Background:  The aging face is marked by many soft tissues changes due to falling tissues. One of those visible aging signs is that of the deepening nasolabial fold. This fold or groove is caused by the sides of the face falling against the fixed tissue of the upper lip. This creates an overhang of facial skin that rolls over toward the lip. As more tissue falls forward, the nasolabial fold gets deeper.

Treatment of the deep nasolabial fold has always been a difficult challenge, particularly at the time of a facelift procedure. No maneuver done underneath a facelift flap has been consistently successful. The pull from the repositioned skin flap during a facelift does not produce a sustained improvement. Even with release of its dermal attachments and the backward pull of the skin flap, nasolabial fold improvement is surprisingly modest.

The only non-surgical treatment, and by far the most common, for nasolabial fold reduction is the use of injectable fillers. This consistently shows that the addition of volume underneath the fold is an effective treatment. The problem with all synthetic fillers is that they are not permanent. Fat injections have been repeatedly tried for more permanent filling of the nasolabial fold but this unfortunately does not work due to fat absorption.

Case Study: This 62 year-old female was to undergo a facial rejuvenation procedure consisting of a facelift, a pretrichial or hairline browlift, bilateral upper and lower blepharoplasties and nasolabial fold reduction by augmentation. Given that she was going to have a hairline browlift, it was decided that her forehead skin would be used as the donor site for the nasolabial fold grafts.  

A browlift was performed using the intial incision that paralleled the hair follicles of her frontal hairline. After the forehead skin flap was raised down to the brow bones and the glabellar muscles partially resected, the forehead flap was elevated and the excess skin removed. This allowed the brows to be elevated but the vertical forehead length not changed. The skin removed was 14cms in length, 8mms wide in the center and 9mms in thickness. The outer layer of skin (epithelium) of the forehead graft was removed and cut into two 7cm long grafts.

Through an incision in the alar crease and another one at the bottom of the nasolabial fold, the forehead dermal-fat grafts was threaded underneath  the nasolabial folds. They were placed with the dermal side of the graft toward the undersurface of the nasolabial fold skin. The reduction in the folds was immediate. The grafts were placed  prior to the facelift being done.

The improvement in the nasolabial fold reduction due to the grafts was both palpable and persistent. At one year after surgery, the fold reduction was still visible.

Case Highlights:

1)      The deep and very visible nasolabial fold is most commonly treated by volume enhancement to soften its appearance.

2)      The most ideal material to put underneath a nasolabial fold is some form of autogenous fat, with a dermal-fat graft being preferable to injected fat.

3)      The tissue normally discarded from a pretrichial (hairline) browlift is ideal in thickness and

4)       length to make for  subdermal grafts to the nasolabial folds.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

The desire for fuller and more shapely lips has been achieveable for some time through injectable fillers. The ability to spot place plumping volume anywhere on the lips can really allow for some true sculpting of certain lip areas. The lips are comprised of numerous anatomic areas which are commonly injected, mainly along the vermilion-cutaneous junction (white roll) and into the body of the lip itself. That will certainly make the overall size of the lips bigger.

The central part of the lips is a main focal area. Known as the prolabial or central part of the upper lip, it is comprised of the horizontal cupid’s bow and the vertical philtral columns. Most injectable filler treatments focus on the cupid’s bow to give the lip more pout. But highlighting the philtral columns by vertical filler placement brings some additional lip accentuation. Injection of the philtral columns along with the cupid’s bow is frequently overlooked.

While injectable filler lip treatments are both immediate and dramatic, they are only temporary. Even in the most ardent and motivated patient, lip injections are not fun and can be the most uncomfortable of any facial injection treatment. (unless done under local intraoral vestibular infiltration…better but still not fun) Permanent solutions to lip augmentation have been tried with varying success. For permanent lip volume augmentation, I have found the use of Advanta soft tissue round or oval implants effective when placed in the body of the lip for horizontal volume fill.

Synthetic implants in the philtrum, however, have not been as successful. They are prone to contracture and distortion with resultant philtral asymmetry. This is because they are not rigid and are placed in the very moveable and often manipulated part of the upper lip. Think about how many times you touch and rub your upper lip…not to mention stretching and pulling it down.

A more effective alternative philtral methods of augmentation is allogeneic dermal grafting. These soft collagen implants can be cut into small strips and placed through a vertical vermilion fissure or crack incision. Depending upon the thickness of the graft (usually 1 to 2mms thick), they can be inserted in either a single or double stacked fashion. Fine tunnel dissection is done just under the philtrum up to the columellar base. The grafts are quickly inserted and the incision closed with one or two small sutures which are removed a week later. (dissolveable sutures can also be used. The change in philtral height and definition is immediate.

Several of the really nice things about dermal grafts in the lip is that they are soft and, because of their collagen makeup, will integrate and become part of the philtral tissue. That is especially important in the upper lip where vertical stretching and compression is part of repetitive daily lip movements.

This simple procedure can be done as part of any other lip procedure, usually as part of surgical augmentation procedures such as lip lifts and advancements. It is done under local anesthesia in the office with minimal swelling and rarely any bruising. There is no visible scar from the  small incision in the vermilion.

The only concern with dermal grafts in general is their volume persistence. While a significant issue in the past, improved tissue processing methods have dermal grafts today offering improved long-term persistence.

Upper lip philtral augmentation (philtroplasty) is an additive component to lip enhancement procedures that helps provide further definition to the central upper lip. Dermal grafts provide a simple, effective, and natural method to accomplish refined upper lip sculpting.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  Frown lines are a major concern for many people as they make them look like they are scowling and angry. The frown lines are one of the major undesired facial features that have accounted for the meteoric rise in Botox sales and for making it a household name. Unknown to most, frown lines are actually the only FDA-approved cosmetic indication for Botox, even though it is widely off-label for other facial areas.

Despite the success of Botox in reducing the undesired actions on the skin between the eyebrows (aka glabella) of the corrugator and procerus muscles, one’s frown lines may not go completely away. Once the long-term actions of the muscles have permanently etched lines or grooves into the skin, muscle weakening along will reduce but not eliminate them. Botox is successful for the treatment of dynamic wrinkling (lines that appear when the face moves), static wrinkling (even when one is not moving muscles) requires a different or companion approach.

This is a case of a 50 year-old female who was bothered by her scowling and the unhappy expression that the lines into between her eyebrows gave. She has received Botox injections and, while it was better, still had some obvious vertical furrows in the glabellar area. She desired further efforts on reduction of these lines.

Adding some form of soft tissue filling is the next treatment strategy. Most commonly this is done with injectable fillers which are widely used. She did undergo Radiesse filler injections and was pleased with the results but wanted something that would last longer.

Other forms of soft tissue filling of facial lines and furrows are non-injectable and require a more invasive approach. (although not that much more invasive) Graft or filling options include one’s own fat, allograft dermal grafts (off-the-shelf) and a synthetic implant. (Advanta, also known as PTFE or Gore-Tex)

She desired a collagen-based implant over that of a synthetic one. Through two small nick incisions, above and below the vertical glabellar lines, the soft rehydrated dermal grafts were cut and threaded underneath. This was done as a simple in-office procedure under local anesthesia that took about 15 minutes to do. This provided her with a result that was equal to that of injectable fillers but which would last much longer. She remains with good results one year after procedure.

Adding an injectable filler or a dermal graft to glabellar furrows does not mean that one no longer needs muscle-reducing Botox injections. Deep glabellar furrows requires a double approach in some cases to get the best result, treating both the muscular hyperactivity and the skin etching.                                                                                                         

Case Highlights:

1) Deep glabellar furrows or wrinkles may be reduced by controlling the muscle action with Botox but will not be completely gone. In long-established frowning, the skin becomes permanently indented which is not responsive to reducing muscle action alone.

2) Soft tissue filling is a companion treatment to Botox for deep glabellar lines. Treatment options include temporary injectable fillers or longer-lasting implants.

3) While Botox and soft tissue fillers can be done at the same time, it is usually best to do Botox first and see what the results are. Management of the grooved skin can always be done later if further improvement is desired.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana