A facelift is one of the most recognized procedures in aesthetic plastic surgery…..but also one of the most misunderstood. The general public’s perception of a facelift….based on TV shows and the internet…is someone after such surgery being bruised from their eyes to their neck and their face wrapped up in a big dressing…like they had been involved in a major accident. And that it will take weeks to even look good enough to go out in public. In reality, this perception is flawed at best and even grossly inaccurate at worst.

 
The name of the operation, facelift, is misleading. It does not really describe what the surgery actually does or what the objectives of the procedure are. More accurately, a facelift should be called a neck-jowl lift, for this is what it actually helps. It is a great procedure for tightening the neck, getting rid of the that neck waddle, and lifting those sagging jowls. The medical name for a facelift, rhytidectomy (old plastic surgery meaning cutting out wrinkles), should be described as a cervicoplasty. (reshaping of the neck) However, the name facelift persists and always will as it is embedded in our plastic surgery nomenclature.

 
Therefore, when you realize that only the neck and jowl are affected by the procedure, many of its misconceptions fade away. In isolation as a stand-alone procedure (which half of my ‘facelift’ patients only have), a facelift causes no bruising or swelling from the nose up. While many facelift patients get their eyes, forehead, nose and other facial procedures done at the same time, this is not a requirement and is only done if one wants the ‘total face’ rejuvenated. I find that after an isolated facelift, one can look pretty good in about a week and can easily be out in public in a few days with a little make-up in the neck area.

 
Remember, the eyes are not swollen at all!

 
One of the great misconceptions about a facelift is what is actually done in the operation. A facelift operation is all about tissue layers and vectors of lifting. The lifting off of the skin from the underlying tissues over the side of the face (to the cheek area) and across the neck through incisions placed in and around the ears is obvious in any diagram of a facelift operation. And movement of loose skin pulled back and over the ears at about a 45 degree angle to the face probably accounts for about 80% - 90% of the result created by a facelift. And often this is the only tissue moved in a facelift. This is the safest and easiest approach with the least likelihood of complications. Deeper layers have also been raised up and moved in more recent versions of facelift surgery. These deep layer that can be moved independent of the skin, is a special layer of tissue over the muscle. This tissue, known as SMAS, is raised and sutured up in a more vertical direction compared to the direction of the skin pull, closer to 60 degrees usually. The public erroneously believes that it is muscle that is moved which is not possible. The SMAS sits on top of the muscle. There is considerable debate as to whether the ‘deeper’ versions of the facelift produce better long-term results than skin movement only.

 
The neck-jowl lift, known historically as a facelift, can lift two different layers of sagging facial tissues in two slightly different up and backward directions.

 
Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.eppleyfacelift.com
http://www.ologymd.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Undoubtably, we are in more difficult economic times than a year ago….even if you compare the gas prices alone. As is well known in plastic surgery, the less ‘luxury’ income that is available the less elective plastic surgery gets done. Cosmetic surgery is one of the first items crossed off the list in hard economic times. However, I have observed no downturn in the number of smaller, less expensive procedures such as Botox, injectable fillers, and skin treatment procedures. Having two spa facilities in different parts of suburban Indianapolis, I am acutely aware of how many such procedures are done. We see no less numbers of those procedures today than one or two years ago.

In the face of the economy, this brings me to one important conclusion….people still want to look and feel good and will still spend some dollars toward that effort. The big surgery dollars, however, may wait until another day.
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 most fascinating human observations in plastic surgery is how quickly patients forget what they looked like before surgery. Patients remembered ‘perceptions’ of their face and body is often quite erroneous…or their memories are quite short. Therein lies the value of preoperative photographs. Not only to marvel at how significant the changes were after surgery (how do you think we get the before and after photos for patients to look at) but, most importantly, it serves as a forever reference. In the past, I would only use them (pull them out) when there was some debate after their plastic surgery as to how much improvement they have had. Now, I routinely provide them to most patients fairly soon after surgery, in the recovery phase, to help remind them that it is all worth it.
Dr Barry Eppley
Indianapolis

One of the most challenging tasks in Plastic Surgery is to try and please patients who are seeking the ‘perfect result’. What I am specifically referring to are three types of patients; a new patient who has never had plastic surgery before, a patient that I have operated on previously and wants the result improved, or a patient who comes in after surgery from another plastic surgeon who is seeking a better result. Every plastic surgeon in practice who seen all of these patients numerous times.

