A strong jawline has been deemed as both a desireable and attractive male facial feature for millenia. A strong male jawline is not a passing fad or temporary fashion statement. It has been and always will be an important feature of a male face. Everyone knows that a strong jawline implies increased masculinity and increased attractiveness. But where does this impression come from and why? Face shape and structure has long been considered a good indicator of dominance. A rounded chin is viewed as more feminine than a more square stronger chin. Recent research has shown that during ovulation women seek out masculine-appearing men whose features suggest high testosterone levels which would indicate a high fertility and well as good quality genes that can be passed on to their offspring. Strong jawlines also imply dominance over other males which may be most important when a woman is at or near their peak fertility. Like so many desireable physical features of men and women, its basis lies deep in history with the need to secure a mate, procreate, and pass along good genes.

Background:  Aging of the face takes on many predictable changes but none is more evident than what occurs along the jawline. The once more discernible and sharp jawline becomes lost as jowls appear and the neck sags. The neck angle becomes more obtuse, the chin may appear shorter, and the transition between the face and the neck becomes obscured. This falling down of the facial tissues over the ledge of the jaw bone into the neck typically occurs due to loss of osteocutaneous ligament support to the skin.

The facelift operation reverses the soft tissue components of this aging process. A facelift is really an isolated neck-jowl procedure that removes fat from the neck, tightens neck muscles (platysma), lifts up the intervening layer of soft tissue between the muscle and the skin (SMAS) on the side of the face, and relocates and removes excess face and neck as it is elevated past the ears.

But often forgotten, and many patients do not see it themselves, is the bony support of the jawline. The strength of the chin and the jawline backs to the bony angles has an influence on how much and how quickly the facial aging process proceeds. Inherently weak chins and a shorter jawline with high mandibular angles indicates a weak system for the prevention of facial tissues from falling over the ‘ledge’ and lack of support to hold the neck tissues up.

As part of any facelift, consideration should always be given to augmenting the jawline. Most commonly, this is seen a simple chin augmentation as weak chins are easy to spot. Chin implant augmentation adds length to the jawline and adds a complementary effect to the restoration of a more acute neck angle. In other cases, an extended implant that incorporates the prejowl area better defines the front half of the jawline.

Case Study: This 65 year-old female wanted to improve her saggy neck and jowls that had been slowly getting worse over the past decade. She was a very thin lady with very little subcutaneous fat. She had rolls of skin over the jowls and into the neck with prominent platysmal bands. Her chin had some horizontal shortness and her jaw angles were extremely high, creating a 45 degree angle to her mandibular plane.

Under general anesthesia, a facelift was performed. Initially, a submental incision was made and skin flaps raised to expose the platysma muscle. The muscle edges were exposed with cautery and a sutured together from under the chin down to the thyroid cartilage. A combined chin-prejowl implant was placed on the chin bone back behind the mental nerve on the lower edge of the bone. Incisions were made around the ears in a retrotragal fashion and long skin flaps raised to connect with those previously made in the neck. Her SMAS tissue was very thin and imbrication by sutures was done rather than raising the flaps. Excess skin was brought back over the ears, the excess removed, and the outline of the ear re-established.

Her recovery was very typical for a facelift and she looked fairly non-surgical in just over two seeks after her procedure. Her jawline was sharp again and the chin had more projection although not overly so. Even the outline of her high mandibular angles could be clearly discerned.

Skeletal jawline augmentation is an underutilized technique in facelift surgery. Its use in patients that have a congenitally short jaw is extremely beneficial and will highly compliment the soft tissue rearrangement. But even in patients that do not have an obvious chin deficiency the jawline can be made more prominent with a prejowl implant that adds minimal horizontal chin projection.

Case Highlights:

1) The woman with a short jaw, as evidenced by a small chin and high mandibular angles, will develop considerable neck and jowl soft tissue sagging as she ages.

2) While a facelift is the standard approach to neck and jowl sagging, adding skeletal support through chin augmentation helps recreate a more visible jawline.

3) Chin and jawline implants can be a valuable addition to lower facial rejuvenation.

Dr. Barry Eppley

Indianapolis, Indiana

As we embark on Father’s Day, one of the very last things one would be thinking about is plastic surgery. But in the Sunday June 16th edition of the New York Times in the Business section, an article appeared suggesting that liposuction, chin implants and Botox may become popular gifts for Father’s Day. (if plastic surgeons had their way)

While this story is perhaps entertaining and certainly fills the column space, it is even further off base than even suggesting plastic surgery would make a good Mother’s Day gift. It shows a fundamental misconception about how men approach considering and having such elective physical changes.

While it is certainly true that plastic surgery is more common in men today than ever before and it is also much more accepted, a man’s desire to be more discrete and even secretive about it has not changed. Most men do not want others to know that they have had surgery or are even contemplating it. Giving Dad a gift of plastic surgery would most likely be considered embarrassing not to mention almost offensive. Even if a man needs and wants a plastic surgery procedure, they would be loathe to admit it. (except maybe to their wife) It is one thing to give a gift for a spa treatment, a deep tissue massage or a facial, but surgery is a completely different matter.

Despite the claims of the physician’s in the article, there are no statistics that support a nationwide surge in requests for male plastic surgery around Father’s Day. It may exist in a select few doctor’s offices that promote it, but for the reasons described this is not a remotely popular celebratory concept.

According to American Society of Plastic Surgery statistics for 2012, the top five plastic surgery procedures for men were abdominal and love handle liposuction, rhinoplasty, eyelid surgery (blepharplasty), gynecomastia reduction and ear reshaping….just not as a gift for Father’s Day though.

Dr. Barry Eppley

Indianapolis, Indiana

The Brazilian Butt Lift is one of the most popular and talked about body contouring procedures in the past few years. Driven by celebrities, models and the desire for a certain look in clothes, a rounder and fuller buttock shape has taken on a new level of aesthetic desire and sensuality. While it is often viewed as having a heavy cultural and ethnic influence amongst African-Americans and Hispanics in the U.S., its awareness has also served to drive in women who simply have a congenitally flat buttocks with no roundness as well.

The main driving force in the desire for bigger buttocks comes from the most common procedure to achieve it…the Brazilian Butt Lift. (aka BBL) Using fat to enlarge the buttocks is both a natural approach and a method of recycling or redistribution. Using liposuction to harvest fat from undesired body places, it is then processed and injected where someone wants it in the buttocks. In essence, every BBL is two procedures in one both of which work to create an improved torso shape. The appeal of this dual approach has led to making it a sought after aesthetic procedure.

But despite the tremendous appeal of the BBL buttock augmentation procedure and its widespread use, much of the science behind it remains undeveloped. The success of the BBL is in making the injected fat survive. But how to best do that is unknown and the techniques touted are based on largely subjective observations. There are no published studies as of yet that have looked at the various methods of buttock fat injection or have even compared them.

The fundamental technique question is whether smaller or larger amounts of fat should be injected in a single treatment session. In essence, what is the appropriate amount of fat to inject during surgery that will survive. There are two schools of thought, pump in as much as you can in a single session (maximum infusion)  or place smaller amounts in multiple sessions. (seeding)

Since it is commonly believed that only about one-third to one-half of injected fat will survive, the maximal infusion approach takes a volume overload concept to overcoming low fat cell survival. Of course every patient wants the most fat put into their buttocks as possible and this can be seen in many internet forums where patient talk and compare about how much fat was injected into their buttocks.  The disadvantage to this approach is that big globs of injected fat may preclude the rapid establishment of vascular ingrowth and nutrition to the fat/stem cells. So while good volume results may be initially seen, lack of significant fat survival will lead to poor results months later.

The seeding approach is when smaller amounts of fat are injected, much of it into the muscle, and it takes time to see these ‘seeds’ grow. Like planting seeds into a garden the analogy is that multiple seeding sessions are needed to acquire the best growth. Smaller amounts of seeding theoretically makes it more likely that nourishment will be established to the fat cells quickly and survival will be much better, even if the actual volume is lower. How much volume that is will depend on the patient’s buttock size but a 300cc to 500cc injection volume per side is reasonable.

While the lower volume seeding approach seems to make the most scientific sense, there are practical issues that preclude its use in many patients. The cost of multiple injection sessions makes fat seeding the buttocks impractical for many patients. This is why the maximal infusion BBL approach is done much more commonly.

