Your Questions
Your Questions
Q: Dr. Eppley, I have stretch marks covering most of the center of my abdomen. They are about two years old. I am curious about the pricing of your fractional CO2 laser resurfacing as well as recommendations for the best type of treatment or any other suggestions.
A: When it comes to treating stretch marks, there are no completely effective strategies. They may be able to be reduced but can never be completed eliminated. Fractional CO2 laser resurfacing, while effective for facial skin wrinkle reduction and skin rejuvenation, has not shown a similar profound effect on stretch marks. The best way to determine if it would have any beneficial effect would be to do treat a small area first (test patch) before embarking on treating the whole area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have pretty substantial acne scarring and I would really like to have a procedure to remedy this. My scars cover a large area of my face, most of them are small indented scars but there are a few larger ones. I’ve looked into laser scar removal and chemical peels, but I’m not sure which one I would be the best candidate for. I’m also unsure of the average cost of these procedures and how long they will last. I want whatever I have done to have permanent results, at this point cost isn’t my primary issue, I just want results that will not fade within a couple of months. Any information you could give me on this would be great, I am definitely planning on having something done within the next couple months.
A: Facial acne scarring is a difficult problem and there is no complete cure for it. It can be improved but rarely can the skin ever be made completely smooth. The most effective treatment is going to be laser resurfacing not chemical peels for acne scars that are not too deep and are large in number. It is often best to have an initial fully ablative laser resurfacing treatment followed by a fractional laser resurfacing three months later. This will give you the best improvement with a sustained result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facelift or facial rejuvenation but just not sure what. Not sure what procedures I would need to get rid of wrinkles, sun damage, and acne scars. I have attached some pictures of my face so you can see how bad I look.
A: In looking at your face, one of the fundamental problems is the large amount of loose skin which is contributing to the appearance of so many wrinkles. Rather than the loose skin just hanging off the facial bones, some people like you have it just pile up on the face. This also makes the acne scars look worse.
With this underlying skin problem, there are two fundamental approaches to take for your facial rejuvenation. The ideal approach would be a two-stage treatment consisting of a first stage lower facelift and browlift to get rid of much of the loose skin and to tighten the face. Then a second stage could be done of a full face laser resurfacing or deep chemical peel to smooth out more of the smaller wrinkles and lessen the acne scars as well. Such skin resurfacing can not be done at the same time as the facelift due to healing concerns of the skin.
The second approach, not as ideal, is to just do the facelift or the laser resurfacing. Both are beneficial and would provide some significant benefit by themselves without the other. But the result would not be the same as if both were done. If one had to choose just one, skin tightening provided by the facelift would be the best choice as the one treatment.
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, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.
A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have rhinophyma. I do not have it nearly as severely as those Elephant-Man-images one sees on the net. However, my nose skin is so thick that it has defied two surgeries to correct it. I know that I need IPL for my roceaca but I went to see a new doctor and he recommended C02 laser for my nose. However, I also have lots of enlarged pores on that poor nose of mine. I need the dilated blood vessels improved by the IPL and I was nervously considering the CO2 also. But I read that CO2 can cause pore size to enlarge. My question is should I have both treatments? The CO2 for the thickness of skin and lesion buildup and than finally the IPL for the redness. I am wondering if you can tell me the order I should do them in or which I should or should not do at all. My dream is to do all them (if that is the correct thing to do) as soon as I can afford it. With all of the horrors that have taken place in the world and with all that are taking place at this moment, still, I am totally “tormented” by my nose. Thank you for your time, patience and kindness.
A: Rhinophyma, as you undoubtably know, is a challenging problem. You have mentioned two treatments, which are correct ones, but I would opt for a vascular laser as opposed to the IPL which is going to be more effective for shrinking of the larger blood vessels that you probably have over the nose. There are arguments both ways as to the order and I don’t think either of them is wrong. If the blood vessels are fairly big, I would first treat them with the vascular laser as they may cause signficant bleeding when doing the laser resurfacing. If they are just fine telangectasias then I would do the laser resurfacing first and treat the telangectasias 3 to 6 months later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 63 year-old female who just recently had a facelift. Because I am thin, I really had no fat just loose kin in the neck and jowls. Now that I have gotten the skin tightened up, how can I keep the facelift in place? I have read about a lot of things such as Thermage, Ultherapy, Exilis and others and, while they sound good in theory, I have read and been told that they don’t work for a lot of people. Some have said that the only really effective method of skin tightening is through collagen regeneration using a fully ablative CO2 laser. But laser resurfacing of the face can be associated with long-term pinkness of the skin. What do you recommend?
A: The reality is that nothing can keep a facelift ‘in place’ forever as surgery does not stop the effects of time and gravity. But there are certainly things to do to help slow down the process. Skin tightening and collagen rebuilding would be the correct approach after a facelift and, for many, should be considered maintenance therapies. There are numerous enery-based devices for skin tightening and you have named a few of the most well known. I do think they do have some benefit even if it is not the same for every patient as each person’s skin is different. In my practice, I currently offer Exilis and BBL (Skin Tyte) as methods of skin tightening maintenance after a facelift in which a series of treatments (usually 4) could be once a year. If appropriate based on how many skin wrinkles one has, light laser resurfacing is also a good choice and can be done with the other skin tightening treatments. Just don’t have any deep laser treatments but more regular lighter ones. That will avoid the prolonged redness and recovery. These treatments will not stop the aging process completely and more tissue sag is to be eventually expected but it will slow down the process and maintain the facelift result much longer. Also don’t forget basic preventative measures for skin aging which includes avoidance of excessive sun exposure, no smoking, a stable weight and a good daily skin treatment regimen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello. I am interested in fraxel CO2 laser surgery for skin resurfacing. I am 48 yrs old and have sun damage, wrinkles and some acne marks. I do not know if I would be a candidate for this procedure. I had a kidney/pancreas transplant almost 22 years ago after being a type I diabetic for 20 years. I am on cyclosporine, prednisone, imuran immunosuppressive medications daily. Please let me know if there are any risks. Thank you.
A: The risks of laser skin resurfacing on someone who is taking immunosuppressive medications is two-fold. First, most long-term immunosuppressed transplant patients develop skin thinning due to dermal atrophy. This can lead to increased depths of penetration (injury) of the laser not seen in immunocompetent patients. Therefore typical laser settings may be too deep in the immunosuppressed patient. There is no way to accurately predict the skin’s response to any depth/power setting of the laser. Secondly, as you know, your healing capabilities are diminished. Since the laser essentially creates a burn injury, the skin must be able to heal the expansive skin wound. In the immunocompromised patient this could be an understandable issue. One can partially overcome the delayed healing effects of steroids with pre-treatment high-dose vitamin A supplements, but that may not be enough to reverse the effects of the other medications.
While all of this sounds very pessimistic, it is fair to say that one has to be cautious about laser resurfacing with your medical history. Fractional laser resurfacing is better than completely ablative laser resurfacing because it only treats a portion or fraction of the skin’s surface, leaving areas of normal skin between the vertical columns of the fractional laser beams. The best way to approach whether you are a good candidate or not is to do a test patch area. Only treat a small area first and see what the healing response is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few wrinkles and extra skin on my lower eyelids that I would like to get rid of. I don’t think I need any blepharoplasty surgery and have read about lasers and chemical peels. Which of these two lasts the longest or do they both last a comparable amount of time? Which is most natural looking result or is there no difference? Which is least likely to excessively tighten skin? I am curious as to why laser resurfacing is so popular over chemical peels. Which has the least downtime?
A: There is no evidence that either method, laser vs TCA chemical peel, is more effective or long-lasting on lower eyelid skin rejuvenation. Laser do have a higher risk of hypopigmentation. Both are commonly used and it is a matter of comfort and experience as to which method plastic surgeons use.
It is likely you may also benefit by a pinch lower blepharoplasty with a TCA peel but I would have to look at your lids to answer that question. This is a favorite method of mine for the lower eyelids because it works very well with a very small amount down time. It is also the most minimalist method to guarantee that lower lid skin would be tightened to some degree.
Lasers are more popular than peels today for a variety of reasons. First they are more ‘high-tech’ and with that comes the assumption that they produce better results. In addition, their high cost and the need for the manufacturers to sell them drives a lot of more visible marketing efforts.
Dr. Barry Eppley
Indianapolis, Indiana
Aging is inevitable and it begins to appear first around the eyes. While eyelid and brow lifts provide immediate and significant improvements, many would prefer to lessen these eye flaws without the costs and recovery of an operation.
There are a variety of non-surgical eye treatments combining neurotoxins, fillers, lasers devices and topical products. Which ones are used often follows the age of the person. Those in their 30s and 40s usually just need Botox to control their frowning and squinting wrinkles. Fillers and light and laser treatments are added for those in their 40s and 50s. At age 50 and beyond, surgery is needed to remove extra upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still needed to preserve one’s surgical investment.
Botox is the most known name when it comes to facial wrinkle reduction by injection. But it is not alone as two other injection drugs, Dysport and Xeomin, are also available. While there are some that believe one is better than the other, they all are really comparable. They all take a few days to a week to start working and their effects will last from three to four months. One is not more powerful than the other nor does one cost less. These injections are given by the unit and the cost per unit varies for each one but so does how they are prepared. As such their treatment costs are all about the same.
While Botox is the most common non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s. This can be treated with fillers to plump the area out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred. They can be delivered under the thin tissues of the lower eyelids with a low risk of lumps and irregularities.
While eye wrinkles can be held in check with Botox and fillers, they can not reverse certain skin problems. Blood vessels and brown spots can be removed with pulsed light treatments. These are often confused with lasers which they are not. When it comes to improving skin texture and reducing fine lines and wrinkles, laser resurfacing can provide improvements beyond what an eyelid lift can do.
Topical skin care products complement eye the benefits of injectable and energy treatments. The skin around the eyes is so thin that it responds well to many Vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Eyelashes and eyebrows can become one-third longer and thicker in a few months.
While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the wave of a laser wand away.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?
A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in removing acne scars. I am trying to decide between punch excision and dermabrasion. As I understand it with dermabrasion I will get minimal results on old and deep scars (however I am not sure what is meant by deep), but with punch excision I will be left with a small scar. As dermabrasion works best on newer scars, would a good option be to start with punch excision and then use dermabrasion to remove the resulting scar? or would dermabrasion or punch excision alone be the best option? or would there be another, better option. I am looking for the most promising option here, I have spend a lot of time and money on snake oil treatments and empty promises with no real results. Thank you for your time.
A: Thank you for your inquiry on acne scar revision. Punch excision is the only thing that will work for ice pick or deep acne scars. Dermabrasion works best on moderate-depth acne scars particularly of the saucer-shape variety. Laser resurfacing works best on more superficial or fine acne scars. The age of an acne scar is really irrelevant unless it is fairly new. The logic would be to work on the deepest scars first with punch excision and then use the skin resurfacing methods (dermabrasion or laser resurfacing) after.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m interested in learing more about dermabrasion or micropeeling. Can this be done on the eyelids? (above and below) Will this help reduce the beginnings of a fold in the top eye crease? I live two hours away. If you can answer these two questions about this procedure would help me determine if I should come in for a consultation.
A: By the way your question is phrased, it appears that you seek a non-surgical solution to the appearance of wrinkles on the eyelids. There are a variety of skin resurfacing methods that are commonly used on all other areas of the face so it is reasonable to ask about their use on the eyelids.
The eyelids represent skin that is very unique from that of the rest of the face. It is different primarily because it is so thin. Being thin makes it very sensitive with higher risks of scarring if the skin resurfacing method is not carefully selected and performed.
Microdermabrasion (superficial) and dermabrasion (deep) are not effective (microdermabrasion) or safe (dermabrasion) skin resiurfacing methods for use on the eyelids. Traditional laser resurfacing is not either for the same reason that dermabrasion should not be used, it penetrates too deep.
The use of laser micropeeling and chemical peels, however, are both effective and safe methods for the eyelids. Laser micropeeling at the depth of 20 microns or less, TCA (trichloroacetic acid) chemical peels of 15%, 25% and 35% as well as the newer Vi chemical peel are all potential choices. Which one of these is best for your eyelids will require an actual consultation to determine.
Another very effective option is the combination of ‘mini-blepharoplasties’ with chemical peeling. The actual removal of a small amount of excess skin and then tightening the rest can be a very effective eyelid wrinkle-reducer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have some acne scarring on my face that I`d really like to get rid of. I have a rolling icepick scar and I want to know if a deep chemical peel would help. It isn`t very deep. One maybe two layers deep. Help! What should I do?
A: To understand whether any form of skin treatment or resurfacing will reduce a specific scar, it is important to appreciate the depth of the scar compared to the thickness of skin. Then one can look at the treatment method and see if it can go to the level of the depth of the scar.
Let us, for the sake of this discussion, assume that facial skin thickness is 1mm or 1000 microns. (some areas of the face are thicker and some areas are thinner, but let’s use this simplistic number as it is easier to understand) The top epithelium usually occupies about 5% or so, around 50 to 75 microns. This is the part of the skin that peels and sloughs off and is easily regenerated. The rest of the skin, 95%, is a thicker collagen called dermis. It is into the dermis that all visible scars really go. Most visible scars are at least several 100 microns (100 to 500 microns) Pitted or icepick acne scars will usually go much deeper than even that level.
Microdermabrasion, for example, removes only 2 to 4 microns of skin. This is why it is not an effective scar treatment, it simple can’t go deep enough. Microlaser peels, or superficial laser peels, remove skin from 10 to 50 microns. They have a minor effect but it will take a lot of treatments to have any visible scar reduction. Deeper CO2 laser peels do go down 200 to 400 microns which is why they can be more effective for scar reduction. But a laser peel can not go too deep (greater than 400 microns or so) or it will be a source of its own scarring.
Chemical peels, even deep ones, do not reach these laser depths. This is why a chemical peel, of any sort, is not an effective scar treatment.
Dr. Barry Eppley