Explore Plastic Surgery

While the subspecialty of medicine known as Plastic Surgery (one of the 22 recognized specialties of medicine) is now so incredibly common, there are few who would not know what it is. But yet, I will occasionally get asked this question by a new patient during our consultation…’now tell me where the plastic goes’…or…’will the plastic used in the operation get infected?’ Indicating that some still believe that the name ‘plastic’ in Plastic Surgery relates to a material and that plastic surgery operations involve putting in plastic materials.
While plastic surgery as a medical specialty and synthetic plastic materials share incredibly similar time periods in development, there is no direct correlation between the two. Plastic Surgery was not given its name because it used plastic materials in surgery. The word, ‘plastic’, as used in Plastic Surgery comes from the Greek word, ‘plastikos’, meaning to mold, shape, or give form. And this is certainly an accurate description of what Plastic Surgeons do…cut, shape, and mold tissues to give human body parts recognizeable forms whether it be for reconstructive purposes or for cosmetic alterations. As a medical specialty, Plastic Surgery became an organized body in 1931 with the formation of the American Society of Plastic and Reconstructive Surgeons (now known as the American Society of Plastic Surgeons). It’s first formal training program began several years earlier in 1924 with the establishment of the first plastic surgery residency at Johns Hopkins in Baltimore. Formal board-certification in Plastic Surgery started in 1937 which dramatically raised the standards for the specialty.
Plastic materials developed right around the same time frame as Plastic Surgery. The earliest true thermosetting plastics had their beginning in the late 1800s with the commerically successful product known as Bakelite introduced in Britain in the early 1900s. But DuPont with its polyamide (nylon 66) plastic in the 1930s popularized the material here in the United States. New plastics followed quickly such as polystyrene and polymethyl methacrylate. (acrylic). All these plastic materials become tremendously popular and necessary during World War II as components of many military products such as aircraft canopies and radar units. And here is where plastic materials share another similarity to Plastic Surgery…their development was propelled by wars, WWI and WWII. Military conflicts and the need for personal protection (plastic materials) and in the treatment of their war-related injuries (Plastic Surgery) served as a catalyst for both of their developments.
A final sidenote of both of their pre-WWII history is that they similarly converged to deal with a growing problem in the 1930s…motor vehicle accidents. As cars became more common, so did auto accidents and injuries from the shattering of glass windshields. Most commonly, severe facial lacerations resulted from windshields at the time. Plastic surgeons expressed concern about this problem and manufacturers, such as DuPont, were spurned on by these efforts to develop shatterproof windshields.
As Plastic Surgery performs many hundreds of different operations from the face and throughout the body, very few have ever actually required plastic materials to make the operation successful. While breast and facial implants, which are very common and popular cosmetic operations today do use synthetic materials, they are a silicone-based rubber material. Technically, not a plastic material in the organic chemistry sense. Only one operation in all of Plastic Surgery has ever really used a plastic material and that is an acrylic cranioplasty where a section of the skull is replaced by a ‘plastic piece’. While not as commonly done today, acrylic cranioplasties are still done by some Plastic Surgeons and neurosurgeons as 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

A facelift is one of the most recognized procedures in aesthetic plastic surgery…..but also one of the most misunderstood. The general public’s perception of a facelift….based on TV shows and the internet…is someone after such surgery being bruised from their eyes to their neck and their face wrapped up in a big dressing…like they had been involved in a major accident. And that it will take weeks to even look good enough to go out in public. In reality, this perception is flawed at best and even grossly inaccurate at worst.
The name of the operation, facelift, is misleading. It does not really describe what the surgery actually does or what the objectives of the procedure are. More accurately, a facelift should be called a neck-jowl lift, for this is what it actually helps. It is a great procedure for tightening the neck, getting rid of the that neck waddle, and lifting those sagging jowls. The medical name for a facelift, rhytidectomy (old plastic surgery meaning cutting out wrinkles), should be described as a cervicoplasty. (reshaping of the neck) However, the name facelift persists and always will as it is embedded in our plastic surgery nomenclature.
Therefore, when you realize that only the neck and jowl are affected by the procedure, many of its misconceptions fade away. In isolation as a stand-alone procedure (which half of my ‘facelift’ patients only have), a facelift causes no bruising or swelling from the nose up. While many facelift patients get their eyes, forehead, nose and other facial procedures done at the same time, this is not a requirement and is only done if one wants the ‘total face’ rejuvenated. I find that after an isolated facelift, one can look pretty good in about a week and can easily be out in public in a few days with a little make-up in the neck area.
Remember, the eyes are not swollen at all!
One of the great misconceptions about a facelift is what is actually done in the operation. A facelift operation is all about tissue layers and vectors of lifting. The lifting off of the skin from the underlying tissues over the side of the face (to the cheek area) and across the neck through incisions placed in and around the ears is obvious in any diagram of a facelift operation. And movement of loose skin pulled back and over the ears at about a 45 degree angle to the face probably accounts for about 80% - 90% of the result created by a facelift. And often this is the only tissue moved in a facelift. This is the safest and easiest approach with the least likelihood of complications. Deeper layers have also been raised up and moved in more recent versions of facelift surgery. These deep layer that can be moved independent of the skin, is a special layer of tissue over the muscle. This tissue, known as SMAS, is raised and sutured up in a more vertical direction compared to the direction of the skin pull, closer to 60 degrees usually. The public erroneously believes that it is muscle that is moved which is not possible. The SMAS sits on top of the muscle. There is considerable debate as to whether the ‘deeper’ versions of the facelift produce better long-term results than skin movement only.
The neck-jowl lift, known historically as a facelift, can lift two different layers of sagging facial tissues in two slightly different up and backward directions.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.eppleyfacelift.com
http://www.ologymd.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Rhinoplasty (nose surgery) is one of the top ten requested cosmetic procedures for both men and women in plastic surgery. The prominence of the nose and its significance to the appearance of the face makes the need for any rhinoplasty surgery to be very precise. Good results in rhinoplasty are dependent upon an understanding of the complex framework of bone and cartilage that make up the nose. Rhinoplasty surgery changes the shape of this framework which is revealed through the overlying skin.

Think of your nose as a house. The shingles are the overlying skin, the framework and timbers are the cartilage and bone, and the drywall the nasal lining. The support that lies underneath the highest roof angle is the septum. (cartilage) What makes anyone’s nose look the way it does, like a house, is a reflection of how the framework is structured and the roof (skin) that drapes over this framework. As plastic surgeons we think of the nose as 4 areas, the upper 1/3 which is bone, the middle 1/3 known as the middle vault which is all cartilage which is straight, and the lower 1/3 or the tip of the nose which is a combination of scroll-shaped cartilages that come together over the septum and is what gives everyone their unique tip shape. (which is the most different between any two people) The fourth area is the skin, which dependent upon its thickness, can show the underlying framework well if it is thin but can hide much of it if it is thick.

When we alter the nose we are changing the way the framework (bone and cartilage) is joined together and is shaped. This could be taking down the height of the roof in one area (that bump on your upper nose), reshaping the tip of the nose (by changing the shape of the scrolled cartilages, breaking the bone along the bridge to narrow the nose (collapsing the walls), or in some cases adding to the roof line with implants or cartilage to raise the height of the roof line.

Due to the complexity of how all of these framework structures come together, most rhinoplasties today are done ‘open’. While this used to be a controversial area (what was known as the most contested 6 millimeters of skin on the body), it is now accepted to produce the best results in most nose surgeries. All that this means is the skin is lifted off of the tip of the nose so all the framework structures can be seen. To no surprise, you can shape better what you can see better. This only leaves a nearly imperceptible scar at the middle of the skin between your nostrils. (known as the columella) This is a very small price to pay for a better rhinoplasty result!
Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.eppleyrhinoplasty.com
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Liposuction, after 25 years since its introduction in the United States in 1981, remains one of the most popular plastic surgeries for both men and women. How it works seems simple enough…’stick a tube and suck it out’ to paraphrase what many patients say. And while it is conceptually simple mechanical process, there is more to it than meets the eye.

At its most basic level, liposuction is a simple two-stage process for removing fat. A hollow tube (cannula) is put under the skin, the tube is moved back and forth until the fat is dislodged, and the attached vacuum source draws the fat back through the cannula into the tubing and finally into the plastic bottle.

Despite this apparent simplicity, there is more science to it than that. There are three interesting components about liposuction, all of which contribute to its safety and effectiveness. These include tumescent fluid infiltration, vacuum pressure, and cannula size and design.

The placing of fluid during the liposuction operation before doing the suctioning is an integral part of the operation. I frequently get asked by patients if I do tumescent liposuction. Patients think that this is a special method of liposuction, when in fact, it is used in every liposuction procedure. Putting large amounts of fluid into the fat areas to be suctioned beforehand is known as tumescent infiltration. This achieves two fundamental things, substantially reduces bleeding (from the fat being broken up by the liposuction tube and it distends the fat compartments which make the tube easier to pass through the fat being suctioned. Without tumescent infiltration, liposuction would quite bloody, give patients more pain, and have them bruised for a month, if not longer.

The amount of suction generated by the liposuction machine, in short, makes liposuction possible. At the accepted amount of suction needed for liposuction (-20 cms of water or -1 atmosphere of pressure), the pulling of fat through the tubing certainly occurs. But it also causes the vaporization of water. If you have ever witnessed an actual liposuction procedure, you may have seen bubbles in the fat or bubbling in the plastic cannister. To some degree, this is actually water boiling….or the pressure in the system falling to the vapor pressure of the water in the fat being removed. It is this vaporization that makes the viscosity (how thick it is) of fat, which is actually a combination of fat, blood, and infiltration fluid, less to improve its ease of flow through the tubing. From a flow standpoint, water that is vaporized ( a gas) flows 100 times faster than liquid water. This is also why liposuction done at higher altitudes, where the water vapor of pressure is less, is somewhat easier to do. (takes less suction from the machine)

The tube (cannula) that is actually used under the skin differs in diameter and the holes at the tip. In days gone by, the cannulas were quite large but left a lot of depressions in the overlying skin after due to removing too much fat too fast and in large pieces. Today, small cannulas are used which removes fat more carefully and in smaller pieces, decreasing the problem of skin irregularities after surgery. The tip of the cannula is rounded so that it travels through the fat easier with less chance of penetrating something you shouldn’t. The holes at the tip are where fat sticks to and then gets sucked into the cannula. The more holes there are at the tip achieves two effects; increases the shearing effect (like a blade) on fat and makes more cross-sectional area through which fat can be suctioned.

Currently, there are newer methods of liposuction or to be accurate, methods of loosening up the fat. These include ultrasonic and laser-assisted. While they sound quite advanced (and they are), there is no convincing evidence at this time that they are actually better than traditional liposuction. Better meaning….you get more fat removed, smoother results, and recover faster with less bruising and pain. They are marketed by the manufactures as such but there is no solid science to prove it. And they still require suction to pull out much of the loosened or liquefied fat.

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

How is a Chin Implant done?
Short chins (both in height and in length) are good indications for what we call alloplastic mentoplasty, otherwise known as a chin augmentation using a synthetic implant. Chin implants are by far and away the most common method for enlarging one’s chin. Its principal advantage is that it is simple and quick to do, allows for a rapid recovery, and the result is very predictable with a high patient satisfaction rate.
A wide variety of synthetic materials have been used in the chin but the standard over time continues to be solid silicone. It is well tolerated, flexible, easy to insert and remove, can be easily manufactured in an endless number of configurations and sizes, and is inexpensive. Its flexibility allows even large extended implants to be placed through small incisions. As of this writing, porous polyethylene (Medpor) is the lone alternative and good results can be achieved with its use although it is more expensive, requires greater intraoperative time and effort for fashioning and placement, and is more difficult to remove should that ever be necessary.
The chin implant is almost always put in through a small incision on the underside of the chin in the submental crease. This provides a direct approach for placement of the implant (shortest distance to the bone) and allows liposuction and neck tightening procedures to be done through the same incision. The chin implant is slide into position on the bone after a pocket has been made that will accomodate its size. Once in place, it is either sewn or screwed into place and the tissue closed over it. While a chin implant can also be placed through the mouth (a common approach done by many oral surgeons), placing it this way disrupts the main chin muscle and the risk of having the implant riding too high on the chin bone after surgery unless the implant is secured by screws to the bone.
The chin implants used today are quite different from those used in the past. Today’s chin implants are better by having ‘wings’ that extend out further to make a smoother transition to the bone on the side of the chin out on the jaw. This allows for the creation of increased width to the chin and improved blending into the lateral body of the mandible without irregular transition zones. The size and style of chin implant chosen is done by pre-surgical imaging of the face and chin and looking at how the different sizes change one’s profile.
Chin implants are a very safe procedure that has few complications if done well. Infection after surgery is rare but the implant could be salvaged by antibiotics alone if it occurs in the early postoperative period. Thereafter, implant removal is usually required for resolution. Some temporary lower lip numbness can occur but this resolves quite quickly after 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