Elevation of low or aging brows can be done by a variety of browlift procedures. But since its introduction in the mid-1990s, the endoscopic browlift has remained a popular method. Its appeal is in the much smaller incisions and the lack of scalp morbidity, such as scar widening and alopecia and persistent numbness that occurs from a transverse scalp incision regardless of whether it is at or way back in the hairline.

The advantages of the endoscopic browlift has never been an issue of debate, the reduction or elimination of complications. What is not as clear is whether it offers similar aesthetic benefits as more open traditional browlift operations…is it effective and does it have lasting effects? Given how long the endoscopic browlift has been around, one would assume that the clarity of its aesthetic effectiveness is well established and documented. While plastic surgeons, including myself, find it to be very effective in the properly selected patient its longer-term stability is less clear.

In the May 2013 issue of the journal Facial Plastic and Reconstructive Surgery, a published study shows that the majority of patients who had endoscopic browlift procedures were satisfied with its long-lasting results. The study reviewed 143 patients over a 13 year period based on questionnaires of satisfaction and postoperative complaints as well as before and after pictures of eyebrow-to-eye measurements.

The study showed that the vast majority of patients were women (96%) who had an average age of 60 years and was rated successful by 93% of patients with 96% saying they would recommend the bprocedure. Three-fourths( 64%) said they looked younger and less tired. Some scalp numbness and itching persisted 3 to 6 months after surgery. Photographic analysis found that brow elevation was maintined to at least 2 years after surgery with an average elevation of over 5mms.

The endoscopic browlift significantly reduces the mobidity of scalp scars with a high patient acceptance rate. This study shows that there is long-term stability of the brow elevation. Thus scalp mobilization (epicranial shift) does work in lieu of forehead or scalp tissue excision. This study did not assess what happens to the frontal hairline, however, which I know moves back (lengthens) as the brows are lifted. For those patients that already have a long forehead, the open hairline browlift will need to be used instead.

Dr. Barry Eppley

Indianapolis, Indiana

Excessive sweating is a not uncommon problem that can result in the need for frequent antiperspirant applications and even constant clothes changing. Known as axillary hyperhidrosis, it is an embarrassing and very problematic problem for those so affected. The historic treatments have been strong astrigents which often are minimally effective or with limited duration of effect. The introduction of Botox injections was a revolutionary treatment for axillary hyperhidrosis that is dramatically effective even though its effect are only temporary and fairly expensive.

The new miraDry treatment, however, offers a lasting non-surgical solution as an office treatment. The miraDry is a device that delivers electromagnetic energy, similar to a microwave, to the underside of the skin where the sweat glands reside. The device delivers controlled energy waves to permanently shrink the sweat glands. Because the device involves the creation of heat, the underarms must first be numbed.

Get lasting results with a quick, non-invasive procedure performed in your physician’s office. The miraDry procedure uses the only non-invasive technology that is FDA cleared to provide lasting results. The procedure uses precisely controlled energy to eliminate underarm sweat glands. Because the sweat glands don’t grow back once eliminated, the results are dramatic and lasting.

The miraDry technique involves two procedures that are spaced 3 months apart to achieve the best results. Because the sweat glands don’t grow back after the treatments a partial to complete reduction in overactive sweating is achieved. This is an FDA-approved device and treatment in which the clinical studies showed an average 82% reductionin sweating.

There is no downtime after ther procedure. Patients may resume all normal activities right after the treatment. There usually is some mild soreness and swelling in the treated areas which takes about a week to go away. Temporary numbness of the armpits is also common which will take longer than the swelling to go away. These are all expected reactions from a device whose effects are based on ‘microwaving’ the sweat glands.

Dr. Barry Eppley

Indianapolis, Indiana

Background: Gynecomastia is a common male problem that affects men of all ages. While it is most commonly recognized in teenagers after puberty, it actually affects middle-aged and older men almost as frequently…and often not less aesthetically bothersome. The older man with obvious breast tissue jiggling in their shirt is a well known phenomenon that is quite easy to find.

When gynecomastia becomes significant, the enlarged breast tissue creates a visible mound. If it is large enough or in an older man where the chest skin is more lax, an actual breast ptosis can occur. This is where the breast mound actually hangs off of the chest wall laying on or over the inframammary fold. While this is bothersome enough for a woman, it is particularly unsettling in a man. No amount of weight loss or exercise will solve this significant ‘man boob’ problem.

The most frequently used gynecomastia surgery techniques include liposuction of all types and open excisions done through an areolar incision. But this more advanced degree of gynecomastia is not going to be corrected by even a combination of areolar excision and liposuction. This is because neither can adequately treat a significant part of the gynecomastia problem…extra or loose skin.

Case Study: This is a 47 year-old male who wanted to get rid of his ‘breasts’. He was also an athletic male who used to work out a lot but had not done so over the past several years. He had gained weight, he developed breasts and his chest dropped. This was a great source of embarrassment for him.

Under general anesthesia, overall liposuction of the chest was initially performed removing about 250cc of aspirate per side. A horizontal elliptical excision of skin was then removed along his inframammary folds but staying below the nipple-areolar complex. Incisions were then made around the areolas and the upper chest skin flap undermined. This allowed the remaining breast mound carrying the nipple-areolar complexes to be pushed upward as the chest skin flap was brought down and closed along the inframammary fold. The skin overlying the buried nipple-areolar complexes was removed and the complexes brought out and sewn to the skin in a more elevated position.

His postoperative course included the use of a drain in each chest for five days. All incision lines had been taped and they were removed a week later. He wore a compression wrap for several weeks after surgery. He went on to heal uneventfully with a dramatic change in the appearance of his chest, being flatter, absent of a breast mound and the nipples back in an elevated and more aesthetically pleasing location.

Gynecomastia surgery that includes wide horizontal excision and nipple-areolar transposition is one of the most extensive treatment methods. But when a large and hanging breast mound exists, this is the only effective approach. While it involves bigger incisions, the recovery time is not much longer than most other gynecomastia surgeries.

Case Highlights:

1) Large gynecomastias that involve breast mounds that hang off of the chest wall with a low nipple position will not respond to traditional gynecomastia treatment methods.

2) Breast tissue and skin must be removed but traditional breast reduction methods in men introduce unacceptable amounts of chest scarring.

3) A horizontal excision of breast tissue and skin with superior nipple transposition can effectively lift and flatten the chest with an acceptable scar location and a preserved nipple in large male gynecomastias.

Dr. Barry Eppley

Indianapolis, Indiana

The use of implants for body augmentation has been around for over fifty years. Breast implants are the most well known and account for the majority of all body contouring implants placed. But there are a variety of other body site implants that are recognized by most even if they occupy a small number of all body implantations performed. Implants exist for the chest, buttocks, arms and calfs. The numbers of these implant sites is increasing along with the array of implant options that are available for them.

One would think that just about every body site that could be augmented or implanted has been…but this is not true. One new area for body augmentation is that of the hips or thighs. Depending upon how you define this location, the goal is to have more curvature to the upper outer thigh. This seems ironic since most plastic surgery efforts are spent trying to reduce fullness in this area by liposuction. But there are women (and transgender males) that want a more curvaceous look to their outer thighs which is naturally very straight.

Upper thigh or hip augmentation can be done with a very soft silicone implant placed beneath the fascia overlying the outer thigh muscles. The surgical approach for the implant’s insertion is a 3 to 3.5cm horizontally oriented incision over the trochanteric region. The underlying fascia identified over the vastus lateralius muscle and opened where a blunt instrument is used to make the pocket. The implant itself is unique as no standard hip implant exists due to the newness of the application and the rarity of its request. I modify other existing body implants, most commonly contoured silicone carving blocks of sizes about 16 cms. long, 9 cms wide and 2 cms thick to fit into the pocket. Since they lie under the fascia and on top of the muscle, their contours are not seen on the overlying skin.

Other than some tightness of the outer thighs and the potential for infection or seroma (fluid collection), the risk of complications is fairly lower. The anatomy in this area has no major blood vessels or nerves. The muscle is not entered or violated so this hastens recovery. The only nerve of consequence is the lateral femoral cutaous nerve which supplies feeling to the lateral thigh, but its course is above and in from of the location of the incision. Recovery is fairly short in terms of returning to normal activities but strenuous activity and exercise requires waiting a full month after surgery.

The hip or upper thigh implant provides a curve or fullness to the upper outer thigh. These relatively thin slightly convex silicone implants are placed subfascially on top of the muscle to augment an otherwise straight leg line. For those women who have little fat to give for fat injection hip augmentation, an actual preformed implant is an alternative body contouring option.

Dr. Barry Eppley

Indianapolis, Indiana

Rejuvenation of the aging face has well established methods for correcting the upper (browlift) and lower face (lower facelift/necklift) that produces consistent and satisfying results. But the face does not age in just individual subunits and the midface has similar aging issues that are uniquely different. Sagging cheeks, lower eyelid hollowness and lines and folds under the eyes present challenges for successful rejuvenation.

The development of midface rejuvenation techniques has historically lagged behind that of the upper and lower face. Only in the past decade has the concept of midface lifting emerged. The vector of the midface lift is different than that of a facelift being more vertical than oblique in orientation and more closely resembles the direction of a browlift. But it has been associated with significantly more complications and dissatisfaction than either browlifts or facelifts.

The factors that contribute to midface rejuvenation complications are several fold. First, most midface lifting techniques go through the lower eyelid and require resuspension after the tissues are lifted. This places the lower eyelid at risk for sagging or ectropion due to the tension placed on it and the very delicate suspension system of the lower eyelid which is easily disrupted. Secondly, where to attach the lifted cheek tissues to is limited and adequate bony support may be lacking.

As a result of this midface conundrum, a wide variety of open and endoscopic midface lifting techniques has developed. There is no consistent midface rejuvenation technique and this has lead to a lot of confusion on the part of both surgeons and patients alike.

To aid surgeons in midface analysis and in the selection of the most successful rejuvenation strategy, a paper on this topic published in the March 2013 issue of the journal of Facial Plastic and Reconstructive Surgery. A retrospective review was done on 150 patients who had midface rejuvenation procedures done by a single surgeon. The procedures included cheek implants, fat injections, limited and full midface lifts and facelifts. The vast majority were women (93%) with an average age of 51 years as would be expected. About one-third of patients had more than one treatment for their midface aging. Patient dissatisfaction in this study was 14%. Fat grafting alone had the highest rate of dissatisfaction of all treatments. The rate of patient dissatisfaction was associated with malar hypoplasia (skeletal deficiency) and loss of skin elasticity.

What makes midface rejuvenation unique from a facelift is that the degree of skeletal support is significant. No matter how well the cheke tissues are lifted, failure to achieve an aesthetically pleasing or a sustained result is doomed if the cheek bone does not have adequate projection to support it. The use of cheek volumizing through implants is needed in such cases. When the cheek skin has poor elasticity, pulling up alone again is inadequate and adding skeletal support needs to be considered.

Dr. Barry Eppley

Indianapolis, Indiana

Facelift surgery is well known to lift, remove and tighten skin that is recruited from the jowls and neck. In its most simplest form, a facelift chases sagging and loose skin from the neck and jawline back to where its removal offers the best incision placement and resultant scar creation…in and around the ears. In its infancy, facelift surgery was all about just removing skin and the wrinkles that it contained, hence the original name of rhytidectomy. (the removal of rhytids or wrinkles)

But for decades the lifting of an aging face has gone deeper to involve more than just skin. A layer under the skin, known by the acronym SMAS (submusculoaponeurotic system), has been lifted as well. The ability to provide deep lifting to the SMAS of the face increases the longevity of a facelift’s effects and helps reduce skin surface irregularities such as abnormal looking pull lines and other facial distortions.

The concept of SMAS modifications in facelifts has undergone a tremendous amount of scrutiny from anatomic dissections published in journals to endless roundtable discussions at innumerable plastic surgery meetings. Some plastic surgeons endorse its most extensive use and  these procedures are generally called ‘deep-plane facelifts’. Other plastic surgeons have an opposite approach and use minimal to no manipulation of the SMAS in their facelifts based on the premise of a quicker and less complicated surgery. It is this group of facelifts that have the most diverse number of monikers such as Lifestyle Lifts and Quicklifts to name a few.

The trend in SMAS facelifts today has trended back now to the concept of less is more. The raising of an extensive SMAS flap, once the gold standard in facelift surgery, is not so today. SMAS techniques are more about limited deep undermining or more simple lifting and tightening it by sutures alone. (imbrication) The more rapid and safer execution of this part of a facelift is a big reason for this trend. There is very little chance of nerve injury and the bulk or volume of the face is preserved. This is particularly advantageous in the thin patient with little SMAS thickness anyway.

In the past I would do a SMAS elevation underneath the facial skin is thick or heavier patients and do only a SMAS imbrication in thinner patients. But in looking at the results months later it was impossible to tell the difference between the two SMAS techniques. So today I just perform a good SMAS imbrication on all facelift patients. Their recovery is quicker and the results appear to be just as good.

The time saved from doing deep SMAS lifting is now spent on other adjunctive facial procedures that add more benefits to the overall facelift procedure. This is usually fat injections around the mouth and nasolabial folds and skin resurfacing with the fractional laser or chemical peels.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The shape of the eyes is determined by many anatomic factors including the amount of fat under the eyelid skin. One undesired aesthetic look of the eyes is a deep depression underneath it. Known as lower eyelid hollows, this is when the lower eyelid skin indents beneath the lashline and lower lid margin. This creates a shadowing effect which lends to a tired or aged appearance.

Lower eyelid hollows are a reflection of the underlying anatomy. It could be due to a natural lack (congenital) of or age-related atrophy of fat, a weak or deficient infraorbital bony rim, a bulging eye (rare) or some combination. The most common cause of lower eyelid hollows, however, is almost always skeletal-based due to the projection of the lower bony rim. Fat deficiency may also be present but is not often the sole source of the problem.

Treatment of lower eyelid hollows requires augmentation which can be done by two basic approaches. The non-surgical injection approach is the simplest using either synthetic (hyaluronic acid-based) fillers or fat injections. A trial with synthetuc fillers is a good first step to confirm whether any type of augmentation will be effective. Fat injections offer a potential long-term solution but there is the risk of lumps or irregularities and its retention is not completely assured. Implants of the infraorbital rim offer an assured permanent solution but it is a surgery that is very technique-sensitive.

Case Study: This 47 year-old male did not like the appearance of his lower eyes. He felt they were sunken in, particularly in the tear trough area. He was not interested in fat injections and had had a prior experience with an injectable filler that left him bruised and irregular over a year ago. He not only wanted the bony rim built up but also wanted some malar augmentation as well.

Under general anesthesia, a lower blepharoplasty (subciliary and lateral canthal extension) incisional approach was used. The bony rim was exposed and subperiosteal elevation done from the medial edge of the rim to the cheek area. The infraorbital nerves were identified in the course of the dissection. Using Medpor infraorbital-malar implants, they were applied to both sides making sure there was not a elevated step-off in the tear trough area. The implants were secured with self-tapping 1.5mm screws into two locations for each implant. The lower blepharoplasty incisions were closed by orbicularius muscle suspension and lateral canthopexies.

His postoperative course had the usual amount of swelling of the lower eyelids and cheeks that took three weeks to completely go away. Despite the swelling, the lower eyelids never experienced any sag or ectropion. His final result as seen at 8 weeks after surgery showed elimination of the lower eyelid tear trough/hollows and some cheek augmentation as well. On his right side, he did have some cheek and upper lip numbness which had completely resolved by three months after surgery.

Synthetic implants can be successfully used for improvement of lower eyelid hollows, which is often deepest in the medial tear trough area. Their placement is just an extension of a lower blepharoplasty procedure which is very similar to the dissection needed for a midface lift. There are specific implants designed for this purpose that produces good results when properly placed.

Case Highlights:

1) Tear troughs or lower eyelid hollows can be permanently improved by orbital rim implants.

2) Orbital rim implants are placed through a lower eyelid (blepharoplasty) incision.

3) Precise placement of the implants on the infraorbital rim and secured by small screws is necessary to prevent implant migration and edge palpability.

Dr. Barry Eppley

Indianapolis, Indiana

While many people enjoy the apparent healthy glow of a good tan, the long-term consequences of looking ‘bronzed’ are far less glorious. Like smoking from many decades ago, most people know it is not good for you but just can not resist doing it. This is particularly true amongst teens and young people who are infused with an understandable perception of immortality.

The Food and Drug Administration (FDA) has now proposed that indoor tanning beds be labeled with consumer warnings about the risks of developing skin cancer from their use. This is just a warning and does not preclude anyone, even a minor, from using them. But it will have in the warning a recommendation that warns young people not to use them. If approved, and I have no doubt it eventually will, this would reclassify sunlamps from a Class 1 device to a Class 2 device signifying the increased health risk with their use.

Despite the position of the tanning industry that indoor tanning beds do not pose any health risks, the reality is that sunlamps do damage your skin and increase your risk of developing skin cancer. According to the American Academy of Dermatology, the use of tanning beds increases the risk of developing the most severe form of skin cancer, melanoma, by a striking 75 percent.

Any patient that undergoes a facelift has understandably great expectations given the commitment involved. But a facelift alone can not correct all facial aging problems. Preparing for a facelift is not only a matter of education but also benefits from before and after surgery skin care. When a patient is looking for and is ready for a facelift, their skin is also ready for a makeover as well.

Because a facelift only treats the sag in the skin and underlying tissues due to effects of gravity and other environmental factors, additional skin issues such as finer wrinkles, brown spots, large pores, red spots and generalized poor skin texture are not treated. Simply lifting up and pulling the skin tight will not get rid of every facial imperfection. Undergoing skin treatments both before and after a facelift can really put the ‘icing’ on the effects of the surgery.

Treatment options before a facelift can include microdermabrasion combined with light chemical peels (what I call a medical microdermabrasion) or medium-depth chemical peels like a Vi peel or the Perfect peel. These should be done no sooner than three or four weeks before surgery. These skin treatments will really freshen up the skin and an immediate improvement in skin texture will be seen.

In addition, the use of Retin-A is a great topical daily treatment in addition to or in lieu of the patient’s existing skin care regimen. While Retin-A has been around for decades and is not a sexy new topical agent, its benefits to the skin are well proven. It makes the skin healthier by thickening the dermis and improving its vascularity. This makes it heal better after surgery or just skin resurfacing. The strength of the cream or gel and how many times to apply it daily depends on the patient’s skin. The thicker the skin, the greater strength and number of applications it will tolerate without becoming too irritated.

After facelift skin care initially can include oral and topical Arnica and mineral makeup to cover the bruising. A return to one’s normal skin care regimens should wait a few weeks after surgery until the bruising is gone and most of the swelling has subsided. A month to six weeks after a facelift is a good time to have a microdermabrasion treatment to exfoliate the skin and buff up the facelift result. While there are many skin care product lines available, the use of topical Retin-A at some frequency of application after a facelift is always a good product to incorporate into one’s skin care regimen.

For many facelift patients, this surgery may be done only once in their lifetime. Many of these patients have never had a good skin care regimen and this surgery provides an opportunity to embark on one. Helping the facelift patient enhance and protect their surgery efforts is a valuable educational service.

Dr. Barry Eppley

Indianapolis, Indiana

Background: Liposuction is a very versatile procedure that can be done just about anywhere on the body where there is fat. Subcutaneous fat exists under any skin area in the body and is amenable to be treated if the right cannula size is chosen. Very small cannulas are available today for fat extraction done at the 1.5mm to 2.0 mm inner diameter size which are effective even in the most minute of fat areas.ht line.

Fat lipodystrophy is most well known on the legs in the thigh area, particularly in the classic saddle bag or outer thigh region. But unsightly fat accumulations can also occur in other areas of the legs even below the knee. A thick calf that extends straight down to the ankles also has a classic moniker known as ‘cankles’. When there is no evident break or taper from the lower calf into the ankle and top of the foot, the drop from the knee to the ankle can appear just like a straight line. This makes the calf and ankle look like a combined structure when aesthetically and anatomically they are two distinctly different structures.

Case Study: This 52 year-old female wanted to have some liposuction done on her legs to give them a better shape. She had always had big thick legs but was most bothered by her legs below the knees which were unnaturally thick. From the middle portion of her calfs down to the ankles it was a straight line on their inner aspect. You might say her ankles were ‘fat’ compared to her calfs.

Under general anesthesia, she initially had a Hunstad solution infitrated along the entire ankle and inner and outer calf areas as well as the inner knees. Then using a 3mm cannula, the inner and outer ankles and the inner leg from the ankle up to the mid-portion of the calfs had liposuction done. The amount of fat aspirate obtained from both lower leg areas was 240ccs. She was wrapped at the completion of the procedure in foam covered with ace wraps from the ankles to the knees.

Her postoperative course was marked by a lot of swelling which was expected. She stopped wearing any compression stockings one month after surgery when they no longer provided more comfortable support. By three months after the procedure, she had a very visible difference in the shape of her lower legs with a clear tapering of the calf into the ankle area.

Small volume liposuction, such as the treatment of cankles, can be thought of as liposculpture which implies shaping rather than gross or high volume reduction. While the calfs and ankles are have relatively small amounts of fat compared to the abdomen, for example, it can still be selectively removed and even small amounts of removal can make a verty visible improvement.

Case Highlights:

1) Cankles is a well known description of lack of any definition between the calf and the ankle.

2) Small cannula liposuction can be safely done below the knee and a little fat removal in the right place can create a more defined calf and ankle transition.

3) Liposuction below the knee is associated with prolonged swelling that will takes months to see the benefits of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana