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Archive for the ‘liposuction’ Category

Case Study – Large Cankle Liposuction

Wednesday, March 8th, 2017

 

Background: Undesirable fat collections around the body, medically known as lipodystrophy, are usually caused by excess calories and results from their storage. But in some people and in certain locations of the body, fatty collections are more congenital in origin and are aggravated by weight gain. Even at a patient’s ideal weight these fat collections persist.

One such congenital lipodystophic condition is that of cankles. This urban term refers to the shape of the leg that is virtually the same from the knees down to the ankles. It occurs because there is a thicker than normal subcutaneous fat layer between the calfs and the ankles. This creates a uniform leg thickness below the knees with no defined or curvilinear leg shape. Whether it occurs in an overall larger leg or in a much smaller leg, the appearance of cankles is unmistakeable.

Case Study: This 36 year-old female presented for cankle liposuction. Despite her fairly short stature, she has a large body frame. She has lost a lot of weight but the thickness of her lower leg did not change. She was unable to wear boots and had to wear pants that were too big at the waist to get her lower legs to fit into them.

Under general  anesthesia and using a tumescent technique, her calfs and ankles ere treated with small cannula liposuction. Different entrance sites were done behind and below the knees as well as on the inside and outside of the ankles. Each lower leg had about 1,500cc per side.

Large Cankle Liposuction result front view Dr Barry Eppley IndianapolisLarge Cankle Liposuction back view Dr Barry Eppley IndianapolisIt took several months until most of her swelling resolved and almost 4 months until her legs felt completely soft and supple again. Her results show substantial size reduction and  the semblence of some better leg shape. She was now able to wear boots which she could not do before the procedure.

Cankle liposuction can be a very effective procedure for lower let reshaping even in extremely large lower legs. The amount of circumferential skin limits as to how much size reduction can be achieved.

Highlights:

1) Large collections of fat in the lower extremities is a congenital condition that not be reduced in size by diet or exercise.

2) Cankles refers to a consistent thickness from below the knee right down to the feet.

3) Large volume liposuction of the lower extremities would be considered any amount over 1,000cc per leg.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Liposuction Necklift

Monday, February 27th, 2017

 

Background: Aging of the neck is associated with numerous well known changes. The neck droops down as excess skin and fat develop in the center and sides of the neck. The underlying platysma muscle separates and allow the deeper neck tissues to come spilling out. All together a neck wattle or turkey neck is the result.

One of the major components of most neck wattles is fat. While removal of fat can be done by liposuction will that create an adequate ‘necklift’ or neck contouring effort. This is highly age-dependent. At younger ages the lack of  skin redundancy and its good elasticity allows for the neck skin to tighten and lift up. But at older ages neck skin excess and diminished skin elasticity make it more uncertain as to what the neck skin will do.

Case Study: This 57 year-old female was bothered by the shape of her neck. She had a reasonably thick fat layer but her skin was thin with numerous wrinkles in it. If possible she wanted to avoid any major surgery and was willing to see how much improvement liposuction alone could achieve.

Under general anesthesia (she was having other procedures as well) her entire neek was treated with small cannula power-assisted liposuction removing 26cc of fat.

Older Neck Liposuction results side view Dr Barry Eppley IndianapolisCA Neck Liposuction result front viewLiposuction can be a very effective for neck contouring method in the properly selected patient. Usually older patients are less than ideal for just liposuction because of their skin excess and diminished skin quality. But for the patient who wants to limit the extent of the surgery and are willing to accept that the outcome may be suboptimal, neck liposuction can serve as a test to determine if a lower facelift is really needed.

Highlights:

1) A sagging and full neck is a common development as one ages.

2) In the older neck liposuction alone will provide improvement but depends on what the overlying skin will do.

3) Neck liposuction is not a substitute for a lower facelift (necklift) but can be used as a ‘test’ to ultimately determine if one is needed.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Abdominal and Flank Liposuction

Sunday, February 26th, 2017

 

Liposuction is one of the most recognizable plastic surgery procedures and is the most commonly done body contouring operation. While there have been many innovations in liposuction devices and techniques over the past forty years since its U.S. introduction in the early 1980s, all such variations can produce effective fat reduction results when performed technically well.

Abdominal and Flank Liposuction one treated side only Dr Barry Eppley IndianapolisThe most common body area treated by liposuction remains the abdomen and waistline. Since this is a central depot area of excess fat accumulation it offers the most reliable and significant area for suctioned fat removal. Performed in the supine position, all of the abdomen and the flanks (love handles) can be treated. The technique of treating one full side first allows both an appreciation of the preoperative body contours but a reductive target for symmetry.

Larger Volume Body Liposuction aspirate Dr Barry Eppley IndianapolisThe safe amount of fat to remove in a single session of suction aspiration has been an issue of discussion. It is generally accepted that five (5) liters of liposuction aspirate is the maximum amount that can be removed without causing significant physiologic changes to the patient after surgery. While this is not an absolute number due to differences in patient’s body surface areas and weight, it provides guidance for what is an elective aesthetic operation. Such volumes of liposuction fat removal, however, is rarely an issue in abodminal and flank liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Chin Correction

Tuesday, February 21st, 2017

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Inner Ankle Liposuction

Sunday, February 5th, 2017

 

Background: The distribution of fat throughout the body is highly variable and is affected by numerous factors including gender, body habitus, weight, lifestyle and genetics. While excess fat (lipodystrophy) is commonly associated with a variety of central trunk areas, it can occur in the extremities as well. When occurring in the extremities without truncal adiposity, it occurs not because of diet but because of congenital lipodystophy. (just the way one was born and developed)

When excess fat occurs in the lower extremities at the ankles, it is commonly called ‘cankles’. This unflattering description signifies that there is little to no difference in diameter between the calfs and the ankles. While this is often associated with patients that are overweight, smaller amounts of ankle lipodystropy can occur in patients of normal weight.

Case Study: This 42 year-old male has long been bothered by the lack of shape of his ankles. He was of normal weight but has excess fullness on the inner side of his ankled between he ankle bone and the lower end of the calf muscle on each side.

Inner Ankle Liposuction Dr Barry Eppley IndianapolisInner Ankle Liposuction result Dr Barry Eppley IndianapolisUnder general anesthesia and in the supine position, local anesthesia with epinephrine was first injected into the marked inner ankle areas. Using a small 3mm cannula the inner ankles were aspirated of 65cc of fat per side with a total of 130cc removed. (this picture shows the difference between one inner ankle treated and the other not yet treated) For the ankle area in an otherwise thin person this is a lot of fat for such a small extremity area. Compression wraps were placed for dressing.

Inner Ankle Liposuction result front view Dr Barry Eppley IndianapolisIn the properly selected patient I have always been impressed with with ankle liposuction can accomplish. The area has to be treated aggressively with the intent of leaving little fat between the skin and the underlying muscle fascia and achilles tendon. Because it is doing liposuction around a functionally loaded and moving joint, the patient should expect that there will be some prolonged swelling and walking discomfort. Because the ankles are in the most dependent position on the body, they will take months for all the swelling to completely resolve and see the final result.

Highlights:

1) Excess fat collections due to congenital fat distribution can affect non-overweight patients.

2) Small cannula liposuction can be very effective at removing fat from the inner and outer ankles.

3) While it is a small area of liposuction it takes the ankle area longer to recover than one would think.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Perioral Mound Liposuction

Sunday, January 22nd, 2017

 

There are numerous fat compartments on the face that can be surgically reduced. The most recognized and easily removed is the buccal fat pads. (aka buccal lipectomy) Located just under the cheekbones, it is a very discrete collection of fat that has its own pedicled blood supply and a surrounding capsule. It is removed from an intraoral approach through a small incision just opposite the molar teeth.

While the buccal fat is a large collection of fat compared to the rest of the face, it is frequently given more credit that it is due. Its removal affects the fullness of convexity of the cheek just under the cheekbones. It does not extend very low onto the face and its thinning effect will be relegated to the upper cheek area. If you drew a line from the tragus of the ear to the corner of the mouth, a buccal lipectomy has its effect above this line.

Perioral Mound Liposuction markings Dr Barry Eppley IndianapolisBelow this drawn line sits another smaller collection of facial fat known as the perioral fat or, when bulging, the perioral mounds. This is a subcutaneous non-encapsulated fat collection that sits between the skin and the buccinator muscle. It is located at the southern end of the cheeks or its lower half. It has no anatomic connection to the buccal fat pad. In rare cases the buccal fat pad has been known to fall or prolapse into the perioral mound area.

Removal of perioral mound fat is done by very small liposuction cannulas. It is never an impressive amount of fat that is removed but a little fat reduction does make for a visible external effect. It is a good companion to buccal lipectomies for a more complete cheek reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

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.

Highlights:

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.

Highlights:

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


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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