Explore Plastic Surgery

As we age, most people will develop lower eyelid prominences otherwise known as lower eyelid bags. Ini addition to the excess skin thaty develops, a big part of these bags is caused by fat coming out from underneath the eye. In plastic surgery, we call this ‘herniated orbital fat’ which has alway been believed to be caused by the weakening of the tissue that runs between the eyelid and the underlying rim of orbital bone. (known as the orbital septum) Much like a hernia, this support tissue becomes weak and allows some of the fat which wraps around the eyeball to come protruding out. As a result, lower eyelid surgery (lower blepharoplasty) has traditionally involved removing this overhanging fat as well as the extra skin to make this area look better and smoother.

A recent study published in the September 2008 issue of the journal, Plastic and Reconstructive Surgery, looked at the progressive development of these lower eyelid fat prominences to try and explain why we see with age. Their objective was to evalute more closely the long-held belief of a fat hernia under the eye. Through MRI studies of forty patients of different ages, measurements were taken of the eye, fat amd surrounding bone. What they found was that the eyeball stayed in the same position throughout life but the amount of fat around the bottom part of the eye actually increased as we age. These measurements suggest that as we age there is actual fat expansion below the eye that accounts for the development of the lower eye bags.

Recent thoughts on aging lower eyelid (blepharoplasy) procedures have leaned toward doing more of a hernia repair rather than relying on traditional excision for management of the lower eyelid bags. These study findings, however, indicate that the removal of lower eyelid fat is still a good thing to do and is an important component of lower eyelid procedures for many aging patients. There is always the concern that removing this fat may make the eye look ‘too hollow’ over time. But this is not something that I have observed nor do I see it reported in the plastic surgery liiterature.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

LipoDissolve offers an alternative non-surgical treatment option for select fat problems. While liposuction, when it was originally in the United States in 1981, was to be used for ’spot reduction’ (and we know its application has been extended well beyond that initial use), successful use of LipoDissolve really depends on the spot reduction concept. Careful patient selection is of the utmost importance in getting good results with an injection-based fat reduction treatment.
After using LipoDissolve in my plastic surgery practice now for two years and having performed hundreds of injection sessions, I have developed my own system for patient selection. This is a simple system based on one practical consideration, how would LipoDissolve compare to Liposuction for each patient’s problem. I divide patients into 4 types. Type 1 problems are ideal for LipoDissolve treatments as one can expect close to similar results if the area was similarly treated with liposuction. This includes areas about the size of your hand and could include areas such as the neck, small abdominal areas, flanks, back rolls, small saddlebags, and the knees. Generally an area that is small enough that it would be hard to justify the expense of going to the operating room for liposuction surgery. Type 2 patients are the opposite of Type 1. In Type 2 fat concerns, liposuction would result in a much better result than LipoDissolve, often considerably so. These would be larger areas or a combination of more than 3 Type 1 areas. The entire abdomen, combination of inner and outer thighs, back, buttocks, or large flanks are typical Type 2 areas. Type 3 areas are patients who have had liposuction and have some residual areas of irregularities due to underresection. (postoperative LipoDissolve therapy) Type 4 patients are those have have fat tumors known as lipomas. I have found lipomas respond particularly well to LipoDissolve injections, although large ones may require 4 to 5 treatments for complete eradication.
With this relatively simple system of classification, it is easy to not only carefully select those patients most likely to be happy with LipoDissolve therapy but it also makes it easy to counsel patients and make them understand their candidacy for treatment or why liposuction is a better treatment option.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As a plastic surgeon, I certainly am asked and do treat a lot of fat concerns. Whether it be liposuction treatments for fat removal or fat injections for adding volume somewhere, plastic surgeons probably handle more fat than any other medical specialty. Yet, we still do not understand much of its physiology and its response to treatments that we routinuely do.

In looking around at a lot of fat in the body, we do know that it is not all the same. Nor is its functions similar. Most patients think of fat as an unnecessary evil and that its only purpose is to store excess fat and be a source of annoyance and embarrassment. While many fat areas in the body are indeed ‘depot’ areas. Many other fat areas, however, are not. For example, fat in the cheek and temple area (the buccal fat pad) is not a depot area but is intended to serve as buffer between the jaw muscles and allow them to glide smoothly and not interfere with each other. Why the buccal fat pad, for example, goes away in the HIV patient due to the antiviral medications (and fat forms on the back of the neck…the buffalo hump deformity) is not understood at all. For the sake of simplicity in patient consultations, I divide fat into depot and non-depot sites. (although not entirely scientifically accurate) So when a patient asks me, for example, during a liposuction consult if the fat will come back, my answer is…..if it is removed frm a depot site such as the stomach, then if you gain weight after surgery it may most likely come back….if fat is removed from a non-depot site, such as the inner knees or neck, it is much less likely to do so.

Fat transplantation, or fat injections, also remain a somewhat unpredictable procedure. The procedure is very appealing because it is your own natural tissue but, unfortunately, that does not mean that it always survives well (and maintains volume) after surgery. Much effort has been put into doing the obvious, such as minimizing the trauma to the fat by the way it is extracted and prepared to be injected as well as how it is placed. But, yet, how well it works is still unpredictable. We know even less about whether where it comes from (stomach vs. knee, for example) makes any difference in how well it works.

Fat, despite its preponderence and ever-presence, still has mysteries that remain to be unlocked. Fat is a hot research topic now because of the stem cell load that it carries. It is better than bone marrow in this regard as there is more of it and it is easier to get out. No one has ever thought of fat before as being a healing tissue. I frequently wonder as I watch a cannister of fat fill up during a liposuction procedure…..as to what potential benefits we may be throwing away.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

htp://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

Liposuction: Is the Fat Removal Permanent?

One common question asked by many potential liposuction patients is…….will the fat come back? Interestingly, the answer to that question is really speculative and highly individual. As there are no long-term studies of liposuction outcomes that have ever been published (and by long term I mean years not months), the answer about maintenance of fat reduction after liposuction surgery is not precisely known.

While liposuction removes a lot of fat cells….and many more probably die from the surgical trauma….a fair amount of fat cells are left behind in any area that has been treated. It is not possible, nor is it desireable, to removal all fat from any area. The skin needs a buffer from the underlying tissues so it does not get ’stuck down’ and become stiff. Fat, therefore, can return by two methods, either the remaining fat cells get bigger or new fat cells develop from other cells. Either way, it is apparent that undesired amounts of fat can return. I always tell a patient that their long-term liposuction results are highly influenced by their weight. If their weight remains fairly stable, the liposuction result will likely be maintained. If they gain weight, fat is going to develop somewhere. The question in weight gain then becomes….will the fat go back to where it was liposuctioned….or will it develop in new places?

My observation in the regaining of fat after liposuction is that….. in some patients it comes back from where it was removed…..and in other patients it develops in new areas. It is impossible for me to tell what will happen in any patient after liposuction. As a result, I encourage all patients to think carefully about being prepared to invest in the maintenance of their liposuction result before incurring the effort and expense.

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