Explore Plastic Surgery - Dr. Barry Eppley

The cheek or the midface region plays an important role in facial appearance. As one

of the five facial bony prominences (brow, nose, chin, and jaw angles are the others),

it is actually the most complex. It lacks any sharp angles, is made up of several bones that

intersect together and is surrounded by three distinctly different soft tissue regions. While

everyone appreciates that a high and strong cheekbone is desireable, it is not easy to

quantitate what that should look like unlike chin projection or jaw angle width which can

be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does

for facial shape and width. As part of understanding cheek morphology, one should not

forget how the soft tissue below it affects how the bone looks above. Known as the

submalar (below the cheek) region, it is affected by the size and prominence of the buccal

fat pad. This golfball-sized fat collection can be surprisingly large and it helps make for a

rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can

make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or

atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and

buccal fat (submalar) areas should be done. Implant manufacturers have recently showed

an appreciation for this concept by expanding traditional cheek implants to include either

(malar and submalar) or both. (combined submalar shells) Combinations of malar

and submalar changes can often make for a better cheek result than just a ‘simple cheek’

implant’ alone. In some cases, cheek bone enhancement and some submalar reduction

(buccal fat removal) may produce better cheek highlights. In other cases, submalar

augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken

into consideration when planning changes in this area.

Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a

surgically simple procedure but it’s decision to do so is more aesthetically complex.

Through a very small incision inside the mouth opposite the maxillary first or second

molars, the buccal fat pad can be gently teased out. When doing at the same time as some

type of midfacial implant, it can be done through the same incision. How much one

removes is a matter of judgment. As a general rule, it is not a good idea to try and

remove all of it. Not only may that be undesireable in facial appearance in the long-term,

but there are several buccal branches of the facial nerve which interlace with the multi-

lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the

buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive

buccal lipectomies may inadvertently damage these branches. I have never observed

facial nerve injury from a buccal lipectomy procedure but this attests to a more

conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a

more complete buccal lipectomy may be justified. Such an approach works well when

‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction

and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or

gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years

ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a

lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or

‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek

(malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be

needed.

When considering cheek enhancement as part of an overall facial improvement plan, both the

malar and submalar regions must be considered together. Between expanded submalar implant

designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results

is now available.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Rhinoplasty surgery, in the purest sense of the term, implies changes to the external or visible parts of the nose. Since the appearance of the nose does not necessarily affect how it functions, your insurance will not cover any of the rhinoplasty procedure if the goal is to achieve an improved looking nose. For instance, your insurance will deny coverage if your primary reason for surgery is improving a nose that is unattractive, too large or crooked.

But there are circumstances where insurance will provide coverage of a nasal procedure. Notice that I did not use the term rhinoplasty. As soon as you use that term, you are talking about changes to the outside of the nose which we know is not covered…unless the source of the problem is from a birth defect, traumatic injury, or from tumor removal. To define those further, birth defect usually means cleft lip and palate or some other craniofacial deformity where the nose has not developed normally. Traumatic injury means a documented history of nasal fracture, that is relatively recent (not 20 years ago or when you were a child) and there are medical records to substantiate that it actually happened. Tumor excision almost always means some type of skin cancer where a portion of the skin on the nose has been removed All of these external nose needs will constitute a reconstructive rhinoplasty procedure and there is not usually  battle to get it approved. (most of the time)

Your insurance will not only cover for these reconstructive issues but they will also cover for breathing difficulties of the nose. A deviated septum is the classic case but there are other internal structures of the nose that can be obstructive, most notably the turbinate bones. Difficulty breathing can also cause headaches and contribute to sleep apnea. All of these are medical issues because they dysfunctional. Many times, the physician’s examination alone is sufficient to provide adequate documentation but other tests may eventually be required including nasometry, CT scans, or sleep studies. One key area that your medical insurance looks for is…what non-surgical treatments have been tried ( and failed) to prove that surgery is necessay. (and the last resort)  This usually means a trial course of steroids or other nasal swelling treatment strategies.

Documentation is key for your insurance company to consider that such symptoms exist. Regardless of whether the medical necessity reason is a structural problem due to a birth defect or trauma or a long-standing breathing problem, a pre-determination letter must first be sent from your plastic surgeon. One must then wait until you receive a written response from the insurance company before ever proceeding to surgery. If you do not see it in writing, do not assume that it is going to be covered.

Do not let the urgency of your or your surgeon’s schedule override written confirmation of medical coverage. This is a common mistake. It is much better to know the financial facts up front (and then pay if you have to) than try and sort it out later when you are receiving bills and late notices from a variety of providers because it has been denied due to a lack of the required pre-determination. Remember, once you have it done without a pre-determination, the insurance company is not really under any obligation to pay after the fact. (even if it would have been  initially qualified) Paying medical charges that are accrued at the rate of insurance billings are a lot higher than those charged for on a cosmetic fee basis. Let the insurance and pre-determination process run its course…or otherwise you may find yourself really paying through the nose.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis Indiana

Liposuction is, by far, the most common body plastic surgery procedure. If not by numbers, then certainly by surface area. One of the most frequently treated areas is that of the thighs. Whether it is unhappiness with saddlebags (outer thighs) or fullness and loose skin on the inner thighs, contouring of the legs between the hips and the knees is prime liposuction territory.

When considering thigh liposuction, there are several important concepts for patients to grasp. Reshaping the thighs with liposuction techniques is more than just ‘fat reduction’ or fat volume removal. Because the thighs are not just a flat surface but a circumferental round structure, treating them must take that into consideration.

The first thigh liposuction concept to understand is that reducing the circumferential measurement or fullness of the thighs is not usually practical. Because all liposuction methods use a straight cannula instrument on a round structure, it becomes easy to see how one major problem can occur…irregularities and unevenness of the contour of the thigh. A straight cannula combined with the fact that the surgery is performed with the patient lying horizontal on the operating room table, where fat areas shift and distort, is a recipe for this problem. Thigh lumpiness and areas of dips and valleys will make the most tolerant patient unhappy. As a result, making the thigh overall smaller is rarely a satisfying approach.

Secondly, volume reduction of thighs is best done on the lateral thigh or saddlebag area. On the outer aspect of the thigh, real visible reduction by significant fat removal can be done while maintaining a fairly smooth contour. (because it is the one area of the thigh that is relatively flat. Reduction of saddle bags can make for a real change in the contour of one’s legs and the way that a woman appears in pants or skirts.

Third, inner thigh liposuction is about shaping and not so much about significant volume reduction. Many women are bothered by the fullness in their inner thighs. But liposuction can not reduce them enough to ‘create a space between them’ or keep them from touching each other. Trying to do so invites indentations, irregularities, and loose hanging skin. Such a result occurs when liposuction is done too aggressively and tries to do too much. This is why inner thigh liposuction is one of the highest dissatisfied liposuction-treated areas. Think reshaping of the inner thigh done through the knees and into the calfs, adding subtle thinning and more shape into and around the knee area.

Lastly, be aware that the common problem of cellulite on the thighs will not be improved by liposuction. Liposuction is not an effective treatment for cellulite, no matter what you have read or have heard someone say. In fact, if liposuction is not done carefully under skin with visible cellulite, fat removal may make it appear worse afterwards. Aggressive liposuction done under cellulite is a mistake. Conversely, liposuction should be done conservatively and treatment should be directed at the lower levels of fat staying away from the underside of the skin. A little thigh reduction with no change in the appearance of cellulite is better than a bigger reduction with worse cellulite…that is not a good trade-off.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

With silicone gel breast implants returning to the forefront of breast augmentation and reconstruction, there are recurrent concerns about their durability and potential rupture. While there has never been any proven link between disease and silicone gel exposure, being able to diagnose silicone breast implant rupture is important. However,sSilicone implant rupture has been associated with local pain and breast hardening. (capsular contracture) Unlike saline breast implants which usually produce an obvious and immediate change in breast size, silicone implants cause silent and externally invisible ruptures.

