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Dr. Barry Eppley

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Archive for the ‘kybella’ Category

Kybella Injections for Neck Contouring

Tuesday, July 4th, 2017


While most people equate fat reduction as part of body contouring it is also relevant to that of the face for submental contouring. Excess fat and fullness under the chin is a common aesthetic concern and many people are bothered by their ‘double chin’ and lack of a better cervicomental angle.

Submental fat or submental lipodystrophy is not particularly amenable to diet and exercise. While it is true that large amounts of weight loss will help improve neck fullness, most people with submental fullness do not need or can not undergo such amounts of weight loss. As a result surgery remains the most effective treatment whether it be liposuction, a submsntoplasty or a lower facelift.

Non-surgical methods of submental fat reduction include energy-based external fat reduction methods or minimally-invasive deocycholic acid injections (Kybella) The use of Kybella is fairly recent being just approved in 2015. It is a medical-grade naturally occurring deoxycholic acid (bile salt) molecule which creates the breakdown of fat cells through an inflammatory process. While the fat cell walls are disrupted the lipids are then naturally carried off and absorbed through normal metabolic pathways. This creates a reduction in fullness under the chin.

Kybella is an office procedure where injections are done in the submental area. The dosage is based on surface area with 2mg/cm2. Using .2ml aliquots a grid pattern is done in the submental area keeping the injected areas 1 cm apart. Up to 10ml of the solution can be given in a single treatment. All patients will require more than one treatment for optimal results.

It is important for the patient to understand that multiple treatments of Kybella will be needed. No results can be guaranteed with just one treatment nor are any clinical results ever shown with Kybella based on just one injection session. How many injections sessions will be needed varies for each patient but they should mentally prepare for 3 to 4 injection sessions to get the best submental contouring result.

The most common and expected side effect of Kybella injections will be the resultant neck swelling that occurs. This will be of some significance and is a reflection of the amount of fat breakdown that its occurring. It takes about a week to go away but it will be noticeable during this time. Postinjection management should include ice and anti-inflammatory over-ther-counter medications. (e.g., Ibuprofen) The use of anti-inflammatory drugs does not appear to suppress the effectiveness of the lipolytic injections.

While injections sessions have historically been spaced apart at one month intervals, I believe this is too soon and is also difficult for patients to have a week of neck swelling every month for potentially the next four months. Longer intervals between injection sessions allows for better patient tolerance and also allows for the full effect of the treatment to be seen. I like to space them 6 to 8 weeks apart. It may take a little longer to get to the final result but it may also the for some patients that they will need one less injection session.

Patients often ask about the use of Kybella for the jowl area, both because of its proximity and a smaller area of fat collection that should be effective. While it is technically an off-label use of the injections I have done it many times and it is effective. The key is to stay out lateral and never inject closer than 1 cm to a vertical line drawn down from the corner of the mouth to the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Kybella Injections vs. Liposuction Surgery

Sunday, February 21st, 2016


Kybella Double Chin Injections Indianapolis Dr Barry EppleyThe non-surgical treatment of fat has historically been difficult as external devices have a limited ability to reduce its thickness. This is particularly true in the ‘double chin’ deformity where excessive (under the chin) fat creates another roll of tissue like an extra chin. Liposuction of the submental/neck area is the gold standard by which the double chin problem is treated. (sometimes it is also helpful to do chin augmentation as well)

Kybella Injections Dr Barry Eppley IndianaolisWith the recent release of Kybella, an FDA-approved injectable drug that has been studied specifically for submental fat, the intriguing question is how this non-surgical injection compares to liposuction surgery. To best answer this question, one only has to know the predicate history of Kybella (Lipodissolve) and translate that prior experience to the present.

Kybella is deoxycholic acid which is a child sprung from its parent, Lipodissolve. Over a decade ago Lipodissolve,  a mixture of deoxycholic acid and phosphatidycholine, was a national sensation as a fat dissolving injection treatment. Having its origins in Europe and South America, it was brought to the U.S. with much fanfare. Lipodissolve clinics opened  up across the country providing such treatments until the FDA stepped in and ceased their operations as providing an untested and unregulated drug therapy. It was always suspected that the active agent in this mixture was the deoxycholic acid and not the phosphatidycholine. Kybella is the fully studied drug that proves this is true.

But the Lipodissolve experience can predict completely what one can expect for Kybella injections in the neck and how to compare it to liposuction surgery. This is just old history repeating itself. Kybella works by causing an inflammatory reaction that breaks down fat cell walls, allowing the release of their lipid content which is then absorbed. This will result in a predictable an profound amount of neck swelling. One essentially will look like a ‘bullfrog’ with the swelling. There is also a rather profound burning sensation that occurs in the first 30 to 60 minutes after the injections (the neck will feel really hot) but this subsides within a few hours. Thus one can expect some significant downtime with the swelling which will take one to two weeks to completely go away. While Kybella injections are non-surgical, patients should be aware that they should not have this treatment within a couple weeks of any major event.

Kybella Injections Indianapolis Dr Barry EppleyWhile the exact number of Kybella injection sessions may be needed, everyone will need more than one. Most patients will need at least two to four treatments, spaced 4 to 6 weeks apart to get maximal fat reduction.

When comparing Kybella to submental liposuction, there are some significant differences. Submental liposuction, if done alone, can be performed under local anesthesia with oral or IV sedation. It is more commonly done as part of other facial and body procedures in my practice which is then done under general anesthesia. But for the purposes of this discussion it shall be talked about as if it was done as a solitary procedure.

Submental liposuction certainly causes some swelling and bruising which can take up to six weeks to completely go away. (although the worst swelling is in the first seven to ten days) Liposuction in the neck is usually a one-time procedure although about 10% of patients may need a touch-up due to any residual remaining fat or asymmetry. (which can be done by Kybella injections if desired) The swelling after Kybella injections is usually much more than with liposuction. It is certainly far greater when one multiples it by the number of repeat Kybella injections that will be needed.

So how does one choose between Kybella injections or liposuction of the neck? In summary, liposuction produces a better result with less recovery but costs more and is an invasive procedure. Conversely, Kybella is non-surgical and costs less but has more recovery (repeated swelling) and produces less of a result. Every patient has to weigh their advantages and disadvantages and make the best decision for their own situation.

Dr. Barry Eppley

Indianapolis, Indiana

Kybella Injections for Jowls

Sunday, December 6th, 2015


The search to non-surgically reduce fat for aesthetic purposes has been ongoing for years and many methods exist today to do so. Numerous energy-based devices are available (e.g., Vanquish) for body contouring which induce fat cell atrophy through an apoptosis process. But such devices have limited use in the face due to the smaller fat collection locations and the difficulty with such device application.

Kybella Injections Dr Barry Eppley IndianaolisFat dissolving injections have recently become available based on the introduction of deoxycholic acid solutions.  (Kybella) This chemical causes the dissolution of fat cell walls which release their lipid contents into the surrounding tissues. The free fatty acids are then absorbed from the injected area reducing the treated contour. Kybella injections have been clinically tested and FDA-approved for the treatment in the head and neck area of the submental area. Known as the double chin neck deformity, the smaller submental area is a good location for the use of fat dissolving injections in properly selected patients.

Kybella Injections for Jowls result right oblique view Dr Barry Eppley IndianapolisKybella Injections for Jowls result front view Dr Barry Eppley IndianapolisKybella Injections for Jowls result oblique view Dr Barry Eppley IndianapolisOther facial areas can potentially also benefit from Kybella injections for small fat reductions. One such area is that of the jowls. The jowls are an area along the jawline which develop from the descent of facial tissues with aging. Skin and any underlying fat drifts down over the jawline creating the classic jowling and increased lower facial width. While fat reduction alone is not the complete solution to jowls in most patients, it is one component whose reduction can help reduce their appearance.

Kybella injections to the jowls works identically to that of the submental area. It requires a series of injection treatments spaced four to six weeks apart. Two to three injection sessions may be needed for optimal reduction. The jowl area is smaller than the submental area so a lower number of injections are needed. There will still be considerable swelling after the injections for the first week due to the inflammatory process of how the solution breaks down the fat cells.

