Explore Plastic Surgery - Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

Weight loss surgery in the United States had grown considerably in the past decade. There are now over 200,000 bariatric surgeries performed each year consisting mainly of either a bypass or lapband procedure. Bariatric centers are located in every major city and I can count at least four major bariatric centers in Indianapolis alone. Despite this large number of bariatric procedures being done, only a fraction of this number actually go on to get plastic surgery for their loose skin that subsequently results from the weight loss.

According to a new study sponsored by the American Society of Plastic Surgeons, many bariatric patients are not aware of the after weight loss body contouring procedures they could have to remove loose skin. The study reports that up to 75% of bariatric patients don’t know about these body contouring procedures. Had they been more fully informed of their options, it is suggested that they might choose to partake of some of these bariatric plastic surgery treatments.

The study looked at nearly 300 patients who underwent bariatric surgery. They found that only 25% of the patients discussed the potential need for plastic surgery with their bariatric surgeon before or after their surgery. After their bariatric surgery, only about 15% were referred to a plastic surgeon for evaluation and just over 10% actually had plastic surgery to remove loose skin. Nearly 40% of the patients said they might have chosen to have the plastic surgery if they knew more about it or were better informed.

Why don’t more weighty loss patients go on to have plastic surgery? Certainly inadequate education before or after bariatric is one major cause. But this reason alone is not why so few pursue body contouring after weight loss. Not every bariatric patient actually needs plastic surgery or is concerned enough about whatever loose skin they have to consider a new set of procedures. There is also the realistic issue that many bariatric patients can only do what insurance may cover. Besides having considerable difficulty in even getting the most obvious sagging skin problems covered, paying out of pocket for many is simply too expensive. Many plastic surgeons today don’t participate or accept insurance for these procedures due to the abysmally low reimbursements.

While many massive weight loss patients do suffer a lot of loose sagging skin which causes rashes and other skin problems, the consideration of plastic surgery should be deferred for at least a year after their bariatric surgery. It is important to be sure that one’s weight is stable, one is healthy from a blood chemistry and electrolyte standpoint, and that whatever skin contraction can occur is given ample time to do so.

It is clear that insufficient counseling at the time of bariatric surgery can leave a patient unaware or surprised after their weight loss as to what their body will really look like. However, in today’s internet world and given the dirth of support groups and chat forums, it is hard to imagine one wouldn’t be aware that they would likely benefit by plastic surgery later. I think the real surprise is that most patients think that their plastic surgery, at least some of it, will be covered by insurance. That feeling is certainly understandable as the need to reshape the body is a direct result of the weight loss surgery. In the regard, however, patients can not be more misinformed.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The growing popularity of bariatric surgery as naturally led to many patients considering or in need of major body contouring surgery after massive weight loss. Almost any plastic surgeon today can testify to the frequent requests for such procecures. Because most of the procedures performed on the massive weight loss patient are extensive and labor-intensive, certain practices make bariatric plastic surgery a focus and have the manpower and commitment to treat these patients.

Interestingly, it is not currently known how often the massive weight loss patient who has had gastric bypass or banding go on to undergo body contouring surgery. A recent issue of the journal Obesity Surgery reports on just that issue. Patients (250 in number) who had undergone gastric bypass surgery between 2003 and 200- returned a questionnaire which obtained information on body image satisfaction and frequency of body contouring surgery after massive weight loss. Perhaps surprising to some, the study found that the majority (75%) but not all desired body contouring after their surgery. Of this group, fifty-three patients (21%) had undergone a total of 61 body contouring procedures. The most common body contouring procedure was a tummy tuck/panniculectomy and lower body lifts.This study illustrates the significant disparity between the number of massive weight loss patients who want a body contouring surgery and those who actually received it. This small study showed that only about 20% of patients have some form of bariatric plastic surgery. No one will really ever know what the percentage is nationally, but it would not surprise me that this number is fairly accurate. The simple reason is economics. These extensive plastic surgeries are expensive and insurance does not cover many of them. While almost all massive weight loss patients expect insurance to cover the removal of their resultant hanging skin after their bariatric surgery, it is disappointing when they find out that it largely isn’t so.

Why doesn’t insurance cover many bariatric plastic surgeries? Because it has to have a proven medical benefit to do so. Just because there is too much skin and it hangs and doesn’t look good is not deemed medically necessary. The most common medical benefit to justify coverage of surgery is that it must improve dermatitis and skin infections. Generally only an abdominoplasty fulfills that medical criteria. This eliminates coverage for necklifts, armlifts, any form of breast reshaping, back lifts, and thigh lifts.

It is also no surprise that the most common body contouring procedure that is done is a tummy tuck or an abdominoplasty. This is largely driven by insurance coverage. Removal of a pannus or skin apron that hangs over the waistline is deemed medically beneficial in many cases. As a result, it is the one bariatric plastic surgery procedure that gets done first to those massive weight loss patients surgically inclined.  

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Without question, the number one concern of bariatric surgery patients after their weight loss is abdominal reshaping. When the weight loss is in the neighborhood of 75 to 100 lbs., the abdominal skin does not redrape or shrink back down. Rather, a large amount of redundant skin results which both hangs and has multiple rolls.

The traditional tummy tuck or abdominoplasty is almost always inadequate to create the best abdominal result in the massive weight loss patient. This is because the excess skin exists in a true three-dimensional fashion, being excessive in both horizontal and vertical dimensions. As a result, I almost always use the combined vertical and horizontal tummy tuck procedure known as the fleur-de-lis abdominoplasty in my Indianapolis plastic surgery practice for bariatric patients. This results in abdominal scars that have a midline vertical and a low horizontal line, known as the anchor scar pattern. Adding the vertical part to the traditional tummy tuck does require more surgery time for dissection and closure, but most relevantly increases the amount of deep space underneath the skin after closure.

In theory, the fleur-de-lis abdominoplasty should be associated with more complications than a traditional abdominoplasty. It takes longer to do and has incisions that meet at an inverted-T area. It also removes a very large segment of skin which leaves more dead space uinderneath. To investigate if this seemingly truth is reality, the May 2010 issue of Plastic and Reconstructive Surgery published a study conducted by the University of Pittsburgh Division of Plastic Surgery on this very question. Over 400 abdominoplasty patient were evaluated of whom 154 (31%) had a fleur-de-lis abdominoplasty operation. The overall abdominal complication rate was 26%. This included all types of complications of which 5% would be considered major. (requiring further surgery) Traditional horizontal excision abdominoplasties and fleur-de-lis abdominoplasties were very similar in complication rates with the exception of a higher rate of wound infections in the more extensive abdominoplasty.

My Indianapolis plastic surgery experience is slightly different than that reported in this very extensive and thorough study. I have seen no greater incidence of wound infection between the two types but have certainly seen more wound openings/separations at the inverted-T area. A traditional abdominoplasty does not have this zone and, as a result, significant wound openings are very uncommon. The dead space in the fleur-de-lis abdominoplasty is managed with an extra drain and I am more conservative about their removal, keeping at least one in place for two weeks after surgery.

The fleur-de-lis creates a better abdominal result in the bariatric patient if they feel that the trade-off of a vertical scar is worth an improved upper abdominal area. In days gone by with open gastric bypass surgery, a vertical scar already was present so the decision for the fleur-de-lis was easy. With laparoscopic gastric bypass today, the patient must consider a new obvious vertical scar.

Another consideration for bariatric patients considering the fleur-de-lis abdominoplasty is insurance coverage. If one’s health insurance will provide an abdominoplasty coverage, that does not include the vertical component of the fleur-de-lis. The insurance company covers the horizontal abdominal excision only. There will be an extra out-of-pocket charge for adding the vertical component to the procedure.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

1.      How soon after my weight loss can I get plastic surgery done?

Large amounts of weight loss, generally 75 to 100 lbs or greater, will cause significant loose skin on multiple areas of the body. It does not matter whether that amount of weight loss is from dieting, gastric bypass, or lapband surgery, the skin can not shrink back done in most people.

Because body contouring surgery is about removing as much excess skin as possible, one should have maximized their weight loss and proven that this new weight is stable. For some patients, that may be 9 to 12 months. For others, it could be much longer than a year.

The other benefit to waiting until your weight loss is stable is to make sure you are in  a good nutritional state. Weight loss, no matter how it is done, depletes one’s body of vital nutrients and other stores that are needed for the healing of long surgical incisions and extensive wounded tissues.

2.      At what weight should I before I can have body contouring surgery?

Many extreme weight loss patients have a specific target weight in mind. Whether they make it or not depends on a lot of factors and one of those is certainly time. Whether any patient will hit their weight target is unknown. But at some point one will realize a point when their weight will not get any lower. Once one has bounced around at a low weight for awhile, then you can be certain this is where your body will live. Once you are comfortable that you have found this weight, and can keep it, then you are ready for surgery.

3.      What’s the difference between a tummy tuck and a circumferential body lift?

The one body area that bothers all extreme weight loss patients is the abdomen or waistline area. Loose skin is always present in front of, over, and behind the hips. For some patients, a skin overhang is only present in the front. For many others, the skin excess extends around the waistline and across the back, resulting in sagging of the buttocks and posterior thighs as well. These concerns are almost always addressed first in most bariatric plastic surgery treatment plans.

When the excess skin overhang is primarily in the abdominal area, a tummy tuck or abdominoplasty is all that is needed. While it can be a conventional horizontal elliptical excisional pattern, the amount and stretched out quality of the skin may need  a modified pattern to provide optimal tightening. This may require the horizontal cutout to go further back along the waistline or to include a vertical skin wedge resulting in an invert T or anchor closure pattern. (fleur-de-lis tummy ruck)

When the loose skin incorporates the entire waistline, a circumferential or 360 degree cutout is needed. This is known as a circumferential body lift. It is a lot like ‘pulling up your pants’. The scar will run completely around your waistline. In some cases, the front side of the circumferential body lift may include the fleur-de-lis cutout pattern as well.

4.      How can I reshape my saggy breasts…or my manboobs?

One of the most challenging of all body parts to reshape after extreme weight loss is the female breast and the male chest. The female becomes essentially a deflated bag of skin with severe sagging and the nipple often pointed downwards. The male chest also loses volume, although less so than the female, but the chest skin shifts and sags downward with a lower than normal  nipple position.

 The breast often requires a combination of an implant, for volume replacement, and a lift (mastopexy)to reduce the amount of sagging skin and bring the nipple back up to a more central position of the breast mound. This is a difficult operation, from an artistic standpoint, and it often requires two separate surgeries to get the best result.

The sagging chest in the male, while not trying to make a mound like in the female, is complicated by trying to limit scarring. There are no natural creases or folds to hide scars in the flat male chest. Getting the nipple back up on the chest and tightening the skin requires a compromise between the result and the amount of scarring. The chest lift in a man is done differently than a breast lift in a woman.

5.      I hate my ‘batwing’ arms, what can I do about them?

Loose skin in the arms is another common extreme weight loss problem. In the back of the upper arms (triceps area), loose skin and fat hang off and below the humerus bone. This creates a large fold of hanging skin. It often extends into and past the armpit and down into the side of the chest. In some cases, I have seen the skin excess goes past the elbow into the forearm.

The good news is that arm recontouring, known as brachioplasty, is the ‘simplest’ of all body contouring procedures. The arm’s circumferential measurement can be measurably reduced.  Skin and fat is removed longitudinally along the arm and the cut out often takes a right turn into and past the armpit. The bad news is that it does result in a long scar in an unnatural area on the inside of the arm. Scar healing problems are not uncommon in the moist and moveable armpit area.

6.      How bad are the scars from bariatric plastic surgery?

Body contouring after extreme weight loss is about making a trade-off…scars for improved contours. Depending upon the body area, scars tend to turn out somewhat different. Breast and abdominal scars generally look best while arm and thigh scars tend to become wider. Most of these scars are more than just fine or pencil-line in width and some of them will end up becoming hypertrophic or wide due to the tension placed on the wound closure.

Regardless of how the scars may look, there can be a lot of them if multiple body areas are treated. Despite the plethora of this new skin ‘problem’, weight loss patients universally prefer them to their prior ‘sharpee’ body look.

7.      Will insurance cover my skin removal surgeries?

While third-party payors often pay for surgical and non-surgical weight loss treatments, such widespread coverage for body contouring is not so generous. The line between cosmetic and reconstructive procedures for removal of excess skin is a judgment call that does vary amongst different insurers. Ultimately they are looking for functional problems that this skin causes, such as infections, to determine medical necessity for the operation. In general, the most commonly covered procedure is the abdominal panniculectomy or frontal abdominoplasty. The procedures never covered are breast and chest reshaping.

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 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