The Evolving Use Of Injectable Fillers for Aesthetic Facial Enhancement

Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into a popular aesthetic technology that has a wide number of facial uses.

Injectable fillers are used for two aesthetic facial applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial results with fillers. There is more art to it than science.

When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as  a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is partially true,  they rarely  give better results than surgery or offer the best value for the money invested to do them.  Fillers can be a quick non-surgical fix but the benefits will ultimately fade away.

For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume.  But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area.  The effect will never be as significant as a surgical implant and the filler material will go away by about one year after injection. This makes using an injectable filler for bony augmentation very patient selective. Filler are best used when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the effect is time dependent based on an upcoming event and one doesn’t have the time to recover from surgery.

The face is also made up areas whose shape is not dependent on the underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles, lies the lateral facial region. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc reconsitution of Sculptra in an almost pure watery form, it is easy to get a good amount of material over this large area. Sculptra does not work immediately and it takes time and three total injection sessions to get a result. But its effect may last for up to two years.


Facelifting In A Nutshell

The concept of facelifting has evolved considerably in the past fifteen years. Not only has the techniques of facelift surgery changed, but how it has become markerted and advertised has changed as well. When you throw in the media coverage of celebrities and some of their results, understanding facelift surgery becomes even more muddled.

The options in facelift surgery are, however, far simpler than it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually the dreaded neck wattle. At its most simplist form, facelifts can either correct the jowls only, the neck only or both.. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version.

The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less technical manevers and tissue manipulations are done.. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery.

A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries. It is these combination procedures that give the impression that a facelift is a very extensive operation from which it takes a month to recover.

In between the mini- and full facelift patients lies an almost third category. This is where a partial facelift is not enough and a full facelift maybe more than what is needed. This may be perceived as a 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.

Dr. Barry Eppley

Indianapolis, Indiana

The Mini-Facelift – Less Can Be More

There are many options to tighten loose skin in the neck and jowls, the most common aging problem in the bottom half of the face. One of the most significant developments in the past decade has been to limit the scarring that goes with the more traditional forms of facelifting. These procedures have become known by a lot of names including short scar facelift, S- lift, MACS lift and dozens of other catchy marketing names. But in the end, there are all ‘Mini-Facelifts’.

These smaller facelifts tighten up sagging jowls and droopy neck skin and do so with less scar. The scarring that is eliminated is in two specific hairline places, in the temples above the ear and in the crease behind the ear. Why is it important, if possible, to eliminate such scarring? The issue is one of scar widening and hairline displacement. When a facelift scar runs up into the temple hair, it will always move one’s sideburn hair up.  (not important for men who can just grow new sideburns) When scars are placed back into the hairline behind the ear, they will become noticeable if one has very short hair or wears a pony tail that may expose the scars.

The incisions for a mini-facelift starts at the top of ear, goes inside it behind the tragus (bump of cartilage in front of the ear), and then tucks around the earlobe. It stops in the crease of the ear just above the earlobe. This incision pattern (and ultimately the scars) prevents loss of the tuft of sideburn hair and eliminates scarring behind the ears. This allows one to wear their hair any way they want without being ‘discovered’.

While less scarring would be an important part of looking better, these mini-facelifts are not for everyone. The vast majority of patients that benefit by them are under the age of 60. Today many people seek neck and jowl improvement by age 45 or 50. These short scar procedures are designed to smooth out the jawline, soften the nasolabial folds and restore a more sinuous and curved facial shape. As one ages, sagging of facial skin and jowls create a more square or ‘bulldog’ look for some. A mini facelift reverses this facial shape change into a more triangular shape which is more synonyous with youth.

The one disadvantage to a shorter scar facelift is it is not as good as improving the significantly droopy neck as that of a traditional lift. This is why older patients with more advanced neck problems have to accept the trade-off of greater scars from more extensive facelifts.

Many mini-facelifts are done with other facial aging procedures as well to get the maximal benefit. When potentially combined with such procedures as liposuction of neck fat, removal of excess eyelid skin and chemical or laser skin resurfacing, that tired aging look can be completely wiped away in a few short hours.


Exilis Non-Surgical Fat Reduction and Skin Tightening Therapy

Today’s patients are more concerned about treating the early signs of aging and unwanted fat than ever before. Women and men alike are looking for faster, less invasive procedures with little if any downtime that can reduce their wrinkles and improve their figure. While many devices have been touted over the years, most have failed to produce satisfactory results for many patients. But a new technology is now available that offers the  latest advancement in nonsurgical, pain free therapy for the reduction of targeted fatty deposits, skin tightening, and sun damaged and/or wrinkles skin anywhere on the face and body.

Exilis is an FDA approved device that offers a non-surgical solution using radio frequency (RF) energy for fat reduction and tissue tightening anywhere on the body. The procedure uses safe radio waves to heat your skin and targeted fat cells. This thermal energy speeds up the metabolic activity of the fat cells causing them to shrink. At the same time it stimulates and strengthens the collagen network which improves skin texture.

Exilis is one of the first systems that produces actual circumferential reduction. By combining RF energy with cooling, all areas of the body where stubborn fatty deposits persist or tighter, firmer skin is desired can be treated. While Exilis is heating the tissues, patients remain relaxed and comfortable. Having no pain alone is a real advancement in non-surgical device treatments.

The most frequent areas treated with Exilis Therapy in men are the love handles, chest, abdomen, face, jowls, and neck. In women they include the face, jowls, neck, decolletage, arms, bra fat, thighs, hips, breasts, buttocks, stomach, and knees. Exilis requires a series of treatments, usually four, to get the best results. The results from Exilis Therapy are gradual and may take from two to four  months to see the maximal effects of the treatments.

During the procedure the Exilis computer-controlled delivery device is guided over the treatment area. One feels a deep heating sensation as the Exilis RF energy is delivered to the deeper layers of the skin. The therapy causes the collagen support tissues to remodel and tighten. The applicator provides cooling to the skin’s surface as the energy is delivered, keeping one comfortable during the treatment. Many patients report the treatment similar to a ‘hot stone massage’. Exilis therapy is performed in the office and takes from 15-30 minutes depending upon the size of the treated area.

The highlights of this new Exilis therapy is NO downtime and NO pain, NO anesthesia, NO numbing creams and NO after care, reasonably quick treatment sessions, progressive results that last, able to treat all areas of the face and body and is scientifically proven and FDA-approved.

Exilis offers a revolutionary non-invasive form of treatment for the reduction of wrinkles and for the reshaping of unwanted fat deposits. Exilis also provides a method of after surgery smoothing and skin tightening from invasive liposuction procedures. Exilis treatments can postpone or eliminate the need for invasive surgery particularly for patients with mild to moderate fat deposits and who may not want liposuction surgery. As the only provider of Exilis therapy in Indianapolis and the state of Indiana, I am very excited to offer my patients a real alternative to fat reduction and skin tightening surgery.

Dr. Barry Eppley

Indianapolis, Indiana


Changing The Face Of Time

Cosmetic plastic surgery is now more than a $10 billion a year industry in the United States that has seen increases in number of procedures across all age groups. The largest growing population of patients, however, are those in their later years. Due to Americans being healthier, living longer and being more active later in life, millions of them want their looks to keep pace with how they feel. As a result, many are turning to cosmetic surgery to help them look younger and feel better about themselves.

In 2010, over 600,000 Americans age 65 or older choose to undergo some form of cosmetic surgery. Compared to ten years ago, that is a five times increase in number of procedures done. However a significant of these procedures, and a big reason for the large surge in numbers being done, is not actual surgery. In the interest of of wanting to look younger and fresher, many are going the injectable route choosing such popular products as Botox and Juvederm. While not as effective as surgery, they do help give one an extra edge in their appearance by decreasing frowning and plumping up certain wrinkles and folds.

Such injectable procedures involve only a minimal amount of discomfort by being placed right under the skin. Between wrinkle reduction and tissue plumping, these injections help give the face a smoother more youthful appearance. These are all procedures that can be done fairly quickly with a limited recovery time and are more economical options compared to surgery. When combined with a variety of available skin refreshening procedures such as chemical peels and light laser resurfacing, one can really take off a few years with next to no recovery or downtime.

While injectable treatments have lead the way in number of procedures for older Americans, ironically they are not the most effective given the amount of aging changes that are usually present. Injectables are more effective in younger patients simply because they have less wrinkles, lines and sagging skin. This is why surgery is also growing in numbers for the Baby Boomer generation with popular procedures being eyelid tucks, browlifts, and face and neck lifts. These anti-aging facial plastic surgery procedures can be done alone or, ideally in combination with surgery, to remove loose and sagging skin that creeps its way across our faces as we age.

We all look for that extra something to look and feel better as we age. My older and more mature patients clients are traveling, playing sports, exercising and doing all of the right things in life to look, feel and stay young. But, unfortunately as we age, all of the activity and exercise won’t make your face look any better. Looking better requires a effort, just of a different kind than that of feeling better.

Dr. Barry Eppley

Indianapolis, Indiana


Making Barbie

The pursuit of the perfect or idealized female appearance is not a realistic goal for any woman, regardless of what plastic surgery has to offer. Improving your own body through diet and exercise, and perhaps a little plastic surgery if desired, is a more common sense approach. Women should only want to have a pleasing face and good body proportions that fall within what their natural genetics will allow.

The Barbie doll, introduced in 1959 and celebrating her 50th birthday in 2009, has always been a controversial figure when it comes to body image. One of the most common criticisms of the doll is that it promotes an unrealistic or unattainable body image for young women to try and emulate. Based on her 1/6 scale at a height of just under 12 inches, she would be the equivalent of 5’ 9” with a weight of 110 lbs with measurements of 36-18-33. Technically at these dimensions she would have a body mass index of around 16 which would classify her as anorexic.

While the Barbie look is not one young women should really admire, it is perhaps interesting to know what plastic surgery procedures one would have to go through to achieve it. In the October issue of O magazine, former model Katie Halchishick served herself up as a example of what she would have to do to achieve Barbie proportions. Posing for a photographer, she used her body to diagram out what she would surgically have to do to change her features to achieve the equivalent of Barbie’s proportions and shape.

Based on this photographic diagraming, it was shown that she would need facial plastic surgery consisting of a browlift, jawline reduction and thinning, nose reshaping, neck contouring and a chin augmentation. For her body she would need a breast lift, upper arm thinning by liposuction and a tummy tuck…and that is for just above the waist. And it was not like this former model didn’t have an attractive face and body to start with.

While this is an entertaining and even humorous bit of photographic morphing, it does actually have a serious message. Trying to have so called ideal body proportions, or even an unrealistic body shape like that of Barbie, is not a healthy pursuit…even if plastic surgery could make it possible. On a more common request, trying to look like a certain model or entertainer is equally unrealistic. Plastic surgery should be used to enhance the face and body shape that women already have rather than pursuing excessive surgery to try and achieve what one isn’t meant to be. This is a healthy and psychologically balanced approach to plastic surgery that many teenage and younger women would be advised to follow.  

Dr. Barry Eppley

Indianapolis, Indiana

A Little Carving For The Turkeyneck

The thought of eating turkey at the upcoming Thanksgiving holiday brings together two inseparable images. While history does not show that turkey was ever actually served at the first pilgrim’s festival, it has become the featured culinary dish since. While many will enjoy the tasteful bites from a turkey leg, breast or stuffing, few will aspire to have the turkey neck.

While few want to eat a turkey’s neck, even fewer want to have one on of their own.  The turkey neck or neck wattle is that well known fleshy fold of hanging skin that is unavoidable for many as we age. The loss of a once smooth jaw line and a shapely neck shows the persistent effects of gravity and time.

While creams and other potions promise much, the turkey neck needs a surgical fix. Forget about non-surgical options and other ‘lunchtime’ type procedures. They simply do not work no matter how hopeful one is. For the fuller neck in a young person, fat removal by liposuction alone may be enough. But when the neck skin is loose and floppy, and you can pinch a wad of skin and fat between your fingers, some method of actual removal is needed.

The removal of a turkeyneck requires some form of a facelift. While often misunderstood, a facelift is really a neck and jowl operation and does not change the face much above the level of one’s mouth. It is a poorly named procedure and the term necklift would more accurately describe it. It is really less extensive and easier to go through than most people think.

When it comes to necklifts, there are numerous options.Which one is best for any particular person is determined by how much loose neck skin one has. Some jowling and a little loose neck skin may only need a limited facelift. If there is a lot of loose neck skin, then a fuller form of a facelift is really needed. This is a powerful neck changer and can produce some really dramatic results. For those that want the least invasive amount of surgery but with a dramatic change, the turkeyneck can also be directly cut out in a procedure appropriately called the direct necklift.

The turkeyneck is not a desired culinary item on the bird and many people don’t like it on themselves either. While year round turtlenecks are always an option, a little skillful carving may be a better solution.

Dr. Barry Eppley

Indianapolis, Indiana


The Real Cost of Groupon Cosmetic Surgery Discounts

Shopping for discounts as an innately human characteristic. Most people like to negotiate or are attracted to sales as the need to feel like one has gotten the best deal is sometimes as important as the item of interest. At no time is this more evident than in economic downturns. While I think the Groupon concept may have been successful at any time in history, it has really taken off since our recent recession started.

While Groupon had its origin in retail items such as restaurants, spa services, and clothes, it has more recently spread to medical procedures such as cosmetic surgery. Groupon discounts now exist on a wide range of cosmetic procedures from Botox to breast implants. These elective medical procedures for some appear to fall into the mindset of any other retail purchase.

While cosmetic surgery today is commonplace, it begs the question why anyone would be willing to buy cosmetic surgery based on a doctor who only offers the lowest price. Choosing cosmetic surgery on price seems to be a poor health decision. Almost all of these cosmetic procedures can cause serious problems if done improperly…and may cause injuries that are hard to correct later.

But beyond this concern, there are other issues that underpin serious problems with the Groupon cosmetic surgery concept. One of these is that not every patient who buys such a discount may be a good candidate for surgery. While Groupon does make a footnote that services are dependent on being qualified, making an online purchase creates a level of provider obligation that may be difficult to reverse. In this discount coupon approach, eligibility is not done before one purchases the procedure. This is the exact opposite of what occurs in common medical practice.

Unlike a meal which you don’t like or a purse whose clasp falls off weeks after you have purchased it, what happens when you don’t like your cosmetic surgery result that requires a revision or a complication that requires further surgery or medical care? Who is going to pay for it? Who is financially responsible? I can assure you that it isn’t Groupon even though they took a hefty profit on the transaction. Having cosmetic surgery because you could afford it due to the discount unintentionally exposes the enthusiastic shopper to a financial risk that they are completely overlooking. 

Equally relevant, why would any cosmetic surgery provider offer an expensive surgery at half price? Would a well qualified plastic surgeon with lots of experience offer cheap cosmetic surgery? More times than not such, cosmetic surgery Groupon offers come from doctors of dubious backgrounds and training for the procedures that are touting. The Groupon concept makes it easy for such providers to find new patients who don’t look past the dollar signs.

Cheap cosmetic surgery may sound attractive…but the consequences later may be anything but cheap.

Dr. Barry Eppley

Indianapolis, Indiana

Topical Botox Anyone?

Botox remains a popular and effective method of reducing unwanted facial expressions and wrinkles. While it is a highly desired anti-aging facial treatment, it must be introduced by a needle and preferably in a doctor’s office or a medical facility. While the injections are not terribly uncomfortable, if there was a way to avoid having needles put into one’s face these anti-wrinkle treatments would likely become even more popular.

The quest to find a ‘topical Botox’ or cream that would penetrate through the skin to reduce the source of facial wrinkles has been much like the search for the Holy Grail. There is a strong belief that such a cream exists but it has remained elusive. Many topical creams and serums claiming to have a Botox-like effect have been touted, but the real beneficiary of those products has always been the manufacturer .

At this year’s annual American Society of Plastic Surgeons meeting in Denver, a new botulinum toxin-based gel was presented that showed promise. Reporting results from a recent prospective double-blind clinical trial of nearly 100 patients, near 90% of those that had the active gel had observable reduction in crow’s feet wrinkles. This compared, interestingly, to just under 30% in those patients that have been treated by a non-active or placebo gel. In a second study that involved nearly 200 patients about 40% of those treated with the botulinum toxin gel had good results. In either study, the effects of the gel lasted around four months which was comparable to that of injectable Botox.

These study results are the first to show that dynamic facial wrinkle reduction is possible through topical application or a cream. It is no surprise that the studies have been done for wrinkles in the crow’s feet region to the side of the eye. This skin is very thin and the most easily penetrated down to the orbicularis muscle underneath. This is unlikely in the substantially thicker forehead tissues where an effective topical cream would be much more challenged to penetrate deep enough.

 While it is encouraging that a botulinum toxin gel has been shown to noticeably soften crow’s feet wrinkles without needles, it remains to be seen how practical it will be. Does the gel work better than injectable Botox? Would it’s cost be similar, less or even more? This information awaits further clinical study which undoubtably is ongoing. Getting rid of some wrinkles may truly be just a dab away in the near future.  

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction May Be Healthy

Being overweight is a well known health risk. Accumulations of fat, particularly around one’s midsection,  contribute to the risk of heart attacks, stroke, and diabetes. Losing this weight through a sustained diet and exercise program is the best way to improve one’s health. There is a large number of medical studies that would support the health benefit’s of overall body fat reduction.

It has long been theorized that the surgical removal of body fat rolls through liposuction may offer some similar albeit less significant health benefits. To date, there has been no medical evidence that would support this belief. It was presumed that the amount of fat removed in most liposuction procedures was simply too small to make a difference. In addition, it has always been believed that the fat that really matters, from a health standpoint, was visceral or intra-abdominal fat. Subcutaneous fat or that which lies right under the skin only mattered because it made up those unflattering outer body rolls.

A  recent study given at the 2011 annual American Society of Plastic Surgeons meeting in Denver  presented some interesting findings on potential health benefits from liposuction surgery. In over 300 hundred patients who had either liposuction, a tummy tuck or both combined, blood levels of triglycerides, cholesterol and white blood cells were studied both before and after surgery. Triglyceride levels in patients with normal levels before surgery were unchanged. However, in patients with elevated triglyceride levels before surgery (defined as greater than 150 mg/dl), they showed a triglyceride level reduction of over 40 percent. Such significant level reductions are usually associated with drug therapies which often are even this effective. White blood cell counts, viewed as an indicator of chronic inflammation and disease inducer, dropped an average of 10 percent.

Does this mean that liposuction is good for your overall health? That is a stretch at this point but this study clearly shows that liposuction causes blood chemistry changes that reduce certain disease risk factors. Much more work needs to be done but it does provide some proof that subcutaneous fat may have a greater metabolic role to play than previously thought. It is not just an idle depot of excess fat whose only relevance is as the creator of undesired body rolls and bulges. At the least it may be comforting to know there may be some benefit, small as it may turn out to be, that liposuction removal of  abdominal and waistline fat may also be good for more than just how you look.

Dr. Barry Eppley

Indianapolis, Indiana