Because fat injection therapy can be done just about anywhere, Kybella will continue to evolve in both its face and body applications.

Dr. Barry Eppley

Indianapolis, Indiana

Kybella Injections For Submental Fat Reduction

Sunday, August 23rd, 2015


Kybella Injections Indianapolis Dr Barry EppleyThe recent approval of Kybella for the treatment of under the chin fat (submental) fat appears like it is a new treatment. And as an FDA-approved drug it is. But the concept of a fat dissolving injectable drug is really now new and has a predicate history in the world of mesotherapy and the now defunct term of Lipodissolve. The active ingredient in many compounding pharmacy (and non-FDA approved) mesotherapy solutions is deoxycholic acid…the same one that is in FDA-approved Kybella.

Kybella is a synthetic version of a naturally occurring bile salt which resides in the gallbladder, known as dexocycholic acid. Known also as deoxycholate and chemically as 3?,12?-dihydroxy-5?-cholan-24-oic acid, it is a secondary bile acid created as a metabolic by product of the intestinal bacteria. The two primary bile acids secreted by the liver are cholic acid and chenodexoycholic acid which bacteria eventually break down eventually into secondary bile acids. Deoxycholic acid is the metabolite from cholic acid.

Kybella Injections Dr Barry Eppley IndianaolisThe role that deoxycholic acid performs in the body is the breakdown (emulsification) of dietary fat so it can be absorbed in the intestine. It has a detergent-like effect on fat to break down the cell walls through solubilization of its  membrane components. It is no surprise then that it is not a far leap to envision how it might work on reducing small subcutaneous fat deposits.Thus the FDA approval after numerous clinical studies for the use of Kybella for a small fat area like that under the chin. (submental fat)

The key to successful use of Kybella is patient selection. It simply is not going to be effective for large fat collections. While patients with larger and fuller necks may be drawn to an injectable therapy for an injectable treatment as opposed to surgery, they will likely be disappointed with the treatment process and the final result. Patients must also understand that this is a series of treatments that works slowly and will take several months to see the final result. It is important to compare this injectable treatment process to what can be achieved just as effectively (and perhaps better0 with a 30 minute surgical liposuction procedure.

Injection treatments take about 15 minutes to complete and are done using a marked grid pattern in the treatment area, spacing them about 1 cm apart. (the solution will diffuse from the injection site about 1 cm in all directions. Based on the treatment area size the number of injections can range from 35 to 50 and takes about 4 ml of the Kybella solution using .1cc volume per injection site. Almost always it takes more than one treatment to see the best result and could be as many as six treatments to see the maximal effect. Injection sessions should be done no closer than four to six weeks to let the maximal fat clearance effect take place.

One immediate and postoperative issue that patients need to be aware of is that significant post-injection inflammation and swelling will occur. Within minutes after the injections the treated area will feel hot and have a burning sensation. Within 48 hours the neck will have a swollen wattle that will go away in one week or less. Some injected areas that will feel numb for a few days. This is the result of how the solution works…an active breakdown and inflammatory process of the treated fat cells. Patients can use NSAIDS and topical ice for pain relief during the first day of treatment. The point is that there is a recovery phase just like surgery. It is not like Botox where they are few noticeable after injection sequelae.

Because there is some important anatomy that runs through the submental area, there are some other associated risks with Kybella injection therapy. This directly refers to the marginal mandibular nerve, the lower branch of the facial nerve that supplies movement to the depressor anguli oris muscle of the lower lip. Such injuries to the nerve have been reported although they all have resolved within several months after the injections. The best way to avoid this disturbing problem is to keep the upper border of the injection level about 1.5 cm below the inferior border of the mandible and to not inject into the jowl areas.

The cost of Kybella injections will vary by physician but a single injection session can run anywhere from $850 to $1,000. Treatment packages of four can run anywhere from $3,500 to $4,000. So patient have to consider carefully the cost of Kybella and treatment times compared to a single surgical submental liposuction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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