While on the one hand, it is not unreasonable for a patient to be seeking the best result possible, there are also limits to what can be achieved by surgery. Plastic surgery is not, unfortunately, like PhotoShop where any result is achieveable. Plastic surgery is still much of an art form and is ultimately modified by the forces of healing. While most patients understand that, the patient seeking the perfect result does not. They are easily identified by a lot of attention to minor issues (when you have to strain to see it, it is minor!) or the patient who comes in with a lot of pictures to demonstrate what they want. Or the patient that requires two or three consultations to be certain you understand what they want. In these types of patients, I used to think all this attention to details was simply out of anxiety or due to their thoroughness. I now recognize that I may not be able to please this type of patient. Surgery in most of these cases is best avoided, however unpleasant that may seem at the time.

 
Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana
Indianapolis

In the most recent issue of our prestiguous journal, Plastic and Reconstructive Surgery (April), I read an article on evaluating the effectiveness of mesotherapy on body contouring. This was a study out of Seoul, Korea on 20 women who had mesotherapy injections on their inner thighs on one side and not the other over a 12 week period. The results showed, not surprisingly, that no measureable improvement could be seen.
This study highlights several important points on aesthetic treatments that are frequently confused. Mesotherapy is the injection of a mixture of different compounds into the skin. (the study cited above used aminophylline, buflomedil, and lidocaine) This is different than LipoDissolve therapies where one specific compound, phosphatidylcholine, is injected into the underlying fat. Mesotherapy (meso = mesium or skin) and LipoDissolve are terms that are often used interchangeably but they really signify completely different types of treatments. Just because both come out of a small needle, like Botox and injectable fillers, doesn’t mean they all do the same thing. I have always questioned the effectiveness of mesotherapy approaches for fat removal or cellulite treatment. It is difficult to see how injecting chemicals into the skin can effect the underlying fat. Perhaps cellulite may have some improvement with mesotherapy since this problem has a skin component to it. But I have yet to see well-controlled studies that have provided convincing evidence to date. But the removal of fat requires agents that directly contact it such as what happens in LipoDissolve. While LipoDissolve requires more study and better analysis, given the large number of patients that are being treated (it is NOT an FDA-approved procedure), but I have first-hand experience with its outcomes and there clearly is some benefit to its use. The issue with LipoDissolve is not its effectiveness but in choosing the right patients for treatment and analyzing for each patient the cost-benefit analysis versus other treatment options, most typically that of liposuction.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Everyone wants the best deal in anything in life…and in plastic surgery this concept is no different. However, the very cost-conscious patient (shopper) in plastic surgery often turns out to be a problem patient.

I am not saying that every patient that wants to negotiate price is a problem, it just seems that there is a disproportionately high number that comes from this type of patient. What I have learned over the years is that discounting price for patients, in and of itself, does not seem like a bad idea since it can create more volume. The problem is…most very cost-conscious patients want more. They take up more of your time and often are more demanding than ‘full-price’ patients. Because they have a lower price, they also value your time less. And they certainly do not thank you for giving them a price break by asking for less of a service or less of a result.

And the real problem can begin…if and when…revisional surgery is ever needed. That is a potential cost issue that few patients factor into their plastic surgery budget…and the very cost-conscious patient most certainly does not. Discounting prices in plastic surgery can be a very bad idea…particularly if it indirectly encourages patients to undergo surgery for which thay can not really financially afford.
Dr Barry Eppley

http://www.eppleypalsticsurgery.com

http://www.ologyspa.com

Clarian West Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana
Indianapolis

The news today of a teenager who has died in Florida while undergoing breast surgery due to malignant hyperthermia is a horrible tragedy. Many will ask could it have been prevented and how can this happen today with all the technology available in modern medicine? Most of the pubic is unaware of this very rare, but very dangerous genetic condition, known as malignant hyperthermia. Its onset will usually only ever happen when presenting for surgery and undergoing anesthesia, either in an operating room, office, or even an emergency room setting. I have witnessed two patients in my academic career who developed this condition during the onset of anesthesia for surgery and it is dramatic and lethal if not immediately and aggressively treated.
Malignant hyperthermia is a bizarre biochemical reaction of the muscles to certain anesthetic agents. These agents include many of the gases (not nitrous oxide) that keep you asleep and to certain of the muscle relaxants which the anesthesiologist uses to temporarily paralyze you to pass a breathing tube. Immediately, the muscles freeze up and body temperature skyrockets, robbing the brain and other vital organs from the necessary oxygen that they need and releasing large amounts of potassium which can stop the heart. This reaction is immediate and without any warning. Even with the best of medical care, death can occur and, even if the patient lives, they may be left with organ damage. Fortunately, the drug Dantrolene has been known to effectively treat malignant hyperthermia for over 20 years and is now widely stocked in most operating rooms that I have been in. This drug, as well as methods to cool the patient, have been life-saving in many cases.
Unfortunately, there is no simple test before surgery to know if one is susceptible to malignant hyperthermia. Nor is it part of any routinue screening due to its rarity. The best indicator is suspicion, a family history that someone has had ‘problems’ with anesthesia in the past. Then a muscle biopsy can be done to confirm its presence.
Anesthesia and sugery can still be done in someone with or suspected of malignant hyperthermia. Local anesthetics, nitrous oxide gas, narcotics, and sedative drugs such as Valium, Versed and Propofol are not known to trigger malignant hyperthermia.
A great resource for further information on malignant hyperthermia as at the website of the Malignant Hyperthermia Association of the United States, http://www.mhaus.org.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medcal Center, Avon, Indiana
Indianapolis

On Tuesday March 25, 2008, Dr Barry Eppley, board-certified plastic surgeon, presented a lecture open to the general public on the topic, ‘Trick, Trend, or Truth: The Insider’s Guide to Plastic Surgery’ at Frederic’s AVEDA Institute in Indianapolis. In this presentation, Dr Eppley reviewed ten of the most popular cosmetic plastic surgery procedures today and discussed the facts versus the myths/misconceptions surrounding them.

Every plastic surgeon understands the importance of listening to patients, either before as well as after any operation. Plastic surgeons understand this better than any other medical specialty, short of psychiatry. (and we have to be part-time psychologists often!) But, quite frankly, listening takes time and extensive time is often not possible at each and every appointment. And just because you listened for a long time to a patient doesn’t always mean you are truly understanding their motivations for surgery or are developing meaningful rapport.

As I have gotten experience in practice, I have moved listening from the passive mode to the active one. Passive listening means you ask a question and let the patient speak until they run out of things to say. This often turns to rambling and provides unnecessary and meaningless information. Active listening is where you guide the patient by pointed questions….like prodding cattle. Interjecting and asking just enough questions to keep the patient on track…to a meaningful conclusion in a timely manner. Medical issues are best served by active listening, personal patient topics are best done by passive listening (particularly when you are doing a procedure when the patient is awake, in the office or in the operating room)
Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana
Indianapolis

 Despite the more recent public awareness of fat removal by liposuction and fat injections for volume addition in the past 20 years, the use of fat in plastic surgery has been around for over 50 years. The history of liposuction dates back to the early 20th century with the famous first case of unsuccessful liposuction in a ballerina who subsequently lost her leg. Necessary improvements in liposuction techniques made it an everyday procedure in the United States by the mid-1980s. Fat transfer or transplantation work by the famous plastic surgeon Dr Peer in the 1950s started by establishing that big pieces of fat don’t survive as well as small ones. The important concept of the need for blood vessels to grow into the transplanted fat as fast as possible for survival was established by this first experimental work.

As we sit here today, what do we know about fat transplantation? Certain aspects of fat transfer do work well and have been used for years. The ‘old’ dermal-fat graft, while completely unknown to the public in general, is still a reliable method for correcting small contour problems or acting as an interface to thicken up some areas. Its problem is that it results in a scar from the harvest (must take skin and a thin layer of fat) so this is only good if you already have a scar somewhere or the scar is more ‘tolerable’ if the procedure is being done for reconstructive purposes rather than purely cosmetic. Small whole pieces of fat can work well but you have to again get the ‘chunks’ from somewhere (scars) and you then have to get it in where you need it. (possibly more scars?) So, these whole fat grafting methods can reliably work but their uses are more limited due to scarring.

Fat injections today remain, by far, more widely done than whole fat methods because they cause little if any scarring and their placement can be more precise……even if they do not work as well. Despite what is frequently touted, fat injections are unpredictable in how much actually ‘takes’. That is why overcorrection is always done. Why do they not always work well? The harvest of the fat, through liposuction, dices it into many minute pieces and kills some of the fat cells. Therefore, what is injected is some portion of liquid fat that will simply be resorbed. While we strain the fat obtained by liposuction, and this helps get rid of loose liquid and blood, and makes it more ‘concentrated’,  there still is ‘dead’ fat in the concentrate. What we have not mastered, yet, is how to make those fat cells that survive this hazardous journey grow in their new home, rather than merely survive.

Recent scientific work and interest has been in the awareness that stem cells, which in theory can grow into any type tissue, are in great numbers in fat tissue. Why do these not grow after being injected with fat into more fat? Perhaps we have just not found the right trigger yet….whether it be a drug to mix with it or the type of fat injected.

The beauty of fat injections, despite their unpredictability, is that they are generally safe, easy to do (in the operating room), and the availability is plentiful in most patients. As plastic surgeons, we will continue to work with fat and I am confident one day we will turn it into a more reliable soft tissue filler.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis