Explore Plastic Surgery

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

Botox, the world’s most popular injectable cosmetic treatment, works by providing a temporary muscle paralyzing effect reducing or eliminating unwanted facial expressions. The vast majority of Botox used for this purpose is done in the forehead and around the eyes. In the masseter muscle, however, repeated Botox injections over time can actually reduce the size of this large muscle improving external appearance and reducing muscle-clenching pain symptoms.
The use of Botox for masseter muscle reduction is well chronicled in the Korean medical journals. In this ethnic group, it is often desired to reduce the size of the muscles for the cosmetic purpose of making the face look less square. Botox done over time is so effective that the surgery historically used to achieve the same effect, masseter muscle reduction and mandibular angle reduction, is now reserved only for patients that demonstrate an actual bony prominence as the primary source of the problem.
Botox injections in the masseter muscle are easy to do. Have the patient clench their teeth together and the prominent bulging of the masseter muscle borders are easily seen. I usually inject right into the prominent bulging areas with 6 units per bulged area and stay closer to the angle areas of the jaw and its lower border to avoid injecting into the parotid gland. Plus, the thickest bulk of the masseter muscle lies low anyway. I have found that it takes about 25 - 35 units per side to get a good effect. So when I run out of bulging areas to inject, I will make sure I inject at the front and back of the muscle at the bottom of the jaw until I reach that number of units.
While effects can be usually been fairly quick, as judged by less muscle pain and headaches, it takes about 6 months before actual visible shrinking of the muscle is seen. Botox injections should be repeated every 4 months up to a years worth of treatment to see the best results. The decreased size of the muscle is impressive after a year of Botox therapy. I have been surprised to see that the results of masseter muscle reduction seem to be maintained even if no further Botox injections are done. I don’t have a good physiologic explanation as to why that would be so, as Botox does not cause any permanent atrophy in the muscles of facial expression. But I have seen it enough now to realize that it is real clinical finding with Botox use.
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

I read earlier this week of another Botox ‘concern’ this week on the internet which reported ‘Botox moves from the face to the brain’. This news story was based on a recently published paper in the Journal of Neuroscience. The concern is that Botox apparently can migrate from where it is injected to somewhere in the brain, suggesting that this may be potentially harmful. At the least, it sounds harmful anyway.
Doing my due diligence, I decided to read the article for myself as undoubtably patients will ask me about it. The article is officially titled ‘Long-Distance Retrograde Effects of Botulinum Neurotoxin A’ authored by an team of scientists at the Neuroscience Institute in Padova, Italy. It was published in the Journal of Neuroscience on April 2, 2008. In this study, botulinum toxin A was injected into rats either into various areas of the brain or into its whisker facial muscles. The most potentially relevant injection site for cosmetic purposes is the facial muscle site. They found that some of the botulinum enzyme remnants were later found at the facial nucleus site in the brain. Thus, confirming the novel finding that botulinum toxin has the ability to move ffrom the nerve endings in the face to the brain…..at least in rats.
What does this mean to the cosmetic patient who regularly gets botox injections? Not much in my opinion. First, this was a study performed in rats, so it does not mean it works the same way in humans. Secondly, the study did not show any harmful effects to the rat despite this finding. Third, the type of botulinum A and the dose used were different than what is used for cosmetic purposes in humans. As billions of cosmetic Botox injections have now been done in humans with no significant problems ever reported to date, this is a very interesting study but the correlation to human applications has not been made.
Or as one of my patients said after asking me about this news story this week……too bad for the rats but I will not stop getting my Botox!
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

