Explore Plastic Surgery

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

As we age, one of the many facial changes is the loss of volume in the cheek area. This is most apparent in patients that are thin or have a normal age-appropriate weight. The cheek prominences become less and more saggy. In addition, the area below the cheek bone known as the submalar or buccal cheek area will often become more indented. In some patients, this can create a ‘gaunt’ or aged look. People who are heavy rarely develop this sign of facial aging as their cheeks remain fuller and more rounded, creating the ‘Santa Claus’ effect. (round and jolly but vibrant)
While the most effective long-term solution to cheek volume loss is surgical (midface lift, cheek implants, submalar implants, or fat injections), injectable fillers offer a quick and effective method of a subtle cheek enhancement. By injecting volume into the cheeks or below in the buccal area, the face can appear more youthful and ‘uplifted’. The effect is not designed to be dramatic, nor should it be, but a subtle improvement that looks natural. This is a quick solution that has immediate effects without the swelling and potential bruising from surgery.
While the effect injectable cheek augmentation is only temporary, how long it lasts will be influenced by what type of injectable filler is used. The hyalurons, such as JuvaDerm and Restylane, will last in the range of 4 to 6 months, in some cases maybe a few months longer. When using the particulated fillers, such as Radiesse or ArteFill, I would expect the effect to last longer in the range of 9 to 12 months. (or basically double that of the hyalurons)
Injectable cheek augmentation can be enhanced by the simultaneous use of Botox injections in the crow’s feet and cheek areas. The objective being to weaked the expression lines around the eyes so that the amount of wrinkling with smiling is less. The combination of these injectable midface treatments makes for a nice rejuvenation of the middle third of the face that looks very natural and relaxed. All done in less than 30 minutes and you are on your way back to work or home for the evening without anyone being the wiser!
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Although there are a number of commercially-available injectable fillers for cosmetic facial treatments, they break down into two main categories or families, hyaluronic acids (hyalurons) and the particulated fillers. Particulated injectable fillers contain non-biodegradable beads or particles which accounts for their longer duration of persistence which is at least twice as long as most of the hyalurons. While the bead composition of each particulated filler only consists of about 20% of each syringe (any larger amount and the beads would not flow through a small needle) and the rest is the carrier vehicle, enough permanent material is placed with each injection session that a good duration of effect is achieved. In theory, with subsequent injection sessions, a greater degree of permanency is achieved each time as the bead layers are built up over time.
Amongst the particulated fillers there are only two types that are currently available, Radiesse vs. ArteFill. While there are differences in the makeup of the beads between the two, Radiesse with ceramic beads and ArteFill with plastic beads, the greater difference is in the type of carrier vehicle which makes up about 80% of the initial injected material. Radiesse uses a polyethylene glycol mixture while ArteFill uses bovine (cow) collagen. Because ArteFill uses an animal collagen, it requires a pre-injection skin test to rule out a sensitivity to it. Radiesse requires no such skin test.
One of the most interesting questions about the particulated fillers is which one is better? Or from a patient’s perspective of better, ,which one lasts longer and would therefore be best? Radiesse reports persistence of the material for up to two years based on animal (rat) studies. Having used Radiesse a lot over the past 5 years, my human experience would not support that time duration. My experience of using Radiesse in the nasolabial (lip-cheek) folds is around 8 - 9 months on average. ArteFill has clinical studies which show persistence in some patients for years but I have not used it long enough to verify these findings in my practice. ArteFill uses a different injection approach by doing a series of treatments over a several month period to build-up multiple layers of the beads, thus creating greater permanency.
The bottom line question is….which is better…. Radiesse or ArteFill? Quite frankly, at this point in time, I do not know.
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 recently had a patient who came to see me to get lipodissolve treatments. She stated that she was a perfect candidate for it. When I asked how she knew that, she said she had been injected last month at a party at one of her friend’s spa. Out of curiosity I queried further to find out (to no surpise) that she had no idea if the person who injected her was even a doctor of any kind, she didn’t know what was injected into her, nor did she have any understanding as to how Lipodissolve therapy even worked. As it turned out she had only 4 injections across her entire stomach area.
The relative ‘ease’ of doing injection beauty treatments such as Botox, soft tissue fillers, and lipodissolve has created the concept of the spa or home party atmosphere for a girls nite out. I won’t go into the obvious, and much written about, issue of…is there a physician on the guest list. Besides the fact that these are true medical treatments that shouldn’t be done outside of a physician’s office (increased risk of complications) and it is against the code of ethics of most physicians to offer medical treatments as a prize or incentive, there is a much more significant issue that most patients/consumers miss. These beauty treatments work best when done in the context of understanding the facial aging process. All injectable therapies play a role in the treatment of facial aging, but where they fit and whether they are good for you can only be determined by sitting down with a plastic surgeon and discussing the big picture. I see lots of patients who come in for Botox, for example, but have no idea how it works and what it is really good for. Injectable fillers are the same way, they can not cure and solve all facial wrinkling issues.
The consideration of these issues brings to light the point that I am driving it…value for what you are getting. Just because you are getting a good ‘deal’ on some injectable treatment by doing it at home or in a spa setting doesn’t mean it is even what you really need. It may not even be the most appropriate type of treatment for what you want to achieve. Injectable home or spa parties miss out on one of the most important issues of any medical treatment, pre-treatment education and consideration of other treatment options. That deal you are getting may turn out to be wasted money and effort. As the old saying goes, many times you do get what you pay for.
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 newest more permanent injectable filler, ArteFill, for facial lines and folds is taking a throwback from history. Its use requires a pre-injection skin test due to its bovine (cow) collagen content. This is what the original collagen injections, Zyderm and Zyplast, required when they were the only injectable filler available from 1981 to 2000.

