As one ages, many facial structures fall unless they are rigidly fixed to bone. One of these falling structures is that of the eyebrows. Normally the eyebrows are situated either directly in front of or slightly above the level of the supraorbital ridge bone. But with time, gravity and expressive movements, the brows may slide off of the bone and push down on the eyelids. This creates a low brow position which leads to a tired or angry appearance and makes the upper eyelid skin look more redundant and full. 

Browlifting is always an option in periorbital rejuvenation surgery which is often combined with eyelid tucks or blepharoplasty surgery. Browlift surgery is unique, similar to a facelift, in that the lifting is done from a superior and far away location to keep scars hidden either at (pretrichial browlift) or within the scalp hair. (coronal or endoscopic browlift) But there is an alternative browlift option that is actually the most effective of all the available techniques, that of a direct or external browlift.

The external browlift or browpexy is where the eyebrows are lifted directly through direct skin excision along the upper edge of the eyebrow hairline. It is very effective because its lifting effect is directly at the eyebrow, thus creating a 1:1 ratio between skin removed and the amount of eyebrow lift. While this is far easier and more effective than any distant browlift technique, the issue is the visbility of the scar…a majoir concern in any cosmetic procedure where other options do exist.

In a recent 2012 issue of Ophthalmic Plastic and Reconstructive Surgery, a paper was published on a single surgeon’s experience with the external browpexy technique. Over a two year period, a total of 28 patients had the procedure of which the average age was 62 years old. (age range from 51 to 76 years of age) Eighteen of the patients were men (64%) with most of the patients having bilateral browlift procedures. The results of the scars were judged as good by patient satisfaction, all with the exception of a single scar. The author concludes that the exterbal browpexy is a straightforward procedure that produces high levels of patient satisfaction. The brow incision heals well without a perceptible scar in most cases and provides a reliable method of elevating the temporal brow. It is a good adjunct to enhancing upper blepharoplasty outcomes.

The key to a successful external browlift procedure is patient selection. The majority of patients in this clinical study were older and were mainly men. Browlifting in men is particularly challenging because the brows are heavy and there is usually no good superior browlift options because of their hairlines or lack thereof. The choices are either an internal browlift techniques, such as using the Endotine device, or the direct browlift as this paper described. With good incision placement and closure techniques, the scar along the upper edge of the browlift can be made aesthetically acceptable. But in younger patients, scars outcomes are not as likely to be as good and other browlift options should be considered.

Dr. Barry Eppley

Indianapolis, Indiana

Successful browlift surgery is based on several key technical maneuvers. These include periosteal release, muscle resection and brow elevation with or without fixation. These steps allow for the brows to not only be elevated but hopefully reduce the amount of chronic muscle contraction in the glabellar region. Patients and some plastic surgeons hope that the muscle effect creates a result that is similar to a ‘Botox-like’ effect between the eyebrows.

But many patients that have excessive frowning, also known as 1s or the famous 11s, don’t need a browlift. While Botox is a tremendously simple and effective treatment for frowning, the need for regular injection treatments has some patients desiring a more permanent one-time surgical treatment. Surgical resection of the glabellar muscles would be an effective treatment but direct access to the muscle area is limited by scan and nerve location concerns. Resection of these muscles can be done either from above through an endoscope or from below through an upper eyelid incision.

Is the superior endoscopic or the inferior eyelid approach better for muscle resection in this area? There are surgeon advocates on both sides of that discussion. I have done it both ways and each method has its own unique advantages and disadvantages.

In the May 2012 Aesthetic Surgery Journal, a study out of Wisconsin compared the transpalpebral (upper eyelid) and endosopic approaches in the resection of the corrugator supercilii muscles. Using cadaver faces, the study looked at the completeness of resection of the corrugator muscle with the transpalpebral and endoscopic techniques. After the procedures were completed on both sides, the tissues were removed and the amount of corrugators muscle resection evaluated. In 95% of the cadaver halfs, complete muscle releaser was obtained. The only failed instance was in one case of endoscopic release. This report demonstates that either method can achieve good muscle release and is operator-dependent.

For the patient seeking a ‘surgical Botox’ procedure for frowning, either endoscopic or upper eyelid approach can be used for the muscle resection. For the majority of patients the upper eyelid approach is often more appealing particularly if they are in need of a blepharoplasty procedure as well.

Dr. Barry Eppley

Indianapolis, Indiana   

One of the classic signs of early facial aging are lines and wrinkles that form in the forehead and between the eyebrows. As a reflection of the numerous muscles that make our facial expressions, wrinkles inevitably form in linear arrangements that are perpendicular to how the underlying muscles are oriented and move. This is ideally what Botox injections treat…dynamic forehead wrinkles.

One other important component of upper facial aging is the position of the eyebrows. With enough downward pull of the central forehead muscles over time, the eyebrows will eventually slide off to some degree from the brow bones. Know as brow ptosis, it makes one’s appearance older, tired or even angry. This is what browlift surgery treats…correction of non-dynamic or static brow sagging.

But browlift surgery understandably gives one pause as it is an invasive procedure that involves recovery and some risks. But the strategic placement of Botox injections can create a browlift-effect in some patients that may even rival that of some browlift surgery results. By chemically weakening or even paralyzing the eyebrow depressor muscles, the eyebrows will raise with the unopposed action of the elevator muscles. This has led to the concept of a Botox Browlift.

The Botox Browlift is effective for either naturally or age-induced low hanging eyebrows. With good injection placements, the skin above and around the eyebrows is lifted so the eyebrow position is a few millimeters higher. Like all Botox injections, their effects will last around four months or a little longer in some patients. The downside, of course, is that its effect are not permanent or relatively short-lived. But that is the trade-off for a non-invasive procedure.

If you have low brows or brow sagging should you have Botox injections or browlift surgery? The answer depends on several factors including one’s age, amount of forehead wrinkles and brow sagging and what other treatments one’s face may need. The most important concept to understand is that a Botox Browlift produces a minor or a few millimeters of change at best. While it can never create an overcorrected or ‘deer in the headlights’ brow elevated result, its concern is whether it can make enough of a visible change. Conversely, browlift surgery depending on the technique used always creates a noticeable change and its concern is whether the effect may be too much or create an unnatural shape to the arch of the eyebrows.

The Botox Browlift technique is useful for many patients and should always be tried first when one has brow position concerns. Even in brows that are quite low it may be beneficial. But injection technique is important and it is just as easy to exacerbate brow sagging rather than create brow elevation if not done properly. If one is considering eyelid/blepharoplasty surgery for removal of skin and fat around the eyelids, this is the ideal time to determine if browlift surgery would be complementary.

The Botox Browlift should not be assumed to be comparable to browlift surgery. They sound similar but their indications and effects can be quite different.

Dr. Barry Eppley

Indianapolis, Indiana

Browlift surgery is frequently used to lift up fallen or sagging eyebrows. Done either through an open scalp, hairline (pretrichial), or endoscopic incisional approaches, the  underside of the eyebrow tissues are freed up from the brow bones (supraorbital ridges) and lifted and secured into a higher position on the bone. As a complementary procedure, an upper eyelid tuck (upper blepharoplasty) is often done  to aid in the eye-opening result.

But lifting of the eyebrows is more than just making them higher. It is not just a function of making them as high as the tissues will allow. If the brows are lifted too high, one will get the classic ‘deer in the headlights’ look. Browlifting should focus on brow reshaping as much as just simple elevation. The shape of the eyebrows (arch) is often just as important as its actual position on the bone for creating a rejuvenated eye appearance.

The eyebrow position and shape has been shown to be just as important on a perception of tiredness as that of eyelid position and number of surrounding wrinkles. In a recent published study which evaluated this concept, a standardized photograph of a youthful upper face was modified using digital imaging software to independently alter a number of variables: brow position/shape, upper/lower lid position, pretarsal show, and rhytides. Subjects were presented with 16 images and asked to quantify on a scale from 0 to 5, the presence of each of seven expressions/emotions from tiredness to happiness. The results showed that the look of tiredness was achieved by changes of increasing and decreasing the upper eyelid skin crease, lowering the upper eyelid, and depressing the angle of the lateral eyebrow. Happiness was perceived by elevation of the lower lid or the presence of crow’s feet. Brow shape had a greater influence than absolute position on perceived expression. Elevation of the lateral brow was perceived as surprise, whereas depression of the medial brow and rhytides at the glabella were perceived as anger and disgust. Elevation of the medial brow elicited a minimal increase for sadness.

This study shows that the perception of tiredness is most likely influenced by the vertical height of the upper eyelid. A ptotic or low hanging upper eyelid (e.g., ptosis) makes one look tired. Modifications of eyebrow shape were shown to have a greater influence on perceived facial mood than the eyebrow position on the bone.

With these study results, it is clear that in browlift surgery it is important to pay attention to the shape of the arch of the eyebrow and not just brow elevation. The widely used endoscopic browlift and the lesser used pretrichial browlift allow for good manipulation of the brow arch through differential forehead skin removal and cranial suspension sutures.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Browlifting is often a frequent component of eyelid rejuvenation. The tired look around one’s upper eyelids may be magnified by a low and falling eyebrow position. The combination of a browlift can make an upper blepharoplasty result look eve better and, at the least, reduce the amount of upper eyelid skin that needs to be removed.

One important consideration in a browlift procedure is it’s impact on forehead length. Of the different types of browlift techniques that are available, most will lift the brows at the expense of lengthening the forehead. This is because any browlift method that uses an incision behind the frontal hairline, albeit a long transverse incision or even an endoscopic approach, pulls back the hairline. As the brows move up, the hairline moves back. By actual measurement and based on proximity to the point of pull, the hairline moves back further than the brow moves up. (this is because the brow is furtherest from the point of pull)

For the women with an already long forehead, the proper browlift technique is done at the hairline. Known as a pretrichial or hairline browlift, the brows are lifted and the excess skin removed right at the hairline. As a result, the frontal hairline does not change. This does result in a very fine line scar right along the frontal hairline but with good hair density and hairstyle, it is not noticeable.

But what of the patient who already has a long forehead and is in need of a browlift? Long foreheads can be shortened by forehead skin removal and bringing the scalp flap forward. But can this be done at the same time as a browlift? The answer is yes. One may wonder how two skin flaps, with diametric movements, can converge and be stable. The key is to secure both skin flaps to the frontal bone. To prevent undesireable scar widening and some degree of flap relapse, a secure anchoring point is needed. The bone fixation point is generally about 2 cms. in front of the existing hairline. Using either outer cortical bone holes or suture anchors, sutures are used to secure the deep layers of both scalp and forehead skin flaps to these points after skin removal and dual flap elevation. The scalp flap can usually be advanced 2 cms. (hence the bone fixation point). The forehead flap which lifts the brow does not usually need to be elevated more than 7 to 10 mms, lest one develop the ‘deer in the headlights’ look after surgery.

Browlifting can and should incorporate forehead reduction in the patient who already has a long forehead. Shortening a forehead adds a rejuvenating effect that nicely complements the correction of brow ptosis. When properly done, it does not increase the risk of unfavorable scarring and any other risks of the procedure.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

One of the typical features of an aging upper face are a variety of skin lines that develop between the eyebrows. The action of specific muscles combined with the effects of gravity create an abnormal skin pattern of vertical, oblique, and horizontal lines. These dynamic and eventual static wrinkles are bothersome for many patients as they create the emotional impressions of anger, grief, and age.

The non-surgical use of Botox injections and the surgical approach of browlifting or foreheadplasty are proven methods of modifying these muscles. By changing the degree or amount that these muscles move, the upper face becomes more relaxed and more youthful.

The corrugator muscle is the main culprit in this indesireable set of glabellar facial expressions. The horizontal portion of this muscle is responsible for pulling the eyebrows inward. When done enough over time, an evident pair of vertical skin creases develop. Known as the ‘11s’, they may also infrequently appear as a single large vertical crease. These vertical lines always extend significantly above the height of the eyebrows.

The oblique glabellar skin lines occur just at the level of the eyebrows, are oriented obliquely, and careful inspection will reveal they are not part of the vertical skin lines. They are caused by the medial eyebrow depressors which consist of the oblique head of the corrugators, the depressor supercilii, and the medial fibers of  the orbicularis oculi muscles.

The skin crease that sits below the eyebrows is horizontal and is often called the ‘bunny line’. It is caused by the procerus muscle which pulls down the inner eyebrows. It creates this crease as it pushes down against the  more fixed skin of the nose.

The combination of these six muscles flexing over time etches this pattern of glabellar lines between the eyebrows. In essence, dynamic wrinkles eventually become static lines if unchecked. This makes a good argument as to the benefit of early use of Botox or Dysport when one first begins to see this skin pattern appears. Such chemical prophylaxis is effective and many younger women today are embarking on this approach.

In established and deeper glabellar wrinkles, Botox and Dysport injections will make them more shallow but will not make them go completely away. In some cases, injectable fillers must be combined with muscle relaxation injections to make for a nearly complete smooth and wrinkle-free area between the eyebrows.

If one is seeking a more permanent or longer-term treatment, this is where the option of a surgical foreheadplasty comes in. Besides altering the shape and position of the eyebrows, this operation is intended to help lessen these unfavorable glabellar skin lines. This is done by weakening the actions of the aforementioned six muscles through removal or excision of some of these muscles. This is best done through an open incision (coronal or hairline browlift) but good and diligent endoscopic techniques can make a dent in their action also.

Most patients, regardless of their degree of glabellar skin lines, begins with injection therapy to see how much improvement they can achieve. In advanced cases associated with excess upper eyelid skin, the combination of a browlift and blepharoplasty can make for a satisfying forehead result.     

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

1.      What is the difference between eyelid and browlift surgery? Which will make me look less tired?

When considering anti-aging improvements around the eye area, it is important to consider both the eyelids and the brows. Both can contribute to a tired look but they create that appearance differently. Eyelids become aged by having too much skin. In the upper eyelid, this can eventually become hooding with skin that can rest down on the lash line. In the lower eyelids, wrinkles and bags develop some of which is also the result of fat which begins to protrude out from under the eyelid. Conversely, eyebrows create an aged eye appearance by becoming positioned too low off of the forehead. The dropping of one’s brows also creates more excess skin in the upper eyelid which is really just skin that has been smushed together as the distance between the eyebrow and the lash line of the upper eyelid becomes closer together.

Depending upon the anatomy of the problem, some patients just need eyelid surgery alone, a fewpatients may just need a browlift alone, and some will need a combination of both to create the best result. Browlifts tend to be complementary to eyelid surgery.

2.      What is the difference between an eyelid tuck and a blepharoplasty?

They are two different terms that describe the same thing. In 1818 Von Graefe coined the word ‘blepharoplasty’ (greek, blepharon = eyelid, plasty = to shape) to describe an eyelid reconstruction that he performed. Today, blepharoplasty denotes excision of excess skin, with or without the excision of orbital fat, for medical or cosmetic purposes. Blepharoplasty is the word we as plastic surgeons use. Patients commonly refer to it as an eyelid tuck.

3.      Will eyelid surgery leave scars?

All surgery that involves incisions or the removal of skin will leave scars. But the eyelids are unique in that superb scars are almost always obtained. Good scarring on the eyelids is the result of two factors. The eyelid skin is one the thinnest on the entire body. Thin skin will always scar less than thicker skin because there is less dermis to react to the healing process. Blepharoplasty incisions are placed in natural horizontal skin folds in the eyelids. In the upper eyelid this natural crease can be seen as a horizontal crease the in the skin five to 8mms  above the eyelashes. In the lower eyelids, the incision is put right under the eyelashes by 1 to 2mms. When these heal, they can be very difficult to see. (the upper eyelid scar can only be potentially seen when your eyelid is closed!)

4.      How much swelling and bruising will occur after eyelid surgery? How long will I look bad?

There is no question that any surgery around the eyes will cause some temporary swelling and bruising. How much and for how long depends on a variety of factors including how many eyelids were done and your natural tendency to bruise. On average, lower eyelid surgery causes more swelling and bruising than uppers. When all four eyelids are done, most patients will start to look more normal in seven to ten days. It will takes fourteen to twenty-one days to look ‘non-surgical’. When browlifts are combined with eyelid surgery, these time frames may be longer.

There are several thins that a patient can do to help improve the rate of looking better sooner. In my Indianapolis plastic surgery practice, I emphasize three things. First, take the herbal medication Arnica Montana one week before and after surgery. This helps control the amount of bruising and speeds it resolution. It comes in multiple preparations. We prefer the spray delivery system. After surgery, keep your head elevated on ice on your eyes for the first twenty-four hours. You can stop the ice the next day but continue to rest and sleep with your head elevated for the first week after surgery.

5.      How is browlift surgery done?

There are multiple methods of performing browlift surgery and the choice of which technique is used is based on each patient’s differing anatomy. There is no one single way to do browlift surgery that is right for everyone.

For women, the approach to lifting the brows is done ‘from above’. This means the incision is placed somewhere in or along the hairline and the brow and forehead are pulled back. Traditional browlifting is done from an incision way behind the hairline, removing scalp hair, to create the lifting effect. For women with long foreheads, this will lengthen the forehead in an unaesthetic manner and the incision is changed to right at the hairline. This keeps the forehead length the same (it cam also even be shortened) while lifting the brows. These open approaches have the advantage of being able to on the forehead and brow muscles to permanently weaken their effects of forehead wrinkling. …but at the expense of a long scar. When one has a scar concern and the forehead is not severe, the endoscopic approach can be used. Like laparoscopic abdominal surgery, several very small incision are made back in the scalp and the operation is done through a scope and a camera. This shifting technique will lengthen the forehead however so one has to determine beforehand of less scar or a longer forehead are more desireable.

Men do not have the browlift options that women do because of their hairline, or loss thereof, issues. It is rare to ever do any of these superior browlift approaches for that reason. Male browlifts are often done through the upper eyelid using a resorbable implant to push the brows up as they heal. This approach only produces a very mild browlift but the ‘less is more’ approach for men is always better anyway.

6.      I would like a browlift but I am afraid I will have that startled look. How can this be avoided?

A browlift is an easy operation to overdo. Most potential patients are aware of this by looking at many Hollywood and famous people results. It can be a fine line between enough brow evelation to show a visible change and brows that are too high. Do not forget also about the shape of the brow. This is another factor that can make a browlift look unnatural. The best way to avoid this potential problem is to have a thorough discussion with your plastic surgeon beforehand, with a mirror and looking at issues of a new brow position and potential shape change. While browlift surgery is not like doing Photoshop on the computer, there is a surgical art to it that a plastic surgeon uses which is influenced by the browlift approach and other intraoperative techniques. Knowing what you want can help the plastic surgeon modify techniques to help meet your expectations.

7.      Will insurance pay for eyelid and browlift surgery if I have trouble seeing?

In the past, insurance companies did regularly cover upper eyelid and browlift surgery if medical evidence existed that visual impairment existed from the excess eyelid skin and low hanging brows. Such routinue coverage is now increasingly uncommon and much harder to get approved. Whether the insurance option is an avenue to pursue can only be determined on an individual patient basis. Any such procedure on the lower eyelids, however, is never covered as there is no anatomic basis for excess skin getting in the way of seeing. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis 

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 12:00 - 1:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the topic of periorbital rejuvenation was discussed. Blepharoplasty (eyelid tucks) now rate as the number one facial plastic surgery performed, exceeding facelifts, rhinoplasties, and chin augmentation. Becuase the eyes are of great social significance, most people feel that they are their most important facial feature. The eye area is the first region of the face which shows aging. Rejuvenation of the eyelids and brows can make a big difference on one’s appearance. Topics discussed with listener questions included blepharoplasty and its many variations for the upper and lower eyelids, browlifts, botox, injectable fillers, orbital implants, micropigmentation (permanent eyeliner), eyelash extensions, and Latisse eyelash growth stimulant.

Free plastic surgery consultation with Dr. Barry Eppley can be arranged by calling his Clarian North office in Carmel Indiana at 317-814-4100 or his Clarian West office in Avon Indiana at 317-217-2200.

One of the manifestations of aging of the forehead is changes in position or shape of the eyebrow. While it is generally believed that one’s brow falls or descends with age, current studies suggest that this is not always true. I have seen numerous patients where the eyebrows are clearly lower than the edge of the brow bone but have observed other patients where the eyebrows seem ‘high’ for their age. Men with thicker skin and heavier foreheads seem to suffer greater eyebrow descent than women. Whether one’s eyebrows are too low later in life undoubtably has a lot to do with where they started to begin with.

Browlifting is a common treatment for rejuvenation of the forehead. While there are numerous techniques for forehead surgery, they all work to elevate the eyebrows with varying degrees of success at abnormal muscle modification particularly between the eyebrows. One of the great fears of most patients about browlifting is that of overelevation of the eyebrows making one look like a ‘deer in the headlights’. Too much browlifting is easy to do since the patient is laying horizontal during surgery and the perspective of what one looks like in a more natural vertical position is lost.

While lifting of the eyebrows is one thing that forehead rejuvenation procedures can do fairly well, they do not do a good job of shaping the lifted brow. Different directions and amounts of the various browlift methods can significantly change the shape or arch of the eyebrow. For this reason, it is extremely important prior to surgery is to sit with the patient with a mirror and manually lift the eyebrows in different amounts and shapes to see what the patient thinks is aesthetically acceptable. Most patients need more lifting of the outer portions of the brows and not so much the inner part near the nose.

It is important that patients appreciate, unlike eyelid surgery, that changing the eyebrows is not as precise. It is difficult to obtain exacting millimeter brow position and shape control. This is particularly true in endoscopic techniques where measured skin or scalp removal is not done. In my Indianapolis plastic surgery practice, I emphasize to patients the browlift concepts of subtle to moderate improvement and getting a more rejuvenated shape of which they decide what that is.         

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

One of the many features of facial aging is changes in the upper face or forehead. As the forehead undergoes aging, horizontal wrinkles appear and the eyebrows descend lower. A lower position of the brows is medically known as brow ptosis. Brow ptosis and excess upper eyelid skin, if severe enough, may even impede on one’s vision.

As everyone has differently shaped and arched forms to their brows, the brows may drop down unevenly. Sometimes it is the inner or medial aspect of the brow that is too low…or it may be the outside or lateral part of the brow that sits below the prominent brow bone. Or it may be that the entire brow has fallen. In most patients, however, the outer or lateral third of the brow ages first and often the most. Aesthetically, eyebrow shape is more significant than height and eyebrow shape is highly affected by the level of the lateral brow.

For brow ptosis, a forehead or browlift procedure creates a rejuvenating effect. There are different methods of browlifting which can be done either through long open scalp or hairline incision or endoscopically through a few small scalp incisions. Browlift surgery, however, usually lifts the medial brow quite successfully but is weakest at raising the lateral brow. This is because the scalp incision from an open browlift tails off over the lateral brow area so not as much tissue is removed. In the endoscopic browlift, only the central part of the lift is secured by fixing it to the bone. The part over the lateral brow is lifted and secured to the temporalis fascia which is not as secure as that of bone.

Because of less effectiveness in lifting the lateral brow and that some patients only need to rejuvenate that brow area, the lateral browlift was devised. The lateral brow lift, also known as a temporal browlift uses incisions which are made at the temples behind the hairline. Skin is removed in this area and internal sutures are used to support the lifted tissue so the scars do not become wide afterwards. This is a simple procedure that can be quite effective. There is usually no connecting incision between the two temporal lifts.

The lateral browlift  can also deal with folds and small wrinkles in the forehead and the corners of the eyes (crow’s feet).  There is also a mild effect of lifting in the cheek area but this is usually fairly minor and one shouldn’t expect too much of a change in this area. Too much lateral brow lifting can produce an exotic look to the outer arch of the brow or a cat look, which is usually not desired by most women.

The lateral browlift may be done alone or as part of other browlifting techniques. It can be part of either an endoscopic browlift or as a modification of a traditional open browlift procedure.

Dr. Barry Eppley

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