Explore Plastic Surgery - Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

The vast majority of Botox and other neuromuscular injections for wrinkle reduction are used in the forehead. While there are some minor complications with these injections, such as bruising, low dose uncorrection and unusual forehead wrinkle patterns, the most severe problem is that of lid droop or ptosis. If injections are done too close to the eyebrows, the agent can diffuse down into the upper eyelids. This can result in inadvertent partial paralysis of the levator muscles of the upper eyelids which are responsible for eyelid opening.

While these untoward Botox effects are temporary, upper eyelid ptosis can be severely distressing to the one so affected. While this is a known risk of Botox injections into the forehead, this does make it any more pleasing to the patient. The incidence of this aesthetic complication is reported to be around 5%, although I have never seen it in my experience to be this high. Once it occurs, it can take 6 to 8 weeks to wear off in most cases. There are a handful of cases in which it can last much longer.

Once placed, there are no reversal methods for Botox, Dysport or Xeomin injections. Time is the only treatment in which these drugs will eventually wear off in a few months. As a palliative treatment, eye drop therapy can be useful for upper eyelid ptosis from these agents. One drug recommended is that of Iopidine. (apraclonidine 0.5%) This eye drop is commonly used to treat glaucoma. It can improve eyelid ptosis  by causing Muller muscles to contract which can elevate the upper eyelid by several millimeters. This drug increases the muscle tone of this muscle causing it to contract. Because Mullers muscle lies just under the inner lining of the upper eyelid, the eye drop easily diffuses into it. It is given by one or two drops three times a day in the affected eye until the ptosis goes away.

Other eye drops options recommended have been brimonidine (0.1%) and neosynephrine (2.5%) These agents can also increase the tone of Muller’s muscle, causing the eyelid to elevate and open the eye more fully. Whether these are as effective as that of Iopidine, or maybe even more so, is not known nor has any comparative study ever been done.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Aesthetic neuromuscular modulators, known more commonly as Botox, Dysport and now Xeomin, has been a decades old concept from an FDA standpoint….and twice that long as an off-label use for the treatment of unwanted facial expressions and wrinkles. Because the dose of each of these injectates will vary between each patient, it has become clear that their use is as much art as it is a science. While manuals exist as guidelines for where to inject and doses to use, each patient must still be treated individually.

The dosing issue has become more complicated now that there is more than just Botox available. Most physicians feel that there is a 3:1 unit comparison between Dysport and Botox and the jury is still out on where Xeomin will compare. I generally use 24 to 30 units of Botox for the glabella, frontalis and crow’s feet areas, the most common area for neurotoxin use. This works well for most patients and is a good value point for a cosmetic treatment that will last around four months. By comparison, the comparative dose of Dysport would be 70 to 90 units for the same areas.

There remains some controversy about whether Botox or Dysport is ‘better’. There is tremendous brand loyalty amongst providers to Botox and the company certainly does a lot of marketing and promotions to maintain it. I think Dysport has done a relatively poor job of how it markets and promotes its equivalent and, as a result, it continues to be occupy a relatively small piece of the injectable neurotoxin market in the United States. Whether that will change depends ultimately on how well it works in the years ahead.

It appears fairly clear that Dysport does have a few days of earlier onset and a greater zone of diffusion than Botox. This makes it preferable to those who want to have a quick onset of action and may be better in the crow’s feet area where the orbicularis muscles are broad. Because of this greater diffusion, some feel that it has a higher risk of unintended effect in areas where numerous muscles have opposing actions such as around the mouth. I have heard and read that Dysport lasts longer and is more cost-effective but these claims are not substantiated by any clinical study.

Unlike ten years ago, the one area that Botox and its competitive analogues have had increasing use is as an adjunct and sometimes a replacement for surgery. For many patients, reducing muscle action in the forehead can delay or eliminate the need for a surgical browlift. While this so-called chemical or pharmacologic browlift is very useful in the forehead, it is ineffective for the mid- or lower face as a lifting technique. For those patients actually undergoing a browlift, injecting Botox either before or after the procedure can enhance the results. I find it particularly useful in my Indianapolis browlift patients for injecting during surgery to get the best lift possible in the tail of the eyebrow. This is an area that can be the most difficult to surgically lift as opposed to the central brow.

Another area that injectable neuromuscular modulators are very helpful is in laser skin resurfacing. By injecting at least a week before surgery, the muscles are relaxed so there is not as much pull on the healing skin as it is healing. That does provide some better comfort although touting it as promoting better healing is not based on any science. A good protocol that I use is to inject Botox two weeks prior to laser resurfacing and then again at three or four months afterwards to maintain a good smooth result. Keeping the muscles relaxed will also prolong the results of many non-surgical treatments besides laser resurfacing such as injectable fillers, chemical peels, and skin tightening devices. (Skin Tyte, Thermage, Ulthera)

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Botox remains a popular and effective method of reducing unwanted facial expressions and wrinkles. While it is a highly desired aesthetic treatment, it must be introduced by needle injection and in a doctor’s office or a medical facility. While the injections are not extremely uncomfortable, if there was a way to avoid needles into the face these anti-wrinkle treatments would become even more popular…and comfortable.

The quest to find a ‘topical Botox’ or cream that would penetrate through the skin to cause similar facial expression muscle weakness has been much like the search for the Holy Grail. There is a strong belief that such a compound exists but it has yet to be discovered. Despite the many marketing scams that have abounded by topical creams claiming to have a Botox-like effect, a topical application that really works has remained elusive.

At this year’s annual American Society of Plastic Surgeons meeting in Denver, a new botulinum toxin-based gel was presented that showed promise. Reporting results from a recent prospective double-blind clinical trial of nearly 100 patients, near 90% of those that had the active gel had observable reduction in crow’s feet wrinkles. This compared, interestingly, to just under 30% in those patients that have been treated by a non-active or placebo gel. In a second study that involved nearly 200 patients about 40% of those treated with the botulinum toxin gel had good results. In either study, the effects of the gel lasted around four months which was comparable to that of injectable Botox.

These study results are the first to show that dynamic facial wrinkle reduction is possible through topical application or a cream. It is no surprise that the studies have been done for wrinkles in the crow’s feet region to the side of the eye. This skin is very thin and the most easily penetrated down to the orbicularis muscle underneath. This is unlike the substantially thicker forehead tissues where an effective topical cream would be much more challenged.

While it is encouraging that a botulinum toxin gel has been shown to noticeably soften crow’s feet wrinkles without needles, it remains to be seen how practical it will be. Does the gel work better than injectable Botox? Would it’s cost be similar, less or even more? This information awaits further clinical study which undoubtably is ongoing.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Aging is inevitable and it begins to appear first around the eyes. With familiar names, such as crow’s feet, 11s, dark circles, bags and hooding, they indicate how visible and concerning these aging issues around the eyes can be. While surgical eyelid tucks and browlifts can offer dramatic improvements, many women and some men would prefer to try and prevent or even camouflage these eye flaws before considering surgery.

There is a progression of non-surgical treatments for keeping the eye area fresh and less old and tired looking. Known as periorbital (around the eye) rejuvenation, these include a variety of treatments combining neurotoxins, fillers, laser devices and topical products. These types of treatments usually follows the age of the person. Those in their 30s and 40s usually just need Botox to control the frowning and squinting. Fillers and light and laser treatments are added for those in the 40s and 50s. At 50 and beyond, only surgery can remove loose upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still very useful to protect and maintain one’s surgical results.

Botox is the most recognizeable name when it comes to injectable wrinkle reduction since it was the first to be used. But it is no longer alone as two other injection drugs, Dysport and Xeomin, are now also available. While patients often believe that one of these is better than the other, they are all comparable in most cases. The differences between them is perceptual and not factual. They all take a few days to start working and will last in the range of three to four months. One is not more powerful than the others nor does one cost less. Because these injections are given by the unit, the cost per unit varies for each one but so does their effectiveness. (e.g., 1 unit of Botox equals 3 units of Dysport) As such their treatment costs are all about the same.

While Botox is the backbone of non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s and early 40s. This can be treated with fillers placed to fill out them out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred as they can be delivered smoothly into the thin skin of the lower eyelids with minimal risk of lumps and irregularities.

While eye lines and wrinkles can be held in check with Botox and fillers, they can not reverse skin color and texture problems. Broken blood vessels and brown spots can be improved with high energy light therapies known as IPL or BBL. These are often confused with lasers which they are not. But when it comes to improving skin texture and reducing fine lines and wrinkles, laser resurfacing around the eyes can produce results that not even a formal eyelid lift can do.

Topical skin care products are important to help maintain the benefits of these injectable and energy treatments. The skin around the eyes is so thin that it responds well to many vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Having thicker eyelashes and eyebrows can really add to a more youthful look.

While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the pass of a laser beam away.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Botulinum toxin, most commonly known as Botox, has a wide range of uses of which not all are FDA-approved. One of these yet-to-be-approved but growing uses is in injection into the masseter muscle. Being the second largest muscle in the face (the temporalis is the largest), it also differs from the other facial muscles being injected since it is not a muscle of facial expression. It is a masticatory or jaw moving and chewing muscle. There are two primary reasons to use Botox injections into the masseter muscle, one being for aesthetic facial contouring and the other for the relief of jaw-related facial pain.

Some patients with a very square face may have a significant masseter muscle thickening or hypertrophy. The contribution of the masseter muscle thickness to the width of the face can be determined by having the patient bite down and looking and feeling the size of the muscle. Extreme flaring or bulging is a sign of a significant contribution to facial width. Masseter muscle reduction is a commonly requested procedure in Asian ethnicities, particularly Korean, due to their inherently wider facial shapes. Compared to surgical thinning of the masseter muscle which is a very traumatic procedure with a long recovery, Botox injections offer an equal result without any of the surgical side effects.

Botox injections can shrink the masseter muscle very effectively but is highly dose and location dependent. A dose of 25 units per masseter muscle is a good starting point and always produces a result. Less of a dose may also work but it is based on the size of the target. The equivalent dose of Dysport would be 50 to 75 units. It is important to inject only into the prominent bulges of the muscle on biting down. Placing it into normal muscle is a waste of injectate and may risk a cheek indentation, particularly at the anterior border of the muscle. It is also important to not inject above an imaginary line that runs between the tragus of the ear and the corner of the mouth. Going above that line places the buccal branch of the facial nerve at risk for months of temporary paralysis of the upper lip.

For this cosmetic facial shaping use, the effect becomes apparent relatively quickly within a month or two. The effects will last about 6 months and repeat injections are needed to sustain the narrowing effect. It is unknown if there is a point when the effect is sustained without further treatments.

For those who suffer from facial pain due to bruxism or excessive clenching, Botox has a similar beneficial effect. It not only stops the amount of muscle spasm and clenching but it can also cause a muscle thinning effect. The injection technique is the same but slightly higher doses may be needed. While I always start with 25 units of Botox per side, optimal pain relief may require a higher dose. But start at 25 units and see what happens. Also, because the temporalis muscle may be a contributor to the clenching, injection into it with 10 units may be needed. The injection point is determined by where the patient points to a temporalis location, but it is often into the muscle just above the zygomatic arch at the anterior edge of the hairline. The duration of these masseter muscle injections approximates that of its upper facial cosmetic effects of around 4 months. Despite this shorter duration, the pain relief can be dramatic.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Migraine headaches are a major concern and lifestyle alteration for those afflicted. While some have only occasional or sporadic migraines, others have more frequent and intense bouts that affects many parts of their life and are even disabling. Drug therapy does help many but not all and it is associated with some side effects. Besides ineffectiveness or a limited improvement, some of the side effects of these drugs are not worth the limited benefits in migraine reduction that they provide.

Newer migraine treatments include Botox injections and surgical decompression. Based on the concept that there is a peripheral trigger in certain migraines, nerve decompression by muscle chemorelaxation and then surgical muscle resection from around the involved nerve has been shown to offer long-term improvement. While there has been compelling evidence that such treatments work, new and independently conducted studies are always welcome.

In the July 2011 issue of Plastic and Reconstructive Surgery, a study out of Texas was published based on a retrospective review  of 24 migraine patients. Botox was used to identify frontal, temporal, and occipital trigger points. The nasal trigger point (septal deviation) was identified by examination but is not an injectable area. If a positive response to Botox was seen, surgical decompression was then performed on the trigger points. The success of the procedures was determined and followed by the Migraine Headache Index up to nearly two years after surgery.

Nineteen of the studied patients (80%) were improved by the surgery. While a few (2) had complete elimination of their migraines, most (17) reported significant improvement. Among those patients who responded to surgery, average improvement from baseline was 97%. Among all patients studied, average improvement was 78% from baseline.

While this was a relatively small patient study compared to some prior published reports, it nonetheless shows comparable findings. This study adds to the growing body of medical literature that shows Botox injections and surgical decompression can be tremendously effective in reducing migraines in the properly screened patient. Since the screening procedure for migraine surgery is Botox, it makes the decision and the probability for surgical success easy.

One thing I have not yet seen reported and have observed in my own migraine patients is different levels of success depending on the trigger point location. By far, surgical decompression of the greater occipital nerve (back of the head migraines) seems to work every time and usually quite dramatically. Less dramatic success is seen in some of the frontal trigger points, particularly the temporal location. This may be because there are different levels of compression along the path of the zygomaticotemporal nerve and other regional nerves, such as the auriculotemporal, may also be a contributing cause.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Botox is well known as an injectable facial treatment for wrinkle reduction. Its effectiveness at reducing or blocking unwanted facial expressions, mainly those in the foreheads and around the eyes, has virtually created an industry around non-surgical facial rejuvenation. As a result, it has been primarily responsible for the popularity of early intervention for preventing or softening certain facial wrinkles.

The concept of early intervention for facial wrinkle reduction has taken on an extreme approach for one 8-year-old California girl. One mother and her daughter has been using Botox to compete in beauty pageants and has raised the question of exactly how young is too young when it comes to using medical treatments for the sake of beauty. According to the mother, it was actually her daughter who wanted to try Botox. As she was getting into beauty pageants, the daughter was apparently complaining about her face having wrinkles. Her mother, who is an aesthetician and uses Botox herself, suggested doing the treatment on her.

This story would certainly be viewed by most as odd enough, but it takes another interesting twist. Since the daughter has seen her mother inject herself with Botox, she agreed to have her mother inject her. The mother states that typically administers the Botox to her daughter through a total of five shots in three different locations on her face. While a child would have no static wrinkles, they felt it did satisfactorily reduce some dynamic facial wrinkles. But it’s enough of a difference for this mother-daughter team to continue on with the treatments.

While many will no doubt be agasp of the extremes that a mother would go to help her daughter compete in beauty pageants, there are actually more serious undertones to this story. Where does the mother get her Botox? Since she is not a physician, how does she legally get it? Either she knows a doctor from whom she is getting it or is being sold to her under some doctor’s name. Allergan, the manufacturer of Botox, requires a physician’s license number to fill an order. The other possibility is that the local Botox sales representative is providing it to her. Either way, shame on the doctor or Allergan for allowing it to happen.

Patients administering Botox to themselves or to other patients is a reflection of just how much Botox is really viewed as a commodity by many and not a medical treatment. While there is a very low risk of any serious complications of Botox in the face and at the doses that are used, it is still a muscle paralyzing agent. It is not the same as inserting a suppository, administering ear drops or performing any other off-the-shelf medicament from your local pharmacy. Self-administration or injecting Botox into a child demonstrates that the potential dangers of a medical treatment are simply not appreciated. Lack of medical training also makes it easy to not be able to balance the risks vs benefits of any type of ‘beauty’ treatment. There is a legal concern also. Botox is not approved for use in patients under the age of 21 unless there is a medical condition being treated. 

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The popularity of Botox for cosmetic facial uses is that it does something that not even surgery can do…stop unwanted expressions. Its downside is that its results are not permanent. Most patients would wish that its effects were either more long-lasting or were permanent.

One question that some patients ask about the long-term use of Botox is whether it becomes more effective or, conversely, does one become resistant to its effects. In the very long-term (10 plus years of regular use), no one really knows for sure as so few patients have been treated for that long. It is tempting to think that regular use of Botox injection over many years results in muscle atrophy and either an increased response to injections or the need for less treatments or lower doses over time.

New research might give some insight into whether such effects from Botox may actually happen. A study shows injections turn muscle to fat. The findings were part of a new study by researchers at the Faculty of Kinesiology at the University of Calgary.

The study found that animals injected with botulinum type A neurotoxin complex experienced muscle weakness in muscles throughout the body, even though they were far removed from the injection site. The study also found that repeated injections induced muscle atrophy in the limb that was not injected with the toxin.The study used dosages that approximated therapeutic doses used to treat conditions like cerebral palsy where muscle contraction can’t be controlled resulting in spasticity. This study shows, for the first time, that over time botulinum toxin type A use also results in muscle weakness and atrophy in noninjected muscles far removed from the injection site.

Previous research has also shown that botulinum toxin A easily crosses the muscle membrane barrier, resulting in muscles weakness in the surrounding (noninjected) muscles as well. We call this diffusion or zone of spreading. (it can account for the potential problem of eyelid ptosis or droopiness that may potentially occur with cosmetic injections between the eyebrows)

What do these study results have to do with cosmetic facial injections with Botox? These were limb injections in animals and relate to what happens to limbs that were not injected. Perhaps nothing as the type of muscle and the doses used were in excess of what is injected into much smaller muscles of facial expression. But it may also suggest that long-term Botox use in any muscle may eventually weaken it through ‘disuse atrophy’. We know that easily happens in extremity muscles but does it or will it happen in the muscles of facial expression? Many patients hope so…the next decade of Botox use will undoubtably answer that questions.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Teeth clenching, otherwise known as bruxism, is a common phenomenon amongst  many people.  To some degree, almost everybody clenches his or her teeth. The issue lies in the intensity of the  teeth clenching is. A person with severe bruxism will often clench their teeth with not only excessive force but with great repetition, often occurring during sleep. Patients awake with tooth and jaw muscle soreness. At pressures on the teeth that can be up to greater than 500 pounds per square inch, it is not wonder that tooth damage can occur.

Why clenching occurs in anyone is largely unknown. Theories usually point to stress or habits  but the problem is no doubt from many causes that collectively creates masseter muscles that are overactive. Besides excessive tooth wear, the hallmark of clenching is sore jaw muscles either near and around the angle of the jaw in front of the ear and in the temple area.                                                                                           

Currently, the most common treatment for clenching is a custom-made mouth-guard that is worn during sleep to prevent tooth damage and, in theory, to stop the muscles from overactivity.The effectiveness of dental appliances covering the tooth surfaces is unchallenged. But the muscle problem is a different story. This is evidenced by the array of other available muscle treatments including drugs, transcutaneous nerve stimulation, thermal therapies and biofeedback, to name a few of the most prominent. For some these work, but for many others the results are less than needed or simply don’t work at all.

One direct muscle treatment for the masseter muscles of clenching is Botox injections. As a well known cosmetic wrinkle treatment for much smaller muscles that cause facial expressions, it can similarly be injected into any other muscle. The intent into the masseter muscles is not paralysis but to control its hyperactivity and break the cycle of spasm and pain. Good candidates are those that have significant masseter muscle flaring or bunching while clenching with palpable pain of those areas.

Injection into the masseter muscles is a very simple and near painless treatment, The key is to stay in the lower half of the muscle near the jaw angle. Using an imaginary line drawn from the corner of the mouth to the lower end of the tragus of the ear, the injection points should stay south of this near horizontal line. Injecting above this line may create weakness of the buccal branch of the facial nerve which would be evident by paralysis of the upper lip during smiling. By having the patient clench, the bulging areas of the muscle are injected. I use 25 units of Botox per side as a baseline dose. Some patients may require more but this is a good economical place to start.

If there is any temporalis muscle tenderness, it can be injected as well. This is best done just above the level of the zygomatic arch at the junction of the scalp and the non-hair bearing temporal skin. This is also the area beneath the temporalis fascia where the zygomaticofrontal nerve branch comes upward from the deeper muscle belly. This sensory nerve branch of the maxillary nerve has been implicated in migraines of the temple region. About 8 to 10 additional units can be injected into each side of the temporal area.

One effective technique is to add Marcaine (with epinephrine), a longer acting local anesthetic, into the Botox solution. This provides immediate relief of pain within minutes of being injected as Botox will take days to exert its beneficial effects. The ratio I find effective is 0.3cc per 1cc syringe of Botox. (0.7cc volume = 28 units of Botox or 4 units of Botox per .1cc) Each masseter or side then receives almost 1cc of Botox/Marcaine solution.

As a direct muscle treatment, Botox works very well for clenching problems. For some patients, it is eliminated completely. For others the relief is significant but not complete. It should be expected to last around 3 to 4 months.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Every cosmetic Botox (also Dysport, Xeomin) patient would love to have it last longer. Whether it would be a new molecular form of Botox  or some additive method of drug prolongation, there is considerable interest in that effect. The offshoot of lasting longer is most manifest for patients in that they would be exposed to lower costs in the long-term and  not having their forehead pierced quite so often.

Recent research from an oculoplastic surgeon in Dallas has resulted in a patent-pending dietary supplement combining zinc and phytase (trademarked as ZYTAZE™) in which an initial clinical study showed improved results with Botox. Over 90% of the patients in their study (41 out of 44 patients) who took the oral supplements showed increased responsiveness to Botox in the treatment of blepharospasm, an uncommon form of eyelid twitching. The study concluded that the Botox seemed to last longer and with greater effect. No mechanism has yet been suggested as to how this combination supplement may prolong Botox’s neuromuscular blockade.

Does this mean we can start prescribing this supplement, or even zinc, to our patients in the hope of making Botox better? While such study results are interesting, they are far from conclusive. Most, if not all, of the patients in this study had blepharospasm, an abnormal neuromuscular interaction. This should not be confused with a normal neuromuscular synapse in the cosmetic patient. Whether such findings will occur as in this study requires a much larger blinded study which I am sure the researchers are currently doing. Recruiting subjects for this kind of cosmetic research would certainly not be a problem.

As appealing as the concept of an oral supplement is to improve the effect of a pharmaceutical drug, it is more science or just hope? Much of the supplement world is often more of the latter. Scientific proof is hard to come by and much of the evidence of their benefits is testimonial and theoretical. This work is novel and will attract a lot of attention by many Botox patients. Until some real science is put forth, I will remain optimistic but skeptical.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana