Your Questions
Your Questions
Q: I wanted to get some information as far as migraines and Botox. I have suffered with migraines for many, many years and have read that Botox can help. My headaches usually start around the eyebrow area. Thank you.
A: The fact that your migraines have a focal area of initiation at the eyebrows strongly suggests that their origin is compression of the supraobital/supratrochlear nerves. Contraction of these muscles squeezes the nerves that they surround and causes a painfuol migraine to start. Botox has a good chance of having a positive effect since it weakens the muscles around those nerves as they exit from the brow bone. This is a simple treatment that looks like it may work well for you. For a few hundred dollars, you can easily prove this migraine theory. While the effect of Botox is not permanent, many responsive patients find it to be a temporary miracle that provides a level of relief that no other medication does. In select migraine patients, plastic surgeons have learned many years ago that Botox around the brow area reliefs headaches. The key to whether Botox will be a successful migraine treatment is to have a very specific point of headache origin at one of the major cranial sensory exit sites from the skull. Botox is not effective for many types of migraines, just ones that have a very specific focus or loci.
If Botox is effective, that would mean that endoscopic supraorbital/supratrochlear nerve decompression may provide some long-term reduction in your migraine symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I just would like to know if BOTOX and DYSPORT would lift a droopy upper eyelid? Thank you.
A: Both Botox and Dysport are equivalent injectable drugs that induce muscle paralysis where injected and weakness in the surrounding region. They are superb at stopping that undesireable frowning between your eyebrows or those crow’s feet wrinkles at the side of your eyes. By weakening the overactive forehead muscles, many people may experience a bit of a browlift. This occurs because the paralyzed forehead muscles no longer pull down on the eyebrow, allowing it to raise a little higher.
It is logical to assume that a similar effect would occur in a droopy eyelid. But that assumption would be wrong. A droopy eyelid, known as eyelid ptosis, is the result of a weak levator muscle. The levator muscle is the primary muscle that moves the upper eyelid. When it is weak for whatever reason or is partially detached from the tarsus of the upper eyelid, the lid margin will hang down lower. It becomes noticeable when the lid margin comes down lower on the iris and it only takes a few millimeters lower to be evident.
Since Botox and Dysport paralyze muscle, it would actually make a droopy lid worse. In fact, one of the most dreaded esthetic complications of Botox and Dysport is a droopy eyelid when it inadvertently diffuses into the upper eyelid from above if it is injected too close.
Eyelid ptosis can only be improved by surgery. The amount of lid droop and its cause determines what type of ptosis repair technique is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I have heard that regular use of Botox and injectable fillers over years can reduce the need to do them so often. Is that true or just wishful thinking?
A: Recent research presented at plastic surgery meetings have indicated that such a ‘rumor’ may have some truth to it. A study out of Oregon looked at women between the ages of 30 and 50 who received Botox every four months for two years. After that time, the frequency of their injections could be adjusted down to every six months and still have sustained satisfying results.
The same observation has been seen with injectable fillers. If the treatments are done long enough, they seem to be needed less often. One possible explanation may be the filler’s ability to stimulate new collagen.
Is less Botox and fillers really needed if they are done long enough? One of the problems is assessing long-term effectiveness is that it is very subjective and not able to be quantified objectively. Can facial muscles be re-trained by long-term Botox? Can injectable fillers create new collagen? Or are these apparent effects more of a function of the patient being able to tolerate a few wrinkles longer or less full lips or deeper nasolabial folds between injection sessions? The economics of regular injection treatments can certainly make patients space out their injection treatment intervals and still be satisfied.
It is tempting to want to believe that Botox and filler’s effects have some long-term benefits after they wear off…but it is far from a proven fact.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a deep vertical line in between my eyebrows that is still noticeable despite having Botox injections. I was wondering if endoscopic browlift could correct this. Im only 27 years old. Please help.
A: The development of vertical wrinkles between your eyebrows, known as the glabellar area, is common and is the result of excessive muscle activity. There are a set of six paired muscles that affect the glabella area and create what has been described as a number system of galbellar wrinkles or furrows. As the popular ad goes, are you a 1, 11 or 111? These numbers describe whether one has one, two or three vertical glabellar wrinkles.
The first approach for glabellar wrinkles is Botox which will be highly effective for most people. For many the wrinkling is completely or nearly completely gone by this temporary muscle paralyzing treatment. For those with more deeply etched glabellar furrows, Botox will soften it to some degree but may not reduce it enough for the person’s satisfaction. This is the result of the skin being ‘etched’ or having a permanent v-shaped change in the skin. Muscle paralysis will not change permanent deformation of the skin.
An endoscopic browlift will not create a better effect than that of Botox because it works on the muscle only. It may help decrease the long-term need for Botox and, rarely, the need for Botox at all.
A companion treatment for the deep glabellar furrow is some type of soft tissue fill. Usually this is an injectable filler but its effect will only be temporary. More permanent options include the threading of an allograft collagen dermis material or actual synthetic implant. (e.g., Advanta)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a brow lift or botox treatment…maybe a facelift. I am 43 years old and I believe I look ten years older. Do you know if I could try one procedure now and then gradually work up to a progressive series of surgeries?
A: The wonderful thing about the many procedures for facial rejuvenation is that both small and big changes can be done. And the procedures can be customized to how much one wants to do, how much one wants to spend, and how much recovery one can allow. Since facial aging is a progressive phenomenon, younger patients will need smaller procedures while bigger changes are reserved for those with more loose skin and wrinkles.
Since you have never had any of these cosmetic procedures before, it is understandable that one often does not know where to start. To ‘put your toe in the water’ so to speak, doing something non-surgical like Botox or injectable fillers is a good way to start. One can venture ‘further into the pool’ with laser treatments and even facelift surgery at a later date. A progressive approach to facial aging treatments is both reasonable and prudent.
Always start with the facial concerns that bothers you the most. To get started, it is helpful to meet with a plastic surgeon and have an educational session about what is appropriate now and what may be beneficial in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Celebrities who undergo plastic surgery without question have a compelling influence on the general population, particularly those under the age of 40. One has to look no further than the checkout aisle in the grocery store to see how celebrity visibility is thrust upon us. From these consumer magazines to numerous television shows, anyone with a Hollywood connection is tracked and speculated upon about their cosmetic surgery, even if they have never had it. The media’s desire to push these cosmetic surgery tales of the stars fuels the public’s obsession with discovering the secrets to what keeps the beautiful and famous looking so.
While the star’s experiences may fascinate, they do little to actually educate. It is easy to confuse entertainment with reality because it is simply more interesting. Take the recent case of 23 year-old Heidi Mondag who had numerous cosmetic procedures done to satisfy her narcissistic and career agendas. While she may have had a lot of procedures, they were all quite small in scope. Most of her procedures were really ‘nip and tucks’ and not major overalls. After all, how many physical problems could a young person really have particularly given her appearance beforehand? But this is not how the media interpreted her surgery. Rather it was made to sound like it was a great undertaking and required supernormal surgical skills to complete.
These ‘tweakments’ are largely what is fueling the increasing visibility of plastic surgery. Botox, injectable fillers, lasers and minor skin lifts of the face have created a whole new set of treatment options that did not exist just a decade ago. While a 23 year-old partaking of this cosmetic menu does border on the overly self-indulgent, those in their late 30s and 40s have a more significant purpose. Fending back the early signs of aging is proving to be a more effective strategy than awaiting the day when major plastic surgery is needed. While my mother may have waited until retirement to wage the battle against the effects of time, today’s middle agers understandably what to look better and more rested now.
What is unique about these minimal procedures is that most of them are fueled and promoted by the cosmetic device and pharmaceutical industry. Plastic surgeons have taken a back seat to the promotions and marketing that billion-dollar-in-sales companies can do. The once retail approach to cosmetic and beauty products has expanded to include drugs and surgery. Targeting consumers through popular magazine and internet strategies, rebate coupons for Botox and eyelash stimulants are widely available as well as even franchise surgery for facelifts. Breast implant sizer kits are mailed to prospective patient’s homes with incentives for other procedures packed inside. Plastic surgeons collectively spend an insignificant fraction on marketing compared to that of the corporate world. This wave of industry’s promotion for profit and media attention for sales is why most people today know something about cosmetic enhancement and why it is now mainstream.
But like all entrepreneurial endeavors, making a profit and driving sales does produce some good byproducts that have wide benefit. Like the old commercial slogan from decades ago, there is ‘better living through modern chemistry’.
Dr. Barry Eppley
Q: I have read numerous blogs that talk about the value of facial exercises. With so many debates on this subject, I wonder if there is any benefit to doing facial exercises to tone up the face. Plastic surgery seems so drastic.
A: Much has been written over the past fifty years about using exercise to lift up a sagging aging face…or to prevent it from happening. This concept is not new. I have an original copy of a book entitled ‘Lifting Up Your Face’ from 1951. The more recent books that I have seen today in the book stores are beautifully done, and even have their own DVDs in the cover, but they are just modern re-inventions of this original concept.
It is certainly reasonable to do anything to avoid actual surgery, if it has some benefit. The problem that I have with facial exercising is three-fold. First, most of the signs of facial aging that are bothersome to people (appearance of jowls, loose skin in the neck, dropping brows, etc) are not muscular in origin. They did not occur because the muscles were loose and sagging. Anatomically, they are the result of the skin and the subcutaneous fat becoming loose and sliding off of the deeper tissues. That is not something that muscle tightening, even if it were possible with facial exercises, can really treat or prevent. Secondly, all facial wrinkles that develop are the result of muscle movement. That is why Botox is so popular, because it decreases this wrinkle-causing muscle movement. Moving those muscles a lot more through facial exercising will likely increase, not decrease the age signs of wrinkling. Lastly, I have yet to see adequate before and after photographs of believeable results from any facial exercising program. The photographs shown are never standardized. There are always some subtle changes in angle and lighting that can make a big difference in how the result looks. We know this very well in plastic surgery. It is very easy, intentional or not, to have an after result that appears to show a facial change that does not really exist.
For the sake of discussion, however, let’s us assume that there is some minor benefit to facial execising. In most patient cases, it is likely that the result would not be adequate…a lot of effort for a minor improvement. With todays’ minimally invasive and limited downtime facial procedures, they quickly surpass what exercising could do and require less effort. Plastic surgery does not have to be so drastic, one can get a few ‘tweakments’ that can make a real visible difference.
Dr. Barry Eppley
Q : Which is better for my laugh lines, Botox or fillers?
A: It is very common that Botox and injectable fillers are confused as to what they do. Because both are administered by a needle and are used in the face, many assume that they do similar things. In fact, they are quite different both in chemical composition and the effects that they create and in how they are used.
Botox works its magic by being a muscle weakening or paralyzing agent. It is primarily used in the forehead and around the eyes to decrease unwanted expressions caused by overactive muscles. As a result, Botox (and now Dysport) is really a ‘northern facial’ procedure. It effectively reduces horizontal forehead lines, furrows between the eyebrows, and crow’s feet around the eyes.
Injectable fillers (there are now over a dozen commercially available brands) work by adding instant volume to deep wrinkles and folds as well as enhancing the size of the lips. By adding a material under the skin or into the lips, the outer skin and lips is pushed outward. Injectable fillers are primarily used around the mouth making it a ‘southern facial’ procedure.
While there are crossover areas in the face where Botox and fillers are otherwise used, they are largely separated in application to these northern and southern hemispheres.
Folds around the mouth are commonly referred to as laugh lines. When one smiles, indentations or wrinkles are created beyond the sides of the mouth. They are different than the nasolabial folds which run from the side of the nose to outside of the corners of the mouth which are situated above the laugh lines. Injectable fillers can be effective at softening one’s laugh lines.
Dr. Barry Eppley
INSIGHTS FROM ‘BEHIND THE NEEDLE’
In the past, plastic surgery was all about having operations to reverse the effects of aging on the face. Time was, once you could no longer stand to see yourself in the mirror or in pictures…facelifts, eye tucks and the like became appealing with all of the associated swelling and bruising, recovery, and expense.
Over the past ten years, non-surgical injectable treatments have become popular for men and women of all ages…and have become part of mainstream society in ways that rival Starbucks, energy drinks, and iPhones. The concepts of muscle paralysis, plumping fillers, and fat dissolving agents have made it possible to have smooth foreheads, fuller lips and softer laugh lines, and maybe some subtle tightening of the jowls and neck in a few simple visits to the doctor’s office. Unlike surgery, injectable facial treatments are as much about the prevention of the effects of aging as they are about reversing what has already taken place.
Along with this explosion of available injectable treatments have come the inevitable, unbelievable marketing claims, and so-called ‘expert’ injectors. But, like much of what you may read on the internet, in popular magazines, and hear in commercials , what can you really believe? How do you separate reality from marketing hype? How can you decide where-or if-injectable treatments are for you? And if so, which ones??
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a broad tour of every injectable treatment option. Providing insight into Botox®, the many injectable fillers, and lipodissolve, Dr. Eppley provides the current science behind the treatments, and talks plainly about his experience and observations. These insights from ‘behind the needle’ about these incredibly popular injectable treatments are available nowhere else.
Whether you are just researching Botox® or fillers, or are a seasoned expert with an upcoming consultation about the next new option, Dr. Eppley gets you ready for Injecting Youth!
Almost everyone has now heard of the facial wrinkle treatment, Botox. While some may not know exactly what it is really good for, its recognition and popularity is because it simply works. When it comes to softening facial expressions, it does something that even surgery can’t do.
Many misconceptions exist, however, about Botox (and now Dysport) and it is time to reveal some of its secrets. Here are some facts about its use that are not commonly known.
Botox is a poison and can be quite lethal if the dose is high enough. It is administered in units which originally stood for mouse units. A unit was the dose of Botox that could kill a mouse. Fortunately, there is a big difference in size between a mouse and a human. To poison a human, it is estimated that it would take about 25,000 or more units to do so. The average dose for wrinkles is around 20 to 30 units, so it is well within the margin of safety. (mathematically, cosmetic dose units are a mere 0.001% of the doses that could be fatal). Cosmetic injections are precisely placed 2 to 4 unit doses in select facial area.
While Botox is touted for a lot of facial uses, it is largely a ‘northern’ face procedure. The areas of the forehead and around the eyes accounts for much of its use. Weakening of the muscles between the eyebrows, in the forehead, and at the sides of the eyes produces the desired effect of less frowning, a more relaxed forehead, and less lines around the eyes. While some do use it down south around the mouth, it is not effective as a primary wrinkle reducer in that area. A little too much Botox there can affect the way you smile.
Botox injections do not produce immediate results. It usually takes one week or more to see its effects. This is because it blocks the release of chemicals from the nerve endings that cross over to stimulate the muscle fibers to which it is attached. Because there is a supply of chemicals in the nerve endings to start, they must first be depleted. As a result, the muscle will work normally for a few days before it begins to weaken as its ‘gas supply’ diminishes.
The effectiveness of Botox can vary from one doctor to another or from one treatment center to another. This seems initially unusual because one of the benefits of a prescription drug is that it has been tested and approved for the uniformity of its effects. But Botox differs from a pill and many other prescription medications. It comes as a dry powder and must be formulated or reconstituted prior to treatment. How well it works, therefore, is affected by how it is mixed and how long ago it was prepared. It is designed to be mixed according to the manufacturers recommendation in a very specific way. (2.5ml of saline per vial) and it should be used either immediately or within a few days after preparation. But treatment centers vary on how they mix it and how quickly they can use it. You have no way of knowing if you are getting diluted or old Botox. If it doesn’t seem to be working well or lasting very long, this could be the reason.
Like all drugs, there is an effective dose to Botox or a ‘sweet spot’ at which it works well. What you want as a patient is to find the Minimum Effective Dose as well as the right injection spots. You may regularly be getting 40 units in the forehead are, for example, when 32 may work just as well. More Botox than necessary does not make it work better or any longer. Don’t be afraid to ask your injector to adjust the does or injection locations to see if the results improve…or become less.
Botox and Dysport have a very consistent duration of effect of around 4 months. Repeat treatments, unfortunately, do not make it last longer. But some patients feel that it does. This is likely an effect of muscle re-education, a chemical training if you will. It may take your body awhile to begin using those muscles again if they have been weakened repeatedly. Conversely, most people will not build up tolerance or immunity to Botox. But a few patients say that they have and resistance to any drug is always possible. One can than switch to Dysport which has a slightly different molecular structure.
Dr. Barry Eppley
The greatest trend in plastic surgery in the past decade has been, ironically, the explosion of procedures that don’t involve actual surgery. Comprised largely of injectable therapies, such as Botox and fillers, and laser and light treatments, making the face look rested, supple and youthful has become as easy as a quick visit to the doctor’s office. By sheers numbers, non-surgical facial enhancement far exceeds the actual number of cosmetic surgeries performed per year.
Such ‘beauty treatments’ have been very successful for concerns of facial aging but the same approach has not seen the same successes for body concerns. The search for an effective non-surgical method for the reduction and removal of fat remains as elusive as finding the magic pill or diet for weight loss. Much has been promised, but little has been delivered so far.
The allure of ‘non-surgical’ is always a compelling one and any device or product that offers it always attracts a large amount of public interest. But within that appeal lies the often ignored fact that non-surgical treatments are not equivalent to surgery. They produce results that are far less and should be of thought as a delaying tactic or a complement to what surgery can do, not a substitute.
Non-surgical facial methods should never be equated to what actual surgery can do. You can reduce a few wrinkles, plump up some thin tissues, and get your skin to look fresher. And, to be sure, those are great changes for many people, but many patients often expect or believe much more will occur. This is unfortunately not helped by the sometimes very ‘broad’ promotional claims of product manufacturers and doctors alike. Unless properly advised, it is easy for one to undergo some form of office treatment, often not inexpensive, and be disappointed with the results. This is especially seen when it comes to a wide variety of ‘facelift-like’ methods. I have seen many such patients, all of whom in the search for something less, did indeed end up with less.
While seriously ‘injurious’ complications are rare with underperforming and overpromised cosmetic treatments, there is always the economic loss. Wasted money may prevent someone from contributing to and having a more significant procedure that would provide much better long-term benefit. The point being is that one must keep an eye on the concept of value when comparing non-surgical versus surgical cosmetic procedures.
One good illustration of this concept is in the highly promoted ‘Liquid Facelift’ procedure. Plumping your face up with injectable fillers does create some more fullness in the face and it could be called a lift of some sort (it does nothing for the neck which is why most people seek a facelift). But its effects last perhaps six months and costs several thousand dollars. Some form of a real facelift (and there are many variations) may cost two or three times more but the results are much more significant and could easily last a decade or more. Is either one wrong? No. Each person has their own objective and needs and either approach could be right for different people. But from the concept of value, removing, lifting and tightening is actually more economical in the long-run than plumping and a little smoothing.
Most non-surgical office treatments have no recovery, a near instant result, and cost less …and do so at the ‘price’ of being less effective as well. Expectations are the key to any plastic surgery procedure and simple office treatments should be judged more for their contribution to value than their ease of doing them.
Dr. Barry Eppley
While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.
Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.
Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer. These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.
But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.
Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.
Dr. Barry Eppley
The recent surprise decision by Senator Evan Bayh to not seek re-election is likely a strong reflection of his desire to flee an unpopular ship as it is with his frustration with the ways of Washington. The recent questionable efforts to ramrod through a monster of major health care reform is certainly one factor that drove him closer to the edge of this decision. Perhaps Bayh knew that as the details of the health care bill began to see the light of day, great public disdain for all those that voted for it was sure to occur.
As a plastic surgeon, I was happy to see that the unsavory ‘Botax’(a 5% tax on all cosmetic procedures, surgery or otherwise) was cut from the final version of the Senate health care reform bill. The ‘Botax’ was eventually eliminated when it was quite rightly pointed out that it was not only a discriminatory tax on women but it was punishing those who sought self-improvement…the equivalent of taxing healthy behavior given the efforts of most patients to take good care of their investment in themselves.
As a replacement for taxing cosmetic surgery, the Senate desperately searched for ways to redistribute more of your money. They turned their focus to… indoor tanning of all things. Known as the ‘Tan Plan’, a 10% federal tax on indoor tanning was quietly included in the revised bill. Optimistically, it is expected to generate close to 3 billion dollars to help pay for the uninsured. Tanning is a more palatable target because it is a debatedly unhealthy behavior that in the very least, doesn’t improve your skin’s condition from the experience.
While I don’t want to be an endorser of any behavior that exposes people to more ultraviolet radiation and thereby increases their risk of developing skin cancer, this new federal tax is just as reprehensible as the Botax and may even be more discriminatory. Though the tanning industry and tanning advocates have put forth their concerns, I have yet to hear anyone mention the very biased nature of this tax. I am most definitely not a tanning expert, but I am certain that the vast majority of the population that patronizes tanning salons are light skinned individuals seeking to darken their natural skin tone. The number of non-Caucasian users of tanning salons must surely be very low, at best just a few percent of the total client base. The Tan Plan is really a racially-biased tax, likely unintentionally but true nonetheless.
What the Botax and the Tax Plan demonstrate is that it is virtually impossible to pick and chose what type of human behavior you want to tax (penalize), and not raise a lot of concerns. If you really want to generate a lot of tax revenue and maybe even change societal health behaviors in the process, there should be a Fat Food Tax. Taxing food purchases with a certain percentage of fat content and the industry that makes them would make these other tax proposals as insignificant as the antioxidants in a soda.
Must we really be deluged with food choices that have such high fat or sugar contents? They taste great and we all love them, but most are a nutritional desert and have led us to be one of the most overweight countries per capita in the world. Obesity and all of the problems that it causes is a far greater health problem that cancer, AIDS and many other medical diseases combined. Such a food tax would, however, cause such a societal clamor that the mere mention of it makes one reach for that bag of Doritos. Taxing personal lifestyle behaviors is risky and will never be a politically popular way to try and fund some levels of health care reform.
Dr. Barry Eppley
One of the first signs of aging is what happens around one’s eyes. We are so expressive with our eyes and forehead that they bear the brunt of much of the early and visible signs of the aging process. How many times has someone said to you…are you tired?…have you been working late?…when in fact you just had eight hours of sleep. The development of extra eyelid skin, lower eye bags, and wrinkles around the eyes can be telling.
This makes the blepharoplasty (eyelid tucks) a vital plastic surgery procedure in making one look more refreshed. Many patients fear, however, that such an eyelid procedure will change their appearance rather than just making it more youthful or rejuvenated. This fear is promoted by just looking at today’s over-operated celebrities who have had too much surgery, or overly aggressive surgery, and look very unnatural. Such changes do make one look different, but not better.
Modern blepharoplasty surgery avoid these problems using a more conservative approach based on a better understanding of how the eyelid and face changes with age. Greater emphasis is placed on not disturbing the eyelid’s complex system of support and removing just the right amount of extra skin. This leads to a more natural looking result that does not alter one’s appearance.Baggy upper and puffy lower lids can now be treated with less tissue disruption and scarring for a safer and more natural long-term result. The goal is to look like yourself…just better!
When considering an upper eyelid procedure, the position of the eyebrow must be considered. A low hanging eyebrow can make it look like there is more skin in the upper eyelid than really exists. A browlift procedure is occasionally done with a blepharoplasty when it is determined that a higher brow is aesthetically beneficial. How do you know if your eyebrow is too low? That would depend on where one’s brow was when they were young. I would submit that most people do not remember where it was in their younger days. You simply have to play with it in the mirror to decide if higher is better.
Browlifts are primarily a procedure for women, they are rarely done in men. When browlifts are done, emphasis should be on more lateral brow elevation and less inner brow elevation. A woman’s eyebrow usually has an upward and outward sweep to it towards one’s temple area. Bringing up the inner part of the eye brow is what creates an unnatural overelevated look.
Today’s in-office ‘needle’ treatments can also provide some around the eye area improvement. Botox (and Dysport), not injectable fillers, is what is used. It is a great treatment for reducing the frowning look between the eyebrows, horizontal forehead lines, and crow’s feet wrinkles at the side of the eyes which can be particularly evident when one smiles. As an early treatment before significant eye aging changes occur or as a complement after blepharoplasty surgery, Botox is a simple and cost-effective non-surgical treatment.
One no longer has to be told that they look tired or are seeing their eyeball slowly disappear in a sea of loose and hanging eyelid skin. Between the three Bs (blepharoplasty, browlift and Botox), a more rested and refreshed you awaits!
Dr. Barry Eppley
I have heard many patients say “Can you fill up my lips with Botox’ or ‘I need a filler between my eyes to stop me from frowning’. This confusion comes from the fact that all these in-office anti-aging treatments come out of a needle. But the reality is not all that comes out of a needle is the same. While such confusion is understandable due to the relative newness and apparent similarity of these injectable treatments, that is a little like saying that one scalpel can do all the same surgeries. Injectable agents are treatments which have different mechanisms of action, even if the end result is often times similar. (facial wrinkle or fold reduction)
To clear up the confusion, I often explain to patients the difference between static wrinkles and dynamic wrinkles that appear on one’s face. Dynamic wrinkles are those wrinkles and lines that appear when your face is moving or expressing yourself such as smiling or frowning. 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 not moving. All dynamic wrinkles, with time, will eventually lead to static wrinkles. When we are older, those static lines look even worse when they become dynamic. What looks cute on a child’s face when they laugh, decades later, will someday be viewed quite differently.
These two types of wrinkles are what separates Botox and any of the injectable fillers. (e.g., Restylane, Juvaderm and eight other brands) Botox is for dynamic wrinkling. It is a muscle-paralyzing or muscle weakening agent so it will soften the wrinkles and lines that occur from a dynamic facial movement, such as between the brows with frowning….or the crow’s feet around the eyes from smiling. 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 at the same when the line or wrinkle is very deep and weakening the muscle action will help preserve the longevity of the filler material but not being ‘beaten on’ by continuouosmuscle movement. This dual combination is almost exclusively in the furrows between the eyebrows from frowning. (also known as the ’11 sign’)
One other important difference between Botox and injectable fillers is where they are used. Botox is primarily a ‘northern’ facial procedure used on the forehead and around the eyes. Injectable fillers are a ‘southern’ facial procedure, used mainly around the mouth.
Feel free to contact me and get a free copy of my book on this subject entitled ‘INJECTING YOUTH’.
Dr. Barry Eppley
Since its commercial availability since 2002, Botox has revolutionized wrinkle treatment of the face with emphasis on improvement in the forehead and eye areas. There are few people who would not recognize the name, even if they may not understand what it exactly does.
Botox is so effective (although only temporary) and simple to do, it has given rise to an entire industry of treatments, cosmetic practitioners, and business models based out of strip malls to doctors offices. Billions of dollars of annual revenues have been created out of what is essentially a chemical poison. But the doses used are so small to treat wrinkles that it is harmless to humans. But calculated out per pound, Botox would roughly cost a trillion dollars… making it the most expensive material on the planet.
With such a proven and desireable commodity, it is no surprise that other manufacturers have been feverishly working on coming up with a competitive product. The recently available Dysport can now stake its claim as second in line. Whether it will make a significant dent in Botox’s business remains to be seen.
Dysport is not new and has been used around the world for years. In those countries where Dysport and Botox co-exist, the market shares of each are not that different. But Botox in the United States has tremendous brand awareness and a huge headstart. As a result, it will likely be the ‘Coke’ for a long time in facial wrinkle treatment and Dysport can best hope to become ‘Pepsi’ in time.
Like any new product, Dysport must seek a marketing edge. Claims have been made that it lasts longer and costs less…the holy grail doctrines of the cosmetic industry. But a close look at the scientific studies and available evidence on Dysport does not support those marketing theories. The company does not actually claim them as the FDA would not allow such unsupported statements based on the studies that were submitted. Such claims appear to be the propagation of rumors and hope… and zealous physician marketing. In my experience, Dysport appears to be a good but equivalent treatment to Botox. In time, it may show a few select advantages (or disadvantages) but they are not obvious yet.
While competition usually drives down price, that does not appear to be the case in this battle of wrinkle reducers. Because they are given in different doses, it is not even possible to compare Botox and Dysport prices on a unit basis…which is how they are given by injection. Because Dysport is new to the public, it is natural to assume that it may be better. Its value at this point, however, appears to be as a treatment alternative for those few patients who are either resistant to or becoming less responsive to their current Botox injections.
For those patients clamoring for a cheaper and better Botox, Dysport will not be the new fountain of youth.
Dr. Barry Eppley
There is sure to be much discussion about a provision in the U.S. Senate’s version of Health Care Reform which would impose a tax on elective cosmetic procedures. With a tax rate of 5%, the measure presumably will raise close to $6 billion of the projected $850 billion price tag of the healthcare bill (most analysts agree that this projected cost is fancifully low).
Given the name of “Botax” by many, the intent of it is to clearly tax those who can ‘afford’ to pay it…some call it a tax on the wealthy. But those who do so clearly have no idea who really makes up the cosmetic population. The Botax name is a clever variation of Botox® facial injections which have become the beacon procedure for non-surgical office procedures used for wrinkle reduction. In theory, the Botax could impact about 12 million cosmetic procedures and surgeries performed each year in the U.S..
As one would expect, all sides of the cosmetic surgery industry from physicians to patients are voicing opposition. Their argument is that such a tax unfairly targets the middle class and working women in particular. Statistics from the American Society of Plastic Surgeons (ASPS) show that only a minority of people who undergo any form of cosmetic surgery has a household income greater than $90,000 per year and the vast majority (greater than 80%) are women between the working ages of 18 to 65. Clearly this is not a tax on the wealthy and is a discriminatory tax that falls largely on women.
While the idea that it is a tax on the wealthy is fallacious, it is a tax on the healthy. Contrary to what many would guess, the vast majority of cosmetic procedures are done are health-conscious individuals. Most are already reasonable fit and are ‘appearance focused’. The obese, smokers, diabetics and other ‘unhealthy’ patients make up just a fraction of those people ever undergoing cosmetic procedures or surgery. This proposed discriminatory tax is targeting those who do take care of themselves to help some who have made poor health choices along the way. It would make more sense to tax unhealthy food items, for example, that have incredibly high fat content…and it would bring a hundred fold increases in revenue to support health care reform.
This type of tax proposal is also troubling because it treads on choppy waters that health insurance companies have trouble deciphering. What is the official or tax definition of a cosmetic procedure? IRS rules for tax deductions state that any procedure necessary to treat a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease is a medical procedure. Anything else is a cosmetic procedure. Some delineation is quite clear- Botox® used for wrinkles or for migraines for example. But what about a tummy tuck to treat the effects of pregnancy? Are the effects of childbirth on a woman’s abdomen a cosmetic or reconstructive procedure?
With so many differences between the House and Senate Health Reform bills, it is difficult to say what will eventually shake out. But this hidden tax will largely penalize health conscious women. It is a troubling signal of how far reaching your legislators will go to get more of your hard earned money. And once again the beneficiaries of your ‘generosity’ will likely be those that have sacrificed less.
Dr. Barry Eppley
The recovery from our recent and ongoing recession has been speculated by numerous economic experts. The recent State of the Union address assures us that the worst is over and better days are ahead. Quite frankly, I take solace in any of the above pontifications about as much as I trust giving the government 1.5 trillion dollars in an ill-conceived overhaul of our health care system.
A recent manufacturer survery that I read has indicated that the number of cosmetic procedures were up during the fourth quarter of 2009 since the downturn in the economy began in mid-2007. Manufacturers of Botox, injectable fillers, and lasers have reported that their sales increased in the fourth quarter of 2009 for the first time in years, up anywhere from 2% to 8% depending upon the product.
Are these survery results a sign that the economy is really improving? Luxury and discretionary spending are often viewed as a sign of renewed consumer confidence. But I would take these apparent positive signs with a grain of salt. These numbers are likely up for a different reason.
As the most expensive plastic surgery offering…operations…are being temporarily (and maybe permanently) shelved by some, patients and cosmetic doctors are turning their attention to lower-priced treatments. One may have to pass on that facelift or eyelid tuck, but Botox and fuller lips remain within the budget. Consumers appear to be still trying to hold on to their cash in these troubling economic times, but haven’t given up completely on some more economical forms of feeling and looking better.
A better yardstick of economic recovery as viewed from a plastic surgery perspective is in the number of breast implants being sold. Larger amounts of discretionary spending are a better indicator of how people are really feeling about the economy. When these elective medical device sales, which remain down in 2009, returns to more familiar territory of brisk double digit growth, we will have more than one reason to be optimistic.
The use of Botox and injectable sales as a gauge of economic recovery is just one way that numbers and statistics can be twisted to support one’s perceptions…and hopes. They are up because the bigger ticket items that often come with them are done. This is like saying the economy is improving because Starbucks coffee sales are up… while customers frequenting Ruth Chris’s is down.
While the government may be hinging optimistic forecasts on upswings in graphs and charts, I will look for more familiar enlargements in different indicators before feeling better about where the economy is headed.
Dr. Barry Eppley