One of the features of facial aging that bothers women the most is the development of upper lip lines. Whether they be small fine lines that are at the junction of the skin and upper lip or much deeper lines that extend vertically way up into the skin…women hate them…as they indicate a more aged mouth look and in more severe cases allows lipstick to bleed up into the lines. Many patients think it is due to smoking and chronic sun exposure (and clearly these can make a big contribution) but the reality is…it is a function of full your lips are and how thick your skin is. This is why this is much more of a problem in Caucasians of northern European and English descent than it ever is in African-Americans, southern Europeans, or those of Mediterranean origins. As all natural wrinkles form perpendicular to the direction and action of the underlying muscles, vertical lip lines develop from the action of the circumferential orbicularis muscle that purses your mouth around a straw, cigarette, or puckers ofr that kiss.
While the diagnosis of this problem is easy, it’s treatment is not. Since you can’t cure the cuse of the lines (thicken your skin or stop moving your mouth), I tell patients to think about improvement (but not elimination of the upper lip lines) and the need for maintenance treatments as we are not curing the root of the problem. Treatment choices are based on three achievable objectives; diminish the muscle movement (Botox), plump up the lips ir fill the lip lines (injectable fillers), or ’sand’ down the wrinkles. (dermabrasion or laser resurfacing). Any combination of two or more of these will produce a better result in most patients. While Botox can certainly weaken the muscle movement and cause less puckering, it must be done carefully so as not to create an unnatural lip movement with smiling. For this reason, this is usually the last procedure I will do or will do it only in combination with everything else in the most severe cases. Injectable fillers are a good option if the patient can accept or wants a larger lip. If not, then dermabrasion or medium-depth laser resurfacing is the only other option. The best results that I usually see is when the upper lip is slightly enhanced with a filler and the upper lip is then laser resurfaced at a depth of 50 - 100 microns. This is probably the best combination if, again, the patient can accept a larger upper lip. It heals within a week and can be done in the office under local anesthesia. Patients will usually have to repeat the procedure once a year for maintenance of good results. However, it is fair to say that upper lip lines defy one single permanent solution.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Dr. Eppley Discusses New Botulinums in Development

Botox is a now a household name and one of the most popular and commonly performed cosmetic procedures in the world. Botox represents one form of botulinum A toxin of which there are at least eight forms. Currently, there are three additional forms of botulinum under some level of clinical development. The ones we are likely to hear about in the next year or so is Reloxin and PurTox. Besides the name, these different botulinum toxins are differentiated by how quickly they start to work, how long they will work, and how far from the injection site the drug will diffuse.
Reloxin, which is the name used in current U.S. clinical trials, is known as Dysport in Europe and other countries. Like Botox, Reloxin is a type A botulinum which lasts twice as long after mixing and has a different unit dosage. My understanding from readings at present is that the dose comparison is 3:1. (300 unit vial compared to 100 unit vial for Botox) Because Reloxin has a slightly different molecular structure than Botox, it diffuses out further from the injection site than Botox which may mean it can treat a larger area. (potentially needing less units than Botox to treat the same area and keeping a smoother look as it wears off) As of this writing, the Reloxin application to the FDA has been denied to being judged as having incomplete documentation. This certainly means that Reloxin will not likely be available in the U.S until 2009.
PurTox is not as far along in clinical development as Reloxin and is invery early clinical trials. I do not expect to hear much about this botulinum analogue until 2009/2010.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Dr Barry Eppley, board-certified plastic surgeon, discusses recent issues about the safety of BOTOX cosmetic

The popularity of BOTOX® for the use in cosmetic facial wrinkle treatment, known as BOTOX® cosmetic, is due to its simplicity and tremendous effectiveness. It has become so familiar by popular culture and media communications that its name is often used as both a noun and a verb. (which is both disturbing and discouraged by the manufacturer) In my readings of recent publicity about outcomes with its use in children with neuromuscular disorders, I do not feel that the media has accurately portrayed many of the relevant safety issues about BOTOX® and how that relates to its use in the cosmetic patient. To allay potential patient concerns, it is useful to review some of the well-established information about this drug to clear up any confusion created by these media reports.

BOTOX® cosmetic and Botulinum Toxin Type A is manufactured by only one proprietary provider, Allergan out of Irvine, California. It has been 18 years since it was initially approved for the treatment of blepharospasm (excessive eyelid twitching) and 6 years since its approval for the cosmetic treatment of the vertical lines between the brows. While accurate numbers are impossible to know, tens of millions of cosmetic patients have been treated around the world with the manufacturer reporting more than 13 million doses given in the United States alone since 2002. According to the American Society of Plastic Surgery, BOTOX® cosmetic is the most commonly performed cosmetic procedure performed in the United States with over 3 million doses administered in 2006. These large patient numbers, combined with thousands of patients enrolled in various studies and over 3,000 published medical articles on the subject, provide a wealth of safety information. Despite the large amount of doses administered, significant adverse reactions to the use of BOTOX® cosmetic is extremely rare. I personally have never experienced any complications with its use, except for a few minor short-lived headaches after an injection session, since I have been treating patients with it. In addition, to date there has never been a single reported death associated with its use.