While the fat grafting science of buttock augmentation is slowly being developed, the marketing of the BBL procedure is way out in front it. Fundamentally the Brazilian Butt Lift is neither Brazilian nor does it cause a buttock lift. It causes no more of a buttock lift than does a breast implant cause a breast lift. It is a volume enhancer. But more is not always better and one should beware of BBL procedures that tout high volume infusions. Besides fat survival issues, high volume may mean fat transfers that contain other components such as tumescent fluid, fat and free lipids. While early after surgery photos may show a big volume buttock change, much if not all may be lost months later.

Dr. Barry Eppley

Indianapolis, Indiana

The dog ear deformity is a well known phenomenon in plastic surgery. It occurs when at the end of any face or body wound closure a puckering or excess tissue occurs. It is best thought of as a bunching or elevation of skin at the end of the incisional closure. Sometimes it is immediately apparent during the operation and other times it becomes more evident as healing is ongoing and the tissue swelling subsides. It is extremely common in such body contouring  procedures as tummy tucks and other long incisional body lifts as well as facial defect reconstructions by primary closure or flap rotations. Its association with the actual appearance of a dog’s ear is a little suspect.

Dog ear wound problems occur for a variety of reasons of which the design and geometry of the tissue excision and closure method is the major contributing factor. Because of its well recognized occurrence, a wide variety of surgical techniques have been devised to eliminate it. Patterns of dog ear excision include various triangles and ellipses of skin. While effective, they all lead to extension of the length of the scar. While for many body areas this may or may not be aesthetically important, it almost always is on the face.

In the May 2013 Archives of Plastic Surgery, a new and easy technique for dog ear correction without extending the length of the original wound is described in an article entitled ‘Aesthetic Refinement of the Dog Ear Correction: A 90 Degree Incision Technique and Review of the Literature’. In their technique, a skin hook is placed in the end of the wound to define the extent of the dog ear. The elevated dog ear is then excised by creating a 90 degree incision at the end of the wound where the dog ear appears. By so doing, a small triangular advancement flap can be raised and removed as desired. This flap is brought across the wound so that the skin excess can be cut in a straight line paralleling the incision line. When sutured closed the 90 degree incision created will disappear. This 90° incision technique enables correction of a dog ear without either lengthening the wound or creating new scars.

The dog ear problem can be corrected with this technique whether seen during surgery or anytime thereafter. The postoperative dogear problem is one patients are acutely aware of but any correct attempts should be deferred until the incision has settled so the full extent of the dog ear can be appreciated. Most dog ear corrections, which are just small scar revisions, can be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

It is commonly perceived that excess body fat and being overweight is better treated by diet and exercise than having plastic surgery. And this is most certainly true. Plastic surgery is not a substitute for making one’s best effort at being at the best body weight possible and getting off those excess bulges. But the reality is that not everyone can lose all of their bulges or are even capable of dropping as much weight as they desire. For some people their genetics, their body type and their natural internal metabolic thermostat, prevent them from doing what others think may be possible. In addition, some patients have irreversible body changes (excess hanging skin and fat rolls) from pregnancy or extreme amounts of weight loss that can never be changed by any amount of exercise. (you can not work off extra skin or tighten it) These are the types of patients that truly benefit by having plastic surgery to help make new body contours and get them over the hump so to speak. Also, plastic surgeons are usually quite resistant to operating on overweight patients. Obesity is one well known contributing factor in causing complications after surgery and creating outcomes that are less than what is usually expected.

Dr. Barry Eppley

Background:  Gynecomastia is historically perceived as being the development of breast tissue in men that creates the appearance of an actual breast mound. While this is certainly true, gynecomastia takes on many forms based on the amount of breast tissue development that actually occurs. Gynecomastia presentations can occur along a spectrum from a full blown development of a breast mound to just a firm nodule under the nipple in the teenager and younger man.

Over the years the young men that appear for the surgical treatment of gynecomastia has changed. While very obvious breast enlargements, either one one side or both sides, used to be the norm, smaller types of gynecomastia now appear. Years go they would have been deferred from surgery as their gynecomastia was not deemed significant enough to warrant the risks of surgery.

But contemporary younger male physiques have a standard of a completely flat chest with no nipple-areolar protrusion. Any amount of chest mound prominence or nipple-areolar elevation is viewed as undesireable. It is embarrassing for young men, or men of any age for that matter, to have nipples that show through their shirt or chest mounds that jiggle as they run or exercise. (or even walk) A flat chest profile prevents these aesthetic and clothing problems, avoids embarrassment and potential ridicule and improve’s a young man’s self-esteem.

Case Study: This 21 year-old make college student wanted to improve the shape of his chest. While he was athletic and muscular, he felt his nipples were ‘puffy’ and stuck out too far. He could feel a small lump under his nipples and wanted it removed to flatten them. Given the size and location of these chest lumps, this type of breast enlargement can be an areolar gynecomastia.

Under general anesthesia, a dual approach to his gynecomastia problem was done. Initially small cannula liposuction was performed through an entrance on the side of the chest wall. The entire chest was aspirated as much as possible to reduce its profile, removing a total of 125cc per side. Then through inferior areolar incisions, hard gritty lumps of breast tissue was removed from directly right under the areolas back to soft yellow fat. A small drain was placed that exited out from the small skin hole which was initially used for the liposuction. Immediately after surgery, he was placed in a circumferential chest wrap for compression.

He wore the chest compression wrap for three weeks after surgery on a regular basis and refrained from any arm exercises. He developed minimal bruising and had a very acceptable amount of discomfort. No fluid collections (seromas) developed. He had achieved elimination of his puffy nipples and a more pleasing chest profile to him.

Smaller gynecomastia concerns are the norm for young men today. Areolar protrusions caused by underlying firm lumps of gynecomastia are aesthetically intolerable as they create nipple show. Direct excision of the breast lumps combined with liposuction to feather the shape of the chest outward can create an effective solutions to the areolar gynecomastia problem.

Case Highlights:

1) Puffiness of the nipple, most commonly seen in younger men, is caused by a small amount of underlying gynecomastia.

2) Puffy nipple gynecomastia does not respond very well to liposuction due to the firmness of the breast tissue.

3) Open excision of the breast tissue causing the protruding male nipple is the most effective approach to getting a flat areolar and nipple profile.

Dr. Barry Eppley

Indianapolis, Indiana

The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.

While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.

While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.

Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.

Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

When it comes to plastic surgery, just like many other areas in life, men are different than women. Not only are their faces and bodies not the same, but their attitudes and expectations about plastic surgery are also different. Having treated a fair number of men over the years in my Indianapolis plastic surgery practice, I have made a number of observations on these gender differences.

It is true that the number of men, particularly younger men, are making up an increasing percentage of the total plastic surgery population. While the number of men having actual surgery or in-office injectable and skin care treatments will always be substantially less than women, men are noteworthy in that their procedures are either unique or require modifications. Numerous cosmetic procedures are not only uniquely different in men, but some of them are exclusive to men.

Enhancement of the male chest is an increasingly popular male plastic surgery procedure.  Chest issues are very different from that of the female breast. While women have surgery for small, poorly shaped or asymmetric breasts, men consider surgery because their chest appearance is not masculine enough due to gynecomastia, prominent nipples or lack of pectoral muscle size and definition. Gynecomastia reduction surgery is vastly different than female breast reduction surgery. Lack of visible scarring in a man takes on primary importance and the use of liposuction tissue extraction subsequently takes on greater importance. Prominent nipples, which occurs far more frequently in men than women, can have a very negative psychological effect for some men. Having them be obscure in a tight shirt is a common goal of all ages of men and this nipple reduction procedure can be accomplished as an office procedure under local anesthesia

Male chest enlargement is done by soft solid silicone implants that have to stay within the  lower and lateral borders of the pectoralis muscle. Female breast augmentation is done with non-solid filler materials in a shell (bag) that must be often be placed beyond the lower border of the muscle to get the proper shaping effect.

When it comes to body implants, the shape objectives between men and women are different. Men undergo have body enhancements, such as the chest, arms or calfs) to create increased muscle size and definition. Women have body implants of the breasts and buttock to create more shapely soft tissue curves which are non-muscular in structure.

The distribution of fat in men is uniquely different from women. Men have liposuction exclusively in the stomach and love handle areas. While women have liposuction in the same areas they have a broader expanse of potential fat collections which leads to aspirated fat removal also being done in the extremities as well as the trunk areas of the back, hips and buttocks.

Excess and loose body skin occurs more selectively in men than women. Because of pregnancies and weight loss thereafter, women frequently require tummy tucks. Men only need such excisional body contouring surgeries after extreme amounts of weight loss. (greater than 75 to 100 lbs) Those skin removal needs are almost exclusively limited to the abdomen (tummy tucks) and chest and almost never in the extremities.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

The face develops many visible signs of aging. But none are more problematic or pesky than that of upper lip lines or vertical rhytids. Such lip lines are very bothersome to women as they not only suggest an older lip but also cause problems with lipstick, often bleeding into the lower end of the vertical line. By far, vertical lip lines occur most commonly in Caucasian women of Northern European descent. They are very rarely ever seen in women that have more skin pigment, thicker skin and fuller lips.

While upper lip lines are often perceived as being caused by those smoke (and this certainly is a contributing factor), but many other factors contribute as well. The most significant, as previously mentioned, is light skin pigment and a genetically thin upper lip. This means that the upper lip has thin skin thickness and less subcutaneous fat which offers little buffer from the motion of the underlying circumferential orbicularis oris muscle. (facial wrinkles develop perpendicular to the action of the underlying muscle movement)

The treatment of upper lip lines is challenging because the source of the problem, movement of the mouth, is something that can not be changed after surgery. One can adopt a new diet to protect a liposuction result or avoid the sun and do numerous topical therapies to preserve other facial surgery changes, but one can not change the thickness of the upper lip or stop eating, drinking or smiling after lip line treatments.

The fundamental treatment of upper lip lines has historically been laser resurfacing. Using deeper laser treatments, the objective is to bring down the entire epithelial thickness of the skin and cause some collagen thickening as well. Much like sanding an irregular surface, significant reduction in lip lines can be achieved by total ablative laser treatments. But it can thin out the skin, cause pigment loss and can not usually be done more than once if the initial laser depth was deep. Thus enters the concept of fractional laser resurfacing where the risks of skin thinning and color loss is minimized. By cutting deep laser holes in just a fraction of the skin surface (22% or less), better collagen production and skin tightening is achieved. When combined with an initial very superficial ablative laser pass (< than 50 microns), significant and sustained lip line reduction can be achieved.

Other lip skin resurfacing methods are available including the dermaroller and old-style dermabrasion. For very deep lip lines, dermabrasion provides the most aggressive method of ‘sanding’ that actually produces the best results. But it is a highly technique sensitive method of resurfacing and is prone to a higher risk of hypertrophic scarring and severe skin thinning. The dermaroller is very much like a poor man’s fractional laser that punches small holes in the skin but its ability to induce collagen production is not as powerful and multiple treatments are needed to approximate even one laser resurfacing.

The other approach to lip lines is to add volume by injectable fillers. Most patients think this means trying to directly inject the vertical lip lines, and this can be done for the very deepest ones, but it really means augmenting the size of the upper lip vermilion. This will  increase the size of the upper lip which directly plumps out the lower end of the vertical lines as they join into the pink part of the lip. For those women that do not mind some increase in their lip size this is an essential step in a lip line reduction strategy. Whether one should use any of the available hyaluronic acid-based fillers (e.g., Restylane, Juvederm) or consider some autologous fat is a matter of discussion with each patient. There is also the option of a lip lift or lip advancement which provides a permanent change in the vertical size of the lip vermilion and cuts out some lower lip lines as well. (lip advancement only)

The best upper lip line reduction therapies incorporate a combination of skin resurfacing and volume addition. If done in the office, fractional laser (22%, 100 microns) with Juvederm upper lip injections is my preferred technique done under topical anesthesia. If done in the operating room, as part of a facelift for example, then I would do a more ablative laser treatment (two passes) with fat injections into the upper lip. Either way the patient needs to be aware that lighter maintenance fractional laser treatments will be needed in the future.

The key word to use in the treatment of vertical lip lines is reduction, few patients will achieve complete elimination of them in a single treatment.

Dr. Barry Eppley

Indianapolis, Indiana