Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?
Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.
February 7th, 2015
Abdominal contouring is commonly done using liposuction. Most of the time this is fat debulking or overall volume reduction to get rid of larger volumes of fat. But in thinner patients, almost always men, they desire a more refined type of liposuction described more appropriately as liposculpture. This is the removal of smaller amounts of fat that are bothersome to the more athletic or thinner body frame patient.
One unique type of abdominal liposculpture is that of abdominal etching. Often called ‘six-pack’ surgery, this is a liposuction technique that creates linear lines to create the appearance of cut abs. This is usually a midline vertical line and several (usually three) horizontal lines. In essence these are artificially created anatomic replicas of the underlying abdominal wall inscriptions. While it may be called cheating by some, it can be an effective surgical technique in the properly selected patient.
Abdominal etching is a small cannula linear liposuction technique that achieves its result by creating a dermal-fascial adhesion. By removing the fat that lies between the skin and the abdominal wall, indentations or grooves are created in the overlying abdominal skin. To help hold the initial linear lines that are created by the etching method, I like to use linear strips of compressible foam along the newly created etch lines applied right after the problem. When a wrap around abdominal binder is applied circumferentially, it helps push the skin down in the fat removed lines and prevent fluid from building up under them. The patient keeps the foam strips on with the binder for two days after the procedure when they can be removed.
Abdominal etching works best in thinner patients and, although it is not really ‘natural’, looks best when it is not overdone with lines that go beyond the locations of the actual abdominal inscriptions. But no matte how they are made, they will not appear at all or will be very shallow if the fat removed under the lines fills with fluid and does not scar down properly. This strip foam dressing method is one technique that I have found useful in abdominal etching that adds no expense or extra effort for the patient.
Dr. Barry Eppley
February 6th, 2015
Gynecomastia is a well known condition of breast enlargement in men. It can occur in any male body shape from a thin teenager to an older male. The size of the gynecomastia and the extent of chest deformity can vary considerably. But the one feature that all gynecomastia patients have is the very firm lump of breast tissue that lies under and around the nipples.
One very unique form of gynecomastia is that seen in male body builders. Even though they have little body fat and are long past puberty, gynecomastia can occur most often due to the use of anabolic steroids or other high dose supplements. While their gynecomastias are small in size compared to many other forms, it is disturbing to them due to their high aesthetic standards and its easy visibility as a stand out feature on their chest which is highly scrutinized if they participate in competitions.
In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Correction of Gynecomastia in Body Builders and Patients with good Physique’. Over a 33 year period, over 1500 body builders underwent gynecomastia reduction. Subtotal excision of most of the firm breast tissue was removed through an open approach using an inferior areolar incision in all cases. Liposuction was minimally used in 2% of the cases. Good aesthetic results was obtained in 98% of the cases. Hematoma rates averaged 6% over the study period. The authors has no infections, contour deformities or redevelopment of breast tissue.
This paper highlights that successful gynecomastia reduction in male body builders requires essentially a near complete subcutaneous mastectomy. The tissue needs to be thinned out under the nipple-areolar complex to just a few millimeters so that it will lay flat on top of the pectoralis fascial/muscle layer. This will also prevent recurrence of the breast tissue since these patients may likely continue taking steroids and supplements that caused the problem initially. Attention to the smallest chest contour detail is important since these patients are by nature of their body types perfectionists.
One very important element of this type of gynecomastia reduction is the postoperative activity level. Male body builders are very religious about their workout routinues and it can be hard to keep the out of the gym for any extended period of time. Exercises of the chest need to be restricted for at least two weeks after surgery with three weeks preferred. Noncompliance is associated with higher rates of hematoma and seroma formation.
Dr. Barry Eppley
February 6th, 2015
Radiofrequency has become a popular treatment method for the non-invasive improvement of wrinkles, skin looseness and spot body shaping. There are numerous such devices that are currently available, one of which is the Exilis from BTL industries. Exilis is different from other radiofrequency devices is that it uses monopolar focused radiofrequency which allows for a layering of energy at different depths. This equates to uniform heating of the skin.
