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Archive for the ‘liposuction’ Category

OR Snapshots – Liposuction and Boiling Fat

Thursday, December 29th, 2016


Liposuction is one of the most common and recognized procedures in plastic surgery. By the way it looks in watching the procedure and how it is commonly perceived by the public, liposuction appears to be as simple as ‘sucking fat out’. But the reality is that it is a more complex extraction process than its name alone implies.

The obvious part of liposuction is the insertion of a hollow stainless steel cannula under the skin. Traditionally a back and forth motion of the cannula is done which essentially cuts tunnels through the fat layers often from multiple different directions. (known as cross tunneling) The cannula is attached by tubing to a vacuum pump which then pulls out the cut or loose fat as well as introduced and other bodily fluids.

boiling-fat-in-liposuction-dr-barry-eppley-indianapolisBut working more occultly are several basic principles of physics that really make liposuction work. One of these can be occasionally observed in the fat collection canister. Looking carefully, or sometimes not very carefully, one can see bubbles coming up from the bottom of the fluid collection to its surface. Sometimes there are so many bubbles it appears that the fat is ‘boiling’.

This bubbling action in the collected fat aspirate occurs because of the vapor pressure of water. All liquids at any temperature exert a certain vapor pressure. This can be thought of at the point where liquid molecules are escaping into the vapor phase. This transition is highly influenced by temperature, the higher the temperature the more the molecules become active and can break free of their intermolecular bonds and escape into the atmosphere. (exceeding the atmospheric pressure pushing down on it). This is well known in water where at roughy 212 degrees F at sea level the vapor pressure is large enough that bubbles are formed.

This is where the influence of atmospheric pressure plays a critical role. At standard atmospheric pressure (1 atmosphere), water boils at 212 degrees F. In essence the vapor pressure of water at 212 degrees is 1 atmosphere. At higher elevations where the atmospheric temperature is lower, water boils at a lower temperature as there is not as much pressure on the liquid water as the water vapor reaches that pressure at a lower temperature.

The vacuum pump of liposuction creates a negative pressure in the collection cannister. The normal negative pressure setting is at least -20cm of water or – 1 atm. This will dramatically lower the boiling point of water or, thinking of it non-thermally, will allow the liquid water to escape into a gas. (bubbles) This is what is happening at a fluid temperature that is somewhere just below body temperature. The collected fat and fluid is truly boiling!

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Pectoral Implants with Abdominal Etching

Monday, December 26th, 2016


The principal method to augment the male chest is with the use of pectoral implants. Like in the female breast, the placement of a pectoral implant creates an immediate chest enlargement. The fundamental difference between a female and make chest implant is that one is a fluid-filled device while the other one is solid. The male pectoral implant is designed to completely replicate muscle and therefore can be more firm. Conversely a breast implant is designed create a breast mound that is softer and more supple.

Pectoral implants come in a variety of sizes with several shape choices. With standard volumes sizes now up to over 600ccs significant chest enhancement cab be achieved in just about any male regardless of their size. As a solid implant they have a low durometer which not only makes the feel much like muscle but also allows them to be introduced through a high axillary incision as well.

pectoral-implants-and-abdominal-etching-result-front-view-dr-barry-eppley-indianapolisA good complement for the male chest enhancement patient is that of abdominal liposuction or abdominal etching. Since they can both be performed in the supine position it is a good opportunity for a ‘male maleover’ with combined chest and abdominal reshaping.

The creation of a ‘six-pack’ is a form of liposculpture using focused fat removal along specific lines. Designed to replicate the appearance of the abdominal inscriptions, etching mimics those lines by creating a dermal-fascial adhesion. Abdominal etching works best in the thin patient. But it can be done at the same time as overall liposuction in men with thicker subcutaneous abdominal wall layers albeit with not the same abdominal etch line definition as in thinner men.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Buffalo Hump Reduction with Power-Assisted Liposuction

Saturday, December 10th, 2016


Background: The accumulation of fatty tissue at the back of the neck is a well known side effect from certain HIV medications. One of these lipodystrophic sites is the cervicodorsal region where abnormal fat distributions can occur. Because of its raised area below the back of the head it has been given the moniker of a ‘buffalo hump’. Such disfigurements can be very distressing to those patients so affected.

The mainstay of treatment for such buffalo humps has been surgery. No non-surgical therapies have been shown to be effective. Excision lipectomy has been most commonly used and has good success rates in small clinical series. The most common complications have been a high rate of seromas and wound dehiscences. Such complications are usually self-resolving and have not required reoperations. Recurrent fat accumulations have also not been reported to occur.

Liposuction offers a treatment approach to the buffalo hump that does not involve an open excisional approach. This avoids the risk of wound dehiscence, significant visible scars and a very low rate of seroma formation. With the many different types of liposuction devices available today, improved reductions are possible compared to traditional suction-assisted lipectomy using standard cannulas.

Case Study: This 47 year-old male presented with a large and painful buffalo hump that had been growing for years. It had gotten big enough that it caused pain on neck extension and was also a source of embarrassment.

buffalo-hump-reduction-result-back-view-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, the buffalo hump was infiltrated with a tumescent solution. Using a power-assisted liposuction device (PAL) and a 4mm basket cannula, a total of 700cc of aspirate was obtained from a two point access approach.

buffalo-hump-reduction-result-side-view-dr-barry-eppley-indianapolisAt his two week follow-up he had a complete flattening of the cervicodorsal area and no signs of fluid accumulation. The treated area was still sore and that would take up a month or more to be completely pain free. The skin over the treated area was numb and would be expected to be so for several months after the procedure.

Cervicodorsal lipodystrophy, aka buffalo hump, is a well known complication of the extended use of HIV protease inhibitor drugs. Because of the fibrofatty composition of the buffalo hump tissue, it has been suggested that only excision can prevent its recurrence or be effective in removing it. This clinical directive is based on the use of traditional liposuction techniques and not on more contemporary liposuction technologies. Today’s energy or power-driven liposuction devices are far more effective at treating denser or scarred fat accumulation sites.


1) A buffalo hump deformity at the back of the neck is a well known sequelae of HIV protease inhibitor therapies.

2) While excision of buffalo hump deformities is effective it is associated with scars and seroma formation.

3) Liposuction of buffalo hump deformities is equally effective as open excision with a lower risk of complications.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Power-Assisted Liposuction of the Abdomen and Waistline

Thursday, September 29th, 2016


Background: Liposuction remains one of the most popular and commonly performed body contouring procedure. Like all surgical techniques liposuction has evolved over the years and there are now a myriad of technologies available to help perform the procedure.  I call all of these liposuction technologies ‘energy-driven’ since they all use various devices and different energies to more effectively break up the fat for vacuum extraction.

Each of these liposuction technologies has their own unique advantages and disadvantages and despite claims that one is superior to the other scientific evidence for comparisons does not exist. What is probably true is that any of the energy-driven devices is better than traditional liposuction which uses the doctor’s energy or old-fashioned ‘elbow grease’.

power-assisted-liposuction-indianapolis-dr-barry-eppleyPower-assisted liposuction, commonly known by the acronym PAL, uses mechanical energy. It would be considered ‘low tech’ because it relies on mechanical oscillation of the tip of the cannula to create its pulverizing effect on fat collections. Its benefits are that it is more effective than a surgeon moving the cannula back and forth as well as reducing surgeon fatigue. Reducing surgeon fatigue may seem self-serving or trivial but the more effective and longer the surgeon can work the better the liposuction result will usually be.  Liposuction is truly an effort-dependent process and the more effective that effort is the better the result will be.

Case Study: This 38 year-old female presented for abdominal and waistline contouring. She had a fairly small body frame but had fat collections that she could not budge with any further diet and exercise efforts. This a common presurgical history that is presented as many people ‘hit the wall’ in their own efforts to reshape their body.

abdominal-flank-liposuction-result-front-view-dr-barry-eppley-indianapolisabdominal-back-liposuctionUnder general anesthesia and through a combined supine and prone positioning, the full abdomen, flanks, waistline and back rolls were treated using power-assisted liposuction. A total of 2200cc of fat aspirate was removed.

While liposuction surgery should never be viewed as a substitute for the patient’s own efforts, it can be a useful when one can no longer make body changes on their own. This patient shown here is the perfect candidate for liposuction surgery since she is not overweight and has unwanted collections that will forever remain refractory to diet an exercise. Power-assisted liposuction can very effectively reduce these fat collections and turn the maintenence of those results over to the patient.


1) Power-assisted liposuction (PAL) is an effective for abdominal and waistline contouring.

2) Power-assisted liposuction offers improved contouring results with less surgeon fatigue. (which undoubtably contributes to the improved patient results)

3) PAL does not add to the overall cost of liposuction surgery since it has no consumable costs and does not prolong the procedure with added time.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Calf and Ankle Liposuction

Tuesday, August 30th, 2016


Background: Liposuction is the most well known fat removal method and has been around now for over forty years. As the surgical techniques and equipment have evolved over this time, fat has been extracted from every conceivable location on the human body. Depending upon the body location and the amount of fat removed liposuction can serve as a volume reduction method or more of a sculpting method.

One of the most challenging areas on the whole body is that of the lower legs. Thick lower legs that have an indistinct shape defy exercise or any other therapy to improve their look. Liposuction is the only method to do so and relies on the premise that too much fat is why they look the way they do.

While excess fat is most certainly a major contributor to the thick lower leg, it is not the only tissue present. The large size of the calf muscles and even the bones are part of he make up of the leg. These tissues are not modifiable and ultimately serve as the limiting factor into how much the size and shape of the lower leg can be improved.

Case Study: This 34 year-old female desired lower leg reshaping. She had thick legs her whole life and would not wear shorts or skirts because of them. They were a lifelong source of embarrassment. While she did not have a thin body habitus she was not significantly overweight either.

Under general anesthesia small cannula liposuction was performed on the inner knees, the entire calfs and on both sides of the ankles. A total of 1,275cc of fat aspirate was obtained between both lower legs.

Calf and Ankle Liposuction results front view Dr Barry Eppley IndianapolisCalf and Ankle Liposuction result back view Dr Barry Eppley IndianapolisHer results show some modest improvement in the shape of her lower legs. They had a more evident knee and calf definition and were somewhat smaller. It took almost three months until all the swelling had completely gone way.

Reshaping of the lower leg by liposuction produces modest improvement. It is usually never dramatic and can not a big leg and make it a small leg. Its improvement comes by making the underlying shape of the muscle more evident.


1) Reshaping of the larger leg can only be done by liposuction from the knees down to the ankles.

2) The effects of liposuction on the lower leg are limited by the amount and location of the fat that can be removed from the subcutaneous layer.

3) Swelling from lower leg liposuction will take up to three months to completely resolve.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Buccal Lipectomies and Perioral Mound Liposuction in the Square Face

Sunday, August 14th, 2016


Background: Faces are well known to come in a wide variety of shapes. One of the well known facial shapes is the square one. The square facial shape is created mainly by the influence of the facial bones. One has to have strong cheek and jawline bones to make such a facial shape….at least in younger and weight appropriate patients. The cheeks and their zygomatic arch extensions must match the width of a strong jawline and jaw angles to create a facial ‘box’ appearance

Square Facial Shape 1 Dr Barry Eppley IndianapolisSquare Facia Shape 2 Dr Barry Eppley IndianapolisIn women the square facial shape can be very attractive and there are numerous examples of famous women who have such a facial shape. It is undoubtably the strong jawline that adds to this attraction. But the one soft tissue feature that they all share is that there is a concavity between the cheeks and the jawline. This is caused by a relative lack of substantial fat in the subcutaneous and deeper tissue planes. In essence the face has a fairly skeletonized appearance.

The aesthetics of the square facial shape can be marred if it has an intervening convexity between the cheeks and the jawline. Such ‘fullness’ can make the square face look less attractive than if there was a convexity present.

Case Study: This 23 year-old female requested fat removal from her face to give a more contoured look. She had a square facial shape with a straight line profile between her cheeks and jawline. She was very weight appropriate for her height.

Female Buccal Lipectomy and Periorall Liposuction intraop Dr Barry Eppley IndianapolisUnder general anesthesia a combination of buccal lipectomies and perioral mound liposuction were done through two separate intraoral incisions. A subtotal buccal lipectomy removed 3 cm diameter fat pads. The microcannula liposuction removed just over 1cc of fat per each side.

Buccal Lipectomies and Perioral Liposuction results Dr Barry Eppley IndianapolisBuccal Lipectomies and Perioral Liposuctgion results submental view Dr Barry Eppley IndianapolisAt 6 weeks after surgery, her square facial shape shows the desired concavity between the cheeks and jawline. This can her face a more sculpted look. It really takes the combination of both facial fat sites to be removed to create the full effect over the vertical distance between the cheeks and jawline.


1) Thinning of the more square facial shape can be done by decreasing soft tissue volume between the convex skeletal shapes.

2) Creating a facial concavity can be done by buccal lipectomies and perioral mound liposuction.

3) Such facial thinning effects creates a subtle but noticeable facial shape improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Maximum Waistline Reduction with Rib Removal and Liposuction

Tuesday, July 12th, 2016


Background: Waistline reduction is effectively achieved by good weight control and exercise for the majority of people. Those with more difficulty in helping reduce the waistline may resort to surgical approaches from liposuction, a tummy tuck or some combination there of. These traditional abdominal surgical approaches will produce very satisfactory waistline improvements in most everyone.

Various maneuvers in both liposuction and tummy tuck surgery can help achieve waistline reduction. Aggressive and focused liposuction at the side of the waistline/flanks can help create a more inward shape. Rectus muscle plication and Scarpa’s fascial advancement performed during a tummy tuck can help pull in the sides of the waistline also.

Rib removal #11 and #12 Dr Barry Eppley IndianapolisBut for those women seeking a maximal waistline change who already are at good weight and don’t need a tummy tuck or a lot of liposuction, resorting to ribcage modification is the end-stage surgical approach. The bottom lower three ribs do have a role to play in the width of the anatomic waistline. The oblique orientation of the free floating ribs (#s 11 and 12 in particular) can serve as an ‘obstruction‘ to the creation of a more hourglass waistline shape.

Maxumum Waistline Reduction Surgery with Rib Rermovals Dr Barry Eppley IndianapolisCase Study: This 33 year-old female presented for waistline reduction surgery. She had prior abdominal and flank liposuction which provided some improvement but not to the degree that she wanted. A plan was devised to do additional liposuction with emphasis on the v-shaped sides of the abdomen as well as supplementing that result with multiple lower rib removals.

Posterior Rib Removal incisions Dr Barry Eppley IndianbapolisPosterior Rib Removal specimens Dr Barry Eppley IndianapolisUnder general anesthesia she initially had full abdominal, back and flank liposuction done removing an additional 1800 of fat aspirate. In the prone position through a 6 cm long oblique incision on each side of the back, the end portions of ribs #10, 11 and 12 were removed.

Effects of Posterior Rib Removal for Waistline Narrowing Dr Barry Eppley IndianapolisIt could be seen during surgery after removal of one side of the ribs how the abdominal contour was already further inward with the partial loss of outer bony support.

At the removal of her liposuction cannula entrance sutures and the taped dressings over the back incisions, improvement in the waistline could already be seen. With the resolution of all of her swelling in the next 6 to 8 weeks after surgery, very evident waistline reduction will be seen.


1) Maximal or extreme waistline reduction requires a combined liposuction and rib removal techniques.

2) Liposuction is done in both the supine and prone position to maximize the reduction along the sides of the waistline.

3) Subtotal rib removal of #s 10, 11 and 12 provide further waistline reduction over what fat removal alone can do.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Power-Assisted Liposculpture of Abdomen and Flanks

Sunday, July 3rd, 2016


Background: Liposuction is the surgical removal of fat by negative pressure evacuation. (suction) It creates its effect through a combination of fat removal and overlying skin contraction. By definition it is a volume reduction procedure. But depending upon the patient and the volume of fat removed the external effect may be a general body shape reduction or one of creating more noticeable curves.

Smaller amounts of fat reduction on a body that has a good weight can be referred to as Liposculpture. The small amount of fat removed is more responsible for creating an improved shape rather than just an overall body reduction effect. In Liposculpture smaller cannulas are used to reduce the risks of irregularities whose risk is higher when thinner layers of subcutaneous fat are removed.

While some that perform liposuction use the term liposculpture as more of marketing or promotional term, not all liposuction procedures produce a true body shaping effect. It depends on where the fat is removed and how much convexities are converted into concavities or at least into more linear shapes.

Case Study: This 36 year-old female was bothered by fullness in her stomach and waistline areas that had developed after having children. While she was at a good weight, her problematic areas were resistant to increased exercise efforts.

Liposculpture results front view Dr Barry Eppley IndianapolisLiposculpture results back view Dr Barry Eppley IndianapolisUnder general anesthesia she had power-assisted liposuction (PAL) performed on her full abdomen and love handle areas. A total of 1750ml of fat aspirate was removed in a 90 minute procedure.

Liposculpture results side view Dr Barry Eppley IndianapolisLiposculpture results oblique view Dr Barry Eppley IndianapolisIn smaller amounts of fat reduction it can takes about six to eight weeks after surgery to see the majority of the body reshaping results. In reality it takes a full three months to see the complete results and to have any residual asymmetries due to swelling subside. While every liposuction result will have some irregularities and asymmetries at the three month period, it is just a question of whether revisional liposuction would be beneficial.

Power-assisted liposuction (PAL) is a very popular method amongst plastic surgeons. The mechanical oscillation of the end of the cannula makes the manual effort by the surgeon less tiresome and offers a more efficient method of fat removal. Such refined cannular movements are particularly effective in more refined liposculpture cases.


1) Many women suffer from small collections of fat around the waistline that are resistant to diet and exercise.

2) Smaller volumes of fat removal in liposuction can be referred to as ‘liposculpture’ as it is more about reshaping than significant volume reduction.

3) Power-assisted liposuction is an effective method of body liposculpture.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Power-Assisted Liposuction of Abdomen and Flanks

Sunday, July 3rd, 2016


Background: Liposuction is the most commonly performed body contouring procedure. Both by the number of body areas and their overall surface area treated, liposuction is widely performed around the world. With all of the surgical fat removal done the most common body area treated is the abdomen and waistline. Regardless of the patient size liposuction achieves a central trunk reduction in a few hours that the patient could not achieve by months of effort on their own.

When patient’s consider liposuction they to try to understand the different types of  technologies that exist to do it. It certainly can be confusing as each surgical fat removal method touts itself as being the ‘newest advance’ and offering the ‘best results with the least recovery’. But the reality is that all liposuction methods are invasive surgery that requires substantial recovery. There is simply no easy and painless method of surgical fat extraction.

Case Study: This 35 year-old female was bothered by some fullness in her stomach and love handle areas that had developed after having children that she could not shed. She was at a good weight for her body frame and could not devote more time to exercise than her current schedule permits.

Under general anesthesia she had power-assisted liposuction (PAL) performed on her abdomen, flanks and arms. A total of 1800ml of fat aspirate was removed in a 90 minute procedure.

Liposuction results front view Dr Barry Eppley IndianapolisFemale Liposuction results side view Dr Barry Eppley IndianapolisFemale Liposuction results back view Dr Barry Eppley IndianapolkisIt takes about six weeks after body liposuction to see the majority of the reductive results. Many patients in the first few weeks will appear bigger than before surgery due to swelling and bruising. But the true final results after surgical fat removal take a full three months to reveal the maximum reduction and any residual asymmetries. While every liposuction result will have some irregularities and asymmetries, it is just a question of how significant they may be and whether any revisional surgery will be needed to improve them.

Power Assisted Liposuction Indianapolis Dr Barry EppleyPower-assisted liposuction (PAL) is a very popular method amongst plastic surgeons. The mechanical oscillation of the end of the cannula makes the manual effort by the surgeon less tiresome and offers a more efficient method of fat removal.


1) Liposuction can be very effective for reducing small collections of fat around the waistline that are resistant to diet and exercise.

2) The type of surgical fat removal used is not as important as the skill and experience of the operator performing it.

3) Power-assisted liposuction is one method of liposuction that works through the mechanical oscillation of the cannula tip.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Bingo Arm Liposuction

Saturday, May 28th, 2016


Background: Fat collects in the extremities just about as well as in the trunk region in many patients. Unlike abdominal fat, for example, fat in the extremities can be very difficult to reduce as it is often less responsive to diet and exercise. While extreme amounts of weight loss (e.g., gastric bypass) can reduce extremity fat, many patients do not need or will undergo these extreme amounts of weight loss.

Excess fat on the arms typically refers to undesired fullness on the back of the upper arms. The triceps area is the most bothersome area of excess arm fat because it hangs down when the arm is raised. A fatty back of the arm will jiggle when the arm is moved back and forth. This has led to the term ‘bingo arm’ or ‘bingo wing’. According to the Urban Dictionary, bingo arms comes from the observation of the excitement of winning bingo at senior’s night where one waves their arms back and forth creating a back and forth movement of the back of the arms.

Case Study: This 44 year-old female was bothered by the size of the back of her arms. While she was not excessively oveweight, the fullness on the back of he arms was aesthetically disturbing. She caller her arms ‘Bingo Arms’ which was the first time I had ever heard this arm issue so described.

Bingo Arm Liposuction intraop Dr Barry Eppley IndianapolisUnder general anesthesia and through small stab incisions right above the elbow as well as on the back side of the armpit, two-directional power-assisted liposuction (PAL was performed using  3mm cannula. A total of 225cc of fat aspirate was removed from each arm.

Bingo Arm Liposuction result left arm Dr Barry Eppley IndianapolisHer results at three months after surgery showed substantial improvement in reduction of the size of the back of arms. While it did not make her arms small, liposuction did eliminate much of the upper arm jiggle.

Bingo arm liposuction can be very effective in the properly selected patient. There is a limit as to how much fat can be removed from the arms and how well the skin will shrink and tighten. When the amount of skin becomes more significant than in this patient, an excisional armlift may be a better treatment choice.

While many different types of liposuction exist, none have proven to produce consistently better results than other. Power-assisted liposuction (PAL) in my hands remains more effective than traditional liposuction particularly in smaller confined areas like the back of the arm. Allowing the mechanized tip of the cannula to do the work, as opposed to the ‘elbow grease’ of the surgeon, makes for a more effective effort. A mechanized cannula tip can move back and forth far faster and more frequently than what    a human can do. (thousands of time per minute as opposed to dozens of times)


1) Liposuction can be performed safely on the arms. (bingo arm liposuction)

2) The back of the arms (triceps area) offers the greatest depot of fat for liposuction extraction in most patients.

3) Power-assisted liposuction (PAL) provides an effective method of arm fat extraction.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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