Unlike the original collagen injections, ArteFill is not solely collagen but contains a significant percentage of pplastic beads which occupies abouot 20% of what is actually injected. The rest is the collagen which must have a higher  ratio than the beads so that the beads will flow smoothly out of a very small needle. While the beads are permanent, the carrier collagen is not.

The purpose of the skin test is to make sure that you are not allergic to bovine collagen. From prior collagen injection experience, we know that about 5 - 6% of the population will get an allergic raection to it is. Better to know that in a small area in your forearm first before putting much more of the material into your face.

The skin test is done like a TB test on the inside of your forearm. The test takes 4 weeks before you can be injected with ArteFill. The test is positive of any amount of redness or swelling develops during this 4 week waiting period. If there is any doubt about whether a positive reacation is seen, then a second skin test is done and another 4 week waiting period is needed.

While some patients may find the need for a skin test annoying, it is an absolute necessity if one is to get the benefits of the longer-lasting ArteFill injections.

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 newest facial injectable filler to enter the commercial cosmetic marketplace is Artefill, a semi-permanent to permanent in-office treatment for deep facial lines. This is primarily intended for the nasolabial fold area, often times called the cheek-lip groove or fold. It is the result of cheek tissue descending with age, falling over the fixed upper lip. (which fortunately does not fall much with age!)

ArteFill falls into my categorization of the particulated filler group, which is in contrast to much of what the public knows about injectable fillers, such as Restlane or JuveDerm , which are the hyaluron or non-particulated group. Like the other current particulated injectable filler Radiesse, Artefill also contains beads (or particles) and a solution into which it is suspended so it will flow through a small needle. In simplicity, ArteFill contains small plastic beads in a collagen solution which is derived from cows. This collagen solution results in its only real drawback to other injectable fillers in that it requires a skin test prior to treatment to determine if you have an obvious reaction to the animal collagen. Short of that, ArteFill does have several advantages over any of the non-particuled fillers for the nasolabial fold area.

First, ArteFill is one of the most extensively studied of the injectable fillers from the perspective of long-term patient follow-up and evaluation of its constituent filler materials. It is the only one of all of the fillers that can truly document years of sustainable results. Secondly, calling it a ‘permanent’ filler is a bit of a stretch (no filler can be truly called permanent when you are treating an aging issue), but it is true that the particles which are injected never go away. But the collagen solution which carries them through the needle does go away, and since that makes up about 80% of what is injected, the initial results from one injection are not ‘permanent’. Understanding this then allows you to eventually see where the concept of ‘permanent’ comes from and how to get there. If one undergoes a series of ArteFill injections over a 3 to 6 month period, it is possible to build up to a result that will last for years. Each injection session will add another permanent layer of beads, which when done enough times, will create a new tissue layer that will not go away.  lastly, this is certainly a different approach that any of the other types of injectable fillers. More injection sessions will be needed up front but with the objective of building to a permanent layer, rather than just re-injecting when it has all gone away as with most other facial fillers.

ArteFill offers a novel approach to the ubiquitous and difficult nasolabial fold area (parentheses), If you are willing to spend more money up front and go through a series of closely-spaced injection sessions, this is likely a better long-term value for this cosmetic facial concern.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Lip Enhancement in Indianapolis by Dr Barry Eppley

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

New Versions of Injectable Fillers keep coming…..and more are on the way!

Next to Botox coming out of a needle, the use of injectable fillers is only slightly less popular as a cosmetic injection method. While collagen was the only injectable filler for lines and wrinkles from 1981 to 2003, there has been a virtual explosion of new injectable fillers since then…..now numbering six commercially available fillers….and four of these have become available in the last year. And collagen as an injectable filler has now become of historic interest only.

The new revolution in injectable filler materials has been the change from collagen to hyaluronic acid. A natural sugar, hyaluronic acid (HA), lasts longer and has much less potential for adverse reactions than collagen. The battle amongst HA manufacturers revolves around the claim of which one is the longest lasting. Despite differing claims, conclusive proof that one type of HA lasts longer than the other remains lacking. Clinical trials for most manufacturers has compared their version of HA to collagen as the control. Few direct comparison studies have yet to be done. While the amount or concentration of HA per cc would suggest greater longevity, there are other issues of importance as well such as the degree of cross-linking. These issues will eventually sort themselves out but it is fair to tell patients that HA injections will last between 4 and 8 months on average, and some perhaps longer. One thing is for certain, however, and that is more variations of HA injectable fillers are coming….and such competition will drive the price of a syringe down. (which is more than can be said for Botox!)

Two non-HA injectable fillers also became commerically approved last year. I call these type of injectable fillers, particulated synthetic injectable fillers. The concept is that they contain a portion of non-resorbable beads or particles mixed in a carrier solution. Radiesse uses ceramic beads and ArteFill uses plastic beads. Either way, the beads do not go away and some percent of permanence remains. As a result, they last longer than the HA fillers even if 80 - 90% of the particulated filler does go away. Because they have the potential to become lumpy due to scarring around the beads, their use in the lips is not recommended. In theory, build-up of the beads can occur over time with multiple injections so that their effect may seem to last longer over time.

With such a wide selection of injectable fillers available today, it can be confusing to the patient. For the physician injector, it is important to use more than one of the available injectable fillers for different areas and different problems.

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

INJECTABLE FILLERS – Many Types, Different Uses

Up until 2002, only one type of facial line and wrinkle filler was available – injectable collagen derived from cow proteins. While it lasted only a few months, due to its animal origins, it was the only treatment option available. Since 2002, six (6) new injectable fillers have been approved for use in the United States, all of which are made up of different (and better by the way) materials which last longer with fewer skin problems. This has resulted in a great amount of confusion and misinformation for patients. (and some doctors as well) With the certainty that more new injectable fillers are on the way in the next few years, it is important for even the patient to have some basic understanding of the similarities and differences between the choices that they have.

Today’s injectable fillers can be classified into two basic types: hyaluronic acid (HA or hyaluron) and particulated (particle-containing) compositions. While both come out of a needle, they are quite different. HAs are now the gold standard of fillers since they arrived in 2002 and have relegated old-style collagen to an almost historic footnote. Since they are synthetic ‘knock-offs’ of natural human hyaluronic acid, the patient does not need a skin test prior to injection and they last at least twice as long as collagen. The alleged differences between the four commercially-available HA injectates (Restylane, Hylaform, Captique, and JuvaDerm) is largely marketing-driven and no clinical studies has ever compared how long all of them last compared to each other. Because they are like injecting a ‘soft form of Jello’, they can be used anywhere on the face including the lips (even though the FDA has never approved any injectable filler for use in the lips) without fear of excessive lumpiness. I prefer JuvaDerm at present due to his observations that it appears to last the longest. (6 – 8 months) The next few years will bring other more concentrated HA injectable fillers to the scene that undoubtably will last even longer. The particulated fillers contain synthetic beads or particles (plastic or ceramic) in different liquid carriers. (Radiesse, ArteFill) Due to the non-resorption of the beads (which usually make up less than 25% of the solution), longer-lasting effects are seen than with the HAs. Equally important, because the beads do not resorb, some ‘permanency’ of volume can be achieved over time with repeated injections. However, because of the particles and the potential risk of lumpiness, these particulated fillers should not be injected into the lips. They are best used for deeper lines and folds such as that of the cheek-lip fold which is a common cosmetic concern for aging patients.

Since no injectable filler is ideal for every patient or type of facial line or wrinkle, the best plastic surgeons usually work with two or three different ones to custom treat each facial problem.

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