Several clinical studies have shown visible skin tightening and reductive body shaping results with up to 35% reduction in skin looseness, a 42% reduction in wrinkles and a 33% reduction in skin photodamage. Given that the average age of the women in these studies was 57 years old, this proves positive changes can occur even in older and damaged skin. Histologic studies of the treated skin showed full thickness collagen remodeling and elastin production. Like most non-invasive devices, a series of treatments is always needed to gain maximal results.
Such results are possible because of the advanced cooling system in Exilis which keeps the temperature below 45 degrees C. This is important because above that temperature the patient will experience a painful burning sensation. But without getting close to this temperature the desired skin changes will not occur.
Animal studies have also shown effects on subcutaneous fat demonstrating that it can selectively heat fat with apoptosis and adipocyte shrinking. The cooling system is very important here so the heat can reach the fat but without burning the intervening skin. Thus Exilis can do some mild fat reduction in addition to skin tightening. But the fat reduction is limited to just the fat immediately under the skin.
Radiofrequency treatments like Exilis can be combined with a variety of other aesthetic treatments. It can be used in conjunction with Vanquish or Cool Sculpting, for example, to create combined maximal fat reduction and skin tightening. Injectable fillers can be placed under facial areas treated with Exilis on the overlying skin. Exilis can even be used with light fractional laser resurfacing. Our practice in Indianapolis has found it vey useful and safe for a variety of face and body aging issues.
Dr. Barry Eppley
February 5th, 2015
Background: Rhinoplasty surgery has been around for almost a hundred years and has its recent origin from European surgeons who attempted to reduce the large ethnic humps on the bridge of the nose. While rhinoplasty surgery has evolved tremendously and now focuses on a more complete approach to rhinoplasty, hump reduction is still a major driving reason patients seek rhinoplasty and is often part of many major nose reshaping efforts today.
Nasal hump reduction lies in the upper half of the nose and is seemingly simple. It is often taken for granted that it is the most uncomplicated rhinoplasty manuever which is an inaccurate perception. A nasal hump occurs at the junction of the nasal bones and upper lateral cartilages and septum and is rarely effectively reduced by simple rasping. (which only works on bone) It requires reduction of both bone and cartilage which is initially done by separating the upper lateral cartilages from the septum. From there the cartilage hump is reduced by taking down the high septum. This then allows the bony portion of the hump to be taken by either osteotomes or rasps.
Taking down the hump will often create the so called “open roof” deformity which is closed by reshaping the sides of the nasal bones by creating fracture lines with small osteotomes. This allows the nasal bones to fall inward, closing the open roof. Most of these osteotomies are never completely visualized even in the most open rhinoplasty. But closure of the open roof is not the end of the hump reduction, final smoothing of the nasal bones is needed as well as re-establishing the septal-upper lateral cartilage relationship which may include the use of spreader grafts.
Case Study: This 26 year-old female wanted to improve the shape of her nose. She always wanted to reduce the hump on her nose. But she not only wanted it reduced, she wanted more of a swoop or concavity to the bridge of the nose. She had good tip projection and rotation as judged by the nasolabial angle. Her tip only needed some width narrowing but no other changes.
Under general anesthesia, an open rhinoplasty was performed with hump reduction as previously described. After closing the open roof, the upper lateral cartilages were put back to the reduced septum height and auto spreader grafts done by folding the redundant upper lateral cartilages over on themselves. Tip shaping sutures were placed but no cartilage was removed from the cephalic margins.
As her results show, a near isolated hump reduction rhinoplasty can be done if other structures of the nose need no to minimal manipulation. For most patients this is not possible since significant hump reduction usually changes how the tip of the nose looks as well as the overall nasal length. Computer imaging will make this need clear before surgery. isolated hump reduction rhinoplasty can be done through either an open or closed approach depending on the surgeon’s confidence and experience.
