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

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

The upper and lower lips are one of the five main facial features that makes up and helps define the most recognizeable central third of the face. In today’s society, full lips are viewed as healthy and sensual, thin or wrinkled lips cast the opposite image. While the lips are paired, they are not identical due to their embryological origins. The upper lip is uniquely different than the lower as it has a central cupid’s bow or two-peak wave form which differentiates it from the smooth and continuous lower lip. That is a key aesthetic difference and very important consideration in any form of lip augmentation.
While injectable fillers are the most common form of lip augmentation, they are not for everyone and every form of injectable filler is not for lips. Patients who have thin lips can not be injected and end up with full pouty lips. The pink part of the lip will only stretch so much before it begins to look distorted, too full, and unnatural. Results like this are evident everywhere on TV and in the movies. Injections will not make a well-defined cupid’s bow nor make the height of the lip bigger either. While it acceptable to try a small amount of injectable filler in a thin lipped patient, and I frequently do, it is best to not overdo it. Let the patient decide whether the result is worth it. I always place injectable fillers in layers and ask the patient to give me their opinion with each new layer. Enough is when they tell me so. Surprisingly, no injectable filler is formally approved by the FDA for injection into the lip even though it is common practice. Only the hyaluron-based fillers such as JuvaDerm, Restylane or Perlane should be used in the lip as they flow in smoothly and have little risk of a foreign-body reaction….and they are completely reversible with time. The particulated fillers such as Radiesse and ArteFill should not be used in the lip as they do have risks of lumpiness and potential reaction to their particle component. As for silicone oil…be very wary. Not only is it not FDA-approved for any injectable application at this time, its track history from the 1960s and early 70s is not reassuring. (even if this is a newer more purified form)
For those thin-lipped patients, some consideration may be given to lip lifts and advancements if careful thought is given to the permanent scar. While these are powerful lip procedures and can do wonders in increasing the size of the pink part and in making a well-defined cupid’s bow, they do produce a fine line scar at the junction of the pink lip and skin. If the patient is certain they can live with that trade-off and has a high lipstick use frequency, this may be the procedure for them. That decision becomes a little easier in the older female where the thinning of the lips and the development of vertical wrinkles on the lip requires more than a simple lip fill with an injectacble can do. If the procedure is done well, it can look fairly natural. If the lip is advanced too much or the peaks of the cupid’s bow made too sharp, it can look very unnatural.
Often patients who have had temporary lip injections desire a more permanent fix. Options include fat injections and synthetic implants. Since fat has to be harvested from the patient in a sterile fashion, I always do this procedure in the operating room and is a strong consideration when the patient is going to be there for other plastic surgery procedures anyway. There really is very little to lose by doing it in that setting. While the take of fat grafts is definitely variable, some patients will do well with it. The test is what it looks like at three months after surgery, not in the first few weeks. If fat takes well, it will last longer than any synthetic injectable but it may not last forever as the lip does continue to age. Therefore, further fat inejctions may eventually be necessary. Permanent lip implants (Advanta) have been around for over a decade and in the right ‘qualified’ patient can do well. Qualifying a patient is one who has had lip injections and is really ready to accept a permanent implant over a temporary filler. My experience with Advanta, a soft spongy tube, has been quite good even though all patients will definitely be able to feel it.
Two of the most important things in creating natural lip results is that they must not be too big or have treatments which result in them ending up stiff or irregular. We touch the lip area very frequently so we are quite attuned to how it feels And the lips need to be soft and flexible to support easy and painless movement.
A good artistic sense in shaping the lips (they enhance the face but should be the focal point), consideration of the many lip treatment options, and preservation of soft flexible lips are needed to get the most natural lip augmentation results.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http:.//www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Lip Enhancement in Indianapolis by Dr Barry Eppley

Improving the size and shape of the lips is a frequent cosmetic request and a very commonly performed aesthetic procedure done in the office. While the vast majority of lip enhancements are done by injectable fillers, and most patients are only aware of this approach, there are other less common but equally effective options.

Injectable fillers are the most common lip enhancement method and the hyalurons such as Restylane and Juvaderm are usually used. The longevity of hyaluron fillers, while touted differently amongst manufacturers, is in the range of 4 to 6 months. While longer-lasting injectable fillers exist, such as Radiesse and Aretfill, these contain particles which may be prone to lumpiness and foreign-body reactions. Because of their predictability and safety, with very few complications, hyaluron lip enhancement is the current gold standard.

There other other types of non-injectable lip fillers. Over the years, many collagen-based implants have been tried, such as Alloderm and Fascian. Unfortunately, while conceptually appealing, their longevity has not been shown to be any greater than the hyaluron fillers. But they are more expensive and cause much more lip trauma to place. As a result, they have fallen into disuse.

Despite the frequent touting of your own fat as an injectable filler, and reports of great longevity and possible permanency, most plastic surgeons have not had that experience. Fat in the lip is simply unpredictable. I will still use it…..when I am performing other procedures in the operating room where the use of fat is ‘easier’ than in the office and there is little to lose by doing so. I suspect that repeat fat injections over time do consistently work but that is fairly traumatic for a patient to go through.

Permanent lip augmentation can be done by synthetic implants known as Advanta. These very soft implants are threaded into the lips, corner to corner, by a metal trocar under local anesthesia. They are non-resorbable, fairly soft, and the volume added is permanent. They can definitely be felt in the lips but I have not had a patient yet who has reported that as a problem. I use Advanta when the patient is ‘qualified’, meaning they have tried injectable fillers first and want to move on to something permanent.

More surgical lip enhancement is known as vermilion advancements or subnasal lip lifts. While these are highly effective are making the lip bigger, they have a trade-off of permanent scars. A patient must be very willing to make this trade-off and accepting of fine-line scars. I use these in patients that have very thin lips and a very flat cupid’s bow and have ‘failed’ lip enhancement by fillers. (meaning it does not look good or do what the patient expected. Lip lifts are often most effective in the older patient whose lips (which were not big to start with) have shrunken with age.

As you can see, lip enhancement has lots of options. All work well at achieving larger lips….but not every enhancement procedure is for every patient.

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

New Versions of Injectable Fillers keep coming…..and more are on the way!

Next to Botox coming out of a needle, the use of injectable fillers is only slightly less popular as a cosmetic injection method. While collagen was the only injectable filler for lines and wrinkles from 1981 to 2003, there has been a virtual explosion of new injectable fillers since then…..now numbering six commercially available fillers….and four of these have become available in the last year. And collagen as an injectable filler has now become of historic interest only.

The new revolution in injectable filler materials has been the change from collagen to hyaluronic acid. A natural sugar, hyaluronic acid (HA), lasts longer and has much less potential for adverse reactions than collagen. The battle amongst HA manufacturers revolves around the claim of which one is the longest lasting. Despite differing claims, conclusive proof that one type of HA lasts longer than the other remains lacking. Clinical trials for most manufacturers has compared their version of HA to collagen as the control. Few direct comparison studies have yet to be done. While the amount or concentration of HA per cc would suggest greater longevity, there are other issues of importance as well such as the degree of cross-linking. These issues will eventually sort themselves out but it is fair to tell patients that HA injections will last between 4 and 8 months on average, and some perhaps longer. One thing is for certain, however, and that is more variations of HA injectable fillers are coming….and such competition will drive the price of a syringe down. (which is more than can be said for Botox!)

Two non-HA injectable fillers also became commerically approved last year. I call these type of injectable fillers, particulated synthetic injectable fillers. The concept is that they contain a portion of non-resorbable beads or particles mixed in a carrier solution. Radiesse uses ceramic beads and ArteFill uses plastic beads. Either way, the beads do not go away and some percent of permanence remains. As a result, they last longer than the HA fillers even if 80 - 90% of the particulated filler does go away. Because they have the potential to become lumpy due to scarring around the beads, their use in the lips is not recommended. In theory, build-up of the beads can occur over time with multiple injections so that their effect may seem to last longer over time.

With such a wide selection of injectable fillers available today, it can be confusing to the patient. For the physician injector, it is important to use more than one of the available injectable fillers for different areas and different problems.

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

The Science of Hyaluron Injectable Fillers in Indianapolis by Dr. Barry Eppley

The use of injectable materials for filling or plumping up facial lines and wrinkles dates back to 1981 in the U.S. when collagen injections became available. From 1981 to 2003, for over twenty years, injectable collagen was the only available facial filler. While the injection process was easy, the popularity of collagen injections was limited as its effects were very short-lived usually lasting around 6 weeks or so. Because the collagen material was bovine-derived (from cows), a skin test was required prior to injection and a small percent of patients had allergic reactions, thus not being capable of treatment. Since 2003, a new synthetic material has become commercially available and collagen is now ‘a material of historic interest’ primarily. This new material is hyaluron or hyaluronic acid.
Hyaluron (HA) is produced today by fermentation in cultures of equine streptococci. The fermented material is then stabilized via epoxidic cross-links of the glycosaminoglycan chains. As a result of this processing method, the HA material does not cause immunologic sensitization and virtually no risk of allergic reactions. Hyaluronan is a polysaccharide that is an essential component of the extracellular matrices in which all human tissues differentiate. In certain tissues, such as the vitreous cavity of the eye and synovial joint fluid, it is the major constituent. Unlike collagen, it is identical across all animal species and microbes. The largest amount of hyaluronan resides in skin, where it is present in both dermis and epidermis. Hyaluronan’s high capacity for holding water and high viscoelasticity give it some unique properties that are useful in various medical and pharmaceutical applications. Because it retains moisture, hyaluronan is used in some cosmetics to keep skin young and fresh-looking. As we age, the water-holding capacity of our skin decreases as hyaluronan depolymerizes. Therefore, the retention or insertion of hyaluronan into the skin is theoretically helpful in wrinkle reduction.
HA can be rather rapidly degraded and is ultimately metabolized in the liver. Modern processing methods have produced more stable forms of HA that have much longer in vivo retention times. As degradation occurs over time, water is attracted to the material at the site of implantation. As the HA concentration decreases, more water bonds to it thus helping with cosmetic persistence. This feature is what probably accounts for its longer volume retention effects than bovine collagen. (isovolemic degradation)
A variety of differing grades of transparent gels are available, based on the same type gel from highly concentrated (20mg/ml)stabilized HA, which varies in particle size and subsequent indication. Restylane has a particulate size of 100,000 gel particles/ml, flows through a 27 gauge needle, and is indicated for mid-dermal applications such as deeper wrinkle reduction, as well as lip augmentation, nasolabial folds, and glabellar creases. Restylane has even been successfully used in the treatment of tear trough deformities.14 Restylane Fine Lines has the highest concentration at 200,000 gel particles/ml, can be injected through a 30 gauge needle, and is indicated for thin superficial wrinkles. The lowest concentration gel is Perlane at 8,000 gel particles/ml which is injected through a 27 gauge needle and is intended for shaping facial contours, correcting deep folds, and for lip augmentation.15 Restylane was FDA-approved in December 2003, Perlane received its approval in 2007. There are numerous manufacturers of HA injectable fillers which, in addition to Restlane, includes Captique and Juvaderm.
The universal HA composition makes the need for pre-injection skin testing unnecessary as the risk for hypersensitivity reactions is minimal. It is easily injected and flows nicely through small-gauge needles. While not permanent, its persistence is reported to exceed bovine collagen with estimates of between 4 and 6 months post-injection.
Rare side effects, that I have not yet seen, include injection site inflammation at an incidence of 0.02% and local hypersensitivity reactions (swelling, erythema, and induration) at an incidence of 0.02% lasting a mean of 15 days.

As of today in 2008, HA injectable soft tissue fillers are the gold standard by which all
future injectable filler materials will be compared.

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

INJECTABLE FILLERS – Many Types, Different Uses

Up until 2002, only one type of facial line and wrinkle filler was available – injectable collagen derived from cow proteins. While it lasted only a few months, due to its animal origins, it was the only treatment option available. Since 2002, six (6) new injectable fillers have been approved for use in the United States, all of which are made up of different (and better by the way) materials which last longer with fewer skin problems. This has resulted in a great amount of confusion and misinformation for patients. (and some doctors as well) With the certainty that more new injectable fillers are on the way in the next few years, it is important for even the patient to have some basic understanding of the similarities and differences between the choices that they have.

Today’s injectable fillers can be classified into two basic types: hyaluronic acid (HA or hyaluron) and particulated (particle-containing) compositions. While both come out of a needle, they are quite different. HAs are now the gold standard of fillers since they arrived in 2002 and have relegated old-style collagen to an almost historic footnote. Since they are synthetic ‘knock-offs’ of natural human hyaluronic acid, the patient does not need a skin test prior to injection and they last at least twice as long as collagen. The alleged differences between the four commercially-available HA injectates (Restylane, Hylaform, Captique, and JuvaDerm) is largely marketing-driven and no clinical studies has ever compared how long all of them last compared to each other. Because they are like injecting a ‘soft form of Jello’, they can be used anywhere on the face including the lips (even though the FDA has never approved any injectable filler for use in the lips) without fear of excessive lumpiness. I prefer JuvaDerm at present due to his observations that it appears to last the longest. (6 – 8 months) The next few years will bring other more concentrated HA injectable fillers to the scene that undoubtably will last even longer. The particulated fillers contain synthetic beads or particles (plastic or ceramic) in different liquid carriers. (Radiesse, ArteFill) Due to the non-resorption of the beads (which usually make up less than 25% of the solution), longer-lasting effects are seen than with the HAs. Equally important, because the beads do not resorb, some ‘permanency’ of volume can be achieved over time with repeated injections. However, because of the particles and the potential risk of lumpiness, these particulated fillers should not be injected into the lips. They are best used for deeper lines and folds such as that of the cheek-lip fold which is a common cosmetic concern for aging patients.

Since no injectable filler is ideal for every patient or type of facial line or wrinkle, the best plastic surgeons usually work with two or three different ones to custom treat each facial problem.

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

Getting rid of those 11s!

Nothing makes yopu look more stressed or irritable than those vertical lines between the brows. Six different facial muscles converge in the area between the brows, and when making that classic scowl with straining or stress, creates two vertical lines in some patients, otherwise known as the 11s. If you frown enough, these 11s can become a permanent fixture of your face.

FDA-approved, specifically for this region, Botox injections can smooth these vertical lines so you can look stress-free for 4 to 6 months after treatment. In the event that these lines are still somewhat visible even after the muscles are relaxed, fillers such as Restylane, Juvaderm, or Radiesse can be used. They help fill in the indentations that left. This combination is particularly powerful at usually results in the best eradication of these lines. But not all patients will need both, however, If in doubt, do the Botox first, wait two weeks, and see if further line reduction is needed. The fillers can always be done later after the Botox.

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

A day does not go by that I find a patient that has confused Botox with an injectable filler in terms of what it can do for in-office facial rejuvenation procedures. I have heard patients say. “Fill my lips with Botox’ or ‘Use Restylane between my eyes to stop me from frowning’. Just because it is an injectable, doesn’t mean that what comes out of the end of the needle works the same.

To clear up the confusion, I often explain to patients the difference between static wrinkles and dynamic wrinkles. Dynamic wrinkles are those wrinkles and lines that appear when your face is moving or expressing. When we were younger, the only lines and wrinkles we had were dynamic. Our face was otherwise wrinkle-free when we weren’t expressing ourselves. Static wrinkles are those facial lines that are evident even when our face is still. All dynamic wrinkles, of course, eventually with age, lead to static wrinkles.

These two types of wrinkles are what separates Botox and any of the injectable fillers. Botox is for dynamic wrinkling. It is a muscle-paralyzing or muscle weakening agent so it will soften the wrinkle that occur from dynamic facial movement, such as between the brows with frowning. Injectable fillers are for static wrinkling. They soften lines and larger wrinkles by plumping them out so they look less evident at rest. In some cases, the combination of Botox and fillers are used when the line or wrinkle is very deep and weakening the muscle action will help perserve the longevity of the filler material but not being ‘beaten on’ by muscle movement. This is most common in the furrows between the eyebrows. (’11 sign’)

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