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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘body contouring’

The Use of Drains in Seroma Prevention in Body Contouring Plastic Surgery

Thursday, April 29th, 2010

The use of drains is a routinue part of many procedures in plastic surgery. From procedures such as facelifts, breast reductions and tummy tucks, drains play an important role in the prevention of postoperative complications. While patients have to tolerate a tube(s) sticking out of their body and go through the process of emptying and recording its output, they happily await the day when it can finally be removed. The removal of a surgical drain often signals the end of the first phase of recovery.

The importance of a surgical drain is just as important after it has been removed than when it was in. This is particularly true in most body contouring operations, particularly tummy tucks, abdominal panniculectomies and circumferential body lifts. But most patients understandably don’t appreciate the biology of their use and this often leads to the one complication that are used to prevent…seroma or fluid accumulation.

When large open cavities are left behind and underneath a closed incision, this unhealed space will fill with fluid. This fluid is largely a lymphatic leak with some intial  blood that is leaking from the raw surfaces of the cut tissues. The larger the unhealed space (such as a tummy tuck), the greater in amount and longer in time this fluid will leak into this space. This collection of fluid prevents the raw surfaces of the cavity tissues from healing together and also serves as a perfect culture medium for bacterial growth.

Drains pull off  this fluid, accomplishing a reduction in the fluid interface between the raw surfaces.  Like the edges of a surgical incision, keeping the raw surfaces of the cavity close together helps them heal to each other. Once this happens the cavity is obliterated and no more fluid will accumulate since the space is gone The time it takes for wound edges to heal often coincides with the slowing down of the fluid leak from the tissues as the cut ends of the lymphatic vessels seal themselves off.

While ideally a surgical drain should stay in as long as the lymphatic leak is occurring, it is impossible to know precisely when the fluid leak is over. The longer drains stay in the better but there does come a point of patient tolerance and often drains become loose. Sometimes they fall or get pulled out and often become sore and painful where they exit through the skin. In tummy tucks, for example, this point is often reached around 10 days or so.

When drains come out, however, the fluid leak may still not be over. While the body can absorb a certain amount of fluid in a cavity, too much fluid leak will create a collection known as a seroma. Once the drains are out, the patient can do two things that can help prevent this problem. The wearing of a circumferential compression binder helps push the sides of the cavity together to help encourage sticking and healing together. Keeping one’s activities limited (no exercise or extensive walking) also decreases fluid leak. More activity acts as a pressure pump, releasing more fluid into the surgical area. Just because a surgical drain is out is not a license to become more active. One should limit their activity for at least two weeks after a drain is out to prevent the likelihood of a seroma build-up.

While seromas can be treated by tapping (needle aspiration in the office), prevention is always better. In my Indianapolis plastic surgery experience, about 30% of tummy tucks for example will develop a seroma that needs to be treated. Limiting one’s activity after drain removal and wearing a binder can help keep one in the more favorable majority.        

Dr. Barry Eppley

Indianapolis, Indiana

Weight Loss Medications after Liposuction Surgery

Sunday, August 23rd, 2009

Liposuction is ideally used to reduce spot areas of fat excess in the trunk and neck. In a perfect world, it is done exclusively in patients that have maximized their weight loss through diet and exercise and are at or near their ideal body weight. In reality, not all liposuction patients fit these preoperative criteria. Some patients are looking for more circumferential abdominal and trunk reduction and may be looking for a jumpstart to continue with their lifestyle efforts. Maintenance of body contouring changes and fat reduction is also a concern for many liposuction patients.

Return of fat after liposuction, contrary to what patients would like to believe, is not rare. It is a myth that fat will not return to a body area that has been treated with liposuction, particularly in the trunk area. (abdomen, waistline, flank and back) In my Indianapolis plastic surgery practice, I tell patients that if you can keep your weight stable after liposuction then you will keep the fat from coming back. But if you gain significant weight (greater than 10 lbs), it has to go somewhere.

Managing or continuing with weight loss after liposuction surgery can be done with short-term weight loss medications. I do not prefer to use the typical metabolic-increasing medications that are all derivatives of phenteramine, such as Adipex. While they may be effective, they have more side effects and the risk of dependency. Safer and equally effective medications are Topamax and Zonegran.

Topamax is an anticonvulsant drug that is most well known in the treatment of migraines. It is really a sugar molecule (monosaccharide related to fructose) that has sulfa-like molecules attached. Topamax has a complex mechanism of action but why it works for weight loss is not precisely known. Weight loss is one of its known side effects and is how it has become known for that use. I usually start patients out on 25mg per day for  a few weeks and then increase the dose up to 100mg per day. This is a very low dose compared to how it is used to treat other medical problems. Topamax should not be used in someone who has a known sulfa allergy. Side effects of note include cognitive issues (memory loss) and the formation of renal stones, although the low doses used do not make these a common problem. Patients should be drinking four to six glasses of water a day on any weight loss problem and this is also preventative for kidney stones.

Zonegran is another anticonvulsant drug that also has a sulfa molecule attached to it. Some refer to it as a new and improved Topamax. Sulfa allergies and concerns about the formation of kidney stones are similar. Zonegran is used by neurologists to treat nerve pain and the side effect of weight loss was observed, leading it to be become used for weight loss about five years ago. It is reported to be very effective for sweet cravings, pop drinking and binge eating. I have patients start off with one 25 to 50 mg pill, then increase the dose slowly up to 100 mg every other night for one week and then increase to one every night. The higher the dose, the more the appetite is suppressed.

Both Topamax and Zonegran provide a short-term medication use for continued weight loss after liposuction. Select patients are started on one or the other beginning three weeks after liposuction and given a three month treatment course. Thereafter their continued pharmacologic component of their weight loss program is turned over to a weight loss specialist. Lifestyle changes are an important element after surgery as is the required daily water intake.

This limited pharmacologic approach to augmenting the effects of continued weight loss after liposuction is very helpful for some patients. While plastic surgeons are not weight loss experts, and liposuction is not a weight loss method, body contouring and weight loss/maintenance are nonetheless often intertwined.

Dr. Barry Eppley

Indianapolis, Indiana


Self-Image, Psychology, and Bariatric Plastic Surgery (Body Contouring)

Friday, January 30th, 2009

The road from the beginning of the decision to make weight loss happen…to bariatric surgery…to the final steps of body contouring plastic surgery is a difficult and long journey. Often, this is a process that has evolved over years. Not only has pounds and inches been lost but your lifestyle has hopefully changed forever. For many, this process may have been the most difficult commitment of their lives. Many start this journey, but only some will make it all the way.

Not that you have done your best to look and be healthy, now what? For some patients, there will remain a disconnect between how they look and how they still see themselves. Changes in the shape of the body, clothing options, scars, relationships with others, and memories of the ordeal may leave one on a rollercoaster of emotions for some time after. This is not abnormal and you may need support as you go through this ‘final phase’. Support groups, counseling, and sharing your experience with others are all good ways to work through these emotions as you remodel your self-image.

As a plastic surgeon, my biggest observation and words of advice are that body contouring is not the cure for a poor self-image or any form of depression. It is designed to be helpful, and often is greatly so, but persistent down feelings after the euphoria of plastic surgery passes may require some form of treatment or professional help. I do know based on my own patient experiences that many body contouring patients go on to have very normal and quite productive lives.

Body contouring through bariatric plastic surgery can be quite liberating, removing a lot of physical limitations. These physical changes will result in other changes as well, particularly in relationships and in how people interact and deal with you. And for the most part, these are quite positive changes. But expect a few bumps along the road and not every change that you make will make everyone happy. Not everyone around you can adapt and change with you. That is just one of the conundrums of life.

Embrace your new body and your new self. What you do from this point on will now be determined by what lies between your ears, not by what surrounds them.

Dr. Barry Eppley

Indianapolis, Indiana

Bariatric Plastic Surgery – Body Contouring After Large Weight Loss

Tuesday, October 14th, 2008

In large weight loss patients, through bariatric surgery or from their own dieting program, excess skin is almost always left behind. If the excess skin is considerable, this results in a ‘new’ problem. The body may be smaller, but the large folds of skin cause problems of personal embarrassment, the need to still buy larger clothing, and the potential for problems of skin irritation, rashes, or infections from the overhanging heavy skin. Unfortunately, the very process that got you to this point will not get rid of loose skin. No amount of dieting, exercise, or wishful thinking will make the skin snap back into place or make it go away. This is a surgical problem that is best addressed with body contouring surgery.

Reshaping the body after weight loss are plastic surgery procedures (i.e., bariatric plastic surgery) that are specifically designed to remove excess skin and fat and reshape specific body areas. Body contouring surgery can remove large amounts of sagging skin and fat that are often dramatic in size. While the removed pieces may look large, they often weigh a lot less than you would think. Think of body contouring surgery as restoring shape and contour to certain areas of the body rather than any more significant weight loss. These surgical procedures will not only remove excess skin but will tighten areas as well. Almost every body contouring surgery is about the actual excision (cutting out) of loose tissue, liposuction (fat removal only) actually plays a very minor role in this type of plastic surgery although it is occasionally used.

While body contouring surgery can produce some dramatic changes that can improve your physical and psychological health, there is a trade-off. That being of scars. Every body contouring surgery results in significant scarring…that is the long-term price that you must pay. I have yet to find a large weight loss patient who balks at that trade-off but remember you are trading off one problem for another…..excess skin and fat for scars. So be certain that this trade-off is a good one. If one is highly concerned about a lot of scarring, then body contouring surgery may not be for you. Body contouring surgery is unique from pure cosmetic body contouring in that the goals are to make you look good in clothes…not to be critically judged out of them.

Dr. Barry Eppley

Indianapolis, Indiana


Circumferential Body Lift in the Bariatric Surgery Patient

Saturday, April 26th, 2008

With the tremendous increase in the number of bariatric surgeries performed in the past five years, to no surprise there has been a near equal increase in the number of post-bariatric body contouring procedures performed to deal with the resultant excessive hanging skin. These bariatric plastic surgery procedures include arm lifts, breast lifts, abdominoplasties, thigh lifts, buttock lifts, and the circumferential body lift.

The circumferential body lift, while an ‘old’ procedure per se, has been reborn in great numbers as a result of massive weight loss patients. The circumferential body lift, or a 360 degree tightening and lift, is really a combination of a frontal abdominoplasty and posterior hip and buttock lifts. In bariatric patients, many will have a frontal overhang of skin (with a sagging pubis) but with a buttock and thigh droop on the backside. The circumferential body lift works so well because it removes excessive overhanging abdominal skin (with a pubic lift) and lifts sagging buttocks, hips and thighs. In the properly selected patient, the resultant circumferential scar around the waistline is worth it. And, surprisingly, it is not a painful procedure to go through unlike what many would think.

If the patient has a midline vertical scar from an open gastric bypass procedure, then the body lift is combined with a ‘vertical wedge’ cut out along this midline scar. This helps produce some horizontal waistline tightening which, without it being done, would not happen as much. If the patient doesn’t have a vertical midline scar then I rarely do this as part of the body lift so as to not make more scar than the patient will already have.

One thing the body lift can not do is to increase the size of the buttocks. Most massive weight loss patients will develop a very flat buttock appearance. While there have been some variations of the body lift touted as taking the excess skin and fat from the back and using it as a ‘buttock implant’, this rarely produces enough bulk in the right place of the buttocks to make it worthwhile. And there are some risks in doing this as part of the body lift procedure. I tell my patients to think about buttock augmentation as a later procedure. It is likely that this concern will fall off the list for many patients over time.

The most significant complications that I have seen in body lift patients are fluid collections (seromas) and wound separations (in the front at the inverted T if a midline wedge is cut out and at the back just above the gluteal cleft). I tell every patient that the likelihood of these issues is very high and most patients will develop some variations of one or both of them. Fortunately, they are managed not by further surgery but by needle aspirations and dressing changes until they heal themselves. These issues always occur, not early, but between 2 to 4 weeks after surgery. If you reach a month after surgery without any of these common problems, then they are not likely to occur.

Dr Barry Eppley

Indianapolis, Indiana

Bariatric Plastic Surgery in Indianapolis

Monday, November 26th, 2007

You Did It!

Losing a lot of weight is the beginning of a new life. When you still have folds of loose skin left over, however, your body may be smaller but not be any more pleasing than before your bariatric surgery. Because of the loose skin, you may still feel inadequate and embarrassed. Fortunately, a unique plastic surgery program is available to you. Through the FORM program, we can tighten sagging skin after weight loss and give you the body shape that you have worked so hard to achieve. This specialty of plastic surgery is known as Bariatric Plastic Surgery or Body Contouring after Extreme Weight Loss.

Looking Your Best

Plastic surgery is often the final step in the surgical weight loss process. The overstretched skin is damaged, has lost its elasticity, and cannot conform to the new shape of the underlying body. This can result in sagging neck, breast, arm, stomach, back, and thigh skin. This excess skin poses cosmetic, hygiene, and comfort issues. Nothing can restore the skin’s elasticity, the excess skin must be removed and each body area reshaped. For some patients, only one or two excess skin areas are of concern. For others, sagging skin is present from the neck to the knees.

Your New Body

Through the FORM program, a series of body contouring surgeries is done, each targeting a specific area of loose and sagging skin. These operations require a high degree of surgical skill and attention to detail as well as an aesthetic eye to ensure that you achieve a pleasing body contour. Procedures include:

Abdominoplasty (Tummy Tuck)
Body Lift (Tummy Tuck and Back Lift)
Brachioplasty (Arm Lift)
Breast Augmentation (Breast Implant)
Facelift (Neck and Jowl Lift)
Mastopexy (Breast Lift)
Thighplasty (Hip and Thigh Lift)

The key to successful post-bariatric body contouring is to select not only the right operations but how to stage or sequence the body areas being contoured to safely obtain a good result. The FORM body program helps guide you through these decisions, choosing those surgeries that are of most importance to you.

Your physical and mental health is of utmost importance, both must be in good shape to undergo intensive surgery that can last up to six hours or more under general anesthesia. While dramatic body changes are possible, you must be willing to accept scars in place of the loose skin.

Surgical Expertise

The FORM program was developed by me as a method of approaching the cosmetic problems of the bariatric patient who has undergone massive weight loss. Through an in-depth consultation and thoughtful treatment planning, a safe and realistic plastic surgical plan can be created for your body to meet your goals and be done with attention to the needs of your home and work life.

Insurance and Body Contouring

The increasing number of bariatric surgeries performed has created many patients seeking body contouring procedures. Just because insurance has covered your bariatric surgery is not a guarantee that they will cover any body contouring surgeries. If there are medical problems that the loose skin is causing, then the surgery may be covered. This can only be determined, however, through an insurance predetermination process. We routinuely handle this insurance step for you. As a general rule, loose abdominal or thigh skin may be eligible for coverage; neck, arm, and breast problems are usually not covered.

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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