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Dr. Barry Eppley

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Archive for the ‘anesthesia’ Category

Herbal and Supplement Medication Guidelines in Plastic Surgery

Friday, June 28th, 2013


The use of dietary supplements is the norm today rather the exception. Between the use of vitamins and herbal supplements, it is estimated that nearly half of the U.S. population is partaking of these alternative or complementary oral aids. This does not take into account whatever pharmaceutical medications that they may also be ingesting. Put together it is not uncommon today to have a cosmetic surgery patient who is taking three, four or five oral medicines even though they have no major medical problems.

Without asking specifically on an intake form in a doctor’s office, some patients do not voluntarily report their supplement use. They may do so because they do not feel they are relevant to having surgery or do not want to admit that they take them. How prevalent is this patient behavior?

In the July 2013 issue of the journal Plastic and Reconstructive Surgery, an article was published on this topic entitled ‘The Incidence of Vitamin, Mineral, Herbal and Supplement Use in Facial Cosmetic Patients’. A retrospective review was done on 200 facial cosmetic surgery patients from a single plastic surgeon’s practice based herbal and nonherbal supplement use. They found that supplement use was nearly 50% amongst the studied patients of which 25% used only vitamins and minerals. In those using herbal supplements, they averaged using nearly three per patient. Herbal supplements were more likely to be used in women over the age of 50 while vitamin and mineral supplements were used by younger patients and men were more prone to take them.

Knowing whether a patient undergoing plastic surgery is using herbal medications is important as some of these supplements can increase intraoperative and after surgery risks. Herbal medications, such as echinacea, ephedra, ginkgo, ginger, St. John’s wort and valerian, have been identified as having adverse reactions such as immunosuppression, cardiovascular effects of hypertension and arrhythmias, hepatotoxicity, increased bleeding and interference or prolongation with various anesthetic agents.

It should not be any surprise that many cosmetic surgery patients have a higher incidence of oral supplement use given their attention to face and body image improvements. Patients should be aware that they need to stop these supplement uses at least 2 and preferably three weeks before their surgery. This is the known time that any potential adverse effects of these supplements should pass as their residues and breakdown byproducts are excreted from the body. Such recommendations are completely in line with that of the American Society of Anesthesiologists. If in doubt as to whether any alternative medication use may interfere with your upcoming plastic surgery, stop it as a few weeks of not being on them will have no adverse health effects.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review: Exparel Local Anesthetic

Sunday, February 10th, 2013


The use of local anesthetics is commonly done in numerous plastic surgery procedures for both immediate and prolonged pain relief. One such operation would be a tummy tuck where the rectus muscles are sutured together. This is the most common source of significant pain after the procedure. Indwelling pain pumps or the injection of long-acting Marcaine (bupivacaine which lasts up to 24 hours) into the muscle is commonly used to help control the patient’s pain after surgery. While pain pumps can work up to 48 hours after surgery they are an additional tube(s) that exits the body and adds hundreds of dollars to the cost of surgery. Injected marcaine with epinephrine will last somewhere in the range of 18 to 24 hours but no longer.

Exparel is a newer local analgesic agent that combines bupivacaine with a unique liposome delivery vehicle known as DepoFoam. This is a multivesicular liposome that entraps the local anesthetic agent and slowly releases it as it breaks down over a few days after injection. This is why the solution looks white and flows like low fat milk due to the suspended liposome particles. This allows a single dose to have a duration of effect of around 72 hours or 3 days. A large number of clinical trials (21) evaluating over 1300 patients who had various surgical procedures were tested for both safety and effectiveness.

Exparel (bupivacaine liposomal injection suspension, 1.3%) has the potential to simplify postsurgical pain management by reducing the need for oral narcotics and/or pain pumps by delivering bupivacaine with a single injection. Better postsurgical pain management may potentially result in less discomfort and earlier mobility in the first few days after a tummy tuck which is the most difficult phase of the recovery. There are other potential applications in plastic surgery where such pain control could be beneficial as well such as breast augmentation.

Dr. Barry Eppley

Plastic Surgery Product Review: Pliaglis Topical Anesthetic Cream

Monday, December 17th, 2012


Pain from an injection, laser procedure or minor surgery in plastic surgery is a common concern for many patients. While numbing of areas to be treated can be done by the injection of local anesthestics, this is often impractical due to the size of the surface area or represents another painful and feared experience. This has led to the use of topical forms of local anesthesia to create enough of a numbing effect to lessen the procedural discomfort.

Over the years various concentrations of lidocaine and tetracaine, the most commonly used local anesthetics, have been used in various topical preparations with up to 4% concentrations being commercially available. They are applied topically, covered with a clear dressing to prevent being wiped away, and take up to 45 to 60 minutes to achieve optimal penetration into the dermis of the skin to be effective.

In October 2012, the FDA approved a new topical anesthetic cream known as Pliaglis. (Galderma) Pliaglis contains a 7% concentration of lidocaine and tetracaine, the highest concentration ever approved for an anesthetic cream. It is intended for use in adults for superficial cosmetic and dermatologic treatments such as injectable fillers and laser procedures. It is to be applied 20 to 30 minutes for most procedures and for up to one hour prior to procedures that cause the most pain. Pliaglis uses a proprietary phase-changing technology that allows the cream to form a pliable peel on the skin when exposed to air.

It is logical to assume that a concentration of 7% topical anesthetics would be more effective than the traditional use of 4% concentrations. Higher local anesthetic concentrations may not only provide more profound anesthesia but maybe in a shorter time after application also. There are a wide variety of cosmetic procedures in which Pliaglis could be used including Botox, injectable fillers, facial laser resurfacing, high-intensity pulsed light treatments, laser hair removal and laser-assisted tattoo clearance

While recently approved, Pliaglis will not be available for commercial use until early 2013.

Dr. Barry Eppley

Plastic Surgery Wisdom – Anesthesia and Surgical Results

Saturday, November 24th, 2012


Anesthesia can consist of local infiltration where one is completely awake, differing depths of IV sedation (twilight) or profound general anesthesia. The range of anesthetic options exist because not every medical procedure needs a general anesthetic to be performed. For example, you don’t need a general anesthetic to have a colonoscopy. Conversely you don’t want to use a local anesthetic to fix a broken leg either. Plastic surgery is unique, however, because many of its operations can be done in whole or in part by any of the anesthetic options. This leaves the option of patient input into how they may want their procedure performed. There are always understandable fears of general anesthesia, such as not waking up, nausea and vomiting afterwards and loss of control. But besides these fears, other factors help form a patent’s desire for a certain type of anesthesia including cost, the way the procedure is marketed,  transportation to and from the facility and the perception of a quicker recovery. (which may or may not be true) But despite these anesthetic options and the plastic surgeon’s desire to please any particular patient, it is important to realize that the results of an operation can be adversely affected by these anesthetic decisions. Choosing a local or sedation anesthetic may limit the extent and thoroughness of the procedure being done. Allowing the plastic surgeon to be able to perform the procedure that way he/she thinks it is best done and with maximal patient comfort almost always assures the best possible result.

 ‘You Are Choosing Plastic Surgery For The Best Possible Outcome Not For The Least Amount of Anesthesia’

Dr. Barry Eppley

Anesthetic Options in Plastic Surgery

Tuesday, November 13th, 2012


Anesthesia of some form is critical to every surgical procedure in plastic surgery. Even with some non-surgical procedures (e.g., laser hair removal, injectable fillers), some level of anesthesia may be desired. Every patient knows that there are different types of anesthesia and many will have a distinct preference for their procedure. But not every procedure can be done with a patient’s anesthetic of choice and often patients are confused about how anesthesia works.

There are four basic choices of anesthesia in plastic surgery ranging from topical, local, IV or conscious sedation and general anesthesia. Here are some basic concepts of how they work and when they are most useful.

Topical anesthetics are based on the application of creams that contain various types of well known anesthetic agents. They need time to work to penetrate the skin so ideally they should be applied at least 30 to 45 minutes before the procedure. To enhance their absorption the area may be covered or wrapped with a plastic dressing to allow maximum penetration of the active agents in the cream. They will make the skin numb but not tissues underneath it. Therefore, they are only good for procedures like laser hair removal and light to medium-depth laser skin resurfacing. They may also help lessen the feeling of injection needles as they pass through the skin.

Local anesthetics have been for a long time and just about everyone has received a local anesthetic injection for some procedure, often dental in nature. In plastic surgery, the local anesthetics used almost always also contain epinephrine to decrease the bleeding at the surgical site. Once injected local anesthetics take about 7 to 10 minutes to exhibit their maximal effects. Local anesthetics do burn on injection due to the low pH of the solution. (acidic) When buffered with sodium bicarbonate they are much less painful on injection. Their numbing effect will last up to 2 hours unless a more long-lasting agent is used that create numbness up to 24 hours. While local anesthetics are very effective, patient soften feel more procedures can be done under local anesthesia than really should be done. Fixing an earlobe tear, removing a mole or small skin cancer or even upper eyelid surgery can be comfortably done under local but bigger procedures like facelifts, breast augmentation and liposuction (even though they may be marketed this way) should give one pause. You want to make sure that the anesthetic selection will not limit the extent of the procedure and the final result.

IV sedation, also known as twilight or conscious sedation, has come a long way in the past 25 years. The drugs available today are so good that they can have an effect on the patient like they feel like they have had a general anesthetic.  (no memory) Sedation drugs can include just oral (pills) or different concoctions given through an IV. Oral sedation is good to take the edge off before a procedure that is using a topical or local anesthetic and the pills should be taken one hour prior to the procedure. IV sedation can range from very light to deep based on the drugs and their dosages used. It can be a difficult choice to choose between sedation and general anesthesia for many procedures as there is a lower risk of nausea and vomiting after sedation  and one may feel like they wake up quicker after it. The best way to think of sedation is that it is an extension of a local anesthetic. If getting the area adequately numb is the issue, then sedation can very comfortably get one past the injections. This approach can be very effective for isolated face or body areas but one should not think of larger surface areas such as in  multiple areas of liposuction, a tummy tuck, or even a more extended facelift as good for a sedation approach. This does not mean that some doctors do not do them but it pushes the balance between getting a comfortable surgical experience and the maximal result simultaneously.

General anesthetics are well known and the difference between them and a deep sedation is a fine line. The difference is that in general anesthetics patients lose control of their breathing and the anesthesiologist must take control. This is done historically with an endotracheal (ET) tube (between the vocal cords and into the lungs) or more commonly with an laryngeal mask. (LMA) With the exception of rhinoplasties and facelifts, most general anesthetics in elective plastic surgery today are done with an LMA. This produces less throat soreness afterwards as the mask stays well above the vocal cords in the back of the throat. General anesthetics provide comfort for every procedure to be performed. The aggressive use of anti-nausea drugs before, during and after a general anesthetic dramatically decrease the likelihood of after surgery nausea and vomiting, the most dreaded fear of most patients when considering a general anesthetic.

For the administration of deep IV sedations and general anesthetics, a board-certified anesthesiologist is the safest approach although the use of certified nurse anesthetists (CRNA) is permitted in some states. For procedures that only need topical, oral or local anesthetics, your plastic surgeon will give the injections or write a prescription for the anesthetic medicine.

Dr. Barry Eppley

Indianapolis, Indiana

Improving the Comfort of Facial Injectable Fillers

Wednesday, August 25th, 2010

Injectable fillers are a tremendously popular method for immediate enhancement of the lips and cheek-lip grooves. They have revolutionized cosmetic improvements of thin lips, lip lines, and a deepening nasolabial groove. With over a dozen injectable fillers to choose from, patients have a variety of options in both the cost of treatment and how long the effects will last.

One choice patients don’t have, however, is that the treatment requires a needle to create its effect. Despite it being a very small needle for most types of fillers, it is not a pain-free experience. Patients may enjoy the benefits but they have to endure the injection session to get it. The manufacturers of these materials is well aware of this concern and many now incorporate a local anesthetic in the injectable filler. While this provide some numbing effect, the needle must first pierce the skin to inject the filler-local anesthetic combo.

Therefore, a need still remains to get past the discomfort of the needle passing through the skin. While many use ice and other topical strategies, they are not that effective. One highly effective method, but one that uses a needle as well, is that of intraoral or dental nerve block techniques. On the surface, the use of one needle to defer the pain from another seems contradictory. However, skillfully placed intraoral injection can be made near painless with the right technique. The problem is that most practitioners have never been trained or are unaware of these time-tested facial local anesthetic techniques.

The first step in this technique is to use only a 1cc syringe and a long 30 gauge needle. Use a 2% lidocaine solution for the injection. While the use of epinephrine in the lidocaine may not seem needed for any lasting effect, it seems to create more profound skin anesthesia. For the cheek-lip groove, two injections placed just under the maxillary vestibule of 0.5cc each using the canines as vertical guides can really make these injections painless. If you shake and squeeze the lip while giving these injections (an old but effective dental maneuver), they can barely be felt.

An alternative to these maxillary vestibular injections is to inject the cheek-lip groove right under the skin. These are quick and not as uncomfortable as injecting a viscous filler material under pressure. The easy flow of the liquid anesthetic through a 1” long 30 gauge needle makes the injection minimally uncomfortable. But the anesthesia is profound and prepares the area well for the greater distension from the various filler materials.

For making the upper lip numb, these same two injections are used. But these alone will not block the entire upper lip. The central third, or the tissue between the philtrums, will be missed by these injections. It requires a small injection (.25cc) just above the upper lip frenum. This is a very tender area but is less painless than injecting a completely sensate middle third of the upper lip.

For the lower lip, injecting the vestibule just below the canines can effectively block most but not all of the lower lip. Again the central third is often missed and the vestibule below it may need a supplementary injection.

Having as comfortable as possible injectable filler treatment session is important given their temporary nature. If your injector is not taking the time or putting forth this effort to make you comfortable, it may be time find someone else who will.

Dr. Barry Eppley

Indianapolis, Indiana

Protection of the Singer’s Voice during Plastic Surgery

Thursday, April 8th, 2010


Professional singers, like many artists, are also occasional plastic surgery patients for facial and body changes. In my Indianapolis plastic surgery practice, I will see about one or two such patients a year who truly do make their living by singing. In larger metropolitan areas like New York or Los Angeles, for example, vocalists as patients are in much higher numbers for sure.


While singers have the usual questions and concerns about their proposed plastic surgery procedures, they inevitably ask about being put to sleep and whether that will have any negative impact on their voice. This is a very understandable concern that undoubtably stems from the historic use of a ‘breathing tube’ for being put to sleep.


The best answer to this question comes from an anesthesiologist who ultimately is in charge of every patient’s airway during any form of surgery that requires a general anesthetic. I have asked Dr. Mark Fletcher, a board-certified anesthesiologist in Indianapolis with over 25 years of practice experience and one of the finest anesthesiologists that I know, for his thoughts on this ‘high-pitched’ question.  


‘Traditional anesthesia involves using a breathing tube that goes between the vocal cords and into the windpipe.  This is known as endotracheal intubation (ET tube) and involves inserting a plastic tube directly between the vocal cords.  After removing the tube, singers have occasionally experienced hoarseness that is temporary.  In rare cases there is the possibility that permanent changes to a patient’s voice could occur. (although this has not been reported in the medical literature)


But it is possible to have surgery today  with no risk to the delicate vocal cords. This technology is available and is known as using a Laryngeal Mask Airway or LMA.  The LMA was invented and developed by Dr. Archie Brain in England and introduced in the United States in 1988. The LMA functions like a cup inside the mouth,  keeping the airway into the lungs open but it does not pass through the vocal cords or gets anywhere near them. Instead it gently cups the opening to the voicebox from above. Not only does it protect the vocal cords from damage, the LMA is also less likely to make your throat sore. Although an LMA is not an option for every surgical procedure, it can be used for nearly all plastic surgery procedures.’


LMA anesthesia is the norm now for almost all plastic surgery procedures. There are a few facial plastic surgery exceptions, most notably rhinoplasty and facelift. In these procedures, the LMA often gets in the way or distorts the neck so it is still used during these procedures. But in all body plastic surgery, the LMA can be used for general anesthesia.


For professional singing patients, or any patient concerned about any change in their voice (even temporary), LMAs are the modern answer to these voiced concerns.


Dr. Barry Eppley

Indianapolis Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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