1) One of the most commonly requested rhinoplasty changes is that of the bridge of the nose or the hump area.
2) Reducing a hump on the nose requires reduction of both bone and cartilage in the bridge area.
3) Hump reduction can be done alone in rhinoplasty surgery but requires the shape of the tip and the nasolabial angle to be favorable.
Dr. Barry Eppley
February 3rd, 2015
There are many bodily changes that take place when one loses a lot of weight and they are well recognized as general skin and soft tissue sag. But the face is not immune to weight loss changes. It creates equal issues of volume loss and sag resulting in a droopy deflated face and obvious turkey neck deformities. In young patients this effect makes them look older and saggy while in older patients it just makes them look even older even though they have dramatically improved a significant medical problem. (their weight)
The treatment of the weight loss face and neck is largely a lower facelift. This is the only way to redrape the loose skin over the neck and jawline. But the weight loss patient also suffers from volume deflation in such areas as the cheeks and temples. This makes weight loss facelifts unique and with slightly different considerations than many of the typical facial aging patients.
In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Face Lifting in the Massive Weight Loss Patient: Modifications of Our Technique for This Population’. Twenty two weight loss facelift patients (15 women, 7 men) were retrospectively reviewed. The average of the patients were around 52 years old with average body mass indexes of 26. Most (near 90%) had noticeable volume loss in the midface and nasolabial folds, 60% has perioral volume loss and over 80% had platysmal bands. For their facelift techniques, 90% had some form of SMASectomy and all patients received fat grafting. The average amount of fat grafting was over 20mls.
This paper highlights techniques that can improve facelift results in weight loss patients. These include extensive fat grafting the cheeks and aggressive SMAS manipulations with sutures to resist the pull down effect of heavy skin. The SMASectomy involves an oblique excision of redundant SMAS which parallels the nasolabial fold and extends from the cheek down to the jaw angle.
Dr. Barry Eppley
February 1st, 2015
Treatment of the tear trough has become quite common since it has been recognized as an aesthetic deformity. A sunken in appearance in the inner aspect of the lower eyelid creates an indentation or trough that creates a shadow and the appearance of being tired or older. Its treatment has become popularized due to the use of injectable fillers. They offer a simple and usually very effective solution for tear troughs by adding volume to the depressed afrea
But even very successful tear trough treatments with injectable fillers is not a permanent solution. While hyaluronic acid based fillers do persist for a year or longer along the orbital rim, they will eventually be resorbed. Fat injections to the tear troughs may offer the potential for longer and maybe even a permanent solution but their take and survival is never a sure thing.
Another approach that offers a permanent solution is that of tear trough implants. Designed to be a bony augmentation implant to fill in the suborbital groove, it is placed through a lower eyelid incision. This makes it a good solution if one is having a lower blepharoplasty or is having other facial augmentations such as cheek implants. While they can be placed as an onlay in a soft tissue pocket, I prefer to secure their position using a small self-tapping 1.5mm screw. It is important to set the the screw into the implant so there is no possibility that it can be felt through the thin lower eyelid tissues.
Tear trough or suborbital implants offer a permanent solution to a recessed orbital rim in the inner half of the lower eyelid. For now such implants need to be placed through a lower eyelid incision. Future developments may allow a tear trough implant to be placed through an intraoral approach
Dr. Barry Eppley
January 31st, 2015
Brazil has almost as many plastic surgeons as the U.S. (around 5,500) but with just half of the population. (just over 200 milllion) As a result there are a large number of cosmetic surgeries done in Brazil and it is well known that the cultural standards of beauty and its pursuit have contributed much to the high number of procedures done there. In Brazil it is usually seen as a badge of honor (and status) to have had cometic surgery and people do not make much effort in camouflaging their aesthetic experiences. Some have phrased that visiting a plastic surgeon’s office is as common as visiting a shopping mall for many Brazilians.
But the high demand for cosmetic changes throughout the population creates a ripe environment for ill advised procedures and a subculture of unqualified and unscrupulous providers. It is estimated that while there are about 5,500 certified plastic surgeons, there are over 10,000 other doctors, paramedics and people with no medical training at all performing cosmetic procedures according to the country’s medical licensing counsel. Such unqualified providers, low prices and the hope of a quick fix set the stage for what has become a bit of an epidemic that is not exclusive just to the country of Brazil.
The Brazilian Andressa Urach became a reality TV sensation after having had numerous plastic surgery procedures from breast implants, rhinoplasty and other injectable treatments. As a result of her ‘success’ and celebrity status, she was a highly visible and outspoken advocate of cosmetic surgery. But after having some injectable material placed into her thighs recently, she went into septic shock and was placed on life support.
Such events are both tragic and completely avoidable and they always come from the same cosmetic procedure, injectable body augmentation with synthetic materials. While such injections create an instantaneous change, such as in buttock, hip or thigh augmentation, they are fraught with potential complications both immediate and long-term. The cause of Urach’s medical crisis is always the same when large volumes of synthetic material are injected into the body…the risk of pulmonary embolism and infection. The very small particles of the synthetic material, often plastic beads, gels or oils, when injected under pressure can find their way into blood vessels which are often bigger in diameter than the material. When entering a vein they can be carried back to the heart and into the fine vessels in the lungs where they become trapped creating a life threatening pulmonary embolus. They can also enter a small artery blocking blood flow to a segment of the overlying soft tissue and skin causing necrosis and tissue death of portions of the augmented area. (tissue ischemia)
These ‘black market’ injectable complications, which happen in the U.S. as well as Brazil and other countries, result from a combination of women focused on attaining beauty through a quick fix. As plastic surgeons we often wonder how people could be so oblivious to the risks of untested and unapproved materials by some providers that have less training than their electricians or plumbers. Body augmentation is a surgical procedure and should only be done by established methods and materials board certified plastic surgeons who have the training and experience to do them. Even in the best of circumstances there are risks and potential complications. In the worst circumstances lifelong disability/deformity and death could be the outcome.
Dr. Barry Eppley
January 30th, 2015
The eyelids are very thin tissues that are well known to swell and bruise easily. Because one’s eyes are so visible, every upper eyelid surgery patient would like their bruising and swelling to go away as soon as possible. For this reason, it is standard practice to do several after surgery strategies including cold compresses, head elevation and the oral intake of Arnica. While no one after surgery strategy is known to be universally effective, it is commonly believed that cooling or cold would be the most important.
The use of eye cooling has led to a wide variety of gel compresses for the eyes for blepharoplasty patients. Most are composed of a gel material that retains cold for a period of time after being removed from the refrigerator or freezer. The historic cooling regime was frozen vegetables (such as peas or corn) but gel pads are lighter and easier to use
In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘The Effect of Eyelid Cooling on Pain, Edema, Erythema, and Hematoma after Upper Blepharoplasty: A Randomized, Controlled, Observer-Blinded Evaluation Study’ was published. In 38 consecutive patients who had upper blepharoplasties performed, one side was cooled with an ice pack and the other eyelid was left uncooled. Evaluations were done on the degree of pain, edema, erythema, and occurrence of hematoma one hour, one day, one week, and two months after surgery. Light photography was used one week after surgery to determine the degree of bruising.
The results showed showed no difference in pain between the cooled and uncooled eyelids on the day of surgery. Pain in the cooled eyelids was significantly lower one day after surgery. No differences were seen in swelling, bruising or occurrence of hematoma between the cooled and uncooled eyelids at any time point in the study. The authors conclude that because the majority of patients had no preference for cooling over noncooling, eyelid cooling after upper blepharoplasty is not necessary.
This study casts doubt on a very long-held and logical treatment after upper blepharoplasty surgery. It just seems so logical that cooling/cold therapy would be beneficial that it is hard to believe that it isn’t. Despite what this study shows I doubt few plastic surgeons will abandon it. Particularly since it is a very low cost treatment that at the least has psychological value for the patient.
Dr. Barry Eppley
January 29th, 2015
Now that silicone breast implants have been back in clinical use for almost a decade (since 2006), they have rapidly become more commonly used than saline breast implants. Their more natural feel and the ability to last longer are amongst several important considerations for their favor over saline filled devices.
But the most compelling feature that silicone breast implants have which make them preferred is that they will never suffer spontaneous deflation. Saline implants are essentially bags filled with water which, should a small hole or tear develop in the bag, will allow its liquid contents to come out. Thus the implant will deflate and the overlying breast will become flatter.
Conversely, silicone can not suffer deflation because its contents are not a flowing liquid but a cohesive silicone gel. Silicone implants can fail and that is often called a rupture from a hole or tear in its lining. But the term ‘rupture’ should actually never be used because that is not what actually happens to a silicone breast implant when it fails.
The term rupture is defined and perceived as a forcible disruption or bursting effect. And that is not what happens to a silicone implant at all. Rather even a larger tear in the implant shell is only associated with an intermittent bulge of material when pressure is applied. (squeezed) When the pressure is removed, the gel material returns back into the confines of the implant shell. Even when a silicone implant is cut it off, it still keep its form.
Due to the highly cohesive nature of today’s silicone breast implants, its failure should no longer be termed a rupture. Rather it is better described as a shell disruption or loss of integrity. This indicates the more benign event and outcome that results from this eventual expected event for many women after years of implantation. Rupture suggests breast implant contents that are lost when the current gel cohesivity no longer permits that to happen.
Dr. Barry Eppley
January 27th, 2015
Background: The shape of the buttocks can take on many different forms. The buttocks have three different sections, the upper buttock, the mid buttock, and the lower buttock. Each buttock section has its own distinct shape. What separates the lower buttocks from the other two sections is the infragluteal fold. This fold makes a usually clear demarcation between the lower buttocks and the thigh below it.
The infragluteal fold or sulcus has been studied anatomically and histologically and has been shown to consist of strong fibrous bands extending from the underside of the skin (dermis) of its medial third to the ramus of the ischium and sacrum forming the letter J. The infragluteal fold, which attaches to both the ischium and the sacrum in a continuous fashion, is an anatomic structure in its medial part and only a crease laterally. It largely disappears in its lateral third as it approaches the outer thigh.
The infragluteal fold is one of the major concerns in reshaping of the buttocks. If an intact infragluteal fold exists with overhanging skin, then a lower buttock lift or tuck is needed. This is often called the butterfly lift if the central part of the buttocks sags with significant obscuring of the infragluteal fold. When the infragluteal fold is lost and the entire bottom of the buttocks sags onto the thighs with skin rolls, then wider excision of sagging skin with recreation of the fold is needed. It is important to remember that these excisional procedures only changes the shape of the lower buttocks and does not increase buttock volume or projection in any way.
Case Study: This 35 year-old female wanted to improve the shape of her buttocks. She was happy with her buttock volume and projection but felt the bottom had ‘fallen down’. She had an intact and defined infragluteal fold but her lower buttocks sagged over it.
Under general anesthesia in the prone position, an excision was done using the existing fold as the inferior aspect. A predetermined and measured line has been previously marked in the standing position to serve as the superior incision line. This wedge of tissue was removed keeping it from extending out too far laterally. Deep dermal sutures attached the superior line down into the existing fold level to rid the buttock overhang.
The lower buttock lift when there is an intact and well positioned infragluteal fold is better termed a lower buttock tuck. A true lift is when the nfragluteal fold is lost and has to be recreated.
1) Sagging of the buttocks takes on several forms depending on the location and prominence of the infragluteal fold.
2) A prominent infragluteal fold with overhanging lower buttock tissue creates a type 1 buttock ptosis deformity.
3) A lower buttock tuck removes overhanging tissue and creates a smoother transition between the buttocks and the posterior upper thigh.
Dr. Barry Eppley