The concept of a Mommy Makeover plastic surgery procedure is about combining abdominal and breast reshaping in one operation. The breast and abdominal components are not new and include many well known procedures such as tummy tucks, breast implants, liposuction and breast lifts in whatever combination each individual women needs. While the effects of a Mommy Makeover can be dramatic, breast and abdominal procedures are major surgery with significant recovery as well.

But there are numerous other procedures of lesser magnitude that could also be lumped into the Mommy Makeover category and consist of a variety of ‘nips, tucks and sticks’ that create effects that mothers would also like. Here are some of the most noteworthy.

BOTOX  For reduction of those facial expression lines that come from the stress of balancing mother and wife roles, Botox injections are probably the most common injectable Mommy procedure.

Vi/PERFECT PEELS With only a few days of redness and flaking, these medium-depth facial peels are essentially painless to go through and provide a real boost to one’s complexion. A few of these a year will keep a mother’s skin radiant and glowing.

C-SECTION SCAR REVISION For those women that don’t need a tummy tuck and have a noticeable c-section scar with just a little pooch above it, widely cutting out the scar can produce a flatter upper pubic area. This scar revision can be combined with some lower abdominal liposuction for an additional and wider flattening effect.

UPPER LIP PLUMPING Some well placed Restylane or Juvederm injections into the upper lip has an instant youthful volumizing effect. This is particularly evident if the cupid’s bow and philtral columns are accentuated.

NIPPLE REDUCTION Breast feeding can elongate the nipple which can be a source of embarrassment and out of proportion to the size of the areola. Under local anesthesia, the nipple length can be reduced by half or more.

EARLOBE REPAIR Fixing stretched out ear ring holes or complete tears through the lobe can allow old or new ear rings to be comfortably worn again.

BELLY BUTTON REPAIR (Umbilicoplasty) Pregnancies can change an innie belly button to an outie due to a small hernia through the umbilical stalk attachment. Tucking the peritoneal fat back through the hole and reattaching the stalk of the belly button back down to the abdominal wall will recreate that an old inne look again.

EXILIS For those stubborn fat areas that just won’t go away despite some diet and exercise, this non-surgical fat treatment can easily fit into a busy mom’s schedule. It takes a series of treatments to see the effects but there is no downtime with 30 minute in-office treatment sessions.

These mini-Mommy Makeovers provide changes that do not require major surgery or recovery and can fit into anyone’s hectic schedule.

Dr. Barry Eppley

Indianapolis, Indiana

Botulinum Toxin A, more commonly known as Botox, is used for facial cosmetic enhancement to soften the appearance of expressive wrinkles by weakening the muscles that cause them. In addition, because Botox is a muscle paralyzing agent, it can also be used to weaken agonist and antagonist muscles to create a lift in certain areas of the face, such as the eyebrows and the corner of the mouth. But these injections, if not precisely done, can cause the opposite effect causing potentially leaving patients with a droop, otherwise known as ptosis.

The eyebrow allows for many lift options because of the different muscles that surround it.  Perhaps a patient feels they look tired and aged, maybe even angry. A medial brow lift can help to bring the middle of the brow up just enough to eliminate the heavy, tired look some people have. Female patients typically prefer to have the lateral part of their brow lifted, for a more aesthetically pleasing appearance. In addition, some people may ask for, although many warn against a “Mr. Spock” brow lift. All of these options along with a few others make it easy to see why the concept of a “Botox Brow Lift” is so appealing.

Muscles such as the corrugator, orbicularis oculi and procerus all work to move the forehead and eyebrows and help to create all of these lifts. These muscles each pull in different directions, some lifting and others depressing, therefore known as agonist and antagonist muscles. Botox is used to paralyze or weaken one action, to enhance the opposite action. A patient is left with brow ptosis instead of a brow lift when the wrong part of the muscle is injected, or if any Botox diffuses to another muscle.

Eyelid ptosis (lid droop) is a well known side effect or complication of Botox when injected around the area of the eye. Ptosis has been found to occur in approximately 5% of patients who receive Botox injections and can occur up to two weeks after receiving the injections. One of the main causes of ptosis from Botox injections is the diffusion of the solution into the levator palpebrae superioris muscle, the elevator muscle of the upper eyelid. This muscle is responsible for elevation of the upper eyelid, allowing it to open fully when the muscle contracts.

Ptosis of the eyebrow with Botox can be largely avoided with careful injection technique. All injections should remain at least above the eyebrow and never injected directly into the eyebtow or brow bone area. In addition, some research says that massage by the injector, pulling the solution up and away from the eyebrow may also help prevent ptosis from occurring. Finally, some research recommends patients remain in a vertical position for at least two to three hours after their injections while the toxin is binding. Once the toxin is bound, there is less to diffuse, therefore decreasing the risk of ptosis.

Despite careful injection techniques, Botox injections into the forehead and around the eyebrow area can still happen. We see it about once a year in our practice. When it happens, it is understandably disconcerting to the patient. There are no drugs to directly reverse or unbind Botox and more Botox injections elsewhere will not undo the upper eyelid ptosis.

One treatment option is the use of a prescription eye drop, Apraclonidine (Iopidine) 0.5%. Apraclonidine causes Müller’s muscle (which lies underneath the weakened levator muscle) of the upper eyelid to contract, lifting the upper eyelid anywhere from one to three millimeters. This medication is typically used to treat glaucoma because it increases muscle tone and decreases intraocular pressure. The only major side effect is that it has been found to cause contact dermatitis. Apraclonidine should be administered one to two drops in the effected eye three times a day until the ptosis resolves.

Without the eye drop treatment, the adverse effects of Botox will wear off…just like it does for its cosmetic effects. However and fortunately, the negative effects of upper eyelid ptosis seem to wear off much sooner than that of its positive cosmetic benefits.

Lora Dillman, RN

Dr. Barry Eppley

Indianapolis, Indiana

Botox is now an iconic brand of cosmetic product that is instantly recognizeable. Originally approved for use in 2002 to temporarily smooth frown lines between the eyebrows, it has grown in the past decade to be a near 2 billion-a-year business. While there are numerous approved and off-label medical uses for Botox, the amount used for its pure cosmetic effects is reported to be about half of all its sales.

Botox is so well known and has such doctor and patient loyalty that it dominates the cosmetic toxin market reportedly accounting for 85% of all sales. Two other cosmetic neurotoxins are also available for clinical use, Dysport and Xeomin, but they have failed to make a significant dent into Botox’s dominance. This is because they do not provide any product improvements…they are not substantially different in effectiveness or duration and they are not significantly cheaper.

This may all change in the near future, however, as Johnson & Johnson has recently announced that they will seek FDA approval next year for an anti-wrinkle drug. They have developed a neurotoxin that is designed to be comparable to Botox in terms of effectiveness and safety. Clinical trials have been done and are ongoing but whether it will be ‘better’ than Botox is not clear. My suspicion is that it will be essentially the same as a botulinum toxin or some derivative as not yet been found that acts quicker, has a more profound effect or, most importantly, lasts longer.

But J & J has one advantage that Botox’s other competitiors don’t have. They are a 70 billion dollar giant with huge name recognition. They can put the muscle behind the marketing and have a sales force that can help drive the product into the marketplace. Through their more recently acquired Mentor subdivision, which is the largest manufacturer of breast implants, it can team up to offer incentives to both plastic surgeons and patients alike to use their product. This will likely allow them to leapfrog right past Dysport and Xeomin to be come the ssoft drink equivalent of Pepsi to Coke.

Plastic surgeons and patients alike love Botox and patients certainly yearn for it to last longer or cost less. While J & J’s yet unnamed neurotoxin probably won’t last longer or work any sooner after injection but the competition it brings may ultimately lead to some economic benefits for the consumer.

Dr. Barry Eppley

Indianapolis, Indiana

Despite the relatively weak state of the U.S. economy, the number of cosmetic procedures continue to increase. According to the American Society of Plastic Surgeons, there was a 5% increase in the number of aesthetic procedures from 2011 to 2012. With over 14 million procedures performed, this is the third year in a row that an increase in these procedures occurred. But the procedure increase is not related to actual surgery but in minimally invasive procedures such as Botox, skin treatments and laser hair removal. Actual invasive surgery number have remained stable but with no real increase.There are a number of reasons why minimally invasives have increased from less discretionary income for surgery, a growing number of middle-aged group of patients who are beginning to show their age to an expanding number of non-surgical treatment options. Leading the way in minimally invasive therapies is Botox injections by a wide margin with over 6 million treatments in 2012. Botox treatments continue to increase because they not only work, are quick and easy to do but an increasing number of people of all ages are at least trying this aesthetic therapy that has worked its way into the fabric of modern American society.

At this point in time, almost everyone has heard of Botox and know it as a changer of facial expression. To those people who receive these neuormuscular injections, they are aware that to receive it is given in dosages known as units. They often are aware of the exact units that they have received because the cost of their treatment is priced per unit in many practices.

While the most common area to receive Botox injections is in the periorbital region (forehead and around the eyes), the perioral region (upper lip and chin) is also treated in a much lesser numbers of patients. What has always been interesting has been the dose differences between these two areas in the amount of Botox to get an effective result. The perioral area requires much fewer injected units by a significant amount. To date, no one has understand why such dose differences exist

In the recent February 2013 online edition of the JAMA Archives of Facial Plastic Surgery, a paper was published entitled ‘Electromyographic Differences Between Normal Upper and Lower Facial Muscles and the Influence of Onabotulinum Toxin A’. An electromyographic (EMG) study was done to investigate why upper facial muscles require substantially greater paralysis than lower facial muscles to get a visible aesthetic wrinkle reduction effect. In 26 adults the dose response to Botox injections of the corrugator muscles in the forehead (20 units) and the depressor anguli oris (DAO) muscles of the chin. (4 units) were given. Muscle activity was tested both before and after the injections. While the activity was similar in the upper and lower facial muscle prior to the injections, the upper facial muscles had a significantly greater response to a much higher dose of Botox. This suggests that there is a need for near-total paralysis of the forehead muscles to get a good result. The lower facial muscles are much more sensitive to Botox and are effected by a much lower dose.

Why do the upper and lower facial muscles differ in their response to Botox? There may be some inherent susceptibility differences in the motor endplates between the muscle groups to the effects of Botox. It may be equally possible that, despite being dose-dependent, that it merely requires less muscle weakening in the lower face to create the desired aesthetic result. Two units to the DAO muscle (to create a mouth corner upturn), two units to the paranasal muscles (to improve a gummy smile) or 6 to 8 units for upper lip wrinkles can create good results. Conversely, a few more units can create aesthetic problems such as smile and lip animation disruptions. Thus the mouth area has a much more narrow therapeutic window than the forehead muscles.

Botox is effective in both the upper and lower face for expression control and wrinkle reduction. But the lower doses needed in the lips and chin means their treatments are very economical but must be precisely placed to avoid aestheti lip and mouth problems.

Dr. Barry Eppley

Indianapolis, Indiana

Hyperhidrosis, defined as abnormally excessive sweating, can affect many areas of the body including the hands and feet, groin area and also the armpits.  Hyperhidrosis affects about 3% of the U.S. population and  is when the amountof sweat produced is much more than is needed to regulate body temperature. As a result it interferes with some activities of daily living and is a constant source of social embarrassment. The specific cause of this condition is unknown although approximately 30-50% of patients who suffer from it do have a genetic predisposition to it.

Hyperhidrosis is more severe in warmer weather and less severe in colder climates. One common complaint found in many patients with hyperhidrosis, regardless of the body area affected, is that they get nervous because they know they are excessively sweating, which in turn then causes the body to produce more sweat.

While topical treatments have been around for decades, the most potent and effective treatment is by injection. The Food and Drug Administration approved the use of Botox, OnabotulinumtoxinA, injections in 2004 to treat axillary hyperhidrosis (underarm sweating). These injections are recommended for use in adults, once a patient has tried other topical agents such as ointments, powders and sometimes even electrical stimulation therapies, with no to limited success. Examples of some treatments are aluminum chloride antiperspirants (prescription deodorants) and oral anticholinergic medications such as Oxybutynin (Ditropan) and Benztropine (Cogentin). All of these treatments aim to reduce axillary hyperhidrosis by treating the symptoms of the condition.

Botox injections also aim to reduce axillary hyperhidrosis, but do so by blocking the neural control of the sweat glands, so they are not stimulated and sweat is not produced. Results from these injections are seen within four weeks of the injections and last approximately six to seven months. It is recommended that at least 50 units of Botox (OnabotulinumtoxinA) is injected into each axilla, which will cost a patient anywhere from $1,000-$1,500 per treatment depending on the price per unit at the facility administering the injections. The side effects associated with this treatment option are very minimal and include possible pain at the injection site, flu-like symptoms, headache, itching and anxiety.

Botox may be just the alternative many people who suffer from the previously undiagnosed or misdiagnosed condition, are looking for without having to undergo surgery. In the clinical studies performed both in the United States and Europe to approve Botox as a treatment for axillary hyperhidrosis, patients found that they had improved quality of activities of daily living, such as changing their clothes less frequently throughout the day due to decreased sweating. What was once an embarrassing and somewhat debilitating condition has an FDA-approved treatment that is not only effective, but also minimally invasive.

Surgical options for axillary hyperhidrosis do exist and include excision and sweat gland removal/disruption using a variety of techniques. Excision works by removing axillary skin that contains the abnormal sweat glands. While very effective, it leaves a long scar that is prone to widening and can never remove all the affected skin given since it is rarely limited to what the excisional pattern can remove. Removing the sweat glands by various ablation techniques on the undeside of the skin has been done for years. It has most recently been advocated by using a fiberoptic laser probe (Smartlipo) to ‘burn’ the sweat glands by running it along the underside of the dermis of the skin. While advocated by some, I have found its effectiveness to be only temporary as it more likely disrupts the neural connections to the sweat glands rather than actually eliminating (melting) them.

The one axillary hyperhidrosis technique that I find most effective, old as it may be, is to open cautery of all hair bulbs that can be exposed without an excessively long axillary incision.  Many sweat glands are aligned with hair follicles so cauterizing the black hair bulbs on the underside of the skin assures some permanent reduction in sweat output

Lora Dillman, RN

Dr. Barry Eppley

Indianapolis, Indiana

On the final day of 2012, it is interesting to look back and see what some of the trends and interests were in plastic surgery over the past year. While plastic surgeons may perform the surgeries, the interest of patients drive the number and type of surgeries that are done. For this reason, it is noteworthy to look at what procedures were most searched for online.

The popular plastic surgery website, Real Self, reported its top searches for 2012 based on over 50 million searches. The top 10 included tummy tuck, breast implants/augmentation, rhinoplasty, Brazilian butt lift, Botox, Coolsculpting, Breast Reduction, Cellulaze and Liposuction. The procedures that had the greatest increase in interest over the past year were the Brazilian butt lift (up 28%), Cellulaze (up 32%) and labiaplasty. (up 22%)

These search results, albeit just from one source but a very reliable one, provides insight into the public’s evolving interest in face and body modifications. Three of the historically popular and still highly performed procedures, tummy tuck, breast augmentation and rhinoplasty, remain on the top of the list. Not surprisingly, flatter stomachs and more shapely waistlines, larger breasts and nose reshaping are still highly desired. While they were far from being up on % increase in searches, it would be hard to do so when you have been so popular for decades.

The popularity of the Brazilian butt lift, a procedure that was largely unknown just less than a decade ago, is a reflection of society in general. Largely an ethnic procedure for Hispanics and African-Americans, it parallels the changing population mix of the U. S.  It is also an indication of the influence of celebrities on plastic surgery. (the Kardashian effect) While buttock implants have been around for awhile, the allure of using one’s own natural fat and getting some fat reduction in other body areas as part of the procedure is undeniably appealing. The large percent increases in interest in the procedure over the past two years is primarily a result of its ‘newness’. But I would wager five or ten years from now, buttock augmentation will be a permanent member of the all-time top 10 plastic surgery procedures of any year.

Coolsculpting and Cellulaze have made their way on the list because they are new body contouring technologies. Both have been approved for use less than five and two years ago respectively and offer non-surgical methods for common concerns about fat reduction and improvement in the appearance of cellulite. Whether they will be on the top ten list a few years from now will depend on how effective they turn out to be in widespread use.

Botox, one of the few drugs used for aesthetic changes, keeps it place in the top ten list and may well be the number one cosmetic procedure performed in the U.S. by number of treated patients. (amongst surgery and minimally invasive procedures) Despite the large number of treated patients, it is not searched as much as some of the other popular procedures largely because its effects and benefits are so well known.

Labiaplasty, reshaping of the external vagina, is gaining in popularity and public awareness. Once just done by a few gynecologists, it is becoming more widely practiced by plastic surgeons as well. As women become increasingly aware of its potential benefits, the interest in how and where it can be done is rising as well.  

Dr. Barry Eppley

Indianapolis, Indiana

Botox, and its smaller market competitors of Dysport and Xeomin, have literally changed the face of wrinkle treatments. Weakening or paralyzing select facial muscles has led to a host of undesired facial expressions being reduced. Although these effects are not permanent, the aesthetic improvements provided has made Botox a billion dollar drug in sales. This has led, perhaps not surprisingly in the competitive anti-aging and cosmetic market, to a variety of marketing efforts to capture patients that have discrete facial expression issues.

The most recent publicity surrounding ‘Pokertox’ is a prime example of a marketing strategy on the well known effects of Botox. This is the application of Botox to supposedly enhance a card player’s face to create a ‘poker face’, masking any facial expressions that may reveal what type of hand they may have. This appears to be for the more professional poker players who may know what their unconscious facial expressions (tells) are. This would have to involve such expressions as eyebrow raising, squinting or corner of lip changes, all areas that Botox can alter facial expressions well. Given that the effects of Botox is only temporary and its costs, one would have to assume that these treatments would only be for the most successful poker players.

Not being a poker player or a gambler, I would have no idea if Botox could really be effective for this type of facial expression management. While there may be uncertainty as to its effectiveness, there is no uncertainty that it is a publicity gimmick.  The simplicity of the Botox name lends itself to a variety of spinoffs based on its name. You can just about put anything in front of the word Tox and come up with a type of Botox treatment. Pokertox is not the first that has used this approach. ChinTox, Notox and Eyetox are some of the examples of doctors and skin care manufacturers capturing on the successful and well known effects of Botox.

If mimicry is the sincerest form of flattery, then Botox can expect more Tox variations in the future. The company undoubtably doesn’t mind any marketing that helps promotes Botox use although it may be less pleased with any non-injection product that suggests its effects are remotely comparable to an injection treatment. ‘Toxology’ is alive and well in facial aesthetics with new names but not necessarily new effects.

Dr. Barry Eppley

Indianapolis, Indiana

While a smile is a critical human expression that exposes one’s pearly whites, too much tooth and gum show is deemed undesireable. Known as a gummy smile, it is technically defined as any gum show that exceeds more than 2mms above the tooth line when smiling. While that is a good quantitative measurement of it, many people with that amount of gum show are not bothered by it. When the amount of gum show when smiling exceeds 5mms or more, almost everyone is bothered by it.

When one has excessive gum show it appears that one has a longer face. Often times this is true and some degree of vertical maxillary bony excess exists. But the amount of vertical maxillary excess may not be significant enough or the patient may not want to go through a maxillary impaction osteotomy to make the formal correction.

Alternative soft tissue strategies for treatment of the gummy smile is directed towards either lengthening the upper lip, decreasing the upward muscle pull of the smile muscles or a combination of both. I have successfully used the surgical approach of a V-Y mucosal advancement, transaction of the levator  superior labii elevator muscles and a shortening vestibuloplasty to lessen the amount that the upper lip elevates which then decreases the amount of gum exposure seen. Even though this approach works, and is a fairly easy surgery to undergo, not every gummy smile patient wants to have surgery to treat it.

In the September 2012 issue of Plastic and Reconstructive Surgery, an article was published on ‘A Simplified Method for Smile Enhancement: Botulinum Toxin Injection for Gummy Smile’. In a non-surgical method, Botox injections were placed into the levator labii superior nasalis muscle using 2 to 4 units per side. Over a 15 month period, 52 patients (smiles) with excessive gum show were treated. The outcomes of the injections were evaluated by photographs and questionnaires. Average patient satisfaction on a 10 point scale was 9.75. In all patients, the positive effects of the injections (decreased gummy smile) persisted for 3 or more months.

Having used this injection technique myself, the sheer simplicity of this approach makes it the first treatment that a gummy smile patient should have.  At just 4 to 5 units per treatment, this makes its $100 price tag (or less) very affordable. That is roughly 1/3 the cost of treatment of the glabellar furrows (the most commonly done facial Botox treatment) to improve an aesthetic problem which is equally distracting. Even though its effects last the usual Botox time of 3 to 4 months, two quick injections on each side of the nose restores the smile improvement.

My recommendation for gummy smile patients is to give Botox a try and judge the benefits themselves. If eventually they want to move to a more permanent and profound correction then a soft tissue surgery approach can be done.

Dr. Barry Eppley

Indianapolis, Indiana

The popularity of Botox injections for facial wrinkle reduction continues to increase. In the U.S. last year alone nearly five million Botox treatments were given. And this does not include treatments for medical conditions. Like all drugs, there are side effects but they are far and few between. The most significant aesthetic one is brow or eyelid sagging from injecting too close to the eyebrow. But because Botox is a poison, dilute as it may be, some patients worry about whether there are toxic side effects such as ending up being paralyzed or even death. The good news is that there has never been a case of paralysis or death after the administration of Botox when given for aesthetic reasons. Thus, Botox has a tremendous track record of safety for an injected drug. It is so safe because of its margin of safety. It is estimated that it would take upwards of 35,000 units of Botox to be injected to cause paralysis and death. Given that the typical dose for facial wrinkle reduction is anywhere from 20 to 50 units, it is easy to see why Botox is so safe.