With the return of silicone gel breast implants in late 2006, the FDA stipulated that patients should be monitored every 3 years by an MRI. An MRI has been shown to be the most accurate method of detecting rupture in women that have no other breast symptoms. Besides not considering who was going to pay for the costs of the MRI (the manufacturers aren’t), the question exists as to whether an MRI is the best way to detect silicone implant rupture in the face of actual symptoms. (breast pain and hardening) Is an MRI better than a mammogram for symptomatic women?

In the March 2010 issue of Plastic and Reconstructive Surgery, a study was reported by Dr. Paetau and others out of Jacksonville Florida and Nashville Tennessee. From a retrospective analysis of 319 capsulectomies, of which about half  were assessed prior to surgery with an MRI and the other by physical exam or mammography, the specificity and sensitivity of these tests were compared. Their results showed that MRI was no more accurate than the other less costly tests  in predicting implant integrity. (78% vs 76%)

MRI is very accurate in detecting silicone implant rupture, regardless of whether a women has breast symptoms or not. Radiologists use the term, ‘linguini sign’, to make the diagnosis of implant rupture. But in the face of breast pain and capsular contracture, where one has a suspicion that implant integrity is lost, the cost of an MRI appears to be unnecessary. The history and physical exam alone has proven to be fairly accurate.

If a women is concerned about whether an implant rupture exists, the presence of symptoms strongly suggests that surgery will likely to be needed for replacement. This appears to be particularly true if the implant has been in for some time. A low cost test like a mammogram is likely to be just as accurate based on this reported study.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

Jaw angle implants have become a more common procedure for men in the effort to achieve a stronger and more defined mandibular shape. By highlighting the jaw angles in combination with a more prominent chin, a triangular lower facial shape is seen from the frontal view. By increasing the divergence of two lines that follow the jawline from the chin back, jaw shape becomes increasingly more masculinized. There is a point at which this divergence is too great and the jaw shape can look  more cartoonish than natural, but this only happens when the jaw angle sticks out further than one’s ears.

This frontal view of the jaw angle oversimplifies, however, the three dimensional shape of this facial area. Because the jaw angle is formed by both horizontal and vertical ramus bone segments, it’s vertical height has a significant impact on how increasing the lateral expansion of the angle will look. A high mandibular angle shortens the face and increases the downward plane of the jaw. A lower mandibular angle lengthens the face and levels out the jaw plane angle. Which one of these jaw angle heights may offer an aesthetic benefit for anyone is based on the other dimensions and shape of their face.

It is important for any patient considering jaw angle augmentation to consider vertical elongation as well as increased lateral protrusion. Besides achieving the best look for a patient, knowing whether this desired angle change is needed changes the type and style of jaw angle implant chosen. Jaw angle implants come in a variety of styles from several different manufacturers. But they fundamentally differ in providing just lateral fullness to your existing angle or both lateral fullness and vertical elongation, dropping the jaw angle lower.

Most lateral only jaw angle implants are made of silastic or firm but flexible polymerized silicone.  Because it has a very smooth and slippery surface, it is not a good material for dropping the jaw angle lower. Even if a curved or notched area exists at its lower edge, it will not stay in position as it easily slides upward by the force of the overlying masseter muscle. More ‘three-dimensional’ jaw angle implants are made of Medpor or porous polyethylene. Their textured and rougher surface offers higher frictional resistance against the bone and are less prone to upward migration. While this is surface biomaterial characteristic is more favorable, I do not trust it enough to not use screw fixation to prevent after surgery migration.

Lowering the jaw angle also causes it to acquire a more 90 degree or square shape versus a more open angle (greater than 90 degrees) when it is higher. This is a profile jaw aesthetic that can be gender-specific. A lower jaw angle means more masseter muscle and a flatter jaw line from front to back, a more masculine facial feature. A high jaw angle reduces the amount of bone for masseter attachment and placed the jaw angle point above the horizontal plane of the chin. This can be more feminine in appearance.

Jaw angle augmentation is more than just about widening the jaw. It requires three-dimensional planning  and proper implant selection to get the desired result.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

The benefits of breast augmentation are many including a changed physical appearance, increased clothing options, and most importantly an improved self-image. But undergoing breast implants has recently added an additional benefit…the opportunity for some extra cash.

From the Mentor corporation, who has the largest share of the breast implant market in the United States, comes the Memory Gel referral program. Memory Gel is the tradename for their silicone gel breast implants. After having received a silicone (Memory Gel) breast augmentation procedure, the patient is given a Memory Gel Referral Program brochure from her plastic surgeon.

In the brochure the patient is referred to the manufacturer’s patient website, LoveYourLook. Once on the website, the patient fills out all the requested fields including her implant’s serial numbers. At this point, she can then enter the name and email address of a friend she would like sent information from the Referral Program.

An email from Mentor is then automatically sent to the friend whose name and email address was provided. If the friend goes on to have breast augmentation surgery (breast reconstruction does not count), a $50 American Express Gift card is sent to the patient who referred her. (for whatever reason, this offer is not available to patients in Texas and Florida)

While $50 may not seem much to someone who has spent $5,000 to $7,000 for breast surgery, it is a token gesture that speaks to an aspect of breast augmentation that few think of. Unlike any other medical device used in the United States, breast implants share many features similar to that of a retail product. First, breast implants are paid in cash directly from the patient and often financed to do so. That is clearly different than other implantable medical devices which are sold and paid for by the hospital, surgery center or physician, leaving the patient out of any financial involvement or burden. Secondly, breast implants carry warranties that provide some financial protection for the patient. Lifelong implant replacement for failures and actual cash reimbursement if these failures occur in the first 10 years after surgery. No other medical devices carry such financial patient protections. And now thirdly, the use of a referral incentive which is very common across the retail industry. By so doing, they are encouraging friends (who were likely going to have the surgery anyway) to use Mentor implants and not the competitors.

The business of breast augmentation is unique amongst medical devices.  It is a significant cash product that offers some financial assurance to the patients receiving them. Because the surgery is entirely elective and paid for out of pocket, confidence in the devices implanted is essential.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis Indiana   

There are many aesthetic changes that can be made to one’s face. The list of potential plastic surgery procedures for cosmetic enhancement numbers over one hundred. Such procedures are usually thought of as the specific region that is being changed. (e.g., nose, eyes, brow, chin, neck, etc.) Some think of these procedures by the anatomic tissues which are being manipulated, hard or soft tissues. And others may classify them by anatomic region. (upper, middle third, and lower face)

But there is also another way to think about facial plastic surgery procedures, and that is from an underlying psychologic or motivational perspective. Why is one having the procedures and how does this influence one’s preparation and expectations from the surgery? By this view, cosmetic facial procedures can be classified into structural and anti-aging operations.

The anti-aging procedures are very well known and include facelifts, blepharoplasty, browlift, midface (cheek)lift, lip lifts, and neck lifts. These are exclusively soft tissue-based because the restoration comes from removing and lifting (nips and tucks so to speak) excess or sagging skin and soft tissues. The word, restoration, is deliberately used because the goal is to try and make one look younger or rejuvenated, trying to return to an earlier look that one had years ago. The common phrase many plastic surgeons use is ‘turning back the clock’. This is a very appropriate phrase because the clock will continue to tick and one will eventually return to looking older. (provided nothing is done for maintenance and other touch-up procedures)

Structural facial procedures, some of which are well known  while others are not, include rhinoplasty, otoplasty, forehead reshaping, and a variety of facial implants. (chin, cheek, and jaw angles) These are more hard-tissue based including bone and cartilage. To no surprise, these are foundational anatomic structures onto which the overlying soft tissues attach and are suspended. These procedures change or alter the face and create a look that is not genetic or how one was destined to appear. The key word here is change. One is trying to look different, to look better. The term that is bantered about by plastic surgeons is a ‘balanced or more proportionate’ look.

The psychological difference between anti-aging and structural facial surgery is significant. One who undergoes a facelift, for example, wants to know many aspects about the procedure (recovery, risks, etc) but is not overly concerned about the outcome. While no one wants to look overdone or unnatural from a facelift (the most common patient concern), the comfort lies in going to a place where one once was. When one is undergoing a rhinoplasty, for example, the concerns about the outcome are much different. One is heading to a place where they have never been and that can cause great uneasiness. Even though one knows that the goal is to look better, not being exactly familiar with what that is can be unsettling. It is for this reason that many structural facial patients will spend a great deal of time analyzing their photos, doing drawings and measurements, and in general doing much more research before the procedure(s).

Structural facial surgery patients require more preoperative time and discussions. It is critically important that a good connection and rapport is developed between plastic surgeon and these surgery patients to avoid a misunderstood outcome. It is also vital that computer imaging is done before surgery to aid this communication process and lower the potential revision rate.

In some cases, most commonly anti-aging surgery, the two types of facial plastic surgery procedures are simultaneously used. But one of them is the dominant approach and the opposite facial procedure is complementary. (e.g., facelift with a chin implant)

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

There are many physical signs that can give away one’s age. Women know these signs very well and they include such areas as the back of one’s hands, the neck at the sternal notch area, and the mouth. The mouth area is a particularly bothersome area for many women. As a plastic surgeon, the mouth seems to be an area that unfairly ages in women much more than in men. It is actually rare to see deep vertical lip lines in men, even if they have thin lips, until they get quite elderly.

In the November 2009 issue of the Aesthetic Surgery Journal,  a study was reported to investigate the differences between men and women around the mouth area.To determine how bad the wrinkles were, the upper lip of male and female fresh cadavers were analyzed using three-dimensional digital imaging and as well as histologic assessment of full-thickness lip resections in different male and female cadavers. Their results showed that women had more and deeper wrinkles than men. Men had a significantly higher number of sebaceous, sweat glands, and blood vessels in their skin. Somewhat surprisingly, the number of hair follicles did not significantly differ between men and women, although men had a higher number of sweat glands per hair follicle.

This study provides scientific evidence as to why women are more susceptible to the development of mouth and lip wrinkles.The skin around the mouth in women has lesser numbers of skin appendages (hair follicles and oil glands) as well as different connections between the skin and the muscles of the lips.

The key anatomic factor is that with less oil glands, there is less oil production to help keep the skin softer, smoother and better protected. I think the observation that the muscles around the mouth are closer to the skin in women than men is also important. This may allow the muscles to pull the skin in tighter, creating a ‘purse-string effect’ and causing more wrinkles.

Outside of this study, there are likely other contributing factors that accentuate these anatomic findings. One of these is the drop in estrogen in women with aging. This hormonal change causes a decrease in the fat (sebum) secreted by sweat glands. Coincidentally, women on hormone replacement therapy have been reported to have fewer wrinkles than those not taking the hormones. Also, most men perform a daily wrinkle treatment, shaving which is a  form of microdermabrasion. Such superficial skin exfoliation done tens of thousands of time over one’s lifetime will help lessen wrinkling also.

While avoiding smoking and sun exposure and using daily moisturizers are extremely helpful and will reduce the amount of wrinking which will develop, that advice does little for the women who already has significant signs of mouth aging.

Several treatment strategies exist that can help significantly with lip lines and wrinkles. These include injectable fillers, Botox, laser resurfacing, chemical peels, and fat injections. The fundamental concepts of these strategies (with the exception of Botox) is inflation (volume fill or restoration) and smoothing. While everyone does not need all or even most of them, a combination of inflation and smoothing will work better than just one of the concepts. Most commonly, the combination of injectable fillers and laser resurfacing is used. But treatment approaches can differ and I do not always do the same approach for everyone.

The anatomy of lip wrinkles indicates that no matter what is done, none of the treatment approaches actually ‘cures’ the problem. The skin of the lip can not be made permanently thicker and the natural oil production of the skin can not be improved. This indicates that no matter what treatments are done, they will have to be eventually repeated to maintain the improvement.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

Injectable fat grafting is becoming increasingly popular for a variety of cosmetic and reconstructive indications in plastic surgery. Because it uses one’s own natural fat, there is no risk of graft rejection. Most of injectable fat uses are for indications in which other treatment methods are more invasive or do not have the potential to interfere with any important medical functions. When it comes the breast, however, implants have a great track record of effectiveness and safety and have been proven to not interfere with breast cancer detection. Fat grafting to the breast, therefore,\  needs to be considered more carefully than any other bodily area.

In the July 2009 issue of Plastic and Reconstructive Surgery, a task force from the American Society of Plastic Surgery reported on the current state of scientific knowledge about injectable fat grafting to the breast. Their recommendations are based on review of case reports and series and the few experimental studies which currently exist. Injectable fat grafting has been done in the breast for small breasts, deformities after breast implant augmentation and reconstruction, congenital breast deformities, and for nipple reconstruction. The total number of clinical cases numbers around 300 or so, which is a very small number of patients. There is only one registered prospective clinical trial with the FDA (BRAVA system)

The highlights of this report are worth summarizing:

1)      Fat grafting may be considered a safe methof for breast augmentation and correction of breast defects from cancer resection and its reconstruction and other medical conditions of the breast.

2)      The longevity of fat grafts is unpredictable. Patients considering injectable fat grafting should be accepting of the potential of the need for additional treatment sessions to get the desired effect.

3)      How well injectable fat grafts work is highly influenced by the surgeon’s experience and technique.

4)       There is currently no one standard way to prepare fat grafts or inject them.

5)      Changes in a patient’s weight can alter the size or shape of the retained fat graft.

6)      Infection appears to be the only real medical risk and is usually solved by antibiotics.

7)      High-risk breast cancer patients (family history of breast cancer, BRCA 1 and 2 positive) should be treated with caution. Although no evidence exists that fat grafting interferes with breast cancer detection, too few patients have been done to know with greater certainty.

      Fat grafting is in its scientific infancy and more experimental and clinical research is needed to improve its survival after grafting as well as fully explore and develop its potential clinical uses.

For patients interested in autologous fat grafting to the breast, this report provides educated insight into its safety and cautious optimism about its potential. Unpredictable fat graft volume retention is its one downside.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

Injectable fillers are one of the most popular in-office aesthetic facial treatments. Used primarily to fill nasolabial and marionette lines as well as lips, they provide an instantaneous result. As of today, there are over a dozen commercially-available injectable fillers of various compositions. Patients frequently ask about what is different between them and which is best for them.

From a practical perspective, you can argue that their differences are only… how long do they last and how much do they cost. Since no injectable filler is permanent, they all have a limited time frame of effectiveness. (silicone oil may be permanent but it is not an FDA-approved injectable material for aesthetic use)

But one very important distinction between some of them is their composition…what are they made of? This can be important because there are some potential adverse outcomes that can occur with some of them that is negligible with others. One of the basic concepts that have been pursued over the years to increase the longevity of injectable fillers by using particles, either resorbable or permanent. Because these beads or particles either do not go away or slowly resorb, the injectable filler will last longer. Because of the need for the material to flow through a small needle, the particulate part of the filler usually only makes up less than 30% of the total volume of the filler. The rest is the carrier material, which often is either collagen or some other biocompatible liquid(s).

While the bead or particle concept does extend the longevity of the injectable filler, there is a potential trade-off for that benefit. The potential always exists for  foreign body or granuloma formation the longer any material persists under the skin. This is a well known phenomenon that is known to occur from buried sutures for example.  The occurrence of granuloma formation from injectable fillers is rare with estimates in the range of 0.01 to 0.02 percent. While I have read that there are no differences in granuloma formation between the pure gel (hyaluronic acid) or collagen fillers and the particulate fillers, that statement does not make good biologic sense.

The particulate fillers include materials such as polymethylmethacrylate, poly-hydroxyethyl methacrylate, hydroxyapatite, and dextran beads. When a foreign body reaction develops from them, it will usually not appear for at least 6 months or even years later. This is due to the ‘frustrated’ phagocytosis that occurs as the macrophages are unable to clear the material. Because of this frustration, the cells become ‘giant’ and a granuloma may develop. Treatment of injectable granulomas may be tried with steroid injections and some may resolve this way or on their own. Persistent ones may require actual incisional drainage or excisional removal.

The choice between shorter vs longer lasting injectable fillers involves more than just cost. Another consideration is the risk of granuloma formation. This is why the particulated fillers should never be injected into the lips where the risk of lumpiness and foreign body reactions is even higher.      

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis