overhanging fat as well as the extra skin to make this area look better and smoother.

A recent study published in the September 2008 issue of the journal, Plastic and Reconstructive Surgery, looked at the progressive development of these lower eyelid fat prominences to try and explain why we see with age. Their objective was to evalute more closely the long-held belief of a fat hernia under the eye. Through MRI studies of forty patients of different ages, measurements were taken of the eye, fat amd surrounding bone. What they found was that the eyeball stayed in the same position throughout life but the amount of fat around the bottom part of the eye actually increased as we age. These measurements suggest that as we age there is actual fat expansion below the eye that accounts for the development of the lower eye bags.

Recent thoughts on aging lower eyelid (blepharoplasy) procedures have leaned toward doing more of a hernia repair rather than relying on traditional excision for management of the lower eyelid bags. These study findings, however, indicate that the removal of lower eyelid fat is still a good thing to do and is an important component of lower eyelid procedures for many aging patients. There is always the concern that removing this fat may make the eye look ‘too hollow’ over time. But this is not something that I have observed nor do I see it reported in the plastic surgery liiterature.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

A smaller lower face has been shown to be more attractive and youthful looking. Recent research (at the University of Texas - Southwestern and published in Plastic and Reconstructive Surgery 2008 by Dr. Joel Pessa) has shown that, as we age, the lower jaw continues to grow more so than the rest of the face. Therefore, there is a change in the shape of the face as we get older that in some patients makes it less attractive. These bony changes combined with the loss of facial fat as one ages accentuates the appearance of age. A youthful face is full which is lost as we age, particularly around the eyes and cheeks. These bone and fat changes make the cheeks more sallow and give the impression, with the development of jowling, that the chin is bigger.

 
Understanding these aging changes provides direction as to how to approach facial rejuvenation surgery in the aging patient. While you can’t make the jaw smaller, you can make it appear smaller by augmentation of the cheek and midface areas. This can be done with either fat grafts or cheek implants. Which one is best must be individualized for each patient. Cheek implants or submalar (under the cheek) implants can help lift a sagging midface as well as provide better cheek projection. If malar crescents (sagging skin from the lower eyelid hanging on the cheek) are significant, then a midface lift may also be done with a lower blepharoplasty to work out the excess skin as well.

 
The lower face and jowling still relies on the ‘traditional’ facelift approach with the objective of eliminating the jowling and tightening up loose neck skin. This effect, combined with cheek volume restoration, helps make the face look younger by changing the disproportions caused by aging.
In the younger patient with early signs of facial aging, injectable facial fillers can be an effective non-surgical approach in the cheek area. When these fillers become more long lasting or even permanent, we will see more of these patients seeking these treatments earlier before the negative facial effects of aging become too noticeable.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Men pose uniquely different challenges than women when it comes to the consideration of facelift surgery. Men age just like women but usually are only concerned with their neck when becomes more of a waddle. As a result, they often are seen in plastic surgery consultation with more advanced facial aging concerns than what one sees in women. Because of their more advanced neck issues and the heaviness of the male skin, minor or more minimally invasive procedures are not going to be effective at making a significant difference in their neck. Only a real facelift procedure will do the trick.

But the typical facelift operation is more difficult in men because of two hair issues….their beard skin and the hairline and quality of hair density (or lack thereof) around their ear area. As the conventional facelift procedure uses incisions in and around the ears, with a subsequent redraping of skin back and over the ear, men will often end up with beard skin behind their ear and potentially even inside their ear after the skin excess is trimmed. For this reason, the male facelift must often use an incision in front of the ear at the junction of the beard and non-hearing skin just in front of the ear to keep hair out of the ear after the operation. Keeping beard skin from ending up behind the ear is difficult and most men should expect that they will have to shave behind their ears after a facelift procedure. ( at least for an inch or behind the ear lobe)

For some men, their sparse hair over the temple areas and around the ear may make a conventional facelift very difficult to do to end up with good camouflaged scars. This is rarely a problem in women. Usually the scar ends up above the ear in the hairline, but with todays’ very short hairstyles particularly in men with thin or little hair,  it may not be very camouflaged and this is a very real consideration and concern. No male wants any area of the facelift scar to be visible so where to end the scar, and how that may affect the outcome of the procedure, must be thoroughly discussed prior to facelift surgery.

Me also will not get as dramatic a change in the neck as women will with a facelift. The heaviness and thickness of male facial skin does not allow it to tightened as much. And the way the facelift must be done in consideration of their hairline will also play a role in the outcome. Men are also prone to more ‘rebound relaxation’ in the jowl and neck area after surgery due to the quality of their skin, another factor that plays into the long-term outcome. Fortunately, men do not usually want a dramatic change anyway from any facial procedure so all of these issues usually add up to a good result that will please most men.

In rare cases of the much older male (usually greater than 65) who has a large neck waddle and does not want or can not undergo a significant operation, the direct neck lift can be an option. Rather than using any incisions around the ears, the loose skin is cut out directly in the neck. This produces a pretty significant change that offers a much more limited recovery. And can be a consideration if the man can accept a scar running vertically down from the chin to the adam’s apple. Surprisingly that scar can heal very nicely due to it being in beard skin which scars less than non-beard skin most of the time. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The concept of a facelift for many patients, initially, seems extreme. Prospective patients often have a vision of being swollen and bruised for weeks over their entire face. Such thoughts have driven some patients to other less or minimally-invasive procedures which are often inappropriate for their facial aging problem. They may have been less invasive and may have cost less, but the end result may have also been disappointing.

Some potential patients suffer two fundamental misconceptions about facelifts…what they are and what the recovery may be. Over half of the facelifts that I do are done in isolation without any other facial procedures. Some patients are only concerned about the appearance of their neck and are not concerned about their eyes, for example. If that is only what concerns the patient, then that is the only issue that needs to be addressed.

An isolated facelift, or a neck-jowl lift, causes none of the issues that many patients fear. There would be no swelling or bruising around the eyes. The neck and jowl line will have some mild swelling and bruising…but it will be painless as the neck and jowl skin are numb for several months after surgery anyway. The only discomfort will be around the ears where the incisions are placed. The ears will be tender for a week or two as these incisions heal. While I use a head dressing that wraps around the neck for the first night….with surgical drains… all of this gets removed the following morning. In limited facelifts, there is no further dressing needed. In full facelifts, a small neck strap is used for a few more days. Showering and washing one’s hair can be done the next morning. There is no concern about getting the incision lines wet. One can style and blow-dry their hair as they wish. Even with some mild swelling and bruising the neck and jowl already look remarkably improved.

Patient fears about facelift surgery are often unfounded.  As an Indianapolis facelift surgeon, I find taht when it is done as the only facial procedure, a facelift is much easier to go through than most envision. An improved understanding of a facelift and its recovery is helpful for patients to make better decisions and ensure a good return on their investment.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com/

http://www.ologyspa.com/

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

I would have to say that one of the biggest misconceptions on the part of patients in plastic surgery is in understanding what a facelift is. On a near daily basis, I explain to potential patients, much to their surprise, that what they envision a facelift to be it is not. Most patients have the perception that a facelift involves the entire face, from the scalp down to the neck. And they envision weeks of horrid facial swelling and bruises. These images are further fostered by what they have seen on the internet and on TV.

In reality, however, this is not what a facelift is. A facelift is a rather poorly named surgical procedure. More accurately, it should be called a neck or neck-jowl lift for this is what it actually does. A facelift affects only the lower third of the face and does nothing for the upper and middle thirds of the face. It helps re-create a sharper neck angle and gets rid of those saggy jowls. When a facelift is done in isolation, there is no bruising or swelling around the eyes or the rest of the face! Many times, however, patients wants a more complete facial improvement and then simultaneous procedures involving the eyes, nose, or mouth may be done with a facelift, the effect of which is to more closely mimic the images that patients originally imagined a facelift to be.

When I do a facelift only, patients do have a head dressing and surgical drains for the first night after surgery. However, these are removed the next day and replaced with a small chin strap that they wear for the rest of the week. Patients may shower and wash their hair the next day. Short of bending over or strenuous exercise there are no specific activity restrictions. Recovery is really of a social nature, rather than that of a physical one. There is virtually no pain and only some mild tenderness around the ears. You really will look pretty from a facelift only procedure in seven to ten days.

Undergoing a facelift should not be viewed, therefore, as a scary or arduous undertaking. Most patients will tell you that it was a lot easier than they had imagined. Many times patients will want a more complete amount of facial improvement and surgery on the eyes (blepharoplasty) would be the most plastic surgery procedure done with a facelift. This is because most patients feel that the eyes and neck are their top two facial aging concerns they want improved.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Facelifts do an excellent job at achieving a rejuvenated facial appearance by tightening the neck and eliminating those sagging jowls. In the world of plastic surgery, there has been much debate over decades as to the best way to get and maintain a good facelift result that will hold up over years. These include such concepts as platysmal release and plication and many different methods of SMAS development and repositioning, all methods that manipulate the tissues from the deeper muscles up to the overlying skin. While there is clearly benefit to doing so, there is no concensus on which methods are most optimal. Moreover from a patients perspective, they are completely unaware of these types of non-skin efforts and, while they are very interested in getting a good long-term result, there are certains aspects of a facelift from which they have more important concerns.

First and foremost, patients certainly do not want to sustain any complications from surgery particularly om their face. The most dreaded complication of a facelift would be an injury to the facial nerve. While such a rare injury, if it occurs may only be temporary, but any form of transient facial nerve paralysis is unsavory. Deeper plane facelifts definitely have a greater risk of this problem. The balance of its benefits vs its risks must be thoroughly discussed with your plastic surgeon during your consult.

Secondly, patient do not want to have any telltale signs of having had a facelift. This would be the result of poor scar placement around the ears or an altered temporal hairline that is moved up too high. In my opinion, proper incision placement is more important than whether one does a deep plane technique or not. Also, patients definitely do not want an unnatural look from being pulled ‘too tight’. I have yet to see a patient who has asked that their face be pulled as tight as possible. What patients have to realize is that their cheek-lip grooves (nasolabial folds) or the down turning of the corners of the mouth will not be improved no matter how tight a facelift is pulled. They require other simultaneously done procedures at the time of the facelift to get improvement in those aged areas.

Lastly, most patients really don’t want a long social recovery after a facelift, meaning that they look ‘bad’ for two or three weeks due to swelling and bruising. No matter how good the long-term result will be, they will never forget that type of recovery. Patients want a good result, but they also want a recover that is not unduly prolonged.

Facelifting surgery is a balance of how aggressive to be with the lifting and tightening process at the risk of a longer recovery and an increased rate of complications. A good thorough consult before your facelift with your plastic surgeon should cover these issues in detail so you can make an informed decision. 

Dr. Barry Eppley

http://www.eplpeyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

While there are many changes that occur in the face as we age, one of the most bothersome to many patients is the changes that occur in the neck. Progessive fullness of the neck, loose sagging skin, the development of vertical banding, the numerous horizontal wrinkles that appear low in the neck and the loss of a good sharp neck angle all capture the eye of the patient and others as well. These neck changes rank right up there with aging around the eyes as the most concerning facial aging concerns to most patients.

 
Like the rest of medicine, it is important to determine what the anatomic problems are in the neck to match up the best operation to improve it. Younger patients often just have some beginning neck fullness and a little bit of jowling. Simple liposuction and a little jowl tuck-up may be all that is needed in these younger patients. In some of these cases, I have used LipoDissolve injections alone and have gotten a good result if the patient can tolerate the temporary swelling that comes after eacj injection session and the 3 to 4 months to get the final result. Older patients usually have more sagging and loose skin and something like a more extended facelift (neck-jowl lift) is more appropriate. This is where sitting down with your plastic surgeon and going over your concerns with the aid of a mirror is so important. The selection of which operation is best for you will depend on a good understanding on your part of what do you want to see changed and what are you willing to go through to get it.

 
The aging neck in the male poses some different issues. They often have more skin excess and the facelift incisions that are used in females have to be altered to account for the male beard pattern. In addition, males have a much greater tendency towards some relapse after facelift surgery due to their thicker and heavier skin. Men also have a much greater aversion to major facelift surgery and may opt for an alternative procedure known as a direct neck lift. This procedure dramatically reshapes the neck and can produce a very sharp neck angle…but at the cost of a midline neck scar from below the chin down to the adam’s apple. For some older men this may be a good trade-off and this scar usually turns out fairly well due to how better hair-bearing skin heals scars.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis