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 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.

The severely sagging breast usually requires a combined breast lift with an implant, known as a mastopexy with augmentation in plastic surgery terms. This combined procedure lifts and repositions the nipple to a more central mound position, tightens and reshapes the breast mound into more of a conical form, and adds volume to create a fuller mound. In many ways, the different goals of this procedure work against each other….tightening the breast but making it bigger at the same time. This may seem like a trivial consideration, but it is these opposing forces which make a breast lift with an implant a difficult operation. It is difficult to do well and even more difficult to get both breasts as symmetrical  as possible.

An extended or full breast lift is needed in the extreme weight loss patient. A large amount of skin must be removed in a ‘keyhole’ or wedge-like pattern. While this skin excision is marked before surgery with a tape measure and the planned incisions made visually symmetric, few breasts are exactly the same to start with. This inherently makes even the most well marked and planned breast lift exposed to risks of asymmetry. In a breast lift, skin is removed but breast tissue (and the nipple) are not. The cutting and redraping of the breast skin provides a more uplifted and better shaped containment sac for the breast tissue. This results in a classic anchor or inverted-T scar pattern on the lower pole of the breast.

During the breast lift, there is ample opportunity and access to introduce and place a breast implant. Because of the blood supply that goes to the nipple through the breast tissue, it is prudent to place an implant under the pectoralis muscle rather than above it. Placing a breast implant above the muscle into the breast tissue may injure or disrupt the nipple’s blood supply, increasing the risk of losing the nipple after surgery due to necrosis. (turns black and dies) What size implant to use will vary greatly. You want to fill out the overlying breast tissue and make a nice round mound but you still want to be able to close the breast lift skin over it. Therein lies the  art and skill of the procedure. It is a delicate balance between choosing the right breast size (expansion) that still allows closing and tightening the breast skin (contraction)without too much tension. Too much tension of the breast lift skin closure will result in wide scars at the least and the possibility of suture line opening or breakdown after surgery.

Because of the complexities of making an improved breast shape through lifting and an implant, every patient undergoing this procedure should be aware of and accept that the need for revisional surgery is likely. Whether it be asymmetry of the nipples, positioning of the implants, and poor scarring from the lift, revisional surgery for this operation is not rare.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The development of loose floppy skin after large amounts of weight loss (greater than 75 or 100 pounds) is a well recognized problem that occurs frequently. While it can be a surprise to some weight loss patients, it should not be.

Whether the weight loss is from heroic dieting efforts or bariatric surgery, the damage that has been inflicted on the skin is irreversible. Once the skin appears taut when fully inflated (high weight), the loss of the underlying fat support causes a deflation of the skin cover much like the deflation of a balloon. The skin does not ’snap back’ for two reasons which is identical to what can occur from pregnancy. First, the slow (or rapid) expansion of fat and weight stretches the skin and, in fact, actually makes more skin as it expands. This is well known in plastic surgery as an older, but still useful, surgical technique known as tissue expansion. (commonly used today in breast reconstruction after cancer) The slow stretching of skin, while causing it to thin somewhat, actually makes more surface area of skin. Secondly, stretching beyond a certain point causes the elastic fibers in the skin to become permanently deformed. The elastic fibers (and collagen) are responsible for skin’s elasticity. Like overstretching a spring, the fibers are pushed beyond their tensile limits and they are no longer able to return to their original coiled shape. The combination of more skin that is no longer elastic results in hanging sagging skin.

There are other factors which can make the loose skin condition better or worse. How much weight is lost, how rapid the weight loss has been, your type of skin (thinner more fair skin stretches more), your age (older patients develop more loose skin), and smoking (smoking breaks down elastic fibers faster) are all contributing factors as well. Clearly, large amounts of weight loss over a short period of time in an older patient with fair skin who smokes does not bode well for skin readaptation.

Unfortunately, no amount of dieting, exercise, or topical creams will restore the elasticity of skin. Simply put, excess skin must be cut out and the skin left behind tightened. This often leaves remaining stretch marks (if present before surgery) and, with time after surgery, there will be some relaxation of the remaining skin which has been tightened. But this small amount of relapse is trivial compared to the size of the original problem.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Body lifts are almost exclusively done in the bariatric surgery patient who has undergone massive weight loss. (> 100 lbs) A body lift is a combined frontal tummy tuck and a posterior buttock lift with a resultant 360 degree (circumferential) scar. While good care after a body lift is not hard, the need for management of several drains can be challenging.

 
1. Body lifts usually have only a moderate amount of postoperative discomfort as
only skin and fat have been removed and no muscle work has been done. In addition
to taking your pain medication, keeping yourself in a partially flexed position (knees
slightly bent toward your chest) when resting in either a chair or bed is very helpful
during the first week after surgery.

 
2. You will have as many as four (4) drains coming out of the pubic and back area after
surgery. They will be removed when the drainage is sufficiently low. As most drains
don’t come out before 10 to 14 days after surgery, it is not important to start
recording their output until after the tenth (10th) postoperative day.

 
3. Get up and walk periodically even in the first few days after surgery. This will help
you breathe deeper and ultimately feel better. Judge your activity level on how you
are feeling. You will tire more easily than expected, even up to one month after
surgery.

 
4. You may shower on the 2ndd day after surgery. Do not submerge your incision in a bath
tub or hot tub/jacuzzi until 1 month after surgery. By this time, your drains will have
been removed and the incision healed adequately to prevent internal contamination.

 
5. Tapes are usually placed across the abdominal and back incisions. They should be
left in place and do not require any care. They will be removed within the
first two weeks after surgery.

 
6. You are to continue wearing your circumferential binder for 2 weeks or more after surgery.
As these binders have a tendency to ride up, it is important to keep them repositioned
low over the hips so some pressure can be maintained over the incision site.

 
7. Numbness of the abdominal and back skin is to be expected and complete return of
feeling may take up to 6 months after surgery. During this period, exposure to heat
(e.g., hot tubs, heating pads) should be done with this consideration in mind to avoid
potential burn injuries.

 
8. Avoid exercise and heavy lifting for 6 weeks after surgery. Abdominal stress and
abdominal specific exercises can be resumed 8 weeks after surgery.

 
9. You may drive when you feel comfortable and can react normally and are off pain
medication. Driving is all about whether you are safe to yourself and others on the road.

 
10. It is not rare to have some small openings along your extensive incision line which
develops several weeks after surgery. This is either sutures which are coming to the surface
or small areas that have slightly separated due to tension and movement on the wound.
Simply keep them covered with antibiotic ointment and a dressing and they will go on to
heal on their own. It is ok to get them wet in the shower.

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

Of the many body deformities that result from excess skin after massive weight loss in the bariatric surgery patient, the most difficult in my experience is that of the breast. Loss of breast volume, a low nipple position, and sagging skin from a ‘deflated balloon’ creates a breast problem that offers a lot of challenges. Lifting and reshaping a bariatric breast is a four-dimensional problem consisting of tightening and lifting the skin sleeve, elevating the nipple into a more central position on the breast mound, adding loss breast volume, and trying to minimize the amount of scars necessary to do accomplish all these tasks.

 
The real challenge in making a better breast in the bariatric surgery patient is that lifting and reshaping the breast and adding volume through an implant (which is almost always necessary) makes it very difficult to predict an exact final result. Then when you factor in the important task of keeping the nipple alive through these manuevers (removing excess skin and putting in an implant can inadvertently knock off the blood supply to the nipple), raises the risk of further complications.

 
Based on these concerns, I advise patients that I will do my best to get a good result in one operation, but my experience has shown that it usually takes two separate procedures to get the best outcome. In other words, the revision rate in these types of breasts is quite high. Whether more skin needs to be tightened, the implants need to be repositioned or adjusted in volume, or the nipple needs to be lifted even higher, it is very difficult to get two, fairly symmetric breasts that match. Inevitably, some aspect of one breast or the other is ‘off”. Therefore, I advise my patients to think of their breast procedure as a two-staged operation with the hope that we do good enough that some patients will get by needing only one procedure. None of this has factored in the issue of scars and how they look which poses another risk. Fortunately, most breast scars turn out fairly well although it takes a considerable amount of time until they blend in well.

 
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 male bariatric surgery patient who has undergone massive weight loss, the resultant chest wall (breast) deformity is often of major concern. The appearance of the male chest, like the female breast, is of understandable significance. This male chest deformity is often called gynecomastia but this is inaccurate and actually signifies a different pathology. Gynecomastia is the enlargement of native breast tissue producing an enlarged nipple-areolar complex to a decent-sized breast. Chest deformity after massive weight loss is a deflation (loss of breast tissue) with resultant skin excess, sag, and a low-hanging nipple. As such, they are quite different from each other in many cases.

In some male bariatric patients, simple liposuction with or without a nipple lift, may be all that is needed. But in many cases, this is simply inadequate. The problem is what to do with the sagging skin and how to get the nipple positioned up higher on the chest……without creating a lot of scarring. (which may be worse than the original problem) In short, there are no easy answers to these issues.

Possibilities for correction include staged, repeat nipple lifts (each time inching it up higher), pectoral implants to add some volume (but you can’t have too much skin or this makes it look worse), or cut-outs of skin along the bottom part of the chest out to the side with the resultant scarring. Either way, getting the nipple up higher and removing excess skin often fights against each other.

Male chest ptosis (sagging) after massive weight loss is somewhat similar to that of the aging male’s chest problem. (but usually with less extra skin) Both are ‘deflation’ issues with low nipple positions. Most of the time a compromise has to be reached. Which is more important….tightening the skin or lifting the nipple? I usually encourage the male patient to avoid any significant scarring on their chest. While cut-outs of skin can very effectively tighten and lift the sagging chest, the resultant scars will usually make you feel no better about your chest problem. If your goal is only to look better in a shirt, then this might be an option. However, I caution the male patient about scarring. Even if they think it won’t matter, there is no magic eraser to take it away later.

As you can see, the male chest in massive weight loss poses a dilemma for many patients to which there is no easy solution in the extreme cases. A good in-depth discussion with your plastic surgeon is really needed here. The consequences of plastic surgery must be balanced against the original chest wall deformity to be certain that enough improvement can be obtained to make the surgical experience worthwhile.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Of the many bariatric surgery patients that I have seen over the years who have lost 100 or more pounds, the concern over their saggy arms is often a top concern. I would have to say that the arm concern combined with the stomach or waistline are almost always the top two priorties of the massive weight loss patient. I should add one caveat, the arms are an issue exclusively for women. I have yet to see a male patient who has put forth this concern to me. That does not mean that men don’t develop flabby arms after bariatric surgery, it just doesn’t cause the same problems that it does for women.

Because of high arm concerns, most female bariatric surgery patients often undergo a combination of an arm lift (brachioplasty) and an abdominoplasty as the first stage of their body contouring. Full arm lifts, which all bariatric surgery patients require, always result in a long arm. The patient can choose whether this scar ends up on the inside of the arm or on the back of the arm. There are arguments for its placement in either location. It is a choice of whether you see the scar but others not so much so (inside of the arm) or whether others see it but you can’t. (back of the arm) Either way, I caution patients that, from my perspective, I have seen very few good-looking scars. Scar from arm lifts seem to do rather poorly in terms of their width, redness, and their tendency for hypertrophy. (raised scar) I think it is the very thin skin and the tension that it is under from the tight closure that makes them often appear fairly unsightly. While they can be raised revised later, from which they turn out much better, an arm scar that parallels the vertical axis of the arm is one of the poorer scar outcomes from body contouring in the bariatric surgery patient. Then there is the scar banding (contracture) issue that can occur as the scar crosses from the arm into the axilla. (armpit) It is always necessary to bring the skin excision pattern into the armpit and often down into the side chest wall. Like all scars that cross areas of movement, a tight band often develops. Sometimes I have incorporated a Z-plasty into the skin cutout and other times, I have just waited to see whether a bothersome scar contracture develops. For most patients, the degree of improvement in the shape of their arms seems to overshadow significant concerns about an axillary scar contracture.

One of the nicest things about an arm lift procedure is that it is associated with little to no postoperatve pain and recovery from it is fairly quick. Other than some mild swelling in the hands during the first few days after surgery, most problems with arm lifts are relatively minor including snall fluid collections (seromas), spotty areas of delayed incisional healing, and the scar issues previously mentioned. For these reasons, an arm lift is a perfect compansion to other more major body contouring procedures in the bariatric surgery patient such as tummy tuck, circumferential body lift, and breast lift/implants.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

According to the annual statistics of the American Society for Aesthetic Plastic Surgery, the number of body contouring procedures performed has dramatically increased over the past five years. Abdominoplasty, lower Body Lift, buttock lift experienced a 200% gain while thigh and upper arm lift experienced a 400% rise. This parallels and is due to the increased number of patients that have undergone bariatric weight loss surgery.” According to Allergan, manufacturer of the Lap-Band® bariatric procedure, 350,000 of these devices have been placed worldwide. Nearly 100,000 bariatric procedures, of either the LAP-Band or bypass variety, were performed last year in the Unisted States alone.

 
After these patients’ large weight loss, loose skin remains that can only be removed surgically. The abdomen, with the skin frequently hanging down like a drape hiding the belly button and pubic area, is a major problem as is excess skin of the arms, thighs, breasts, and faces. These patients seek out plastic surgeons to correct these problems. The American Society of Bariatric Plastic Surgeons(ASBPS)was founded to help meet the needs of these patients. It is composed of plastic surgeons that specialize in body contouring after weight loss.

Cheryl, who lost 125 pounds after her gastric bypass had an outward appearance left her disappointed and discouraged. She waited until her weight stabilized and then had face and body contouring. A Lower Body Lift (an Abdominoplasty and Buttock Lift) and Facial surgery were performed as a hospital inpatient. Then, several months later, she had a Breast and Upper Arm Lift and Liposuction as an outpatient. “For me, having the plastic surgery was like crossing the finish line with my weight loss journey,” said Cheryl.

 
As gastric bypass and LAP-BAND® procedures exponentially increase, so too will body contouring operations. Even though the number of post-bariatric patients seen by plastic surgeons has dramatically risen over the past five years, it is projected that these numbers will become overwhelmed in the coming years by these patients seeking cosmetic improvement.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis