While breast augmentation, despite the economy, remains a tremendously popular plastic surgery procedure, it certainly has its detractors. Not infrequently, I hear from patients and non-patients a questioning of why anyone would ever want breast augmentation. This is often followed with such statements as….’I would never do that to myself’…or…’How vain does someone have to be to want breast implants?’
While desires are certainly in the eye of the beholder and everyone sees everything from their own perspective and experience, misconceptions about motivations for breast augmentation are common. Some are certainly held by those women who already have way too much breast tissue (breast reduction candidates) or for those women who are in very stable relationships or have passed the age whether the psychosexual benefits of breasts are all that useful.
It is very clear that the vast majority (99%) of women who seek breast augmentation are not seeking to be dancers or professional models. Rather they are seeking to improve what is often a total or near total lack of any breast tissue. Whether it is due to developmental breast hypoplasia or breast involution after child bearing, the loss of breast tissue is often remarkable. For some, if you were just looking at pictures of their chest, you could not tell if they were adolescent boys or girls. In my Indianapolis plastic surgery practice, such patients are the norm not the exception.
While many breast augmentation patients are single, an equal number of them are married. In either case, having some breast tissue is integral to their psychological state of feeling like a woman. Having no chest support or shape also severely limits clothing options or what they will look like in them. The vast majority of bras, tops and dresses are simply not made with the flat-chested women in mind. And certainly the benefits of the design is not enhanced by the lack of any breast support.
While it I true that some breast augmentation patients are building on or enhancing what nature has already given them, the majority of prospective patients are seeking to become or return to a more womanly physical state. The psychological benefits of doing so are huge and potentially life-altering for some.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
While rhinoplasty is one of the most sought after plastic surgery procedures, it is also one of the most challenging to perform. Its complexity of numerous anatomic elements coming together to form the many subtle shapes of the nose allows a lot of different factors to come into play in what will result in the final outcome. The challenges of rhinoplasty are often magnified in the male patient for a variety of reasons.
I find that male plastic surgery patients in general tend to have two distinct characteristics that can make for a more difficult experience. They tend to be more demanding than women in terms of the final result and they usually pay less attention during a consultation. They often shake their head like they are understanding or may unconsciously act like what you are saying they already know. These two characteristics are particularly apparent in the young male patient, which just happens to make up a large percent of the male rhinoplasty population. Some describe men as having a poorer understanding of their problem and being able to less accurately describe what they want…but this has not been my Indianapolis plastic surgery practice experience. Most of the men I have seen are usually quite specific about what they want and have often studied their problem in detail…. sometimes in too much detail. It is of great concern to me when the patient comes in with drawings and numerous images of themselves that they have photographed and analyzed or even computer imaged.
These male characteristics come to the forefront in facial surgery, particularly rhinoplasty. The key to a successful male rhinoplasty is to thoroughly discuss in what exactly the nasal concern is and go over this in detail with computer imaging before surgery. Often this will take more than one ‘computer’ session or exchange of imaging changes and possibilities. When the imaging discussions and a list of improvements has been completed, it is important to emphasize what can be realistically achieved. Rhinoplasty is not like Photoshop (which is what computer imaging can be), it is a communication tool that works to put the plastic surgeon and the patient on the same page as to goals. But it is not a predictor of outcome nor should a rhinoplasty be judged after surgery based on the results obtained from presurgical imaging.
From an execution standpoint, rhinoplasty in men is more about producing subtle improvements than dramatic sweeping changes. This is so for two reasons. First, the thickness of male nasal skin does not lend itself to seeing some of the changes that have been made to the underlying bone and cartilage framework. As a result, finesse sculpting a male nose is more theoretical than reality. Some basic changes can be made but making fine detailed changes is more difficult. The thickness of the male skin will also lead to more prolonged postoperative swelling, particularly in the tip area. Secondly, men do not look good with an overlying refined or too small of a nose. Take a look at Michael Jackson for example to see that point well illustrated. A hump reduction, nasal bone narrowing, and some tip modifications are the three basic changes where improvements can be seen and still keep a male nose looking…male.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The treatment of large breasts with breast reduction surgery is one of the most common plastic surgery procedures performed on women in the United States. It is remarkably effective and every women gets an immediate and significant reduction in their musculoskeletal symptoms.
While one can see the final scars on the outside of the breasts after surgery, they do not really reveal how breast reduction surgery is actually done. Many patients ask how the operation is performed and it is a difficult concept to explain in a few sentences.
Think of a breast reduction as two separate operations (breast lift and breast reduction) rolled into one combined procedure. One step is how the skin is reduced and tightened. (breast lift) The second step is how the breast volume is reduced and the nipple preserved. (breast reduction)
Breast Lift Step: By using precise measurements which are marked out before surgery, extra skin is removed similarly to making a cone out of a flat piece of paper. (cut a wedge out of a piece of paper and fold the edges together) A large wedge of skin is removed with the apex of this wedge being at the desired new nipple position. This wedge skin cut out flares outward as it passes below the nipple and each side angles towards the sides of the breast. This skin removal allows the breast to be lift and tightened as it is brought together. This closure (at the end of the operation) creates the classic anchor or inverted T scar that everyone familiar with breast reduction surgery can identify.
Breast Reduction Step: Taking breast tissue is what accounts for the weight reduction of the operation. Think of breast tissue like a mountain with the nipple sitting on top. The size of the breast is made smaller by cutting off the sides of the mountain, but not removing too much that the tissue underneath the nipple is undermined. In most breast reductions, the nipple remains attached to the breast tissue so that it will remain alive and have feeling after surgery.
With these two concepts, the breast reduction operation can be understood. The first step is the outside skin removal. The second step is reducing the sides of the ‘mountain’. The third step is to bring the skin edges together over the reduced breast mound. The fourth and final step is to deliver the nipple back through the skin closure so that it appears again on the outside.
This approach to breast reduction is the classic and most commonly used inferior pedicle technique. There are other methods of breast reduction and even variations on the inferior pedicle method, but the fundamental principles remain the same.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Fat accumulation below the jaw line is a common problem for many adults over the age of 40. Because the fat creates a bulge below the prominence of the chin, this problem is often seen and referred to as a “double chin.” It is the result of one ‘s weight and genetics and is a major reason many patients seek treatment for aesthetic improvement of their neck appearance. (loss of one chin)
Laser-assisted liposuction (Smartlipo) is a very effective method for reducing fat along the jawline and neck areas. When done by itself, it can be done under local anesthesia, avoiding general anesthesia and its associated costs. Some doctors tout this treatment as an alternative to a facelift…but this is overstated at the least and frankly dishonest at the worst. No method of liposuction can tighten or lift skin like a facelift. A better question is…can I get away with Smartlipo in the neck alone without needing a facelift? Or…will I be happy with Smartlipo treatment alone. That answer is going to depend on how big your double chin is and how much of that problem is due to loose or extra skin.
While no one can give a precise answer without actually doing an examination, there are several things to look for to determine if you are a candidate for Smartlipo of your double chin. Younger patients under 40 have skin, in quality and quantity, that is most likely to maximally shrink and contract. As one ages much beyond this point, the favorable characteristics of the neck skin of youth diminish. Neck or double chin skin that has visible rolls does not bode well for good skin contraction. If you can put your fingers in front of and/or behind the ears and lifting it makes the neck look better, then you have too much skin for liposuction to improve alone.
For patients whose neck fat with questionable skin, the results from Smartlipo can be improved when combined with other rejuvenating methods. Procedures such as laser resurfacing, chemical peels, and fat injections for facial volume enhancement are good complementary options in some patients with more aged skin or a more aged face look. Combining Smartlipo with these other procedures may delay needing a facelift for 5 or 6 years.
One of the concerns when doing any form of liposuction of the neck is injury to a motor nerve branch (marginal mandibular branch of the facial nerve) which comes up over the jaw line into the side of the chin. If this nerve is rubbed over during the surgery, there can be some temporary weakness to the lower lip. This is most likely to happen when treating the jowl area. While this is rare, it can happen occasionally. It usually takes several months until full recovery of the nerve happens.
One of the very common issues after neck liposuction is firmness and scar tissue that develops. This makes the neck feel tight and full (although less than before surgery) While this will usually go away, early massage of the neck can make it soften sooner as the swelling subsides. If there are some hard nodules of scar tissue, a little bit of low dose cortisone injected into the scar nodules will help soften them up.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
An FDA review panel today called for safety restrictions on the popular over-the-counter pain reliever Tylenol, including reducing its maximum dose. Concerns over cases of liver damage and failure prompted expert review. The panel recommended lowering the maximum dose of over-the-counter Tylenol from 4 grams, or eight pills of a medication such as Extra Strength Tylenol. They did not specify how much it should be lowered. The panel also endorsed limiting the maximum single dose of the drug to 650 milligrams. That would be down from the 1,000-milligram dose, or two tablets of Extra Strength Tylenol.
The experts also ruled that prescription drugs that combine acetaminophen with other painkilling ingredients (such as Vicodin and Percocet) should be eliminated. They cited FDA data indicating that 60 percent of Tylenol-related deaths are related to prescription products. If the combination products are eliminated, the acetaminophen and the other ingredients could be prescribed separately. In effect, patients would take two pills instead of one, and be more aware of the acetaminophen they are consuming.
These panel recommendations have impact on plastic surgery as Percocet and Vicodin are the most common postoperative pain medications that we prescribe. Many of my patients have concerns about the doses of Tylenol to which they may be exposed. For this reason, I have been using when possible ActiPatch technology for its pain management and anti-inflammatory effects which reduces patients needs for these drugs.
ActiPatch is a topically applied battery-operated device that elicits pulsed electromagnetic fields that is proven to be capable of modulating inflammation and edema in local tissues. It is easily applied and removed and is inexpensive. I have used it in my Indianapolis plastic surgery practice over the past two years and have found it effective for postoperative relief of pain and swelling after breast augmentation, liposuction, tummy tucks and certain types of facial surgeries. I have patients apply it for up to 48 hours after surgery. While it may not completely eliminate the need for some prescription medication, the overall doses and duration of need certainly appear reduced.
The timing of these Tylenol (acetaminophen) recommendations further validates my use of the ActiPatch devices for my patients. They provide a natural and drug-free adjunct to conventional pharmacologic therapies that have no risk of any adverse reactions. Unlike drugs, they do not induce prolonged use or dependency and more quickly help patients get back to an unmedicated lifestyle after surgery.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Rib Graft Rhinoplasty - Saddle Nose Deformity and Secondary Reconstructions
Author: barryeppley
Patients may have unsatisfactory results in their first rhinoplasty that may lead them in seeking a secondary rhinoplasty or revision rhinoplasty. Secondary rhinoplasty may also be needed for traumatic nasal injuries, particularly when the nasal bridge is impacted inward. (saddle nose deformity)
Many plastic surgeons prefer to use autologous cartilage tissue whenever possible for these types of rhinoplasty due to its much lower risk of infection or long-term exposure or extrusion. Autologous cartilage will be incorporated into the surrounding tissues of the nose allowing it to remodel if necessary rather than the overlying skin or internal lining (mucosa) breaking down.
These type of nasal deformities may require a good source of cartilage. Of the three cartilage donor sources, (septum, ear, and rib) rib cartilage is a natural and only autologous source that can offer an unlimited amount of cartilage that has more than adequate lengths.
One of the main advantages of rib grafts is its plentiful supply. However, rib grafts are almost always curved and cartilage is well known for its memory. (recall of shape) As a result, it has a tendency to warp or return somewhat to its original shape despite being carved and shaped. Symmetric concentric carving of the rib cartilage will lessen the incidence of postoperative warping. Another way to prevent warping is to insert a thin metal pin through the graft to keep it straight.
The most common reason for a rib graft rhinoplasty is the saddle nose deformity. Correction of this nasal problem requires a significant amount of graft material. The rib graft is carved and reconstructed by assembling it into a two-piece L-shaped graft which is placed through an open rhinoplasty. A longer larger piece is shaped into a dorsal graft and a smaller piece into a columellar strut. If an intact septum is present, then only the onlay dorsal graft will be needed to correct the deformity. Careful graft carving and assembly is needed to minimize the risk of graft warping. Once positioned, the tip cartilages (dome) can be sutured over the end of the rib grafts.
One of the big concerns for patients who require rib graft rhinoplasties is the location and pain from the donor site. Rib cartilage grafting is the taking of cartilage from the cartilaginous portion of the rib. (the rib also has a bony portion too) While many take the fifth or sixth rib, I find this is usually not necessary. This takes more work and risk and causes a substantial amount of pain after surgery. Having done a lot of ear reconstructions with rib cartilage from this area, this is far more cartilage than is needed. I prefer to harvest the graft from the free floating 10th rib and the attached 9th rib. This is more than an ample amount of cartilage. In some cases, a split or shaved cartilage graft can be taken from the outer portion of the 8th rib. This is easier to harvest although it will have some curve to it. When the grafts are harvested from these areas, there is nor risk of pneumothorax, a release of air from the lungs by perforating its lining. The access incision is small, about 4 cms., and will lie along the bottom of one side of the rib cage.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Love handles, a well known slang term, refers to a layer of fat that develops around one’s midsection, especially apparent on the sides over the abdominal external oblique muscles. I assume they are called love handles because they can be grabbed or rested on while one’s arm is around another person. But I don’t know anyone that really loves them. Love handles are also called a spare tire, midriff bulge and muffin tops. (my personal favorite)
While there is no doubt that diet and exercise are the first line of offense to reduce love handles, this is often not that effective. I have talked to many patients, both men and women, in my Indianapolis plastic surgery practice who have made gallant efforts and are still stuck with love handles. They may have lost it most everywhere else, but the love handle area is often quite resistant. Perhaps they weren’t doing the right exercises or weren’t really trying hard enough, but they remained with love handles nonetheless. I do not believe that most people can lose spot areas of fat by exercise.
The love handles happen to be a particularly good area to be reduced by liposuction. I consider it the most ‘responsive’ area on which to do liposuction because the results are always significant and there is very little risk of contour or shaping problems. It is an area which can be treated very aggressively with liposuction techniques because of the thickness of skin and the acceptance of an overall ‘indentation’. If the side of the waist ends up either straight up and down or becomes more like an hourglass, all patients would consider that a good result. In short, maximal removal of subcutaneous fat around the waistline into the back is the approach for love handle removal.
The newest laser liposuction method, Smartlipo, works particularly well for this waistline problem. It appears that the heat build-up in the love handle area helps to create significant collateral damage to fat, beyond what is liquified and melted, to optimize the results. Suctioning the love handle area traditionally creates very noticeable bruising and pain in the back area around the waistline, but that seems to be reduced with Smartlipo. I didn’t say eliminated but definitely reduced.
I like to leave the small entrance skin sites for the laser probe and suction cannula open to drain after surgery. This drainage is easily caught in dressings that are placed against the skin over which a circumferential abdominal binder is placed. This drainage will stop in 24 to 36 hours. It is better to have this fluid out, rather than in, so there is less blood and fluid for the body to have to clear afterwards. Love handle liposuction results are immediately apparent, even the next day when the dressings are removed. The results continue to improve as swelling and bruising resolves.
Be aware that love handle reduction is only as permanent as the stability of your weight permits. Like the abdomen, it is an area of preferential fat deposition (particularly in men) and treating it with liposuction will not change this biologic predisposition. Keep working on those exercises after!
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
One of the many concerns that one has when considering having a facelift is what the recovery will be like. How long will I look bad? How much pain will I be in? When can I go back to work? When can I go out of the house and won’t look like I have had surgery? These are a few of the common facelift recovery questions.
A facelift is not what most people think it is so its recovery is much better and quicker than one might think. Facelifts are neck and jowl procedures so they do not affect anything north of the jaw line. So swelling and bruising is limited to the side of the face and the neck. Now many people do other procedures with a facelift (most typically the eyes) which causes swelling and bruising there but this is not the result of the facelift. An isolated facelift affects the neck primarily.
Even with some swelling and bruising of the neck, it will look better in contour and shape than it did prior to surgery. So factor out swelling as a significant concern, it is the bruising which may be most apparent. I prefer to use drains for the first 24 hours in my full facelifts as this definitely helps decrease the amount of bruising that will occur. Most of the bruising that develops will end up very low in the neck. Over the first week or so, gravity will pull this bruising even into the upper chest area. This is common so do not be alarmed. Bruising can be easily covered up with makeup. Clearing of the faintest of facelift bruising in the neck may take up to two weeks after surgery.
Since a facelift obviously uses incisions, a big concern is what my incisions or scars will look like right after surgery. In the vast majority of patients, and providing there are no healing problems, these incisions will turn out to be of no concern for you. Because of the way they are placed (in, out, and around the ear) and the superb healing of facial incisions in general, they look remarkably good quite early. The attached photo to this blog shows facelift scars just three weeks out from surgery. While close inspection may reveal them, they are not apparent to the casual observer even this early after major facelift surgery.
The side of the face and entire neck will feel somewhat numb, stiff, and little ‘lumpy’ for the first few weeks. This is normal as the skin nerves have been disrupted (temporarily losing feeling particularly close to the ear) and the skin has not yet healed completely healed underneath it. Some areas of fluid and blood will make it feel irregular. This will go away naturally by the first month after surgery.
While the thought of facelift surgery is scary, it is much easier to go through one might imagine. There is very little pain (most of my facelift patients don’t take pain medications after the first day or two) and the swelling and bruising is not that significant. The incisions around the ears are barely noticeable. When it comes to going out or returning to work, I tell my patient in my Indianapolis plastic surgery practice that 10 to 14 days should be more than sufficient for full facelifts. For more limited facelifts (e.g., Lifestyle Lift), it is more like a week.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Smartlipo and Tummy Tuck Surgery on Indianapolis Doc Chat Radio Show
Author: barryeppley
On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 - 2:00PM on Saturday afternoon, hosted by plastic surgeon Dr. Barry Eppley, an encore show in which the topics of Smartlipo (laser liposuction) and tummy tucks were discussed. With guest Dr. Lee Corbett, plastic surgeon from Louisville Kentucky, an open discussion on reshaping the abdomen and waistline and laser lipolysis for fat removal were reviewed over the hour. What a tummy tuck is, how it is done, what the different types are, how do they differ in men vs. women, and what recovery is involved was reviewed.
The newest version of liposuction, Smartlipo which uses laser energy to melt fat and tighten skin, was reviewed for what its advantages were, how it works, and what type of patient would best benefit by it. Its use in combination with tummy tuck surgery was highlighted.
Breast augmentation surgery involves the placement of an implant underneath the muscle in most cases. The pectoralis major muscle is separated from the minor one and a pocket for the implant is created between the two. In some cases, a portion of the pectoralis major muscle where it attached at its lowest point to the sternum is released to allow the implant to sit down low enough. (the lower edge of the pectoralis muscle is way above the inframammary fold, making it aesthetically undesireable to have complete muscle coverage of the implant)
Placing a breast implant under the pectoralis major raises two important muscle-related questions. First, is there any negative effect on the function of the pectoralis msjor muscle afterwards? And secondly, what is the best way to recover after this ‘muscle injury’?
I have yet to hear any patient in my Indianapolis plastic surgery practice who have had any complaints about ‘weakened chest muscles’ after breast augmentation. Most patients are not athletes however so this is not a surprise. But many do workout regularly. It is fair to say that there is no perceptible change in pectoralis function after such surgery. An interesting report has looked at more athletic women. The effects of breast augmentation on pectoralis major muscle function in athletic women was studied and reported on in 2004. In the Aesthetic Surgery Journal in May-June 2004, Drs. Sarbak and Baker reported on their assessment of twenty female athletes who spent at least 6 hours per week weight training. They evaluated the ability to perform various exercises after breast augmentation. Their results showed that it required an average of around 7weeks before they could resume their normal weight-room routines, which was twice as long as those patients who had implants placed above the muscle. These data suggest a longer recovery period for implants placed under the muscle before return to preoperative weight training activity. Placement under the muscle is also associated with reports of some decreased performance in exercises dependent upon the pectoralis major muscle. Overall satisfaction with breast augmentation was high regardless of implant location.
Recovering after breast augmentation is about physical therapy of the pectoralis muscle. This consists of several types of stretch exercises.
Arm range of motion exercises (stretch) should start the night of surgery. This consists of raising your arms from your side out to 90 degrees to the shoulder level. Repeat this 10 times every two hours on the day of surgery until you go to bed that nite. The day after surgery increase the angulation of the arms from the body up to 120 degrees every three hours or so. The following day you should be able to get the arms up to 180 degrees from your side. By the fourth day after surgery begin slow wind mills of 360 degrees going forward and then back. These stretching exercises should continue for the first week after surgery.
The second type of pectoralis stretch exercise uses the help of a door way. Stand in the middle of a door way with one foot in front of the other. Bend your elbows to a 90 degree angle and place your forearms on each side of the door way. Shift your weight on to your front leg, leaning forward, until you feel a stretch in your chest muscles. Hold for 15 seconds, relax and return to starting position. Repeat this manuever 10 more times. This should be done four or more times per day during the second week after surgery. This type of stretch introduces some resistance which may be felt more down at the low sternal attachment, some of which has been partially released.
Rapid recovery after breast augmentation requires an early initiation of a pectoralis stretching program. By starting the night of surgery and continuing for two weeks, most patients can have complete and full recovery within this time period.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis