Explore Plastic Surgery - Dr. Barry Eppley

One of the most common facial areas that bothers many patients is the development of the nasolabial folds, also referred to as the lip-cheek groove, or in a recent television commercial known as the parentheses. You can argue whether it is a fold or a groove but it is probably closer to a fold. It develops as the cheek tissue from above ages and begins to sag….falling over its border with the upper lip. The upper lip is ‘fixed’ so the overhanging cheek tissue creates the appearance of a deepening fold. With time, aging, and the anatomy of one’s face, this nasolabial fold extends south past the corner of the mouth and sometimes nearing the lower border of the jaw in extreme cases of skin laxity.This area is commonly treated by injectable fillers and in my practice as many patients wants their nasolabial folds treated as they want their lips enlarged.

 
The most common method for nasolabial fold reduction is with injectable fillers. Like all filling procedures by injection, the results from nasolabial fold reduction is quick, easy to do, and the results are immediate. I usually perform them under a local anesthetic block so the treatment is as comfortable as possible. While all of the injectable fillers will work, I think some are better for this area than others. And the ones that I think are best are those that last the longest and have the greatest ‘push’.

 
While all of the hyaluronic acid fillers such as Restylane or Juvaderm will work, they do not last as long as any of the particulated injectable fillers. Currently Radiesse (ceramic beads) and Artefill (plastic beads) are the only two particulated fillers currently available. The evidence is clear, not surprisingly because of their solid bead component, that they consistently last longer than any of the hyaluronic acid fillers. While beaded injections can cause lumpiness and irregularities, this is not a significant cosmetic issue (nor can it usually be seen) in the forgiving area of the nasolabial fold. Conversely, in the lips this is a different matter. Also, because the bead composition makes the injectable material more thick and viscous, I think it provides more push as it goes in resulting in a better cosmetic effect and having to use less injectable filler. Because of particulated fillers longevity and thicker volume, it is my preferred injectable approach to the nasolabial folds. This injectable treatment will give a 9 to 12 month result.

 
There are other treatment options for the nasolabial fold as well. The best way to eliminate them is the one way which is almost never done….cut them out. That gets rid of the fold immediately but also leaves a fine line scar which may only be acceptable in an older patient. The other more commonly done alternative is to use an implant. I specifically use an Advanta implant for those patients that want a permanent volume solution. A very small incision is made in the nose crease and at the end of the lower fold line. The implant is slide into place from one end to the other. This is a procedure that can be done in the office under local anesthesia. An implant approach to the nasolabial fold is a good solution for someone who no longer wants to do injections, doesn’t mind the concept of an implant in their face, or has very deep nasolabial folds which would take a lot of injectable filler volume. My experience with an implant in this area has been quite good but it is not a first line approach for most patients.

 
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 upper and lower lips are one of the five main facial features that makes up and helps define the most recognizeable central third of the face. In today’s society, full lips are viewed as healthy and sensual, thin or wrinkled lips cast the opposite image. While the lips are paired, they are not identical due to their embryological origins. The upper lip is uniquely different than the lower as it has a central cupid’s bow or two-peak wave form which differentiates it from the smooth and continuous lower lip. That is a key aesthetic difference and very important consideration in any form of lip augmentation.

 
While injectable fillers are the most common form of lip augmentation, they are not for everyone and every form of injectable filler is not for lips. Patients who have thin lips can not be injected and end up with full pouty lips. The pink part of the lip will only stretch so much before it begins to look distorted, too full, and unnatural. Results like this are evident everywhere on TV and in the movies. Injections will not make a well-defined cupid’s bow nor make the height of the lip bigger either. While it acceptable to try a small amount of injectable filler in a thin lipped patient, and I frequently do, it is best to not overdo it. Let the patient decide whether the result is worth it. I always place injectable fillers in layers and ask the patient to give me their opinion with each new layer. Enough is when they tell me so. Surprisingly, no injectable filler is formally approved by the FDA for injection into the lip even though it is common practice. Only the hyaluron-based fillers such as JuvaDerm, Restylane or Perlane should be used in the lip as they flow in smoothly and have little risk of a foreign-body reaction….and they are completely reversible with time. The particulated fillers such as Radiesse and ArteFill should not be used in the lip as they do have risks of lumpiness and potential reaction to their particle component. As for silicone oil…be very wary. Not only is it not FDA-approved for any injectable application at this time, its track history from the 1960s and early 70s is not reassuring. (even if this is a newer more purified form)

 
For those thin-lipped patients, some consideration may be given to lip lifts and advancements if careful thought is given to the permanent scar. While these are powerful lip procedures and can do wonders in increasing the size of the pink part and in making a well-defined cupid’s bow, they do produce a fine line scar at the junction of the pink lip and skin. If the patient is certain they can live with that trade-off and has a high lipstick use frequency, this may be the procedure for them. That decision becomes a little easier in the older female where the thinning of the lips and the development of vertical wrinkles on the lip requires more than a simple lip fill with an injectacble can do. If the procedure is done well, it can look fairly natural. If the lip is advanced too much or the peaks of the cupid’s bow made too sharp, it can look very unnatural.

 
Often patients who have had temporary lip injections desire a more permanent fix. Options include fat injections and synthetic implants. Since fat has to be harvested from the patient in a sterile fashion, I always do this procedure in the operating room and is a strong consideration when the patient is going to be there for other plastic surgery procedures anyway. There really is very little to lose by doing it in that setting. While the take of fat grafts is definitely variable, some patients will do well with it. The test is what it looks like at three months after surgery, not in the first few weeks. If fat takes well, it will last longer than any synthetic injectable but it may not last forever as the lip does continue to age. Therefore, further fat inejctions may eventually be necessary. Permanent lip implants (Advanta) have been around for over a decade and in the right ‘qualified’ patient can do well. Qualifying a patient is one who has had lip injections and is really ready to accept a permanent implant over a temporary filler. My experience with Advanta, a soft spongy tube, has been quite good even though all patients will definitely be able to feel it.

 
Two of the most important things in creating natural lip results is that they must not be too big or have treatments which result in them ending up stiff or irregular. We touch the lip area very frequently so we are quite attuned to how it feels And the lips need to be soft and flexible to support easy and painless movement.

 
A good artistic sense in shaping the lips (they enhance the face but should be the focal point), consideration of the many lip treatment options, and preservation of soft flexible lips are needed to get the most natural lip augmentation results.

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

Improving the size and shape of the lips is a frequent cosmetic request and a very commonly performed aesthetic procedure done in the office. While the vast majority of lip enhancements are done by injectable fillers, and most patients are only aware of this approach, there are other less common but equally effective options.

Injectable fillers are the most common lip enhancement method and the hyalurons such as Restylane and Juvaderm are usually used. The longevity of hyaluron fillers, while touted differently amongst manufacturers, is in the range of 4 to 6 months. While longer-lasting injectable fillers exist, such as Radiesse and Aretfill, these contain particles which may be prone to lumpiness and foreign-body reactions. Because of their predictability and safety, with very few complications, hyaluron lip enhancement is the current gold standard.

There other other types of non-injectable lip fillers. Over the years, many collagen-based implants have been tried, such as Alloderm and Fascian. Unfortunately, while conceptually appealing, their longevity has not been shown to be any greater than the hyaluron fillers. But they are more expensive and cause much more lip trauma to place. As a result, they have fallen into disuse.

Despite the frequent touting of your own fat as an injectable filler, and reports of great longevity and possible permanency, most plastic surgeons have not had that experience. Fat in the lip is simply unpredictable. I will still use it…..when I am performing other procedures in the operating room where the use of fat is ‘easier’ than in the office and there is little to lose by doing so. I suspect that repeat fat injections over time do consistently work but that is fairly traumatic for a patient to go through.

Permanent lip augmentation can be done by synthetic implants known as Advanta. These very soft implants are threaded into the lips, corner to corner, by a metal trocar under local anesthesia. They are non-resorbable, fairly soft, and the volume added is permanent. They can definitely be felt in the lips but I have not had a patient yet who has reported that as a problem. I use Advanta when the patient is ‘qualified’, meaning they have tried injectable fillers first and want to move on to something permanent.

More surgical lip enhancement is known as vermilion advancements or subnasal lip lifts. While these are highly effective are making the lip bigger, they have a trade-off of permanent scars. A patient must be very willing to make this trade-off and accepting of fine-line scars. I use these in patients that have very thin lips and a very flat cupid’s bow and have ‘failed’ lip enhancement by fillers. (meaning it does not look good or do what the patient expected. Lip lifts are often most effective in the older patient whose lips (which were not big to start with) have shrunken with age.

As you can see, lip enhancement has lots of options. All work well at achieving larger lips….but not every enhancement procedure is for every 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