Your Questions

Q: Dr. Eppley, I have 2 questions about injectable brow augmentation and chin asymmetry.

1. Is it possible to create a more deep set (masculine) brow via fillers? 

2. the bottom of my chin is a bit asymmetric. Can filler be used to even this out? Thank you for your time.

A: Inejctable brow augmentation and correction of chin asymmetry can certainly be done by using injectable fillers. It takes a fair amount of injectable filler to augment the brows, usually about 2 syringes. But it can create a significant brow augmentation effect. The improvement of chin asymmetry will take far less volume. While effective, like all injectable fillers, its effects will be temporary in the range of 6 to 9 months at best.

Injectable brow augmentation can be a very good initial ‘test’ to determine if overall brow augmentation produces a good result. If not it can always be easily reversed by hyaluronidase injections or simple the passage of time to let the filler resorb naturally. If one likes the result, one may progress to the use of fat injections or to a permanent brow bone implant. Permanent brow bone implants are made from the patient’s 3D CT scan and are usually placed through an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 female with bad dark circles. I would like to have hyaluraunic acid injectable filler to improve the look of my under eyes. I have attached some pictures without makeup for your consideration. I have never had any procedure performed before. Am I a good candidate for the under eye filler? Also, could you please let me know the cost of the procedure. Many thanks.

A: Thank you for your inquiry. A hyaluronic-based injectable filler is a good place to start for your dark circles under eye issues even though it is not the best treatment for it. It is important that you understand that any filling of the under eye hollows is not going to solve your hyperpigmentation problem. It will improve the hollows but that alone will not make the dark color go away. Ideally you would treat them with fat injections combined with a peel of the skin with pre- and post treatment topical hydroquinone. But starting with a temporary filler will determine for you whether the correction of the hollows alone can be done by injection of any material and is a ‘pre-test’ for future fat injections which are superior in terms of both volume retention and potentially aiding in the hyperpigmentation issue.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have had injectable fillers in my cheeks with injections of several popular products over the course of three years now. It is costing a fortune since I metabolize it quickly. (so I’ve been told) I have used Radiesse, Juvederm, and most recently Voluma and love the results for correcting diagonal mid cheek lines and loss of fullness but they do not last more than 4 months. How do I find a surgeon who has sufficient experience in cheek implants ? What is cheek implant surgery downtime? Longevity? Any other cheek augmentation alternatives?

A: Your injectable filler story is not uncommon and many patients will be in your same situation in the years ahead. Injectable fillers are great at doing what they are intended to do most of the time. But despite the good results they provide, many patients have or will find out that the long-term costs of injectable filler ‘maintenance’ will become prohibitive for some patients. Thus seeking a permanent cheek augmentation solution has merits.

Cheek implants can provide a very satisfactory solution provided the proper implant style and size is chosen. Because the cheek area and the cheek implants chosen to augment it defy any exact method of measurement (unlike chin implants for example where the amount of horizontal augmentation needed can be measured) it takes a surgeon with a lot of cheek augmentation experience to get it right the first time. While the concept of cheek implants is simple, it can be difficult to get their placement anatomically correct with good symmetry. This difficulty is imposed on top of how to select the best cheek implant style and size for the patient.

Cheek implant recovery is largely about facial swelling and the time it takes for it to look acceptable. In reality expect that to be longer than one really wants. It takes about ten days to look socially acceptable, three weeks to ‘normal’ and really three months to judge the final result and how one feels about the facial change.

The intermediate step between injectable fillers and implants for cheek augmentation is fat injections. While far simpler and with a very quick recovery compared to cheek implants its issue is how well the fat will survive and how long it will persist. These are unpredictable and can be different for each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting injectable fillers for nasal folds and vertical mouth lines  I am allergic to many things and wanted to find out how common are allergic reactions and can a test be done prior to the actual full procedure?

A: The majority of injectable fillers today use hyaluronic acid-based materials (synthetic sugars) that are also present in many tissues of the body. Because of their very low risk of hypersensitivity reactions, skin testing has never been recommended or advised with their use in first time patients. This is quite unlike that of the now defunct bovine collagen injectble filler products (Zyderm and Zyplast) from the 1980s and 1990s. That being said the risk of hypersensitivity reactions (aka allergic reactions( is not zero although it is less than 1%.

When in doubt or in a patient with a lot of known allergies it can be convincingly argued that a skin test should be done before even a hyaluronic acid-based injectable filler is done. If there is any doubt or concern, I always perform a skin test which is simple and easy to do. It is done just like a TB test.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had 3 syringes of Restylane Silk and 1 syringe of Radiesse over the past year placed under my eyes and on the cheeks. The injections were placed down deep on the bone. When these fillers dissolve would there be any side effects? The reason I am emailing you is because I was so impressed by your answers on many plastic surgery boards. Is there no risk of underlying tissue or muscle becoming ‘lax’ from fillers especially with four ccs. of injectable fillers in just 12 months? I appreciate your time in answering my concerns. 

A: All of the mentioned fillers are completely resorbable and they are not known to cause any long-term problems because of their relatively short duration of effects. Your question, however, is a good one but I am not aware of such injectable filler volumes causing lax skin or muscle tissues. That is because, while the injection volume creation process is acute, the resorption process is very slow giving the tissues time to recover due to its natural elasticity. Once the tissues deflate after such volume, however, I could understand how one could believe they are more lax because of the getting used to the volume that had been present.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Hello! I came across you on RealSelf. I have been wanting to get this small bump in the bridge of my nose evened out. After reading the positive reviews of Dr. Eppley, I am interested in speaking more. Thank you for your time! 

I have always had a small bump on my nose and I am looking to fix that in order to have a better profile view. I have always been extremely self conscious about my nose and it also doesn’t help that I do not have a strong jawline either. 

I have looked into rhinoplasty surgery, but I thought maybe injectable fillers would be better if my issue is minor.

A: Thank you for sending your picture. Based on this picture, I would say that putting filler above the bump is not a good idea. You have a bump on your nose because the nasal tip is too low, not because the bridge and the edge of the nasal bones is too high. You are a rare example where what you have is a ‘pseudohump’. A hump that is artificially created by other nasal structures that are too low. Your bridge or hip height is actually normal.

In my opinion, rhinoplasty surgery would be much better. But you can always try fillers and if it does not create a better result it will always go away and then you will know for sure about rhinoplasty surgery for sure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if you do Artefill or Radiesse injectable filler in the legs?Because I have skinny lower legs and I would like some volume. Also do you do butt injections for lift. Thanks!

A: Injectable fillers are never used to provide volume for such large body areas as the lower legs. Besides that fact that they are only temporary, the sheer volume of injectable fillers needed would cost $25,000 to $50,000 to create the desired effect. All of which would go away in less than six months. Injectable fillers are only used in the face where smaller volumes can have a more profound effect.

The correct injectable filler to be for augmenting any body area, including the legs and the buttocks, would be your own fat. Fat injections are the most common method used for buttock augmentation, known as the Brazilian Butt Lift. They could also be used for the legs such as in calf augmentation. Whether you have enough fat to harvest to have a successful buttock or leg augmentation procedure is the key question and is the rate limiting step in any patient considering a fat injection augmentation procedure. That could be determined by seeing some pictures of your body.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you and I spoke previously about temple implants. cheek implants, and forehead fat grafting. You did some imaging for me as well, and I realize you understand my goals in reshaping my face better than anyone. With this said, I would be interested to see how the overall look of what we discussed previously would first look by using injectable fillers to achieve the results in widening my face and adding more volume.

A: The issue with fillers for augmentation of various facial areas is one of pure volume and the associated costs. When it comes to small areas like the lips (1cc) or even the cheeks (2ccs), voluminization by hyaluronic acid-based fillers is reasonably cost-effective even though the effects will not be permanent. Beyond these volumes one has to look to the use of a filler like Sculptra to achieve a broader or wide-based facial volume effect. While these longer-lasting particulated fillers can achieve better volume enhancement of the cheeks and temples, the need for multiple treatments to achieve their effects and an increased risk of reactions to the implanted ‘seeds’, it is usually better to venture into the realm of injectable fat grafting where there are no volume restrictions or risks of any injectate reactions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the most natural lip augmentation filler that you offer?

A: When someone speaks of a ‘natural’ lip augmentation result or procedure, they could mean two distinctly different things…that the material that is implanted is natural or that they want a natural-looking result. For lip injections, the most natural filler is fat. (although by far the most common lip filler materials used are hyaluron-based like Juvederm for example) Fat may be the most natural injectable filler for the lips but it has a poor track record of graft take and requires more of a surgical procedure to do it. (liposuction harvest)

A natural result in lip augmentation is generally one that is not overdone or has had too much filler placed. It is unnatural when the upper lip becomes bigger than the lower lip. Most of the time patients want an upper lip augmentation whose size (vertical vermilion height) matches that of the larger lower lip. That is influenced as much by the technique and volume of injectable filler material added than it is by any specific injectable filler material.

Most likely you are referring to the latter where the result does not appear as if ‘something had be done’ or the dreaded ‘duck lip’ result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I developed a depression/dent on the middle of my forehead that is circular after the birth of my second son. Whenever I bend over or pressure is applied to my abdominal area, the depression on my forehead fills up with fluid and a huge bump is visible. I have had a CT scan done and the results showed that it was not a dent on the skull surface, however it did not explain the cause. Why do I have it and will it ever go away?

A: The simple answer is I don’t know why you have it nor can I predict with any certainty if it will go away…but if I had to guess I would not think it is going to go away. Since the dent does to have a bone-basis for its presence, one can assume this is a soft tissue deficiency. That is predictable since if the dents as due to a bone issue, it would have been present essentially since birth. (short of some traumatic event) I have no doubt that the dent fill sour when you bend over but that is not because it fills with ‘fluid’ per se. That is probably due to blood vessel engorgement from the pressure which would be more obvious when the tissues are thinner.

What I would initially is to some temporary filler injections to make it more level and probably resistant to that bulging engorgement effect. If that us successful the you can eventually move on to a fat graft or fat injections for a more permanent result once you are assured that a soft tissue fill solves both problems.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to correct mild midface hypoplasia with fillers? Will it be a result that is approximate to what facial implants can do?

A: If you add enough volume of injectable fillers in the cheeks, orbital rim and paranasal regions, some midface hypoplasia correction (increased projection) could be achieved. But no filler is permanent and substantial filler volume would be needed. It is also important to remember that gel-like hyaluronic acid-based fillers (e.g., Juvederm Voluma) do not provide the same type of push on the soft tissues that implants do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question concerning using injectable fillers in the jawline. I’m considering doing a jaw implant, not so much to widen the jaw but to lengthen the jawline down in the vertical direction. I know that injectable fillers (such as Juvederm Voluma) is a great option when it comes to widening the jaw and this is commonly done. But my question is if it´s possible to also lengthen the jawline in the vertical direction with fillers. Is it a good use of an injectable filler? I don´t want it to float about when your laugh for instance but I guess it could be a good strategy to start with fillers before possibly doing an implant. I also would like to know how much approximately you can lengthen it with fillers, maybe 4mm to 5 mms?

A: Injectable fillers can be a good starting point when considering any type of facial skeletal augmentation including the jawline. It will work equally well for vertical jawline lengthening as well as jawline widening/accentuation. It will not move around anymore on the lower edge of the jawline than it will when it is placed on the side.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, I am interested in getting injectable fillers into my tear troughs (tear trough injections) but am very nervous about it. I have read numerous horror stories of significant bruising and clumps and irregularities in this area. What is the best way to inject the tear troughs and not have these problems?

A:  Injections for tear trough (nasojugal) effacement is the most technique sensitive of all injectable filler treatments of the face. I used to use a 1/2 inch 30 gauge needle and injected down to the level of the periosteum along the medial orbital rim. But the periosteum over the orbital rim is quite adherent and recent studies have shown that the periosteum and the retaining ligaments in this area are very difficult to elevate and are prone to bleeding and external bruising.

I have subsequently changed my tear trough filler technique to using a microcannula rather than a needle. Coming though the thicker cheek skin rather than the thinner eyelid skin, I enter the submuscular plane above the periosteum to inject. This approach puts the microcannula directly into the tear trough and has no risk of causing bleeding or bruising afterwards. This more superficial submuscular deposition of filler has improved my results dramatically. In addition, the entire tear trough can be filled from a single puncture in the upper cheek. The microcannula can reach the most medial part of the tear trough.

It is important when filling the tear trough to only use hyaluronic acid-based fillers to avoid clumping and to not overfill. Less is more when it comes to filling the tear troughs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ll be getting eyebrow transplants done next Monday. I’ve also been looking at getting some fillers to augment my radix (and possibly glabella). Anyway, my surgeon has advised me that it should be fine to get fillers shortly after the transplants (he suggested doing it next Friday) as they won’t be in the same area as the transplants. Just wondering though, will getting fillers so shortly after the eyebrow transplants have any adverse effects on hair growth? Thank you for taking the time to answer me.

A: In short, there is no correlation between having eyebrow transplants and injectable fillers. Even if the fillers were being injected right under the brow at the same time as having hair transplants, it would not affect the take of the hair transplants or how well they would subsequently grow. Given that the injectable fillers would be placed in the radix of the nose, away from the hair transplants, makes it even ‘safer’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing because I have a quick question regarding cheek implants, which we had briefly discussed, vs fillers. I may have rheumatoid arthritis and I’ve heard that injectable fillers aren’t the best route with autoimmune disorders. I’m curious to know if cheekbone implants would be any better, and if you offer any that are non-silicone.  I would be grateful to read your thoughts on this topic.

A: The use of injectable fillers in patients with known autoimmune diseases is a bit of a mix bag. Historically the thought was that only collagen fillers should be avoided since they are a foreign collagen processed from a bovine source, hence the understandable apprehension when the body is injected by that material.  But more recent anectodal reports have come out that indicates even the very popular and well tolerated hyaluronic acid-based fillers may pose some concern. This has not been definitely proven and it may just represent the general ‘reactivity’ of the autoimmune patient to any stimulus, but the safest route would be to avoid any injectable fillers and lower the risk of that concern to zero.

This, of course, raises the question of whether any cheek implant, regardless of the material, might not pose the same risk…although they have not been to my knowledge in the medical literature or experience. Your concerns about silicone cheek implants is understandable although that feeling undoubtably comes from fluid-filled silicone breast implants of yesteryear and not solid preformed silicone facial implants. But alternative materials for cheek implants include PTFE-coated silicone, Medpor (porous polyethylene), pure PTFE and mersilene mesh. Whether these are all chemically and structurally different than silicone, whether one is better in the automimune patient is not known.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue.  Can you help me decide between fillers and cheek implants?

A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.

Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be  a good test or trial if one is uncertain about whether cheek augmentation is for them.

The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.

Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.

When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants placed over 25 years I have lost weight and would like to know if facial fillers can be used close to the implant. Is there and increased chance of infection? Thank You

A: Cheek implants that have been in place for 25 years had to have been some of the first cheek implants every put in, usually of a small ovoid shape that were positioned on the anterior end of the cheekbone. This location creates that ‘apple cheek’ look that is very appropriate for many women. While the bony augmentation has remained stable, over the years the soft tissue around the implants has undoubtably changed becoming thinner and developing some malar sag. Thus the impetus for injectable fillers to recreate some lost cheek highlights due to aging. Generally it should be no problem to place injectable fillers in the tissues overlying such ‘old’ cheek implants. Having removed several cheek implants of a similar age, the scar capsule that surrounds them can be incredibly tough and even partially calcified. It would be probably be unlikely that a needle could even penetrate the capsule should it inadvertently come into contact with it. This is also a good use of the microcannula method of injectable filler placement which has a blunt tip and would have zero chance of breaking through the cheek implant capsule and inadvertently injecting into the implant itself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to inquire about getting injectable fillers under my eyes. What product do you use, what are the risks and what does it cost? What is the general satisfaction with patients having this procedure. I am excited about having it done but also nervous since it is around the eyes.

A: Under eye hollows, tear troughs and malar creases are becoming a popular treatment site for injectable fillers. When done well they can provide significant visual improvement of problems areas that previously were only treatable by surgery. For under the eye hollows, I generally use Juvederm placed with a microcannula technique. This usually eliminates any risk of bruising. The biggest concern in injecting under the eyes is that it is not overdone and that it is as smooth as possible. This means that it is injected down at the bone level along the infraorbital rim Of all the facial areas to treat with injectable fillers, this requires the most careful and skilled technique and a comfort zone with the surrounding orbital anatomy. The biggest risk is lumpiness or unevenness of the lower eyelids. The cost of treatment, which will usually last a year or more is around $550.

Q: Dr. Eppley, I want to know about facial fat injections. I know a 24 year old who is unsatisfied with her facial appearance. She weighs 118 lbs, and is 5’6”. She does have a lot of facial fat especially in her lower cheek and the areas around the mouth. Ironically, this makes her mouth look fat. She has had braces, but is still unsatisfied because she says that the most noticeable part of her face is still her mouth. She is pretty, but she does not smile because the “excess skin makes creases” at the sides of her mouth. I did a little research and deduced that she has noticeable perioral mounds due to a lack in facial volume. Do you offer fillers such as sculptra and radiesse, or would fat transfers to the cheeks be possible and could this possibly improve her appearance to a noticeable extent? She is doing all she can to avoid getting cheek implants. She is so young to be unhappy about her face.

A: Some of what you ate saying is a it contradictory. Perioral mounds are excessive collection of fat just to the sides of the mouth. They do not occur ‘due to a lack of volume’ as you have described. You may have mispoken in that regard. Thus I am not sure your friend had too much fullness at the perioral mounds or a lack of it.

Injectable fillers are always a good first step to try if one is uncertain whether the addition of volume is the correct facial approach. If one is certain that the addition of volume is needed, facial fat injections would be a better approach as it has the potential to offer some permanency while synthetic fillers do not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had an injectable filler treatment done for my hollows under my eyes. Besides a few lumps there is one lump that actually has a bluish color to it. I thought that it may be because it was bruised. But three weeks after he injections it has not changed. What is causing this coloration and will it eventually go away?

A: You undoubtably were injected with one of the hyaluronic acid-based injectable fillers which is the most common one used in the thin skinned area under the eyes. What you are seeing is known as the Tyndall effect, a well known phenomenon from injectable fillers which can be seen when they are placed right under the skin too superficially. Because the injectable fillers is really a colloid and not a solution, there are large molecules of the hyaluron chains that are floating around in the gel solution. When injected too close to the skin the superficially placed filler material allows light to be scattered off of the floating particles. It appears blue because only the scattered longer wavelength blue light is reflected back to the viewer while other light wavelengths are less scattered. While aesthetically disturbing it is not harmful and will eventually resolve itself as the material absorbs. Because filler can last a very long time in the eyelids, you may consider hyaluronidase injections to help it dissolve much sooner than its expected implantation duration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a consultation for getting hyaluronidase injected to remove too much restylane that has been injected into my cheeks. It looks extremely unnatural as I am 35 and did not want to look fake. Please help and thank you!

A: You are correct in assuming the the proper treatment for too much of a hyaluronic acid-based filler, such as Restylane, is hyaluronidase injections. This enzyme solution catalyzes the hydrolysis of hyaluron which lowers its viscosity and makes it rapidly absorbable. The action of hyaluronidase is very quick and starts to work immediately, with most of the effect taking place within 24 to 48 hours.

The most difficult aspect of treated overdone fillers with hyaluronidase is judging the amount required to dissolve a certain amount of filler. There is no table or established doses in units for how to treat any facial area. It is quite easy to undertreat the injected area. Patients should, therefore, expect the possibility that a second treatment may be required if some filler still remains.

There is the possibility of hyaluronidase injection side effects, although they are quite uncommon. It would be an inflammatory reaction with redness and swelling and is more likely to occur in those people who are allergic to bee stings.

The reversibility of hyaluronic acid fillers with hyaluronidase is one of many reasons that such injectable filler compositions are the preferred choice for most patient’s aesthetic facial needs as a non-surgical treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Specifically I have had a problem with “marionette lines” since my early thirties, I am now 41. I had Juvaderm twice about five years ago and I had Restylane this past October. I definitely prefer the Juvaderm and I was going to do that again. Maybe with some Botox as well because I also have smokers lines around my lips. I am not a smoker but I have a habit of constantly chewing on the sides of my mouth and that, along with genetics, appears to be a big contributor. I have not actually tried any Botox yet but research indicates the two treatments together could get me a nice result.

The reason I am inquiring about the Thermage is because my face is aging just like my mother’s, she had Thermage done in 2009 and had a great result. She has not had any follow up treatments and her face is looking very saggy again but I do think if she had kept up treatments she would be looking pretty good right now.

I am wanting to know which treatments would give the best long term results. The Thermage appeals to me more than injecting things into my face and it appears that it is something I could maybe do around once a year, where as the injections would need to be done more often. I am not opposed to injections and pain is not a factor. It is more about what is being injected into my face.

I currently get microdermabrasion every two weeks and I use vitamin C and lots of sunscreen because I am very pale.

I have been doing research on line for years about procedures. Now that I have some background information on what seems like a million options, I need to know what would work best for me and still be in my comfort zone. I have a big fear of looking plastic and unnatural, but now my fear of looking older than I really am is becoming bigger.

A: Thank for clarifying your problems. While the options for your concerns may seem endless, they really are not. The reason it seems there are so many is that none of the non-surgical approaches have any lasting effect and the differences in the results many of them produce are negligible. Hence, many things exists when none of them really work that well…at least compared to surgery.

For marionette lines, injectable fillers are the only real effective non-surgical option as you already know. Botox is not going to help the marionette lines because that it is not a muscular/animation problem. Botox can be effective for helping reduce some vertical lines in the lips and may help turn up the corners of the mouth a bit but it is a deanimator not a filler.

The use of Thermage is for the treatment of jowls and for some mild facial skin tightening. While once state-of-the-art in its day, it has largely been surpassed by many other ‘tissue heating’ technologies such as Ulthera or Exilis. They all work the same even though the energies that cause their effects are different. (ultrasound vs radiofrequency) While they do some good facial effects for some patients, they don’t really make new collagen that is sustainable and thus their effects are short-term. It takes a lot of maintenance treatments to keep their effects and that can quickly surpass the effects of surgery which is much longer-lasting. Face and neck treatments like Exilis when combined with overlay treatments of light fractional laser  resurfacing skin treatments is a very fine combination that for the right patient can produce some really good effects.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, have there been any new developments in the delivery of injectable fillers. I love what they do for my lips and have been doing them for years, getting Juvederm at least once a year. But getting injected is just something that I dread. I know beauty is painful but I am slowly reaching my limit of tolerance. I am due for another injection but have been putting it off for months now as I dread the process. I don’t care how it done and I have tried everyway from ice to dental blocks. Please tell me you have something new that makes it painless!

A: In case you didn’t know there has been a major advancement in the delivery of injectable fillers known as microcannula delivery. Unlike a needle which has beveled sharp edges and cuts the tissues as penetrates them, always causing some discomfort and potential bruising, a microcannula has a smooth rounded tip. It does not cut the tissues as it goes through causing no pain at all as it delivers the filler through a small side port just off the end of the cannula. This is a remarkable improvement over needles and only involves one small needle stick to make a tiny hole for the microcannula to get under the skin. For the very sensitive lips this will change your injection experience dramatically. In addition there will also be zero chance of any bruising. If your current injectable filler provider does not offer the microcannula method ask them to start doing it. If not, run to a provider that uses it. It will completely change your feeling about getting injectable fillers to your lips.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have very little earlobes. Can I increase their size and shape using dermal fillers??

A: The size of your earlobe can be increased (expanded) by the use of either injectable fillers, fat injections or even a small dermal-fat graft placed from an incision on the backside of the earlobe. Which technique is better for you depends on the current size of your earlobes and the amount of earlobe skin that you have. You may feel free to send me pictures of your earlobes for a more definitive recommendation. But as a general rule, the first step to do is to use temporary injectable fillers to see of you like the change they make. If so then you may consider a more permanent solution with one of the fat grafting options.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am now 10 weeks after cheek implant removal. Implants were removed because of infection and incorrect asymmetry. I am now thinking of getting Sculptra, Radiesse or Juvederm but am getting different answers as to how long I should wait to get the injections after removal. I still have some fluid, swelling and lip numbness after 10 weeks post op. My implants were put in October 2 and removed November 2, so they were only in for one month. I am very concerned about my health and healing from this and want to wait long enough to make sure the filler injections are safe. But my face looks worse than it did before the implants. Your expertise is very much appreciated!!

A: I would agree that complete healing should take place before you place any injectable fillers, even though the tissue plane where they will be placed is differngt from that were the implants were. That would be a minimum of three months. But a better barometer rather than just raw time is when the cheeks are no longer tender and any signs of numbness has completely dissipated. In short, don’t do fillers until your cheeks feel completely normal again.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year-old white female who has the beginnings of lip lines. I don’t smoke and have never tanned excessively. I have fairly pale skin. While my lips have never been really big they have never been thin either and have always had good shape. I have noticed over the past few years that I am getting several noticeable lines in my upper lip. My lipstick now is starting to bleed into the upper lip along these lines. My lips still have some shape but they are beginning to lose their shapes. What can I do to get rid of these lines and get some plumpness back to my lips?

A: Vertical lip lines or wrinkles are one of the peskiest facial aging problems. They are not easy to treat and they are relentless…always fighting to come back no matter what is done. Lips lines, like all wrinkles, appear because of underlying muscle action. The mouth is encircled by a ring of muscle known as the orbicularis oris. Anytime you pucker your lips or suck on a straw, this muscle is activated and contracts. Wrinkles appear on the overlying lip skin perpendicular to the direction of the muscle movement, thus the appearance of vertical lip lines. The thinner the lips one has (most common in Caucasian females), the more likely that lip lines will appear. Since it is impossible and impractical to completely stop moving your mouth (although not sucking on a cigarette or water bottle helps), treatments must be directed toward either inducing some muscle weakness (dilute Botox injections) and/or plumping up the lips by injectable fillers. In more advanced lip aging with a greater number and deeper lines, laser resurfacing or dermabrasion must be considered. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One week ago I had a syringe of Juvederm injected injected under my eyes. So far, the results are not fantastic but at least It did not create bags, as I often read in “horror stories”. Maybe I look less tired. I know I won’t go for a touch up, I had a bruise which freaked me out and “perfection is the enemy of good”. But I m wondering… Does this HA create any long term side effect such as lumpiness or swelling  months after the injection? Also based on your experience, how long does it really  last?  Because my injector said it could last for 3 to 5 years because there is no hyaluronidase in this part of the face (!!). And if people get treated again, it is because they have aged, the filler won't disappear. What do you think? Does HA under the eyes ever get broken down by the body? Thank you very much.

A: The information you have received about the longevity of Juvederm or any HA (hyaluronic-acid based) injectable filler is erroneous. No form of HA is permanent and they all eventually go away by the absorption of water which breaks down the filler. How long they last depends on the concentration of the HA in the filler and how it is cross-linked. It is true that they do seem to last longer in the lower eyelid/periorbital region, perhaps up to 12 to 18 months but definitely not three to five years. One of the real advantages of an HA filler is that it is a natural material as the body is composed of lots of HA material in its tissues. Thus there are no known untoward effects of repeated HA filler injections such as accelerated aging or tissued damage. Age also does not seem to play a role in how quickly or slowly any particular HA material persists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from sever temporal wasting. It’s rather noticeable. I’ve heard fillers are recommended but are they for minor filling and not severe cases of hollowing of the temples? Can they really fill my temples?

A: While injectable fillers or fat can be very good for more minor or moderate cases of temporal wasting, they have limitations in deeper temporal depressions. When it comes to more severe wasting of the temporal regions, fillers do not do a good job of augmentation as they take a  fair amount of volume (high cost) and are temporary anyway. Fat injections are often a problem in severe temporal wasting as the patients may have little fat to harvest on the rest of their body. There is also the issue of what caused the fat wasting in the first place which can work against any transplanted fat survival.

Synthetic mplants as part of a more complete treatment strategy for temporal wasting can be more effective and also are permanent. Different-sized temporal implants are available to fulfill various volumetric needs.

Q: Dr. Eppley, I had my buccal fat pads removed over 10 years ago which looked great. Then I lost a considerable amount of weight, over 50 lbs, and now look too sunken in. What is the best filler used to replace where buccal fat pads have been removed?

A: The answer to your question partially depends on how much volume is missing (how sunken in you are) and what method (surgical vs non-surgical) you want to pursue. But using the injectable filler criteria as your question posed, I will answer based on that one variable only. Because of the volume of the buccal fat pads (usually 5 to 10cc per side), the best replacement filler is fat injections. While the injection of fat is unpredictable, it offers an unlimited amount of volume for facial injections and it has the potential for some permanent volume retention. While there are many proponents for the various synthetic injectable fillers that are currently available, one has to recognize the cost of the volume needed per side based on the volume lost and that none are permanent. But if one had to go for a synthetic injectable filler, I would first use one of the longer-lasting hyaluronic acid fillers, like Perlane or Juvederm, to see if you like the effect. While there are longer-lasting fillers, such as Sculptra, Radiesse and Artecoll, they can be associated with higher risks of lumpiness and irregularities than the non-particulate hyaluronic acid-based injectable fillers when it comes to larger volume augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some volume back in my face. I lost a fair amount of weight over the past two years and my face has become quite gaunt. After doing a lot of reading, I know that there are the options of either some type of injectable filler or using your own fat. There doesn’t seem to be any consensus as to which is best. What is your opinion?

A: The development of synthetic fillers has created a whole new field of aesthetic medicine, mainly for facial rejuvenation. They are understandably hugely popular because of their instantaneous effects. While some last longer than others, in the end they are all temporary fillers. This issue only becomes truly relevant with major facial volumization is desired. The issue is simply one of cost. Given the volume of synthetic filler needed and the time that they last is the cost worth it? That, of course, is an individual question but the cost:benefit ratio does come into play for most patients.

Fat injections do not suffer from volume concerns and are more cost effective when considering the volume that is capable of being injected. Fat also has the added benefit of providing some stem cells as well although what their role is and how much they contribute to fat graft survival and overall tissue rejuvenation is still a matter of some debate. While fat grafts have the potential for long-term survival, their retention is not completely assured. Fat grafting procedures are a surgical procedure, however, and need to be performed under either local anesthesia or IV sedation depending upon the volume needed.

In the end, both synthetic fillers and fat grafts have their advantages and disadvantages. When it comes to substantial facial filling as in the gaunt face, fat grafting has more advantages as long one is willing to commit to more than an office procedure with some downtime.  

Dr. Barry Eppley

Indianapolis, Indiana