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Archive for the ‘liposuction’ Category

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

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.

Highlights:

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.

Highlights:

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.

Highlights:

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


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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