Explore Plastic Surgery - Dr. Barry Eppley

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 - 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the topic of Bariatric Plastic Surgery was discussed. After massive weight loss (MWL) which is usually done through bariatric surgery (lapband and bypass procedures),  many patients suffer with a lot of excess and hanging skin. What to do with all the excess skin has led to the development of specialized plastic surgery procedures for these patients. Todays guest was plastic surgeon Dr. Peter Rubin from the University of Pittsburgh. As one of the world’s authorities on bariatric plastic surgery, he discussed when such procedures should be considered in the MWL patient, whether medical insurance will provide coverage for them, the differences between a tummy tuck and a lower body lift, breast and chest reshaping, arm lifts, and thigh and buttock lifts. Numerous body contouring after weight loss procedures can be combined in a single operation but overall body recontouring requires several stages to complete. These operations are complex and one must be nutritionally sound to go through them to prevent wound healing problems from the long incisions that are required.

Free Body Contouring and Bariatric Plastic Surgery consultations with Dr. Eppley can be arranged by calling his Indianapolis suburban area facilities at Clarian North office at  317-814-4100 or his Clarian West office at 317-217-2200.

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 - 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the topic of Bariatric Surgery was discussed. With guest host Dr. Samer Mattar of the Clarian Bariatric Center, many aspects of obesity and the different types of  bariatric surgery to treat it were reviewed. Who is a good candidate for bariatric surgery, when should surgery be performed, what are the different types of bariatric surgery, will my insurance cover the procedure, how quickly will the weight loss occur, what are the complications of the surgery, what do I do after my surgery, and what can one do with the hanging skin after the weight loss were discussed. Patients can call to schedule an appointment with the Clarian Bariatric Center at 317-275-7010.

Large amounts of weight are being lost in this country through the popular procedures of bariatric surgery, most notably gastric bypass and the lapband operations. Despite the popularity of bariatric surgery, I see in my practice just as many patients who come in for body contouring procedures who have lost weight through diet and exercise. Because these weight loss methods are so different, with theoretical higher risks of poor healing in gastric bypass patients due to malabsorption, it would be interesting to know if the complications from major body contouring surgery are different between these two groups.

This exact issue was looked at and published in the January 2009 issue of Plastic and Reconstructive Surgery by Drs. Gusenoff et al at the University of Pittsburgh. In 220 massive weight loss patients (191 bariatric, 29 diet and exercise) patients that underwent body contouring surgery, the complication rates and outcomes were looked at and analyzed. The conclusion was that there was no evidence that either weight loss method increased the risk of complications from a number of common bariatric plastic surgery procedures such as panniculectomy, mastopexy, brachioplasty, body or thigh lifts. It should be pointed out that there was a large difference in the number of patients in each group (29 vs 191) but statistical analysis based on matched procedures did not show a significant difference.

Bariatric plastic surgery involves the most extensive removal and reshaping of body tissues that exists in all of plastic surgery…or for any form of surgery for that matter. These body contouring operations, while safe, are not complication free. Wound separation (dehiscences) and small areas of infection are common in most patients and I point this out to all patients in advance. Because the bariatric surgery patient is more likely to have nutritional deficiences than non-bariatric weight loss patients, one would assume they would have higher rates of complications. This does not appear to be so. However, I would point that the plastic surgeons that performed these procedures and did this study are experts in the field and undoubtably have a keen sense of patient selection and surgical execution. Their expertise has most likely prevented some potential complications. Preoperative nutritional assessment and the type and number of procedures performed in any weight loss patient (I rarely go over 5 hours of surgery at one time) are still extremely important issues for all weight loss patients, no matter how they lost it.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Breast reshaping in the extreme weight loss patient almost always require the combination of an extended breast lift and a breast implant. The loss of breast tissue from the weight loss and the now overstretched skin results in a deflated breast with a significant sag. The nipple lies below the lower breast crease and in many patients it points directly to the floor. Such a misshapen breast requires both volume (breast implant) and a radical skin reshaping. (lift)

While this combination breast reshaping procedure is commonly done, it is not easy to get a good symmetrical breast result. The need for secondary revisions with this approach is not rare. Revision rates may be as high as 25% to 35%. The reason this procedure is difficult from a cosmetic standpoint is that the breast lift and the implant work against each other in achieving their goals.  A breast lift is a skin reduction procedure that lifts and tightens, a breast implant is an expansion procedure that stretchs and lifts. There is no exact science that can tell a plastic surgeon exactly what size implant is needed for how much skin is removed in a lift. It is as much an art as anything else.

One valid approach is to do the breast lift first and defer the placement of the breast implant as a second stage months later. While this staged approach has its advocates, it condemns the patient to two operations 100% of the time. While the combination of a lift and implant may require a significant percent of patients to need two operations due to a revision, the majority of patients (> 50%) will be able to get a satisfactory result in one combined operation.

The primary objective of this form of breast reshaping is to get the nipple lifted and centered on the breast mound. This results in the classic anchor breast scars to achieve it and the blood supply to the nipple is always in jeopardy with the low but real risk of nipple loss. The implant is placed through the same approach as that of the breast lift.

The combination of breast scars, an uplifted nipple position, breast implants, and having two breasts makes achieving  perfect symmetry and shape between the two breasts a difficult proposition in the combined lift/augmentation procedure. Fortunately,  most extreme weight loss patients are quite satisfied with significant improvement in their breasts even when revisional procedures may be needed.

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 excess skin and fat from extreme weight loss often creates a circumferential hanging effect at many levels of the body. While many think of the body lift as only one contouring procedure, they are only thinking of the lower body lift or circumferential body lift procedure. There is another body lift procedure for the upper body, not surprisingly called the upper body lift.

Like the lower body lift, the upper body lift is a combination of three body contouring procedures. A frontal breast procedure (for both women and men), a side chest wall lift, and an upper back lift. In some cases, the cut out of loose skin may extend into the arms as well. This combined operation leaves long scars around the upper body but are usually a worthwhile trade-off for the dramatic improvement in the shape of the upper body. The resultant scars across the back and on the side of the chest are horizontal, much like the lower body lift. The change is in what occurs across the chest/breast area. Usually I like to keep it in the lower chest/breast crease and make it horizontal also. It can certainly be combined with a breast lift or a gynecomastia reduction if needed. But the one thing you don’t want to do is cross the midline/lower sternal area with a scar if you can avoid it. The risk of scar widening is very likely in this area, not to mention being very noticeable particularly in women. Therefore an upper body lift is not always completely circumferential as a lower body lift would be.

Upper body lifts are not as common as lower body lifts because it takes a very extreme amount of weight loss to create enough skin to justify the operation. Usually the patients must have lost 150 to 200 lbs after their bariatric surgery. The upper body lift has its greatest effect in the problematic area of the side of the chest wall and upper back. As a result, it would not be uncommon to just do a partial upper body lift stopping short of the chest/breast area and not crossing the exact middle of the back. Upper body lifts have the same riska and postoperative issues as lower body lifts including poor scarring, small areas of wound separation, and fluid build-up after the drains are removed.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

While every type of plastic surgery has risks, most of the time they don’t happen. Body contouring surgery, however, not only has risks but it is not a question of if you will develop complications…it is question of how when and severe will they be. This may initially sound pessimistic, but the reality is that body contouring patients all develop some of the complications of their surgery. Fortunately, most of these problems are small and manageable and end up being inconvenient and self-limiting but not health or life threatening.

When I talk about complications from body contouring surgery, it is important to clarify what procedures we are talking about. Smaller procedures, such as necklifts, breast lifts, or armlifts, have less risk of complications that body lifts or thigh lifts. It is simply a matter of how long are the incisions and how much surgery was done. Body lifts, example, have a much longer incision and is a bigger operation than an arm lift for example. The point being….not all body contouring surgery procedures have the same risk of complications as others. You need to discuss with your plastic surgeon the different procedures you are having and how these risks differ. Suffice it to say, the more procedures that are done together the more incisions are made. As more incisions are made, the following potential risks are more likely.

By far, the most significant ‘complications’ from body contouring surgery are wound related. And they are as follows; incision/wound separation, seroma formation, and infection. Some slight or partial separation of certain incisions is likely and happens in many patients. These usually are at areas of high tension (tight skin closure) and or at the ‘T’ intersection of many procedures. (e.g., breast lift/reduction, combined horizontal/vertical abdominoplasty, above the gluteal crease in the body lift) When they happen, little can be done to close them except the allowance of time for healing in on their own.

Seromas, or fluid collections, are remarkably common. This is why we use drains after surgery. In my experience, 30% or so of patients who get drains will still develop a seroma after the drain has been removed. While no one dies from a seroma, it is inconvenient as the fluid must be ‘tapped’ with a needle and removed numerous times before it stops building up. While the use if drains helps eliminate many seromas that would otherwise form, it is not an absolute cure for them.

Infections occur in many body contouring patients although most of them are small and very limited. Most commonly, some stitches will spit later even if they are of the dissolveable type. This often makes a nice-looking and healing incision turn unsavory for a while. Mild infection and cellulitis of some skin areas can also occur but usually resolves with antibiotics alone.

Body contouring surgery patients need to know that they all will likely develop some of these issues. Once one gets past four to six weeks after surgery, the risk of these issues has passed and attention turns toward how the result looks.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Many body contouring surgery procedures have a significant impact and stress on your system. Extreme weight loss patients are more likely than normal weight patients to have some changes in their blood chemistries as well as heart and lung issues that may impede healing and place their general health at risk. For these reasons, all extreme weight loss patients will require medical clearance by their primary care physician before surgery. It is critically important that any medical condition be identified and treated beforehand.

Many extreme weight loss patients see their physicians routinuely and get regular laboratory studies. The important laboratory tests to get or to have are a complete blood count (CBC), metabolic panel, bleeding time, and electrocardiogram. (EKG) The CBC evaluates the health of your white blood cells (fights infection), hemoglobin (oxygen-carrying capacity) and platelets. (helps clotting) Changes in normal for any of these blood cells will delay surgery until the reasons are found and corrected. The metabolic panel tests more than a dozen functions of your organs, most pertinently the levels of electrolytes (which help your heart and body work) and your protein and albumin levels. (which are indicators of your nutritional status) The bleeding time tests how long it takes for your blood to clot. (a critical issue when large segments of skin are being removed) The well known EKG tests the electrical activity of the heart, ruling out heart rhythm problems and evidence of past heart attacks. Any abnormalities in any of these tests are likely to require further testing.

As long as these tests have been performed within six months of your scheduled surgery, and the results are normal, no additional presurgical testing will be needed. With normal laboratory studies, your physician should be able to provide written medical clearance for your bariatric plastic 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

What does body contouring surgery cost? Because surgical fees vary across the country and even within any given city, it is impossible to provide an accurate answer for any specific procedure on a general basis.

The first question most patients will ask, however, about body contouring surgery costs is whether their health insurance will pay for part or any of the surgical procedure. As a general rule, there are very few body contouring procedures that insurance will cover. This may seem unfair to many, but the reality is health insurances don’t consider most of the excess skin as causing any significant medical problems. Removal of the abdominal overhang, or pannus, may occasionally be covered due to skin rashes and its weight, but problems of the breast, arms, back, and thighs are almost always rejected.

Therefore, it is best to think of paying out of pocket for most or all of the body contouring procedures. The cost of a procedure is always a combination of three fees…use of the operating room, anesthesiologist’s charge, and the time of your plastic surgeon. Two of these costs are fixed, the operating room and anesthesiologist. They charge by time and at a fixed rate. The longer the operation is, the more their costs will be. Your plastic surgeon’s fee is variable…it is completely up to the plastic surgeon as to what they want to charge and whether they may offer discounts for multiple procedures. Additional charges may be incurred for overnight stays, postoperative garments, and any preoperative lab work. The good thing about elective surgery costs is that they are fully disclosed up front in their totality.

The issues surrounding elective surgery costs and payment are fairly universal across the country. After your consultation, you will receive a surgical quote at some point which will detail the costs. You will likely be required to place a deposit before booking your surgery. Full payment is usually required in many plastic surgery practices one or two weeks before your surgery. Make sure you read and understand the cancellation policy as unforeseen circumstances do occur to some patients and they have to reschedule or cancel their booked surgery.

Also, be aware and be clear on your plastic surgeon’s policy regarding revisional surgery. The need for revisional surgery due to complications or adverse results is not rare in major body contouring 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

In almost any geographic area with a significantly sized metropolitan city, there are dozens and maybe hundreds of plastic surgeons. But which one is right for your surgery? Like any specialized form of health care, you want someone who is both well qualified and has a fair amount of experience in body contouring surgery.

Sometimes it is easy…you know someone who has had the plastic surgery that you want and has had a good experience…so you go to their plastic surgeon for an initial evaluation. Word of mouth is almost always a good referral method. More often, however, you are not as fortunate and you have to start a search on your own. Here is how to do it.

First, only go to a board-certified plastic surgeon. This may sound territorial to some, but when it comes to major body contouring surgery it is not. For something like Botox or laser treatments or other minor cosmetic procedures, a host of so-called ‘cosmetic surgeons’ may suffice and the outcomes may be only marginally different. But body contouring surgery is not trivial and requires a lot of training and experience from doing reconstructive procedures of the body. There is a huge difference between managing not enough Botox and dealing with a postoperative wound separation of a thigh lift. Only someone trained in the full scope of plastic and reconstructive surgery has the knowledge to deal with major surgery….and their potential complications. Search for plastic surgeons in your area online at www.plasticsurgery.org, the official site of the American Society of Plastic Surgeons. Plastic surgeons listed there have to have the right training and board-certification to be a member.

Once you have found a handful of potential plastic surgeons to see, visit their websites and view what they have to say and show about bariatric plastic surgery procedures. Although not having any info or results to show does not mean they don’t have adequate experience, those plastic surgeons that do certainly have an interest in performing these types of plastic surgery. Cross check their names at the website of the American Society of Bariatric Plastic Surgery, www.asbps.com, an interest group of plastic surgeons who have or are sharing expertise in body contouring surgery. Today there are also a handful of young plastic surgeons that have received special training by completing a fellowship in bariatric plastic surgery beyond their basic plastic surgery residency.

Do as many consultations with different plastic surgeons as you feel necessary. Yes it will cost to have consultations but this is peanuts compared to the actual cost of surgery and the risks to which you will be exposed. The right plastic surgeon is often the one that makes you feel the most comfortable and takes the time and energy to spend time with you. Many patients are told to ask their prospective surgeon what their experience is and how many they do per month, year, etc. While there is nothing wrong with these questions, I don’t know how helpful these answers often are. How many operations do you have to do to be good at it? For some plastic surgeons it may be just a few every now and then, for others it many take many more. A more pertinent question is ask to see photos of results or talk to patients of the plastic surgeon who have had the procedure in the past several months. This is a more tangible question that can be very informative. Lack of photos or an unwillingness to share them or put you into contact with former patients is more revealing than a numbers question.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

It is understandable and natural for patients who have undergone large amounts of weight loss to want to complete their body contouring surgeries as soon as possible. Getting the exterior part of the body to reflect your weight loss accomplishments completes the final physical step in the journey. But the concept of staging is an essential consideration in anyone considering bariatric plastic surgery.

Staging is the separation of a large number of body contouring changes into a series of operations over a period of time. This is of great importance in most body contouring procedures due to the size of the operations and the physical stress that they place on one’s system during the procedure as well as in the recovery phase. While many weight loss patients will never complete total body contouring ( or the number of operations that can maximally improve their body), many will have at least two operations which are usually staged three to six months apart.

Because of the magnitude of major body changing surgeries, the realization of potential risks and the time needed for adequate recovery…..safety is absolutely paramount. Body contouring surgery is not just a technical exercise to see what can be done…but an operation planned that can be done with maximal safety and very visible results. For this reason, I will not do a body contouring procedure that exceeds five hours. This limits the exposure of the patient to general anesthesia and the chance for significant blood loss. In addition, I like to do a single operation in which the patient can still go home the same day. By keeping it to a five hour time limit, common combinations could be abdominoplasty/arm lifts, circumferential body lift (by itself), breast lifts/abdominoplasty, etc. Enough is done to make the surgery very worthwhile but still keeping safety as the utmost concern. And recovery is still a very manageable two to three weeks for all of the potential combinations that can be done in this time frame.

Doing body contouring surgery in stages is not only safer but usually leads to better results in my experience. I do not get too tired (plastic surgeons are just human) and attention to detail in a long operation is not lost. Furthermore, the amount of stretching and pulling on loose skin is not in too many directions at one 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