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Dr. Barry Eppley

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Posts Tagged ‘lip augmentation’

Lip Fat Injections using Buccal Fat

Thursday, April 14th, 2016


Lip augmentation is a popular facial filling procedure that has been done by a wide variety of materials. Synthetic fillers, fat injection and implants have all be done with well known advantages and disadvantages. The perfect lip augmentation material, however, remains elusive

Of all the known injectable fillers, fat has a high appeal but is the most vexing. Fat is a natural material that is unique to each patient and everyone has enough to harvest to do lip augmentation. But even in small volume placements like the lips, its retention and survival is far from assured. In fact, substantial clinical experience has shown that the lips actually have one of the lower rates of fat grafting success on the face. Whether that is due to high motion activity of the lips or their lack of much native fat tissue is unknown.

The donor site for lip fat injections has been harvested from just about every body donor site imaginable. No one knows if the donor source of fat grafting affects how well the fat graft takes although it is hard to imagine that it does not play some role albeit even if it is a minor one.

Buccal Lipectomy intraop Dr Barry Eppley IndianapolisOne donor source for injectable fat grafting that has not been previously described is that of the buccal fat pad. There is more than enough fat in the buccal fat pads for transfer into the lips. But buccal fat pad harvesting should not be routinuely done due to potential undesired aesthetic tradeoffs of facial hollowing that could occur in many patients. But for those patients with rounder faces that desire facial slimming, a buccal lipectomy can be aesthetically beneficial.

Buccal Fat Injections to Lips Dr Barry Eppley IndianapolisHarvested buccal fat pads can be pass back and forth to create an injectate that can easily be injected through a small blunt-tipped cannula. And for the buccal lipectomy patient who also desires lip augmentation this can be a superb method of fat recycling/redistribution.

Buccal Fat Lip Injections result Dr Barry Eppley IndianapolisDoes fat from the buccal fat pads survive better than other donor sites. The fat is clearly different in being encapsulated and with much larger globules. It is tempting to hypothesize that it survives better than subcutaneous fat, and I suspect that it does, but it remains to be scientifically proven.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Lip Augmentation with Juvederm Ultra XC

Wednesday, October 7th, 2015


Lip Augmentation Dr Barry Eppley IndianpolisLip augmentation is one of the most common and historic procedures for hyaluronic acid-based injectable fillers. It would surprise many then to find out that despite its popularity and common usage, few of these injectable fillers are actually FDA-approved for use in the lips. There are a variety of reasons for this lack of approval but safety and effectiveness are not among them.

On October 1, 2015 the US FDA has approved Juvederm Ultra XC for injection into the lips and perioral (mouth) area for aesthetic augmentation in adults. Juvederm Ultra XC and Juvederm Ultra Plus XC injectable fillers are already FDA-approved for injection for moderate to severe facial wrinkles and folds around the nose and mouth. (nasolabial folds) Juvederm Ultra XC is a well known modified form of hyaluronic acid with prolonged duration (up to a year) that has lidocaine in it to improve the comfort of the treatment.

juvderm ultra xc injectable filler, dr barry eppley indianapolisIn FDA trials of Juvederm Ultra XC for lip augmentation, almost 80% of patients had visible improvement in lip fullness three months after injection. A near similar percent, (78%) stated that they had persistent improvement in lip size one year after injection. The most common adverse effects for Juvederm Ultra XC injectable filler are the same as other hyaluronic acid gels such as temporary swelling, redness and lumps and bumps.

What is unique about Juvederm Ultra XC injectable filler is that it offers long-term retention of lip augmentation results. Many hyaluronic acid-based injectable fillers are used for lip augmentation but their results often last six months or less.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Permalip Implant Lip Augmentation

Sunday, August 30th, 2015


Background: Lip augmentation is the historic location for injectable fillers since the early 1980s and remains as one of the top injectable filler sites even today. There are a wide variety of injectable fillers and manufacturers but the use of hyaluronic-acid (HA) based fillers is primarily used in the lips as they have the lowest risk of potential complications.  HA injectable fillers flow in the smoothest and the easiest and this makes them ideal for lip augmentation.

While injectable fillers for lip augmentation is highly effective and safe, it is not permanent. (I am excluding the use of silicone oil from this discussion since it is not FDA-approved for this use) This lack of permanency poses a long-term issue in terms of cost. Few women are going to spend $500 to $1,000 per year over their lifetime to maintain a lip augmentation result. It simply is too costly to do so for most women.

The concept of lip implants has been around for a long time and numerous types of lip implants have been tried. While effective in increasing the size of the lips they have posed numerous problems including hardness, irregularities, scar tissue, lip numbness, extrusion and difficulty with removal. This has given lip implants an historic poor reputation.

Permalip Implants Indianapolis Dr Barry EppleyWhile no permanent lip implant can be perfect as the lip is a very soft and distensible structure, the problem with past implants is that the materials used were too firm. No matter how it is engineered and designed, polytetrafluroethylene (Gore-tex) is too firm for the lips. A newer lip implant, Permalip, offers an improved material that is of a very soft flexible solid silicone material. Just by feel it seems more like a soft lip structure.

Case Study: This 42 year old female had various HA injectable filler materials placed into her lips for the past six years. While she liked her lip augmentation results, the cost of repeated treatments was becoming prohibitive. She sought a permanent lip augmentation result with implants.

Lip Implants result side view Dr Barry Eppley IndianapolisLip Implants result front view Dr Barry Eppley IndianapolisUnder local anesthesia in the office using infraorbital and mental nerve blocks with direct infiltration into the lips, Permalip implants were placed. A 4mm implant was placed in the  upper lip and a 3mm implant placed in the lower lip through small incisions placed just inside the corner of the mouth.

Indianapolis Permalip Implants Dr Barry EppleyPermalip implants offer the only permanent method of lip augmentation. Of all lip implants ever manufactured, their soft silicone composition is the best material and design offered to date. They are easy to place and, just as importantly, easy to remove should that be necessary. Because they have a smooth surface it is very important that the chosen length of the implant is at least as long as a measurement taken across the lip from one mouth corner to the other. If the implant is short of this distance it will become displaced with asymmetry of the implant between the two lip halfs.

Permalip Implant Size Options Dr Barry Eppley IndianapolisCurrently the largest Permalip implant is 5mms in size. This produces a very noticeable lip augmentation change but will not create dramatically large lips. The use of larger lip implants, even if they were available, would not be advised. When the ratio of the implant size to that of the natural lip exceeds more than 50% the rate of complications is bound to exponentially increase.

While lip implants offer a permanent method of lip augmentation, it is important that patients realize that they have the potential for complications like implants placed anywhere else in the body. The most common complications are palpability and implant asymmetry being at different tissue levels between the two lip halfs.


1) The only permanent FDA-approved method for lip augmentation are silicone implants. (Permalip)

2) Permalip implant are generally used in qualified patients who have tried other injectable methods and now seek a permanent lip augmentation solution.

3) It is important to remember that Permalip implants are implants that are placed in a flexible and sensitive body part with exposes them to certain risks.

Dr. Barry Eppley

Indianapolis, Indiana

Cupid’s Bow Lift of the Upper Lip

Monday, August 17th, 2015


Augmentation of the upper lip is one of the most commonly done non-surgical facial enhancement procedures. This can usually be successfully done through the use of a variety of different hyaluronic acid-based injectable fillers. Despite their popularity and frequency of use, however, injectable fillers can not solve all aesthetic upper lip concerns. A thin upper lip with little vermilion height often does not respond well to volume addition alone and is prone to result in the dreaded ‘duck lip’ look where most of the filler volume comes horizontally forward rather than increasing vertical vermilion height.

Surgical lip augmentation offers a better result in the thin upper lip because it can alter the location of the vermilion-cutaneous junction…the one anatomic feature by which lip size and shape is mainly judged. This can be done by an ‘upper’ lip procedure known as a subnasal lip lift or a ‘lower’ upper lip procedure known as a vermilion advancement. While very close by location the effects of these two surgical lip procedures can be dramatically different.

One way that they differ is in the effects on the cupid’s bow area. An aesthetically important feature of the upper lip, the cupid’s bow or tubercle, is a double curve of the lip which resembles a bow laid on its side. The peaks of the bow coincide with the vertical philtral columns coming down from the nose giving a prominent bow appearance to the upper lip. While a subnasal lip lift will pull up on the central cupid’s bow area it will really reshape or ‘sharpen up‘ its shape. Only a vermilion advancement can create that change since it changes it directly by skin excision.

Cupid's Bow Augmentation Surgery Technique Dr Barry Eppley IndianapolisCupid's Bow Upper Lip Augmentation Surgery Dr Barry Eppley IndianapolisA cupid’s bow lift can be created as an isolated procedure (in an upper lip with adequate volume) or can be combined with other lip enhancement procedures such as injectable fillers or a subnasal lip lift. Removing a few millimeters of skin can really change the cupid’s bow appearance even if it is just limited to the peaks of the cupid’s bow alone.

While cupid’s bow augmentation does create a fine line scar at the new vermilion-cutaneous junction it typically heals very well as it is not under undue tension due to the limited resection area.

Dr. Barry Eppley

Indianapolis, Indiana

The Perma Facial Implant For Lip Augmentation (PermaLip)

Saturday, June 7th, 2014


Lip Augmentation Dr Barry Eppley IndianpolisDespite that lip augmentation is sought by many women (and a few men), the perfect procedure to accomplish it remains elusive. A wide variety of treatment options exist to achieve bigger lips from injectable fillers and fat to surgical manipulations of the vermilion and skin excisions. Injectable fillers are by far the most common lip augmentation method because of their simplicity and immediate results. Their drawback is that no FDA-approved injectable filler is permanent and the treatments have to be repeated. Those filler materials that are permanent (silicone oil) is both non-FDA approved and has a propensity for nodules and foreign body reaction if improper injection techniques are used. (and sometimes even if they have been placed with good technique.

A lip implant, just like any other facial implant, would provide a stable and permanent lip augmentation effect. But the history of synthetic implants in the lip is very checkered with numerous materials and implant designs introduced and then eventually removed from the market (and often from the patient’s as well) due to a high rate of complications.

Permalip Implants Indianapolis Dr Barry EppleyIn the May 2014 issue of Plastic and Reconstructive Surgery Global journal, an article describing a newer lip implant was published entitled ‘Five Year Experience With Perma Facial Implant’.  This paper reports on the experience and long-term effects of the silicone lip implant known as PermaLip which is a very soft smooth solid elastomer tapered tube. The authors placed 832 lip implants on 420 consecutive patients.(91% female, 6% transgender and 3% men) with an average follow-up of over two years. The vast majority had both upper and lower lips done simutaneously. (98%) Of the three available implant thicknessess, the 4mms was most commonly used (78%). The largest 5mm diameter was only used for implant replacement when patients wanted more lip volume. Of the three implant lengths available, the 60mm and 65mm comprised almost 90% of the implants used. Of the 832 implants placed, the complication rate was 12% with malposition representing the majority of them. Infection, hematoma or extrusion was less than 1%. Equally relevantly, implant buckling or permanent loss of lip sensation was not seen in any patient.

While one may interpret that a 12% complication rate with a two-year follow-up of lip implants is high, it is not. (it is far less than that seen in breast augmentation for example) One must remember that this is an implant placed in the body which will always be more prone to complications than when one uses natural tissue. Since it is a smooth silicone tube, it is easily reversible which was a big drawback to previous lip implant materials and design.

Permalip Implant Size Options Dr Barry Eppley IndianapolisLike all implants, sizing and proper tissue positioning are the key factors in a low rate of complications for the PermaLip implant. For many patients, the largest 5mm size implant is too big for an initial augmentation, thus the popularity of the 4mm size. The hardest or trickiest part of the procedure is to get the implant is an even tissue plane across the whole lip and this is what accounts for implant malpositions. It is a problem that has always existed in lip implants. Because the lip is a curved structure and the implant instruments for placement are straight, it is not always easy to be in the same tissue plane from the side of the lip enter the instrument to the opposite side you exist from the corners of the mouth. This takes a bit of practice and and experience to keep the malposition rate low.

The Permalip implant is the best lip implant that I have seen in the past 25 years. It is nor perfect but it offers a simple and easily reversible method of lip augmentation for those women who are tired of repeat injectable filler treatments. Patient selection is critical as one has to have enough vermilion and lip tissue in which to place the implant with good soft tissue cover. Thus it is for patients who have very thin lip with little vermilion show unless they have had a prior or simultaneous subnasal or vermilion advancement lip procedure.

Dr. Barry Eppley

Indianapolis, Indiana



Case Study: Upper Lip Advancement in a Man

Monday, April 14th, 2014


Background: There are many options for lip enhancement today of which injectable fillers is by far the most commonly used. But for a permanent change in size, surgical options must be considered. Two basic types of lip lifts exists done either from under the nose (subnasal lip lift)or from the edge of the top of the upper lip. (lip advancement) Each of these has their own advantage sand disadvantages but the very thin (pencil thin) upper lip can only be effectively treated by a lip or vermilion advancement.

The lip advancement procedure works because it physically moves the upper border of the pink portion (vermilion) of the lip upward. (in the case of the upper lip) By so doing, the vertical length of the lip is increased permanently which creates a bigger visible lip appearance. The lip advancement also has the advantage of being able to change and enhance the shape of the cupid’s bow of the upper lip, which frequently is flat in the lip with little vertical vermilion exposure.

While women are most commonly seen as having lip enhancement procedures, men occasionally do as well. Men usually consider lip augmentation for a very thin upper lip not necessarily to make an already decent sized upper lip just a little bigger. Men also do not usually want to have repeated procedures but would prefer a one time permanent result.

Case Study: This 40 year-old male wanted to have a permanent upper lip augmentation. He wanted have an upper lip that matched the size of his lower lip with better accentuation of the cupid’s bow. Interestingly, he had a full goatee that covered much of his upper lip perhaps as a camouflage for his perception of his upper lip size concerns.

Male Lip Advancement markings before surgery Dr Barry Eppley IndianapolisHis upper lip hairs were trimmed back to expose the amount of upper lip advancement to be done. With a calipers, a 4mm skin excision was marked (1/4 of the total philtral length)mwith a cupid’s bow highlight and lack of a taper near the corners of the mouth. Under vestibular local anesthetic blocks with direct upper lip infiltration, the skin was excised and the upper lip advanced along the line of the marks. The incision was closed with 6-0 plain sutures with a few deep 6-0 monocryl sutures. Antibiotic ointment was applied as the dressing.

Male Upper Lip Advancement result fronkt viewMale Upper Lip Advancement result side viewThe final lip advancement result with mature scars was seen four months later. While he still had a goatee, the upper lip scar was virtually undetectable and the increase in the size of the upper lip was doubled.

While there is always a concern about the scar from any lip advancement surgery, that concern is magnified in men. (because they do not ever use lipstick) But my experience in men has shown that the lip advancement scar heals well and is not more of a concern than when done in women.

Case Highlights:

1) Thin upper lip concerns in men, while not as common as in women, can be treated with the same types of lip enhancement techniques.

2) An upper lip or vermilion advancement offers a permanent solution to an improved lip size and shape.

3) Upper lip advancement scars heal well in men ( and perhap better than even in women) presumably due to the hair follicles in the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Lip Implants

Friday, September 27th, 2013


The use of implants for lip augmentation is a surgical procedure that adds permanent volume to the lips. It is done as an office procedure under local anesthesia if done alone or in the operating room under general anesthesia if it is included as part of a collection of other plastic surgery procedures. The implants are inserted through small incisions inside the corners of the mouth through the body of the lip form one corner to the other. The following is a list of after surgery care and considerations for the lip implant procedure.

1.  Lip implant surgery will cause some slight discomfort for the first 24 to 48 hours. Most patients find it can be relieved with mild pain relievers such as Alleve or Ibuprofen. The lips may be sensitive to touch and pressure (caused by activities such as drinking from a straw and kissing) for up to two weeks.

2.  There are no dressings applied after lip implant surgery. Antibiotic ointment can be applied to the corners of the mouth at the incision site to keep the area soft and supple.

3. You will experience swelling in the lips after surgery. Swelling typically takes three days to peak and then will begin to subside over the next two weeks. You may use ice packs to help reduce the swelling and provide comfort during the first day after surgery.

4. The incisions in the corners of your mouth can get wet with no concern for infection. You may shave (men), wash your face and perform oral hygiene (brushing your teeth, mouthwash) as normal.

5. The small incisions in the corners of your mouth will have sutures that need removed one week after surgery (unless you are from out of town). These sutures should be kept moist with antibiotic ointment, applied three times a day, to the corner of the mouth. If dissolvable sutures are used, it is normal for the corners of the mouth to get slightly red in color as those sutures dissolve, applying antibiotic ointment can help lessen this effect.

6. Your lips will feel a little tight when you open your mouth widely. That will take several weeks to a month to return to normal. You may stretch open your mouth and lips as much as feels comfortable. You may eat whatever you like.  Focus on liquids and soft foods for the first few days after surgery.

7. You may experience some bruising after surgery. Taking Arnica Montana tablets prior to your surgery may help to prevent bruising. In addition, topical Arnica gel may be applied after surgery to help reduce any bruising that may occur.

8. There are no physical restrictions after lip implant surgery. You may return to work and resume physical activities such as working out as soon as you feel comfortable.

9. You may begin driving again as soon as you are off pain medications, can react normally and feel comfortable doing so.

10. If any lip redness, tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Plastic Surgery’s Did You Know? The Cupid’s Bow of the Upper Lip

Friday, May 18th, 2012

One of the most distinguishing and desired features of the upper lip is that of its cupid’s bow shape. The double curve of the upper lip is called the cupid’s bow because it resembles the bow of Cupid, the Roman God of love…laid on its side. At the two heights or bends of the bow, the vertical and raised philtral columns ascend into the base of the nose. There is a relationship between the size of the upper lip and the prominence of the cupid’s bow. The larger the lip the more prominent is the bow. Small lips have very flat and nearly indistinguishable bow shapes. While lip augmentation by injectable fillers can make the lip bigger, it can not make a cupid’s bow. This is one reason some lip augmentation results look unnatural.

Getting Good Results with Injectable Fillers for Lip Augmentation

Wednesday, February 15th, 2012

Valentine’s Day evokes many images, one of which is juicy full lips. While once only achievable by genetics, plumper and more full lips can be obtained by almost anyone thanks to a variety of  cosmetic procedures and products that are available today. Between celebrity news and photos, endless models in magazines and a plethora of  plumper and lipstick products,  lip augmentation has become one of the most sought after office procedures for women.

By far the most common method of lip augmentation is injectable fillers. While they are fairly quick and easy to do (notice I didn’t say completely painless), and effective for the majority of patients, they are several insights for a successful outcome and a satisfying experience.

While there are over a dozen commercially-available injectable filler products in the U.S., not all are appropriate for injection into the lip. The only ones that should be used are those composed of hyaluronic acid or hyaluron. These natural sugar products flow evenly and smoothly and have the less chance of causing  problematic nodules and lumps afterwards. Many such options exist (e.g., Juvederm, Restylanse) and the fundamental difference between them is how much they cost and how long do they last. Currently only Restylane is formally FDA-approved for use in lip augmentation but all other similar hyalurons can be safely used off-label. Though they may last lomger, avoid fillers that contain granules or crystals as they are more prone to foreign-body type reactions.

Not every lip can be made beautifully plump and full. As fillers work by expanding the size of the vermilion (pink part of the lip), one has to have enough of it to be expanded to create a fuller lip appearance. Very fine and thin lips simply can not be made two to three times their size to create a sensually full appearance. Trying to do so will make the vermilion expansion more horizontal than vertical, creating the classic and well recognized ‘duck lip’ appearance. Quite frankly, the most ideal and sensuous lip augmentation results occur in those women who already have what many people would consider good-sized lips. This doesn’t mean thin lips shouldn’t undergo a trial of lip injections to determine the results as some women will find the outcome acceptable. (anything is better than what I have concept) But if unsatisfactory results are obtained, it is time to consider surgical enhancement methods.

Lip injections are done by placing linear fills at either the vermilion-skin junction, into the body of the lip, or both. Most lips benefit by increasing the size of the white roll of the lips (vermilion-cutaneous junction) which creates a natural highlight. This is always good place to start. But size increase may also require direct vermilion body injection as well as augmenting the central pout of the vermilion or even the philtral columns of the skin of the upper lip. Good outcomes are a function of the skill and artistry of the injector as much, if not more, than the type of injectable filler product used. All lip augmentation results and injectors are not the same.

No matter how good a lip augmentation result can be, one will not be tempted to repeat it if the experience was uncomfortable. While there is no way to make lip injections pain-free, there are methods to make it more tolerable. Much is made today of some injectable fillers containing the local anesthetic lidocaine. While this does make the lip numb once it is injected with it, it is still necessary to get it in there in the first place. The choices are to either take a few injections directly into the lip to start to get it numb or to have a dental block done first. A recent innovation, known as a blunt-tipped cannula (e.g., Dermasculpt), is the best way in my opinion as it truly feels more comfortable than a beveled sharp needle of the same gauge (30 gauge) inside the lip.

Lip augmentation with fillers can have very a highly satisfying result and experience if one understands these basic concepts.

Dr. Barry Eppley

Indianapolis, Indiana   

The Unique Skin of the Eyelids and Lips

Friday, September 23rd, 2011

The skin throughout our bodies is often perceived as being fairly similar. Although the basic makeup of the skin (epidermis and dermal components) is the same from the face to the toes, there are substantial differences in their ratios and thicknesses at different bodily locations. These differences can not only take advantage of , but require, the benefits many topical products that are available. This is particularly relevant in the unique skin around the eyes and the lips. These areas are often where cosmeceuticals can have the greatest impact on their appearance.

The skin around the eyes, particularly the eyelids, is very thin and one of the thinnest on the entire body. What makes it so thin is that it has an epidermal layer on the dermis that is substantially thinner than that found on the rest of the face. This scant epidermis is exposed to the constant effects of blinking, squinting and smiling which easily lends to the formation of wrinkles. This is exacerbated by the lack of any substantative oil glands in eyelid skin to keep it supple. While Botox can help with reducing the dynamic component of eye area wrinkles, moisturization of eyelid and periorbital skin is critical. Because of the thinness of the epidermis, it is also an area that can be exquisitely sensitive to exfoliating and peeling agents. This is why every skin care product line has specific eye topical agents which usually have lower concentrations of and milder exfoliating agents to reduce reactive redness and the flaking of the skin.

The skin on the lips is also unique. Besides being less thick than the surrounding facial skin, the lips have no sweat or oil glands. As such there is no natural protective barrier to keep the lips smooth. When exposed to theenzymes that the saliva in our mouth contains, the lips can be a facial area of constant dryness and irritation. This becomes exacerbated in colder weather where moisture loss occurs more rapidly and the lips become drier. Similar to the eye area, lips have their own need for topical products that both hydrate and exfoliate. Lips need more hydration than exfoliation so a topical lip product contains different ingredients than that used around the eyes. This has led to many types of lipstick containing more than just color. Reactive inflammation is better tolerated aesthetically in the lips due to the swelling which can occur. The creation of a temporary enlargement of the lips is more pleasing then swelling around the eyes.

The eyes and the lips are unique areas of facial skin that are prime targets for the benefits of topical products. Such products are an integral part of any skin care maintenance program as well as after aesthetic eyelid (blepharoplasty) and lip augmentation procedures.

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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