The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.

While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.

While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.

Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.

Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

The importance of a smile in human interaction can not be denied. It is a seemingly simple facial expression that actually involves a large number of facial muscles that must work with great precision to create what one recognizes as a genuine smile. There are 43 muscles in the face and the number that help make a smile has been debated to be between 17 and 26 of them.  But not all smiles look and feel the same.

Scientific research has actually been done to discern the differences between a genuine and a fake smile. Analyzing photographs of people smiling at an actual positive event and then contrasting that with the same people faking a smile, the subtle difference between the two is a function of the number of muscles activated. In a genuine smile the elevator muscles of the upper lip (zygomaticus major) as well as those around the eye (orbicularis oculi) are activated. This creates an upper lip that moves upward, eyebrows that are pulled down and cheeks that are lifted up. This creates crow’s feet wrinkles at the corner of the eyes as the lips move in smiling. In a fake smile, the lip is lifted in a grin but the orbicularis muscle is not activated and there is little to no change around the eyes. The change in and around the corner of the eyes is what changes the real from the faked smile.

What is the relevance of understanding the mechanisms of smiling? Botox and the art of aesthetic facial expression management is the reason. Botox is powerfully effective for reducing glabellar furrows, horizontal forehead creases and crow’s feet. But when it is ‘overdone’, one can appear unnatural. Understanding the mechanism of the smile explains why this happens.

When enough of the orbicularis muscle is deactivated, crow’s feet wrinkles are either significantly reduced or eliminated entirely. Thus when one smiles, even in a completely genuine smile evoked from real emotion, it may appear fake in the person who has been treated by Botox. Many patients express concern that if their forehead has too much Botox it will make them look unnatural. But the science of facial expression indicates that the area around the corner of the eye is the real culprit.

To get the optimal benefits from Botox, the concept of less is more may really apply. A more conservative approach to Botox dosing with the goal of reduction rather than elimination of muscle movement leads to more natural results. This is why I prefer ni more than 16 total units for both sides in the crow’s feet area…so patients can maintain a natural and genuine smile.

Dr. Barry Eppley

Indianapolis, Indiana

A recent news report indicates that more younger people are jumping into plastic surgery than ever before. Delving into the report shows that this is not for invasive surgery but is based on the migration of Botox use into patients down into even 20 year olds. According to the 2012 Plastic Surgery Statistics Report put out by the American Society of Plastic Surgeons, Botox use in 20 years olds rose by 8% last year. Much of that use was for wrinkles between the eyebrows and in the forehead as it is in older patients.

Botox in many ways is little bit like a fountain of youth in a syringe. It provides a near immediate reduction in frowning or scowling as well as horizontal forehead wrinkles. Its benefits in those with such forehead signs of aging is well recognized and, as a result, Botox has worked its way into a mainstream beauty treatment that is now not much different than getting coffee at Starbuck’s.

As could be predicted, there is a trend towards younger patients doing prophylactic aging treatments rather than waiting until they actually have the ‘symptoms’. These 20 year olds see getting Botox as a jump on the aging process using it as a preventative measure rather than an actual treatment. There is actually real science behind that approach because static skin wrinkles are always the sequelae of dynamic wrinkling beforehand. Like repeatedly folding a piece of paper (dynamic wrinkling), eventually a permanent crease will result. (static wrinkle)

While Botox is enormously safe and has no permanent side effects, the concerns in young people with its use are economic and not aesthetic. Is a young person really prepared to maintain the results of Botox over the long haul? Getting it at least twice a year, Botox would cost, on average, around a minimum of $6,000/10 years. While it would definitely defer the onset of wrinkles, its consistent use in this young age group may be cost prohibitive.

As a result of cost, younger people may be advised to defer the use of Botox until their mid- to late 30s. In the interim, there are more economically efficient methods of skin wrinkle prevention including sunscreen and excessive sun avoidance, not smoking, regular microdermabrasions and chemical peels and daily use of topical skin agents.

Dr. Barry Eppley

Indianapolis, Indiana

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