These cosmetic experiences must be contrasted with the media reports where its use was in the treatment of limb spasticity, which is not an FDA-approved application. In these neuromuscular uses, substantially larger doses (up to 100 times) are given compared to cosmetic doses and are injected in patients who are often ill and weakened from their disease. There simply is not a correlation between these two patient populations. The FDA clearly recognizes these differences and has issued no cessation of its uses to any health care provider at the present time for any of its approved indications. While no drug is ever completely without some complications, and all drugs will experience some complications if given in a high enough amount, the low doses used in the cosmetic patient are completely safe.

The accurate portrayal of the safety data on BOTOX® cosmetic should provide great comfort to those patients who regularly receive aesthetic treatments or to those considering it in the near future.
Dr Barry Eppley
http://eppleyplasticsurgery.com
http://ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Who’s Treating You at your Local MedSpa?

In the past 6 months, I have been contacted no less than ten times by nurses and aestheticians for injector training. Some of these folks I have known or interacted with in the past through our local hospitals and operating rooms, others I have had no idea who they were. This represents a disturbing trend that has developed over the past few years, that of the medspa business concept, which has been largely made possible by the number of injectable cosmetic treatments which have become available in the past five years. Since treatments such as Botox, injectable fillers, and laser hair treatment, to name the most prominent, are fairly ‘easy’ to do (compared to real surgery), many medical and allied health personnel as well as day spas and hair salons want to jump on the bandwagon of what they see as easy money, is fun to do, and is part of their beauty business.

While there is much to be said as a plastic surgeon about this concept, our comments are usually viewed as self-serving, territorial, and economically defensive. Personally, I don’t care what others do, inside or outside of medicine. I have enough to worry about in my practice and I prefer to focus on honing my own skills and being the best that I can be. The cosmetic marketplace is not like traditional medicine…it is really let the buyer beware. There are few regulatory agencies or guidelines for a burgeoning field that is not behest to federal and private insurance rules of reimbursement. In this market, only the attorneys and the threat of malpractice and liability issues keep it from spinning completely out of control.

What I find most troubling, however, is the complete disregard or lack of concern about patient safety…..all in the pursuit of cash revenues. Here in Indianapolis, I know of aestheticians who regularly perform Botox in their own home, cosmetologists doing injectable fillers in hair salons, nurse assistants doing lipodissolve injections, and ENT surgeons doing breast augmentations in their own surgery centers. Providers that have little to no training, not to mention being well outside what their licenses and certificates would permit, treat patients as study subjects. (when you are training on someone without supervision by a qualified provider….you are a study subject) And I wouldn’t call visiting someone for a few hours in their office or watching a DVD by a manufacturer bona fide training! I am not sure exactly what these patients think…..is it the allure of a more convenient or cheaper service…..or is it the appeal of a well-crafted advertisement or website?

Equally disturbing….and the genesis of this rant is……stop calling me to provide you with some training! I got my training to do what I do the old-fashioned way….I earned it through the proper channels. And what makes you think I would have any interest in doing it anyway? So you can get a free ride and benefit from my hard-earned experience?…..And no, you can’t pay me for this training either…..a few dollars is not equal compensation for years of time.

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

Botox is Effective in the Treatment of Specific Types of Migraine Headaches

Botox is the single greatest non-surgical aesthetic treatment that has been discovered to date. It is a near 1 billion dollar drug in sales because of one simple fact…..it works and it works well. It effectively weakens select facial muscles so that certain undesireable facial expressions, such as frowning, are eliminated. In the process of weakening the facial muscles between the brows, know as the glabellar area, it has been observed that some patients’ migraines were improved or eliminated. I have observed this is in several of my patients here in Indianapolis and it has been observed in plastic surgery for many years.

While Botox is not approved by the FDA for the treatment of migraines, there is little clinical doubt from our experience in plastic surgery that it works. The exact way it works seems to be through relaxation of the forehead muscles that wrap around a sensory (feeling) nerve that comes out of the brow bone. (supraorbital/supratrochlear nerves) This is also a common area that gets Botox for cosmetic purposes. By relaxing the muscles, the nerve is no longer ‘pinched’ and the trigger for the migraine is temporaily removed. This same phenomenon works on migraines that start in the back of the head in the occipital region of the upper neck. In this area, the large occipital nerve (which provides feeling to the scalp on the back of the head) exits from the bone in the back of the skull up through the occipital muscle.

These observations do not mean that every migraine patient will get relief of their headaches with Botox injections. It appears that only a very specific type of migraine patient will get improvement. My belief is that those patients that have a ‘focal’ or specific origin of their migraine headache have a good chance to have a 3 -4 month relief, or as long as the Botox is working. If the migraine begins specifically in the brow region and spreads for there, this is a good sign that Botox will be effective. If Botox is effective, this also indicates that surgical decompression of the nerve (removing muscle from around the nerve) through an endoscopic approach may provide a more permanent cure. Botox, therefore, can be a pharmacologic treatment or a qualifier for possible surgical treatment.

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

Botox – How Does It Work?

Botox, the miracle drug of the cosmetic world, is so popular for one reason…..it simply works and it works well. While its effects are not permanent, usually lasting around four months or so, it is so effective at what it does that it is a near billion dollar drug in sales for its manufacturer, Allergan. (http://www.botoxcosmetic.com/)

Botox, or rather its generic name botulinum toxin from which it is derived, can cause botulism, a form of poisoning. Because botulinum bacteria produce neurotoxins, the disease brings forth images of paralysis and possible death. When I was a child, the most likely way to get botulism was from improperly canned food. Botulism bacteria in nature are encased and protected in spores. If canned food which contained any of these spores was eaten without cooking, botulism may be contracted. Proper heating of canned food kills the spores.

Botulinum bacteria produce a variety of neurotoxins, classified alphabetically from A to F. Botox is derived from toxin strain A. These neurotoxins attached themselves to the nerve endings right before they go into the muscle. Like an electric signal, the nerve endings activate the muscle by releasing a chemical neurotransmitter, acetycholine, which triggers muscle contractions. Botox works specifically by blocking release of acetylcholine from the nerve endings, essentially pulling the plug and removing the signal for the muscle to move. Historically, death from botulism poisoning was because it affected the respiratory muscles, allowing the affected patient to die from chemically-induced inability to breathe. On a much smaller scale if you paralyze a small muscle in the face, fro example, you decrease movement and hence the amount of wrinkling seen. Therein lies the difference between cosmetic Botox and deadly botulism.

Why are cosmetic Botox injections, then, not dangerous and don’t run the same risk as botulinum poisoning? Because the amount of toxin is incredibly small, diluted, and injected into a specific muscle rather than floating loose in the body. The use of Botox to treat human medical problems is not new. Since 1989, Botox has been used to treat painful muscle spasms in certain neurologic disorders and even the muscles around the eyes to treat persistent eyelid spasms. (blepharospasm) Botox was used ‘off-label’ for cosmetic facial wrinkling for years and, only in 2002, was it formally approved for these indications by the U.S. Food and Drug Administration (FDA). While it was only specifically studied for the treatment of glabellar (between the eyebrow) frowning, it can be used anywhere on the face where one wants to decrease the amount of muscle movement. The most comon area other than the glabellar region is the crow’s feet area. (wrinkling around the outside of the eyes)

Why are the effects of Botox only temporary? Obviously because the drug wears off, but it is not quite so simple at the microscopic level. The muscle movement recovers the blocked nerve endings sprout new growths called axons that bypass those nerve endings that are blocked. Like a potato in a dark closet, the nerve grows new ’sprouts’ which cross over and reattach to the muscle…..and it begins working again…after four months or so.

Botox is now widely used for many different medical problems, most of which are due to undesired muscle activity. (e.g., migraine headaches, rectal fissures) However, Botox also appears to be effective for many problems in which nerve blockage is desired but not necessarily to a muscle. It has been a miracle cure for the problem of hyperhidrosis, excess sweating of the armpits, hands and feet. When used for these problems, the effect of Botox lasts much longer (up to a year) although it is not completely understood as to why. (http://www.botoxseveresweating.com/) Anewer application for Botox, although investigational at this point, is in the treatment of hypertrophic and keloid scars. Again it is not injected into the muscle but into the newly forming scar. In some cases, this has been shown to be helpful. More work is needed however before it can be claimed that it is universally effective.

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