Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘laser resurfacing’ Category

Treatment Options for Vertical Upper Lip Lines

Tuesday, June 11th, 2013


The face develops many visible signs of aging. But none are more problematic or pesky than that of upper lip lines or vertical rhytids. Such lip lines are very bothersome to women as they not only suggest an older lip but also cause problems with lipstick, often bleeding into the lower end of the vertical line. By far, vertical lip lines occur most commonly in Caucasian women of Northern European descent. They are very rarely ever seen in women that have more skin pigment, thicker skin and fuller lips.

While upper lip lines are often perceived as being caused by those smoke (and this certainly is a contributing factor), but many other factors contribute as well. The most significant, as previously mentioned, is light skin pigment and a genetically thin upper lip. This means that the upper lip has thin skin thickness and less subcutaneous fat which offers little buffer from the motion of the underlying circumferential orbicularis oris muscle. (facial wrinkles develop perpendicular to the action of the underlying muscle movement)

The treatment of upper lip lines is challenging because the source of the problem, movement of the mouth, is something that can not be changed after surgery. One can adopt a new diet to protect a liposuction result or avoid the sun and do numerous topical therapies to preserve other facial surgery changes, but one can not change the thickness of the upper lip or stop eating, drinking or smiling after lip line treatments.

The fundamental treatment of upper lip lines has historically been laser resurfacing. Using deeper laser treatments, the objective is to bring down the entire epithelial thickness of the skin and cause some collagen thickening as well. Much like sanding an irregular surface, significant reduction in lip lines can be achieved by total ablative laser treatments. But it can thin out the skin, cause pigment loss and can not usually be done more than once if the initial laser depth was deep. Thus enters the concept of fractional laser resurfacing where the risks of skin thinning and color loss is minimized. By cutting deep laser holes in just a fraction of the skin surface (22% or less), better collagen production and skin tightening is achieved. When combined with an initial very superficial ablative laser pass (< than 50 microns), significant and sustained lip line reduction can be achieved.

Other lip skin resurfacing methods are available including the dermaroller and old-style dermabrasion. For very deep lip lines, dermabrasion provides the most aggressive method of ‘sanding’ that actually produces the best results. But it is a highly technique sensitive method of resurfacing and is prone to a higher risk of hypertrophic scarring and severe skin thinning. The dermaroller is very much like a poor man’s fractional laser that punches small holes in the skin but its ability to induce collagen production is not as powerful and multiple treatments are needed to approximate even one laser resurfacing.

The other approach to lip lines is to add volume by injectable fillers. Most patients think this means trying to directly inject the vertical lip lines, and this can be done for the very deepest ones, but it really means augmenting the size of the upper lip vermilion. This will  increase the size of the upper lip which directly plumps out the lower end of the vertical lines as they join into the pink part of the lip. For those women that do not mind some increase in their lip size this is an essential step in a lip line reduction strategy. Whether one should use any of the available hyaluronic acid-based fillers (e.g., Restylane, Juvederm) or consider some autologous fat is a matter of discussion with each patient. There is also the option of a lip lift or lip advancement which provides a permanent change in the vertical size of the lip vermilion and cuts out some lower lip lines as well. (lip advancement only)

The best upper lip line reduction therapies incorporate a combination of skin resurfacing and volume addition. If done in the office, fractional laser (22%, 100 microns) with Juvederm upper lip injections is my preferred technique done under topical anesthesia. If done in the operating room, as part of a facelift for example, then I would do a more ablative laser treatment (two passes) with fat injections into the upper lip. Either way the patient needs to be aware that lighter maintenance fractional laser treatments will be needed in the future.

The key word to use in the treatment of vertical lip lines is reduction, few patients will achieve complete elimination of them in a single treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Antiviral Prophylaxis in Perioral (Lips and Chin) Laser Resurfacing

Monday, January 21st, 2013


Did you know that over 80% of people in the United States have been exposed to herpes simplex 1 virus (oral herpes) and 20% to 40% of these people will experience an outbreak of cold sores of some frequency. Once a person becomes infected with the virus it stays in their body for life, lying dormant in the nuclei of the trigeminal nerves. Cold sores occur mainly on the lips and around the mouth but can also be seen to erupt on the cheek, chin and even the nose.

Cold sore reactivation can occur in a few different ways, but trauma to the lips is one well known mechanism. The most notorious traumatic event for activating the cold sore virus is cosmetic laser resurfacing treatments of the lips and around the mouth. During these treatments, multiple layers of skin are either partially or completely removed. Therefore, even if a person does not have an active sore at the time of treatment, it is crucial to know if they have a history of cold sores. Knowing that 80% of the population has been exposed to the virus leaves little to no room for assuming someone does not have or has never had the virus.

Reactivation of the herpes simplex 1 virus by laser resurfacing can not only cause a cold sore to reappear, it will most likely cause multiple lesions or a crop of blisters to appear. The raw surface of newly resurfaced skin makes a fertile environment for the spreading of cold sores. Usually the size, extent and duration of the cold sores will be even greater in the face of laser resurfacing than just a typical outbreak. If extensive enough, scarring may even be the sequel of a laser resurfacing-induced outbreak.

Laser resurfacing patients should always be asked if they have a history of cold sores prior to these treatments. If a patient does have a history of cold sores (herpes) they should be put on an antiviral medication for a minimum of one week prior to treatment and one week after treatment to prevent the reactivation of the virus. Even with before and after laser resurfacing antiviral prophylaxis, some patients will still develop some virus outbreaks but it will be smaller and will heal quicker.

Antiviral medication options for treatment of cold sores (herpes) are Acyclovir (Zovirax) 200mg by mouth, four times a day for five days (pre and post treatment) and Valacyclovir (Valtrex) 2 grams by mouth, every 12 hours for one day (pre and post treatment). The cost differential between the two is one of the main deciding factors when choosing which antiviral medication is chosen. Acyclovir is approximately $10.66 without insurance to fill for the needed amount, while Valacyclovir is approximately $50 without insurance.

In addition to oral antiviral medications, there are also topical antiviral creams that can be applied. This may be beneficial to use with the oral medications prior to treatment if the patient has a lesion or blister present, but would be most beneficial for after treatment especially if some outbreak occurs. Abreva (composed of 10% Docosanol) is sold over the counter for approximately $14.21 a tube and is applied directly to the cold sore five times a day. Denavir (Pencyclovir) is a prescription cream that is applied directly to the cold sore every two hours for four days and costs approximately $103.98 per tube. The use of both topical and oral medication together will help the virus heal quicker.

An interesting question is whether all perioral laser resurfacing patients should be put on antiviral medication even if they have never had cold sores. There are some patients who develop cold sores after laser resurfacing even though they have no prior history. There is no established standard of care that says such prophylactic medications should be used when no herpetic history exists.

Lora Dillman, RN

Dr. Barry Eppley

Indianapolis, Indiana

Fully Ablative vs Fractional Facial Laser Resurfacing – Which Is Better?

Saturday, January 19th, 2013


Facial laser resurfacing has evolved over the past twenty years from in both how the energy is delivered to what depths into the skin that is treated. When initially introduced laser resurfacing was known as ‘fully ablative’, meaning that at any energy level it treated 100% of the skin’s surface. While many of the results a fully ablative laser resurfacing treatment creates can be impressive in the amount of wrinkle reduction and skin tightening, it can be associated with loss of skin pigment and long healing and recovery times.

Such skin resurfacing concerns led to the development of fractionated or a ‘fractional’ laser technique. In this approach the laser only treats a part or fraction of the skin’s surface. By leaving untreated or skipped zones of skin, there is less traumatized tissue which substantially reduces the risk of hypopigmentation and shortens the recovery time. Treating less skin may seem counterproductive to getting a good skin result (less wrinkles) but this is compensated for by having each penetrating laser light column go much deeper. This is why fractional laser treatments create pinpoint bleeding areas while fully ablative lasers do not.

The theoretical benefits of fractional laser resurfacing is that these deeper penetrating columns of laser light cause at least an equal amount of increased collagen formation and skin tightening as that of more superficial fully ablative laser treatments. This would seem to make perfect sense given the greater depth of dermal injury and it has always been assumed to be true. It also accounts for its popularity as a widely used treatment.

In the October 2012 issue of Dermatologic Surgery, a human study was done to directly compare the molecular changes that result from fractional vs fully ablative carbon dioxide (CO2) laser resurfacing in skin damaged skin. In 34 adults with substantial facial skin damage, matched facial areas with treated between the two laser types. Real-time reverse transcriptase polymerase chain reaction technology and immunohistochemistry were used to quantify molecular responses to each type of laser treatment. Their results show that both fully ablative or fractional laser resurfacing resulted in significant skin changes of dermal remodeling and the creation of new collagen. After one treatment, however, fractional laser resurfacing effects were only about half of that seen by a fully ablative treatment. The fully ablative laser treatments created greater changes with more pronounced collagen formation.

What this study indicates is that the fractional laser approach is not superior to fully ablative treatments (in a single treatment) as many may believe or purport that it is so. This is no surprise given that much less skin surface is treated, often 78% to 95% less.  The value of fractional laser resurfacing is that it has less risks of skin problems particularly in patients with more natural skin pigment.Whether better skin results, particularly in its tightening effect, may occur with repeated treatments can not be determined from this one study. The value of fractional laser resurfacing is that such repeated treatments can be safely done.

Dr. Barry Eppley

Indianapolis, Indiana

Treatment Options for Facial Acne Scars

Saturday, January 5th, 2013


Acne is a common skin condition that results in a wide variety of scars types and patterns. Even though there are a number of available treatments for acne scars, they are not always universally successful. Acne scars represent a difficult challenge for improvement and every option must be considered in each patient. Often different treatment approaches may be used on the same patient based on the type of acne scars that they have.

When evaluating acne scars, there are three main types based on their shapes. Ice pick scars are the most common acne scar and are semi-round in shape but narrow and deep. They occur most commonly on the nose and cheeks. Rolling hill scars are wide deep scars that roll into the skin. They often occur in bunches and are the result of large and deep cysts. Boxcar (atrophic) scars are somewhat similar to ice pick scars but are not as deep and are wider. The morphology of acne scars goes a long way in determining the correct treatment choice.

The options available for acne scar treatments include injectable fillers, subcutaneous incision/subcision, punch excision, punch elevation and fractional laser resurfacing. Which of these approaches is best? Again, the shape and depth of the acne scar is the determinant.

Hyaluronic acid injectable fillers work by lifting up the depth of the scar depression and trying to make it more level with the surrounding unscarred skin.  In essence, try and raise the valley to get closer to height of the surrounding mountains. Fillers may stimulate collagen regeneration in the skin but this is more theoretical than ever actually seen on a consistent basis. This acne scar technique works best for broad and shallow scars. Deep pitted scars are too fibrotic to be elevated by the push of a filler. While the improvement occurs immediately with injectable fillers, it is a temporary effect that will last as long as the composition of the filler.

Subcision is a technique that inflicts injury to the skin at the base of the scar. This causes the scar to release and accumulate blood underneath it. This is done by using the beveled edge of a small needle like a miniature scalpel. This will result in some bruising and swelling. The dermal collagen injury and bleeding may act as a stimulant for new collagen growth. This technique works best in rolling hill type scars. Multiple sessions are often needed for the best results.

Punch excision is a very well known acne scar technique that does exactly what it describes, it cuts the scar out in a circular pattern. This is done using punches which are small cooker-cutter tools with varying diameters. (1 to5mms) Once the scar is removed, the circular hole is then treated by one of two closure techniques, small suture closure or the hole is filled in with a full-thickness skin graft of the exact size usually cut with the same tool. (punch elevation) Once healed, laser treatments are often done for the smaller scars left behind from excision and closure or the raised scars from the punch graft.  Punch excision works best for ice pick and boxcar scars.

Laser resurfacing works best for the most number of acne scar types. The laser fundamentally works by removing the top layer of skin so that shallow scars may be eliminated and deeper scars appear more shallow. But in a 100% ablative laser, where top layers of skin are removed in even unscarred skin, no net gain may often be seen. The better technique for acne scars is fractional laser resurfacing where just a portion of the skin is treated but the penetration is much deeper. The deep skin channels cut by the fractional laser stimulates the skin to contract and get tighter, narrowing the diameter of the scar. Multiple fractional laser treatments are almost always needed.

The challenge of improving facial acne scars is met with a variety of treatment techniques. While perfectly smooth skin is never possible, mixing and matching  several of these treatment techniques almost always provides visible improvement for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? The Myth of Laser Scar Removal

Monday, August 6th, 2012


When most people think of scar revision they usually think of two things; elimination of the scar and the use of lasers to do it. The reality is that both of these perceived principles of scar revision are wrong. Scars may be able to be improved but they can almost never be removed. Plastic surgeons wish this was possible but it is not. Once the skin has been injured and healed by scar, it will be forever changed. It is merely a question of how much reduction can be obtained and how much less visible it can be. Secondly, while lasers have a role to play in scar revision it is less significant than excisional techniques. Lasers are not magical wands that work like erasers. They are most effective in prophylactic treatment of early scars and incisions. They will make little difference in well-established mature scars, particularly those that have visible surface contour issues. (wide, deep, raised) Revision of significant scars requires excision and closure, often using geometric rearrangement techniques. Laser resurfacing may then be done after to get the best camouflaged appearance.

Plastic Surgery’s Did You Know? Lip Wrinkles

Sunday, July 29th, 2012


Lip lines, particularly the vertical wrinkles of the upper lip, are a common problem amongst many Caucasian women. Thinner less pigmented skin is more prone to wrinkling due to repeated lip motion and less dermal thickness and elastic fiber content. The wrinkles form perpendicular to the horizontal orientation and sphincteric movement of the underlying orbicularis muscle. Regardless of how they form, they are very pesky problems to treat so prevention plays a critical role. Stopping smoking is one of the most important preventers as its toxins damage collagen, resulting in fine lines. Sun protection with lipsticks and balms that contain sun protection factors and hydrate the lips works from both the outside and inside. Pursing the lips when drinking through a straw or sipping should be avoided. But when lip lines do occur, they can be substantially reduced by injectable fillers, fractional laser resurfacing or even dermabrasion if severe enough.

Total Hand Rejuvenation

Wednesday, July 11th, 2012

While the aging of the face seems the most visible and subsequently the most treated by plastic surgery, it is not the only visible and unclothed body part that ages. I have seen many older women whose face is quite smooth because of numerous facial rejuvenation procedures but whose hands give their age away. The hands simply don’t go with their face, age or lifestyle. The hands are as much exposed to the elements as the face but are far less pampered and protected.

Like the face, the hands age in a similar way. They lose volume through fat atrophy, the skin loses elasticity and becomes wrinkled and age spots appear. As the fat layer in the hands disappears, which is already thin to begin with, the skin becomes partially translucent and thinner. This creates the classic skeletonized hand appearance where the veins and tendons are clearly visible. The rows between the hand bones become sunken in. The skin when you pinch it on the back of the hands doesn’t bounce back due to loss of elasticity.

The aging of the hands can clearly be seen in many tabloids and magazines. Famous aging women with youthful faces and great bodies have old-looking hands. Their veins can clearly be seen bulging out on their emaciated hands. This may be why some performers wear fingerless gloves in an effort to hide the back of their hands.

Treatment of the aging hands can be done through various rejuvenation methods. The most common treatment by far is for the brown age spots or sunspots. Intense pulsed light (IPL) or broad band light (BBL) can quickly remove brown spots, many of which can be eliminated in a single treatment session of about 15 minutes. It turns them dark and speckled and they then fleck off over the next week or so. A touch-up treatment may be needed a month later to clear what remains. It is important to wear sunscreen on the back of the hands afterward to prevent reflaring of some of the brown spots. A minimum of SPF50 sunscreen should be used.

These light therapies can be supplemented with laser resurfacing to help tighten the loose skin and reduce the wrinkling. Fractional is the best laser method because it has enhanced collagen stimulation effects. Laser resurfacing can be combined with light therapies to get a better overall effect than either one alone. Laser treatments take the same amount of time to do, about 15 minutes per hand.

Most so-called ‘hand lifts’ employ the use of injectable fillers to plump out the atrophic subcutaneous tissues and ‘deskeletonize’ the back of the hand. Fillers like Juvederm, Restylane and Radiesse can be quickly injected in the office for an instant filling effect. Placed right under the skin near the wrist level, they can be pushed into the indented rows once injected right under the skin. While they are not permanent the filling effect will last anywhere from six months to a year.  Fat injections are another option and generally create a better result because the volume injected is greater. It is a minor surgical procedure where fat is harvested from inside the belly button, concentrated, and then injected just like synthetic fillers. Unlike off-the-shelf fillers, fat has the potential to be longer lasting.

Other hand treatment options included the use of skin tightening devices like Exilis and the sclerosing of hand veins by injection or their actual extraction like varicose veins of the legs. One treatment option that is not used is a formal hand lift where skin is excised and the skin tightened. While it can be done by making an incision at the wrist level, the scarring is not acceptable.

A complete hand rejuvenation approach is the combination of injectable filling, light therapy for brown spots and fractional laser for wrinkling and skin tightening. Both hands can be treated in one hour in the office with complete healing in just one week.

Dr. Barry Eppley

Indianapolis, Indiana

A Structured Approach to Treatment Planning of the Aging Face

Sunday, June 3rd, 2012

Patients with facial aging concerns frequently come in and want a general overall assessment of what can be done to improve their face. Others come in because they are looking for a very specific facial rejuvenation procedure, whether it is some type of tuck-up, filler or laser resurfacing. They are driven to these procedures largely because of something they have seen online. But despite the plethora of available internet educational forums, such as websites, blogs and even YouTube videos, wanting a specific procedure does not make one very educated about it. For many, the amount of available information is so overwhelming that they have no greater understanding  after they have digested the information than before.


While every face is very different in shape and appearance, the aging process affects them all. But the extent and progression of the aging process differs in every face  so, while they are many predictable changes, every face has varying degrees of them over time. When combined with what bothers any particular patient, it is fair to say that every aging patient needs a unique treatment approach. Despite the need for a unique treatment plan for every patient, there are only so many known facial rejuvenation treatment options. This is exactly how a plastic surgeon thinks when looking at a face…what procedures does the patient need and which ones will make the biggest difference?


Translating a facial aging treatment plan to a patient requires an organized and thoughtful approach if they are to understand the logic of what they need and the procedure(s) required. I find it most helpful to divide the face into thirds and break down their concerns and what can be done. The surface texture of the skin is the fourth facial element and is always discussed last.


The upper face consists of the frontal hairline, forehead skin, brows and the upper eyelids. This is a unit because changing one aspect of the upper face affects all others. How much excessive eyelid skin is there, what is the position of the eyebrows, what is the vertical length of the forehead skin, how much muscle activity and lines exists in the forehead skin, and what is the location of the frontal hairline and its hair density? These determine whether only an upper blepharoplasty is needed or whether it needs to be combined with a browlift and what type of browlift would be best?


The middle third of the face involves the lower eyelids, cheeks and nasolabial folds. Is just a lower blepharoplasty needed and what type? Do the cheeks need lifted or will just more volume do? Does the patient have tear troughs or malar bags? How best to reduce the depth of the nasolabial folds? The relationship between the lower eyelid and the tissues beneath it is a complex and challenging one and there are many options available today.


The lower face includes the neck and jowls, lips, mouth and chin. Does the patient need a full facelift or only that of a more limited variety? Does the neck need platysmal muscle plication or just liposuction with the facelift? Will chin augmentation improve the shape and definition of the jawline? Do the lips need vertical wrinkle reduction, corner of the mouth lift, or vermilion lip enlargement? The central mouth area can not be separated from the neck and jowls in improvement of aging.

Lastly, skin texture must be considered. Lifts and tucks will not reduce fine wrinkles, give the skin a more youthful glow, reduce pore size or get rid of brown spots. Simultaneous or delayed skin resurfacing with laser or chemical peels is a great asset to all other tissue lifting or excisional procedures. More commonly, skin resurfacing is being done simultaneously at the time of surgery.


If you break down the face into its four structural elements and go through it a sequential fashion, patients are more likely to understand and retain the options given to them. This should lead to less misunderstanding and disappointment after surgery.


Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Resurfacing of the Neck

Wednesday, May 30th, 2012

Resurfacing of the facial skin for wrinkle reduction is well known to be effective. Such laser improvements have been particularly enhanced by the use of fractional ablative laser treatments. The deeper penetration of the vertical laser columns, albeit on just a fraction of the skin’s surface, causes collagen production and skin tightening not previously seen. But venturing off of the face onto the neck and chest, however, is more precarious with laser resurfacing or even deeper chemical peels.

Although the neck is right under the jawline and adjacent to the face, it reacts differently to skin resurfacing efforts. Complications such as delayed wound healing and pigmentation changes are not rare and have been seen with every laser approach. The conclusion historically is that only very light laser treatments with minimal improvements can reduce the risks of these after treatment problems.

Why the neck and chest is different has been theorized due to a change in the anatomy of the skin. The dermal component of the skin is definitely thinner and has less pilosebaeous units per square centimeter. Since most skin cell regeneration (re-epithelization) comes from these hair-sweat gland follicles, healing is slower and more challenged by thermal injury. The thinner dermis also lends itself to greater thermal injury at similar laser setting that are used on the face.

Fractional laser resurfacing offers a theoretical improvement to traditional laser resurfacing of the neck. Its microscopic vertical columns leaves normal skin tissue between them, acting as a reservoir of uninjured fibroblasts and pilo-sebaceous units to provide a good healing source. With a treated to untreated skin ratio ranging from 5% to 22% (Sciton Fractional Laser), there is plenty of healing cells available to expedite wound healing. The traditional higher incidence of complications in neck resurfacing should therefore be appreciably reduced with fractional laser techniques. In my experience this is certainly true and much better skin improvements are seen. Skin texture, wrinkle reduction and small amounts of skin laxity are improved.

An important distinction, however, should be pointed out between improvements in neck skin texture and laxity. I see too many people who erroneously believe that neck laser skin resurfacing is going to create the effect of a facelift. (neck-jowl lift) This is certainly not the case except in the slightest of degrees. The amounts of improvements seen in laxity reduction will not make most of the patients I see happy. This is asking too much of laser therapy even though some make market it as a non-surgical facelift.

Dr. Barry Eppley
Indianapolis, Indiana

Plastic Surgery’s Did You Know? Laser Resurfacing at a Fraction

Tuesday, May 1st, 2012

Laser skin resurfacing has now been around for several decades and involves a simple treatment principle…uniform removal of the outer layers of the skin. This can be done from very superficial to deep depending upon the power settings of the laser and the depth of the skin contour problem. Fractional laser treatment represents a paradigm shift in laser skin resurfacing by treating just a fraction of the skin’s surface, hence the name. But each area treated or laser dot penetrates much deeper creating vertical columns down into the deeper layers of the skin. This results in much greater collagen stimulation. But because less skin is injured (5% to 22%), it heals much faster. This has been a revolutionary advance in the treatment of previously difficult problems like scars.

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits