Explore Plastic Surgery - Dr. Barry Eppley

Cheek augmentation is done for a variety of different aesthetic reasons. Besides the obvious need to fill out a sunken in cheek appearance and improve facial balance, they are just as commonly used for an anti-aging effect. By augmenting the soft submalar tissue to fill midfacial hollows, the lifting of this tissue provides a facial rejuvenating effect and may even soften the depth of the nasolabial fold beneath it. This tissue lifting or anti-aging effect is unique amongst facial implants.

The shape of the cheekbone and its location between the convex orbital rim and the concave maxillary wall make it the most complex facial area to augment from an aesthetic standpoint. Where along the cheekbone should the implant be positioned and what shape and size of implant should be used are what the plastic surgeon ponders. There really are no guidelines as to how to exactly to make these selections. Artistic technique is as important as any type of scientific approach. This high degree of variability lends to revision rates that are higher than any other facial implant currently used.

Cheek implant complications usually are of two types, undesired aesthetic outcome and implant shifting or migration. Unhappy outcomes come from either an implant that is too big or positioned in the wrong location. Either way, an unnatural appearance often results. Because of where cheek implants are located, they catch attention almost as much as one’s nose or eyes. Cheek implants come in a variety of sizes and shapes but can fundamentally be divided into malar and submalar implants. Malar implants being placed on top of the zygomatic bone and submalar implant highlighting the underside of the bone. (submalar hollow or buccal space) Malar implants have different extension that either go back further onto the zygomatic arch, up around the lateral orbital wall , or anteriorly along the underside of the orbital rim. Because of these variable implant shapes, it takes a good aesthetic eye and communication with a patient beforehand to get a good result.

Cheek implants are also unique because of where they are positioned on the zygomatic bone. They often are sort of hanging from the side of the cliff, which makes them prone to shifting. Shifting will usually occur in a downward direction from whence they were initially inserted, which is usually through the mouth. For this reason, it is possible for cheek implants to shift around and end up with asymmetry. This is particularly true if the implant is made from silicone which is very smooth and slippery. Other implant composition have a much greater frictional grip on the bone and will not move as easily.

One interesting silicone cheek implant design which can effectively address the shifting problem is that of the Conform midfacial implant. Its undersurface is not smooth silicone but rather a pebbly or nubbed surface. The many little ‘’fingers’ of silicone allow it to develop some degree of frictional gripping to the bone surface. Also when soft tissue grows around it, the capsule will absolutely lock it into place. This is very similar to the concept of placing a textured surface on a breast implant which was developed nearly twenty years ago. Its shape also allows it to be trimmed and used as either a malar or submalar implant. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The recent controversy regarding the potential skin color change of Sammy Sosa is fraught with issues of history and culture. If you’ve seen recent photos of him, it is easy to see why it has stirred up such debate. My last visual memory of him was that his skin color was closer to mahogany, not the off white of recent photos taken at the Latino Grammy Awards. His explanation for the appearance of his skin was that it was from a combination of a skin rejuvenation process and the bright TV lights at the awards show. Which, quite frankly, I don’t believe. There are too many shades of difference coming from such dark skin to start.

A similar but milder issue was raised with Beyonce from a recent L-Oreal ad where her skin appeared much lighter. The company denied any alterations, chemically or digitally produced, and credited the lighting from the photo shoot. This I do believe as it is but a shade or two lighter from skin which isn’t as dark as Sammy Sosa’s originally was.

One concept to grasp is that specific zones of abnormally high pigmentation can be reduced by topical creams or gels. In cases of vitiligo (loss of skin pigment), the condition that Michael Jackson allegedly had,  the surrounding skin may be lightened to achieve a more uniform appearance. Zone depigmentation has also been successfully used to reduce the typically darker pigmentation of the genital and perianal area. However, in cases where these spot treatment creams are used in attempt to lighten the entire complexion, all of the current topical creams are ineffective for that purpose. Complete skin depigmentation on a wide scale is not possible. So to say that someone can lighten their complexion significantly by a topical agent alone is fantasy, not medical reality.

But these celebrity issues, as interesting or controversial as they may be, bring attention to the treatment of a different but very common skin problem…that of hyperpigmentation. Reactive hyperpigmentation comes from a variety of causes, the most common in a plastic surgery or dermatology practice, is from pregnancy (chloasma), as a reaction to many available skin rejuvenation treatments. (e.g., chemical peels, lasers) known as melasma, and from long-term sun exposure. (solar lentigenes)

Most skin-lightening treatments that are used today can reduce or block some melanin production and do so by inhibiting the enzyme tyrosinase. Many treatments use a combination of topical lotions or gels containing melanin-inhibiting ingredients along with a sunscreen, and a prescription retinoid or RetinA derivative. Depending on how the skin responds to these treatments, we can progress to skin exfoliation through chemical peels or light-activated devices.

Drugs make up the primary treatment approach for pigmentation problems. Hydroquinone is the gold standard to which other agents are compared. Topical hydroquinone comes in 2% (available in cosmetics) to 4% (or more) concentrations (by prescription). More recently it has been combined with tretinoin in a very effective cream known as Tri-Luma. Research has shown that the combination of hydroquinone and tretinoin to be very effective against sun- or hormone-induced melasma and it is a great combination for the treatment and prevention of wrinkles as well.

Hydroquinone has come under some fire because has been shown to cause leukemia in laboratory animals. As a result, Europe banned in 2001 and rumors continue to float that it may eventually be banned in the United States as well. But for now it remains available as an over-the-counter drug, but with a concentration not exceeding 2 percent. Alternatives to hydroquinone is azelaic acid in 15% to 20% concentrations and Kojic acid which is usually combined with glycolic acid.

 Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Making changes to one’s face is always a big consideration that requires a good deal of thought from surgeon selection to the final choice of operation(s). While there are lots of facial procedures to consider, they can be divided into those operations that treat aging changes (skin and soft tissue sagging) and those that can change structural shape of the face. (bone and cartilage)

From a psychological standpoint, these two facial procedure categories are not the same. Reversing aging changes of the face is about making one look younger…turning back the clock so to speak. Facelifts, blepharoplasties, and browlifts, for example, aim to return one to something that is familiar…a younger you.  That is an easy decision to make for most. The desire to return to what once was is deep seated. The biggest fear in anti-aging surgery is that the operation may be overdone and look unnatural. (not like oneself)

Structural changes of the face, however, pose different psychological considerations. Rhinoplasty, facial implants, and any facial bone changes head one to something unfamiliar…a changed face and a new look. This can create much greater uncertainty because one doesn’t always know what to expect. While one may have a great desire to improve one’s appearance, there is always the trepidation that one won’t like it or it may not turn out well…and then forever be stuck with it. These concerns are magnified in that many of these procedures are often done in younger patients whose sense of self-image is less established and more fragile.

Structural facial changes are usually done in one or two areas at a time This is most commonly seen in rhinoplasty alone or rhinoplasty in combination with chin augmentation or other facial implants. Making a male’s face more masculine or defined often involves the trifecta of structural facial surgery… chin, cheek, and jaw angle implants. Derounding the face usually involves neck and buccal fat removal with a chin implant for women, men may get jaw angle implants as well.

In my Indianapolis plastic surgery practice, I have seen numerous patients over the years who have come to me because they were unhappy with the results of their structural facial surgery done elsewhere. In listening to their concerns, it has become clear that in some cases there was a fundamental misunderstanding or miscommunication about objectives. Sometimes it was the ‘wrong’ operation for their concerns. (e.g., treating submalar and lateral facial concavity with jaw angle implants) Other times, it was an operation that was over- or underdone. (e.g., too large a facial implant or a nose that didn’t have enough of a change) Most of the time, their operations were done well…but the patient’s aesthetic target was missed.

While no plastic surgery operation is an exact science, one’s objectives prior to surgery should be. The use of computer imaging is absolutely essential for structural facial surgery. This is a critical method of visual communication that often unravels the specifics of a patient’s objectives. Looking at combinations of procedures and amounts of changes can almost always avoid an unexpected outcome. While predictive computer imaging is not a guarantee of outcomes (I think of it as Photoshop plastic surgery), it does put the plastic surgeon and the patient at least on the same page.

When considering any form of facial structural surgery, it behooves the patient and the plastic surgeon to meet for several consultations. Computer imaging plays a vital role in setting the surgical plan and helping with postoperative expectations. The emotions and psychological implications that come with forever changing one’s facial appearance is a high stakes proposition that should not be taken lightly. This type of facial surgery is associated with much higher rates of patient dissatisfaction than with more commonly performed anti-aging procedures.    

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

As the U.S. population continues to become increasingly multicultural, one of the increasing ethnic groups is that from the Middle Eastern region. This is a geographic term that does not have a true precise meaning as it can vary based on which countries one chooses to include in the region. Most commonly, many would include the countries that surround the Gulf Sea as well as that of Northern Africa.

While the Middle Eastern region is a blend of many cultures, there are certain nasal characteristics that are commonly seen. The overlying skin is almost always thick and heavy, a large dorsal hump is present, the nasal tip is ill-defined and bulbous, and the columella is frequently short. These characteristics give the appearance of a long and plunging nose with an acute nasolabial angle.

The Middle Eastern nose, like all ethnic rhinoplasties, poses challenges based its thick skin and cartilaginous make-up. But beyond the anatomy of the nose, it is important to have clear communication with the patient about their nasal goals. When the plastic surgeon and the patient have different ethnic and cultural backgrounds, it is easy to have objectives that are unintentionally different. Computer imaging and multiple consults can help to prevent this communication gap.

The open approach should almost always be used. To rework the cartilage framework in a way that will make a significant change in nasal appearance requires optimal visualization. Some plastic surgeons may be able to achieve a great rhinoplasty result in the Middle Eastern patient through a closed approach, but that has not been my experience in my Indianapolis plastic surgery practice. While there is always a concern about the columellar scar in patients with increased skin pigmentation, that has not been a problem. That is not a surprise given the known experience with other ethnicities.

Structural support to the tip and the middle vault is essential. The thick skin of the nasal tip can make it challenging to achieve definition and a more upright position with an increased nasolabial angle. Septal grafts to the columella are always needed to support the large and heavy skin sleeve. Tip grafts are usually beneficial to create more definition through tip skin which has been slightly defatted. The septum can provide more than enough graft material and almost always needs work anyway as it is frequently deviated and off midline.

The dorsal hump must be looked at and analyzed carefully during surgery. While it can appear to be high, it may not need to be as significantly reduced as one initially thinks. In some cases, this is an illusion due to the downturned tip and decreased nasolabial angle. Rasping and radix grafts may be all that is needed. In other cases, however, a large bony hump does exist and full osteotomies are needed to bring down the dorsal line.

Alar and nostril narrowing  by excising skin at the sill or base is often needed. One should not hesitate to do so when indicated as adverse scarring is rarely seen.

Rhinoplasty in the Middle Eastern patient is challenging but successful results and a happy patient can usually be achieved. The use of well known structural support principles through an open approach are important intraoperative maneuvers. Preoperative planning with an understanding of the patients aesthetic objectives is just as important in any form of ethnic rhinoplasty.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Dysport, with its recent FDA approval, offers a competitive product to Botox. Another neurotoxin for aesthetic use is highly welcomed by many as some are frustrated by the service and price that comes from a monopolistic manufacturer. As Dysport has become commercially available, rumors abound that it lasts longer than Botox and its price will be less.

To date, no large scale studies have been published that can support or refute these supposed properties that Dysport provides. In the November 2009 issue of Plastic and Reconstructive Surgery, Kane and colleagues have published results from the clinical trial that evaluated the effectiveness of Dysport for glabellar lines. I presume that this information is what made up most, if not all, of the manufacturer’s submitted clinical data to the FDA for consideration for approval.

This was a phase III, double-blind, placebo-controlled study that was conducted in 27 centers and involved 816 patients. Patients were stratified by race and received a single treatment with Dysport or a placebo based on a variable dose that differed for women and men. They were evaluated up to 150 days after treatment. In essence, this was a very well designed and conducted clinical study.

In reading the results, one can draw the following conclusions of  clinical relevance. First, onset of the effects of Dysport were seen as early as 24 hours with a mean onset of 4 days. This does seem earlier than that of Botox and so the rumor that Dysport has an earlier onset of action does seem to be true. But it is not always within the first 24 hours but rather days. This means that it kicks in a few days earlier than Botox on average. The mean duration of effect for Dysport averaged slightly less than 110 days. When compared to Botox, this is a very comparable length of active time. The rumor that Dysport lasts longer than Botox appears to be just that…a rumor not fact. What is very interesting in the study is that the response and duration of action was slightly higher in African American patients. They do not speculate as to why.

A cost analysis was not done as part of this clinical study nor would it be appropriate for a clinical investigation. The study shows that there is not a dose comparison between Dysport and Botox as everyone knows. Given that the ‘average’ dose of Botox for the glabella is around 20 units, Dysport doses ranged from 50 to 80 units based on muscle mass and sex of the patient. That equals roughly 2.5 to 3 units of Dysport to 1 unit of Botox in dose administration. Knowing that ratio should help physicians and patients determine if they are getting a Dysport treatment that is equal to or less in cost than that of Botox.

The rumors that Dysport is ‘better’ than Botox are not substantiated in this large clinical study. It does show that it is just as effective and does offer a true competitive analogue. Whether it will cost less is determined completely by the pricing and incentives that your local provider may or may not give.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 12:00 to 1:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the topic of body contouring in men was discussed. Male body reshaping generally includes liposuction, modified forms of tummy tucks, gynecomastia reduction, and chest reshaping.  Interviewing several patients, both before and after their surgical procedures, was done to listen to their concerns, apprehensions, experiences, and the results afterwards.

 Each year, plastic surgery in men becomes more popular.  As Americans live longer and healthier lives, the expectation of looking and being vital is important even into one’s sixties and seventies.

One of the most popular surgical procedures among men is liposuction. As with women, men are genetically designed to accumulate fat in certain areas. While women tend to accumulate fat in the hips and thighs, in men fat generally goes straight to the waistline. And for some patients, once this excess fat has accumulated, no amount of diet or exercise may be able to make it disappear. Such individuals are often excellent candidates for liposuction. I typically perform circumferential liposuction of the trunk for male patients, to improve the aesthetics of the torso not only anteriorly but also in profile and when viewed from behind. Another area where liposuction is commonly performed in men is the area below the jaw, where removal of fat can significantly improve the male facial profile. Liposuction of the anterior neck and the area below the jawline is frequently performed at the same time.

Many of my liposuction patients are very active individuals who have essentially ‘hit a wall’ in terms of improving their body contours through dietary modification and exercise. The boost they get from liposuction in recontouring their ’stubborn fat’ areas quite often motivates them to be even more intensive in their exercise and nutrition regimens. I have many patients who at one year post-op have a result that is perhaps 75-80% the direct result of body contouring surgery, and 20-25% is the result of their own efforts at maximizing the result of surgery through diet and exercise.

In men that lose a significant amount of weight, the abdominal skin may be left loose and sagging. In such patients a tummy tuck (abdominoplasty) or mini-tummy tuck can instantly restore a more appealing abdominal contour. While women undergoing abdominoplasty usually require abdominal wall repair (from prior pregnancy), in some male patients the tummy tuck consists of only skin and fat removal, which has a much faster recovery time.

Male tummy tucks are usually combined with liposuction of the abdomen, waist and chest. Depending on the degree of abdominal skin laxity, a male abdominoplasty may be performed with or without umbilicoplasty (the surgical creation of a new umbilicus or belly button. The surgical approach is always individualized to the particular needs (and goals) of each abdominoplasty patient.

Enlargement of the male breast is referred to as gynecomastia which can occur in response to certain medications or hormonal conditions but most often has no clearly identifiable cause. Gynecomastia may develop at any age, and may occur on one or both sides. In most patients it can be corrected with liposuction or with a combination of liposuction and direct excision (removal) of breast tissue and/or skin.

Surgical correction of gynecomastia produces a dramatic, positive change for patients with this troublesome problem, as it is usually a source of significant self-consciousness and embarrassment. For most patients the results are quite liberating, especially in terms of participating in athletic endeavors and relaxing at the beach or pool.

Whenever possible, my strong preference is to avoid skin excision and thereby limit the surgical scar to the inferior border of the areola. When a patient with gynecomastia has breast enlargement to an extent where too much liposuction is likely to produce a ‘deflated’ appearance, I often will stage the procedure, which allows time for the skin to retract to some extent between the two liposuction surgeries. In many cases this completely eliminates the need for skin excision, and in some it reduces the need for skin excision to that which can be accomplished with a peri-areolar scar only (instead of standard ‘inverted-T’ breast reduction scars).

Men interested in body contouring can arrange a consultation with Dr. Eppley by calling his Indianapolis suburban area facilities at Clarian North office at  317-814-4100 or his Clarian West office at 317-217-2200.

The use of injectable fillers as an in-office procedure has become a mainstay of contemporary aesthetic facial treatments. Millions of such procedures are performed per year. Between 2002 and 2008, a dozen injectable filler products have become commercially available. While the pace of new product release has been brisk, ongoing development promises that more such products will be forthcoming.

The release of Prevelle last year was the first filler that had the local anesthetic lidocaine incorporated in it. That concept is understandably appealing to patients and physicians alike. Many physicians were already mixing lidocaine into their filler at the time of injection but this product obviated the need for that step. In July 2009, Radiesse received FDA approval for mixing lidocaine in it. While this is not the same as having it already premixed, it is comforting to know that it does not cause any adverse effects by doing so. (hence the FDA approval) As a result, other fillers are following suit and Juvaderm (one of the most popular fillers currently) is awaiting FDA approval for its lidocaine mixture.

Sculptra, which was originally approved in 2004 for the treatment of facial lipoatrophy, received FDA approval for aesthetic use earlier this year in July 2009. Even though it was widely used off-label for aesthetic treatments, it is now formally approved for shallow to deep nasolabial folds as well as other facial wrinkles. While not permanent, it does provide up to two years of sustained results. It is the longest lasting of the ‘temporary’ fillers.

But in the pipeline awaits newer filler compositions which promise to be more than just competitive analogues to what is available now.

Aquamid, manufactured by a Danish company, has been used as an injectable filler for years in Europe and is now submitted for FDA approval. It is a water-based polyacrylamide gel that consists of 97.5% water mixed with 2.5% cross-linked acrylamide polymer. It is purported to be permanent. (11 years is the longest follow-up of a patient that had been injected)  It has been used in Europe and Asia for the past 7 years and reports over 300,000 patients treated. Anectodal reports from physicians participating in the clinical trials in the U.S. have confirmed the positive experience that have been seen for years across the Atlantic. How Aquamid will stack up against a similar FDA-approved permanent filler (not composition-wise), ArteFill, remains to be seen.

Belotero Balance, using a hyaluron composition, has just recently submitted its application to the FDA for review. This comes from the company that makes the popular topical scar treatment, Mederma. This hyaluronic-based monophasic gel is made with a proprietary cohesive polydensified matrix (CPM) technology. It is not clear yet what is unique about this hyaluronic acid filler that will allow it to develop a niche in the already crowded hyaluron-based injectable filler market.

Newer injectable fillers are a certainty as the market for them continues to grow. It will be interesting to see when and whether these newer filler compositions offer significant advantages over what is currently available. Their marketing information will undoubtably say so, but it remains to be demonstrated clinically on a wide use basis. Physicians are not quick to change their injectable filler use unless there is a clear advantage to a new product. One can not simply afford to stock every injectable filler that is available… and patients are largely guided by what the physician chooses.         

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Having a complication after an elective cosmetic surgery procedure is usually something no patient envisions…or even gives much thought about. While it may be explained before surgery that there are risks involved, most patients understandably are not focused on those issues. This potential problem is given no more thought than the risk of being in an accident when buying an automobile.

Yet they can and do occur. Fortunately most problems after surgery are not major and do not frequently require a return to the operating room or a hospital stay to solve them. But when they do occur, the experience combined with potential cost exposures can be significant. The type of complications I am referring to are really major ones that would require the use of a hospital facility, either for the use of the operating room and/or hospitalization.

While such complications occur, rare as they may be, they must be taken care of immediately. One is not initially concerned about cost nor should cost concerns prevent anyone from doing the proper medical treatment. The majority of major medical health insurance policies, however, now exclude treatment of medical complications if they are the result of an elective cosmetic surgical procedure. This would leave the patient with the responsibility of paying the accrued hospital or other facility costs.

In response to this very real patient concern, the Aesthetic Surgeons’ Financial Group (ASFG, a private insurance group) has developed a program called CosmetAssure. This insurance program addresses the lack of coverage for medical expenses complications arising from elective aesthetic surgical procedures. CosmetAssure is a very low cost insurance policy that patients can buy per surgery to cover certain cosmetic surgery complications. This plan is endorsed by the American Society of Plastic Surgeons (ASPS) and is only available to its Active and Candidate members.

To participate in the program, the patient must have surgery by a plastic surgeon that is enrolled in the CosmetAssure program. The policy covers 17 procedures only but these are all the major types of cosmetic surgery that are commonly performed. In order for patients to receive benefits in the event of a covered complication, not only must they be registered through their participating plastic surgeon, but they must be admitted to a hospital, emergency room, or an accredited surgical center within 30 days of the cover procedure. The 30 day period begins on the day of the patient’s surgery. While this seems fairly time limited, the reality is that almost all major complications (bleeding, infection, etc) will have occurred within days to weeks after surgery. Major complications from elective cosmetic surgery do not occur months or years later.

The Cosmetassure program is not new nor is it available in every state. The concept is a good one and, like most insurance policies, it is really great if you need to use it. Whether this is a good idea can only be determined on a patient by patient basis. For those patients that are concerned about risks and want financial piece of mind, then a few extra hundred dollars for your surgery are certainly worth it. Some may think that such a program is similar to purchasing an extended warranty on that new refrigerator or flat screen TV. But then again, one’s body has the potential to cost a lot more to repair than the ‘original purchase price’. Just look at any hospital bill.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Chin augmentation has been a procedure that has a near seventy-five year history of being done in humans. It remains as a fairly simple and highly effective method for improving the most prominent area of the lower third of the face. Many different materials have been used to serve as a chin implant but synthetic technology accounts for most augmentations due to their ease of use, low cost, and long-term stability of the result.

For patients considering chin augmentation, there are three considerations one should ponder. While many plastic surgeons have their preferred methods, usually with good reasons, patients today are better educated and can participate more fully in preoperative planning.

The first consideration is that of the choice of implant material. Vulcanization technology has allowed for silicone rubber (silastic) to long be the only material of choice. Silicone chin implants are the least expensive and the most flexible and they can be inserted through the smallest of incisions. Medpor (polyethylene) and polytetrafluoroethylene (PTFE or Gore-Tex) are more recent chin implant materials who have a long history in many other types of surgical implants. Medpor is fairly stiff (needs bigger incisions to insert) and is porous, which in theory offers some biologic advantages. (vascular ingrowth) PTFE is softer than even silicone with some limited porosity on its surface.

The different chemical compositions and properties of the implant materials may seem confusing.  But in my opinion, they are no proven biologic advantages to any of the implant materials. They all will work. The body still sees them as a well-tolerated foreign body which becomes encapsulated. The important differences between them, in my opinion,  relates to the second consideration….what different styles, shapes, and sizes do the various manufacturers offer. Chin augmentation today can create a wide variety of geometric changes to this part of the lower jaw… from round to square, central to more lateral projections, to even include the creation of a chin cleft or dimple. Think about your chin shape carefully and how it will affect your overall facial shape. What shape does it have now and what would you like it to become? Do you want a more sculpted and more defined facial look? Do you want to overcome a larger nose and a shorter neck? Do you want it to look more masculine or feminine? Many implant styles and sizes exist. Consult carefully with your plastic surgeon to get the look you are after that best fits your face.

Lastly, what insertion route for the implant do you prefer? They can be placed through an incision under the chin (submental) or through the inside of the mouth. (vestibular) Each has its own advantages and disadvantages. In the right hands, either approach can work successfully. The most versatile and least prone to potential problems is the submental approach. Many patients worry about the potential scar but that is an unnecessary concern. Coming from below has the advantages of getting the implant down at the inferior edge of the bone, permits easy screw insertion if desired, and allows neck liposuction or submentoplasty to be performed through the same incision. The submental approach is also associated with the least potential for mentalis muscle dysfunction and lower lip incompetence.

Chin augmentation today offers subtle but important aesthetic options for patients to consider. There is no one single way or one implant that is better than another. Consult with a plastic surgeon who is well versed with the different materials and approaches so you are not getting just the ‘standard approach’, but a chin augmentation surgery that has been designed for you.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Liposuction continues to be the most commonly performed of all body contouring plastic surgery procedures. The large surface areas that can be treated make for significant changes in the contours of one’s body. The marketing and promotion of liposuction across all types of media strongly suggest that it is a precise surgical procedure. Inferences are not subtle that surgical fat removal is able to achieve results that are comparable to ‘sculpting’ or the chiseling out of body parts.

While there are some body areas that truly can be sculpted, most liposuction results are relatively imprecise. At the least, they are not usually like the model that appears in an advertisement. The outcome of a liposuction procedure is certainly influenced by the surgeon performing it and the tools that are used. But there are numerous logistical factors that will always limit the quality of the results that can be achieved.

The topography of the treated area is one important factor. Most of the body is not flat but rather a curved surface that has different thicknesses of fat as it curves around from area to another.  This certainly makes it difficult to ensure evenness of fat removal, particularly when the aspiration is done with a straight cannula.

Liposuction surgery is almost always done with the patient in the supine or horizontal position.  While this does not significantly affect some body areas, such positioning allows most fat collections to shift backward and become distorted as they lie or are pressed up against the operating table. The concept of ‘standing up’ liposuction is theoretically appealing but currently impractical.

Skin quality remains a very important determinant of liposuction outcomes. Looseness of skin, stretch marks, and cellulite over a treated area does not bode well for needed skin contraction of deflated areas. One must appreciate that it is highly likely that the smoothness of overlying skin will never be better after liposuction and, in some cases, can be made worse. Liposuction, by any method, is not a treatment method for cellulite as some patients mistakenly believe.

To work around these limitations, there are some presurgical and intraoperative  techniques that are used to get the best results possible. Marking the surgical sites immediately prior to surgery is critical. One must look at the planned treatment areas like a topographic map. The marks will indicate how far one has to go as the body areas shift and distort when one lies down. Marking the high and low spots also indicates how much time should be spent or tissue removed from one encircled area to another. Positioning the patient on the table can help tremendously with seeing the marked areas more ‘three-dimensionally’. For example, it is better to treat the lateral thighs or the flanks with the patient turned on one side. While this is more difficult for the surgical team, it is the best way to avoid seeing irregularities and missed areas of fat when the patient is seen standing weeks later in the office.

While new liposuction technologies appear fully capable of improving how well and even fat is removed, they are not magical devices. The use of laser liposuction (a.k.a. Smartlipo) is one example of how using a thermal approach (melting and liquefaction) may produce more consistent and even fat removal. The heat that it creates is promising for helping skin contraction, but it will not transform skin that is already damaged.

Liposuction is an improving plastic surgery technique but it is not yet an absolutely precise science. Its results are still somewhat of an art form. Patients should appreciate that perfect symmetry and evenness throughout a treated area can not be guaranteed and the desire for secondary improvement through touch-up procedures is not rare.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis