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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘extreme weight loss’

Getting Rid of the Turkey Neck in Massive Weight Loss Patients

Wednesday, January 21st, 2009

With massive weight loss comes total body changes with many areas of loose hanging skin and fat. The neck , more than any other part of the face, suffers a similar fate with the development of a loose and low hanging waddle in some weight loss patients. This neck waddle (turkey neck) is not usually on the top of most patient’s priorities and is rarely one of the first plastic surgery procedures massive weight loss patients undergo. However, it is the most visible and to those most severely afflicted, an area of concern for sure.

Neck waddles are treated through a full facelift procedure. As many patients do not understand what a facelift is, and it is somewhat of a misleading name, it should more accurately be called a neck-jowl lift. Or in the weight loss patient, a neck lift. Using well placed and often hidden incisions around the ear, the neck and loose facial skin is worked out backwards toward the ear. As the loose neck skin moves up and back (and removed and closed around the ears), a better defined shape to the neck is seen. This is what a facelift is…..a neck procedure and a neck procedure only. It does nothing for the rest of the face. More complete facial changes require other procedures often done at the same time as a facelift, which creates the common misconception that it is a full facial operation from the scalp down to the neck.

While necklifts are tremendously effective, the amount of loose neck skin and its loss of elasticity make for a realistic appreciation of what can be achieved. Most weight loss patient necklifts will not get a perfectly sharp neck angle. Many such patients never had a very chiseled neck to begin with. Only so much neck skin can be lifted and tightened. Also, because the skin has lost a lot of its elasticity, there will be some rebound relaxation in the months after surgery. Have no fear it is not going to return to where it started but the very tight feel right after a necklift will relax a little bit and it will not be quite as tight 6 months or a year later.

Necklifts (facelifts) are surprisingly easier to go through than most people think. Most of the neck and face skin is numb so there really is very little discomfort after. When the necklift is done by itself, all swelling and bruising is low in the neck area so the eyes and face continue to look the same after surgery as before. Recovery after a necklift is really social (How do I look?) rather than physical. (how do I feel?)

Dr. Barry Eppley

Indianapolis, Indiana

Reshaping the Chest in Men with Severe Gynecomastia

Sunday, January 18th, 2009

In men who have lost a lot of weight or in overweight men in general, breast enlargement is a common problem and concern. As a general rule, these forms of more severe gynecomastia are not just about having large breasts but having breasts that are large enough to have significant sagging. This form of gynecomastia poses much different problems than lesser degrees due to the low nipple position and excessive hanging chest skin. While traditional forms of gynecomastia respond well to liposuction or open excision through a nipple incision, these more complicated forms will not.

The fundamental surgical concept that must be incorporated in improving this form of gynecomastia is that of a breast lift…..and the scars that will be created. Not only must breast tissue be removed, but skin as well. In addition, the nipple must be repositioned and the overall chest reshaped to be as flat as possible rather than end up looking like a female breast mound. When breast lifts are involved, it is all about how much the nipple must be moved upward and how much scar can be tolerated to achieve this reshaping.

The most effective radical gynecomastia procedure is a simple mastectomy with free nipple grafting. Unlike a mastectomy for female breast cancer which would leave a straight line scar across the center of the chest, the ‘male mastectomy’ removes the overhanging breast tissue and places the scar along the inframammary fold, which is in a more natural skin crease. The nipple is first removed and then put back as a skin graft in a farther northern position at the end of the procedure. While nipple sensation will be lost (which isn’t that useful to most men anyway) and the nipple will never look quite normal, this approach is the most assured way to get a dramatic improvement in a single operation.
Using the traditional anchor or inferior pedicle approach is another radical gynecomastia surgical approach. This is the least desireable from a scar aesthetic standpoint (vertical and horizontal scars are more obvious) but its primary benefit is that it keeps the nipple alive because of the underlying attached pedicle. Because you can’t thin out the breast tissue under the pedicle very much, for fear of having the nipple die afterwards, a second liposuction procedures may be needed to bring the chest mound prominence down further.

The most aesthetically pleasing, but the most difficult gynecomastia operation to perform, is the periareolar (around the nipple skin excision or donut procedure) operation. The whole purpose of this approach is to not only keep the nipple alive but keep the scar limited to around the nipple only. What makes it difficult is not the surgery per se, but that it will take at least 3 and sometimes 4 operations to get the final result. Only some much skin can be removed in a donut fashion each time as well as only so much breast tissue. This is a long road to go in severe gynecomastia cases and poses some obvious economic hardships. But for those men who want the least scar possible, this is the only way to go.

Dr. Barry Eppley

Indianapolis, Indiana

Does The Method Of Extreme Weight Loss Increase The Risks of Body Contouring Surgery?

Wednesday, January 7th, 2009

Large amounts of weight are being lost in this country through the popular procedures of bariatric surgery, most notably gastric bypass and the lapband operations. Despite the popularity of bariatric surgery, I see in my practice just as many patients who come in for body contouring procedures who have lost weight through diet and exercise. Because these weight loss methods are so different, with theoretical higher risks of poor healing in gastric bypass patients due to malabsorption, it would be interesting to know if the complications from major body contouring surgery are different between these two groups.

This exact issue was looked at and published in the January 2009 issue of the journal Plastic and Reconstructive Surgery. In 220 massive weight loss patients (191 bariatric, 29 diet and exercise) patients that underwent body contouring surgery, the complication rates and outcomes were looked at and analyzed. The conclusion was that there was no evidence that either weight loss method increased the risk of complications from a number of common bariatric plastic surgery procedures such as panniculectomy, mastopexy, brachioplasty, body or thigh lifts. It should be pointed out that there was a large difference in the number of patients in each group (29 vs 191) but statistical analysis based on matched procedures did not show a significant difference.

Bariatric plastic surgery involves the most extensive removal and reshaping of body tissues that exists in all of plastic surgery…or for any form of surgery for that matter. These body contouring operations, while safe, are not complication free. Wound separation (dehiscences) and small areas of infection are common in most patients and I point this out to all patients in advance. Because the bariatric surgery patient is more likely to have nutritional deficiences than non-bariatric weight loss patients, one would assume they would have higher rates of complications. This does not appear to be so. However, I would point that the plastic surgeons that performed these procedures and did this study are experts in the field and undoubtably have a keen sense of patient selection and surgical execution. Their expertise has most likely prevented some potential complications. Preoperative nutritional assessment and the type and number of procedures performed in any weight loss patient (I rarely go over 5 hours of surgery at one time) are still extremely important issues for all weight loss patients, no matter how they lost it.

Dr. Barry Eppley

Indianapolis, Indiana

Back Lift Surgery in the Extreme Weight Loss Patient

Wednesday, January 7th, 2009

The back is not spared from the extreme weight loss process. While skin may sag worse in the front (abdomen) after a lot of weight loss, sagging in the back occurs as well. It tends to not sag as much as other areas due to three factors: the thickness of back skin (one of the thickest in the body), the back skin has more attachments to the underlying tissues which hold it up better, and it was never expanded as much as the abdomen due to less fat initially. Back skin sag is usually a concern more in women than men due to the skin rolls that occur underneath the bra, being noticeable through certain types of clothing. These skin rolls frequently extend down to the side of the waistline and may consist of at least two distinct rolls in many patients.

A common misconception is that liposuction or fat removal will help tighten this loose sagging skin. Nothing can be further from the truth. Only removing the rolls themselves by cutting them out can make the back more flat and tighter.

Back lift surgery involves the removal of an elliptical (football-shaped) cutout of skin and its underlying attached fat. The cutout pattern and the final scar which results can be placed either in a horizontal or oblique orientation on the back. If done horizontally, the final scar will lie higher up within the bra line (ideally) so it can be fairly camouflaged. The back skin removal can also be oriented along the way the skin rolls fall in an oblique fashion. While the resultant back scars will be more obvious, this approach removes more skin and tightens the back better in my experience. Either way, a surprising amount of skin can be removed in a back lift.

Back lifts do not cause much discomfort and are often done in conjunction with other body contouring procedures. Like many body contouring operations, a drain will be placed in surgery to remove fluid from the space left under the skin after closure. These drains will need to stay about a week when the fluid output has dropped significantly.

Back lift surgery does produce scars but they usually heal surprisingly well compared to some other areas of the body. Back lifts are usually done as one of the last body contouring procedures as patient’s concerns about them are secondary to abdomen, breast, arm, and thigh skin issues.

Dr. Barry Eppley

Indianapolis, Indiana

Thighplasty (Thigh Lifts) after Extreme Weight Loss

Wednesday, December 31st, 2008

The thighs suffer loose and hanging skin after extreme weight loss and often look like ‘wax melting on a candle’.  Thigh lifts or thighplasty is the plastic surgery procedure that can address some of these issues.  Thigh liftsconsist of a variety of procedures that differ based on the location and extent of the procedure.  There are inner and outer thigh lifts and vertical and  extended vertical thigh lifts, all based on the nature of the excess skin on your thighs.

The outer thigh lift is done as either part of the circumferential body lift or as an isolated procedure. When the circumferential skin cutout of the body lift crosses the outer waistline (actually lower so it is an upper or outer thigh lift), the saddlebag area of the thighs is lifted. The final scar will cross or be just above the hip bone so this area can be quite tight when closed at the time of surgery. Some plastic surgeons choose to anchor the underside of the thigh skin to the tough lining of the hip bone (iliac crest) and this maneuver can be a good one to prevent scar widening later. In the extreme weight loss patient, the extended nature of the sagging ski n around the waistline makes the body lift a logical choice to get a tummy tuck, outer thigh lift, and buttock lift all in one procedure. Isolated outer thighs in extreme weight loss patients is unusual because if one has sagging thighs there will be other areas that sag as well.

Inner thighs lifts consist of two basic types, simplistically those that are oriented horizontally and those that are more oriented vertically. In either type of thigh lift, I don’t recommend doing them until after the tummy tuck or body lift is first completed. This is because these procedures will provide a mild thigh lift effect which may change the amount of thigh skin removed or the incision (cutout) pattern. Either inner thigh lift approach is a compromise. A horizontal inner thigh lift removes a crescent of skin and fat along the groin crease and this is where the final scar will be. A groin crease scar can be long, extending back into the buttock crease, but it is placed in a natural skin crease that is not that visible. A vertical thigh lift usually includes a horizontal excision of skin along the groin crease but also has a long vertical cut out, a T excision pattern. This is a very effective thigh reshaping procedure but results in a long visible scar down the inner thigh. Most extreme weight patients are usually better off with the combined horizontal/vertical inner thigh lift, if the scar is acceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Nutritional Issues in Bariatric Plastic Surgery Patients

Monday, December 29th, 2008

Body contouring plastic surgery after extreme amounts of weight loss must take into consideration the nutritional condition of the patient. Unlike traditional cosmetic surgery where one can assume that the patient can heal satisfactorily, such an assumption can not be safely made in patients who have lost a lot of weight.

This is particularly true in the patient who has lost weight through bariatric surgery. Bariatric surgery alters the way that foods are digested and processed. In the gastric bypass patient in particular, foods that are taken by mouth are not fully absorbed in the intestinal tract, a process known as malabsorption. This malabsorptive process is a major reason that this weight loss operation works. Nutritional deficiencies following this type of bariatric surgery are common from a combination of this malabsorptive process and an intolerance  to certain types of foods that have valuable nutritional ingredients.  The most common nutritional deficiencies from a gastric bypass procedure include vitamin B12, folate, calcium, and iron.

Gastric tightening or a restrictive surgical approach to weight loss include the Lap-Band and vertical banded gastroplasty. These procedures can also have nutritional deficiencies, even though the absorption of nutrients is normal, due to persistent vomiting or a low amount of food intake. Common nutritional deficiencies include folate, thiamine, and potassium. Such nutritional deficiencies may also develop in non-surgical weight loss diets which are very restrictive, especially if the weight loss is quite rapid.

These nutritional deficiencies can usually be prevented through proper supplementation after bariatric surgery. But it usually requires working with a dietitian in a structured program. Even in a bariatric patient who may be years after their surgery, I am still not comfortable with extensive body contouring surgery unless I know the patient is part of a structured nutritional program and is monitored. Periodic laboratory tests and follow-up evaluations are important and a necessary requirement prior to large plastic surgery procedures.

 Dr. Barry Eppley

Indianapolis, Indiana

Pubic Lifts (Monsplasty) in Extreme Weight Loss Women

Sunday, December 28th, 2008

One area of sagging skin in the abdominal region that is not frequently addressed is in the pubic or mons area. Although a tummy tuck or body lift removes a lot of loose abdominal skin, it can still leave excess pubic skin behind resulting in a mons sag. This is often disturbing for patients as they did not anticipate this residual problem. In some, this sagging pubic skin is significant enough that it may interfere with intimacy or the urinary stream in some female patients.  Mainly, however, it is just a cosmetic problem with a mismatched sagging pubic mound sitting below the horizontal abdominal scar from their abdominal contouring surgery.

A pubic lift (monsplasty) can be incorporated as part of a body lift or tummy tuck. I use a more inferior placement of the lower central abdominal incision when performing a body lift or tummy tuck so that the sagging pubic area (if present) gets lifted more than the surrounding areas.  This is a simple modification of the frontal abdominal excision that may avoid the need or desire for a secondary pubic procedure. It is like dropping a shallow ‘U-shaped’ extension of the planned lower abdominal incision. One of the cosmetic ‘problems’ that this modification will create, however,  is the the buffer zone between the final incision/scar and the pubic hair line is lost. The pubic hairline will be brought right up to the scar line. This can be easily remedied later by laser hair removal.

If a sagging mons area exists after a tummy tuck or an abdominal panniculectomy, it can be lifted by a fairly minor operation later. An inverted U-shaped cutout pattern is done starting at the existing lower abdominal incision. The extra loose skin is removed so that the sagging part of the pubic area is brought up to the scar. The same problem with connecting the upper part of the pubic hairline with the horizontal abdominal after will result also.

Dr. Barry Eppley

Indianapolis, Indiana

Understanding the Combined Breast Lift and Implant Procedure in Breast Reshaping after Extreme Weight Loss

Tuesday, December 23rd, 2008

Breast reshaping in the extreme weight loss patient almost always require the combination of an extended breast lift and a breast implant. The loss of breast tissue from the weight loss and the now overstretched skin results in a deflated breast with a significant sag. The nipple lies below the lower breast crease and in many patients it points directly to the floor. Such a misshapen breast requires both volume (breast implant) and a radical skin reshaping. (lift)

While this combination breast reshaping procedure is commonly done, it is not easy to get a good symmetrical breast result. The need for secondary revisions with this approach is not rare. Revision rates may be as high as 25% to 35%. The reason this procedure is difficult from a cosmetic standpoint is that the breast lift and the implant work against each other in achieving their goals.  A breast lift is a skin reduction procedure that lifts and tightens, a breast implant is an expansion procedure that stretchs and lifts. There is no exact science that can tell a plastic surgeon exactly what size implant is needed for how much skin is removed in a lift. It is as much an art as anything else.

One valid approach is to do the breast lift first and defer the placement of the breast implant as a second stage months later. While this staged approach has its advocates, it condemns the patient to two operations 100% of the time. While the combination of a lift and implant may require a significant percent of patients to need two operations due to a revision, the majority of patients (> 50%) will be able to get a satisfactory result in one combined operation.

The primary objective of this form of breast reshaping is to get the nipple lifted and centered on the breast mound. This results in the classic anchor breast scars to achieve it and the blood supply to the nipple is always in jeopardy with the low but real risk of nipple loss. The implant is placed through the same approach as that of the breast lift.

The combination of breast scars, an uplifted nipple position, breast implants, and having two breasts makes achieving  perfect symmetry and shape between the two breasts a difficult proposition in the combined lift/augmentation procedure. Fortunately,  most extreme weight loss patients are quite satisfied with significant improvement in their breasts even when revisional procedures may be needed.

Dr. Barry Eppley

Indianapolis, Indiana


Breast Lifting (Mastopexy) and Implants for Breast Reshaping after Extreme Weight Loss

Monday, December 15th, 2008

The severely sagging breast usually requires a combined breast lift with an implant, known as a mastopexy with augmentation in plastic surgery terms. This combined procedure lifts and repositions the nipple to a more central mound position, tightens and reshapes the breast mound into more of a conical form, and adds volume to create a fuller mound. In many ways, the different goals of this procedure work against each other….tightening the breast but making it bigger at the same time. This may seem like a trivial consideration, but it is these opposing forces which make a breast lift with an implant a difficult operation. It is difficult to do well and even more difficult to get both breasts as symmetrical  as possible.

An extended or full breast lift is needed in the extreme weight loss patient. A large amount of skin must be removed in a ‘keyhole’ or wedge-like pattern. While this skin excision is marked before surgery with a tape measure and the planned incisions made visually symmetric, few breasts are exactly the same to start with. This inherently makes even the most well marked and planned breast lift exposed to risks of asymmetry. In a breast lift, skin is removed but breast tissue (and the nipple) are not. The cutting and redraping of the breast skin provides a more uplifted and better shaped containment sac for the breast tissue. This results in a classic anchor or inverted-T scar pattern on the lower pole of the breast.

During the breast lift, there is ample opportunity and access to introduce and place a breast implant. Because of the blood supply that goes to the nipple through the breast tissue, it is prudent to place an implant under the pectoralis muscle rather than above it. Placing a breast implant above the muscle into the breast tissue may injure or disrupt the nipple’s blood supply, increasing the risk of losing the nipple after surgery due to necrosis. (turns black and dies) What size implant to use will vary greatly. You want to fill out the overlying breast tissue and make a nice round mound but you still want to be able to close the breast lift skin over it. Therein lies the  art and skill of the procedure. It is a delicate balance between choosing the right breast size (expansion) that still allows closing and tightening the breast skin (contraction)without too much tension. Too much tension of the breast lift skin closure will result in wide scars at the least and the possibility of suture line opening or breakdown after surgery.

Because of the complexities of making an improved breast shape through lifting and an implant, every patient undergoing this procedure should be aware of and accept that the need for revisional surgery is likely. Whether it be asymmetry of the nipples, positioning of the implants, and poor scarring from the lift, revisional surgery for this operation is not rare.

Dr. Barry Eppley

Indianapolis, Indiana

Full Breast Lifts For The Saggy Breast After Extreme Weight Loss

Sunday, December 14th, 2008

One of the many unfortunate body changes that occurs after losing a lot of weight in women is a deflation of the breast. Rarely does any woman lose significant weight and not create a much greater sag of the breast. This breast sag is known in plastic surgery terms as ptosis. Occurring in varying degrees, severe breast ptosis results in the breast hanging completely below the lower breast crease with the nipple pointing toward the floor.

As a result, almost all extreme weight loss breast patients need some form of a breast lift. While some breast lifts may be accompanied with an implant for increased volume, an implant alone will not lift the breast or nipple. This is a common misconception of what a breast implant can do. It will merely make the breast look like a low hanging ‘udder’if a lift is not performed with it.

Breast lifts common in a variety of forms based on the amount of movement that the nipple has to be raised.  If the nipple needs to be raised more than an inch or two, then a full or extended breast lift is needed. This is the case in almost all extreme weight loss or bariatric surgery patients. A full breast lift, from an incision and scar standpoint, is exactly like a breast reduction….with the exception that no breast tissue is removed. Only skin is removed which reshapes the whole breast. The skin is the sac or containment bag for the breast tissue. In a breast lift, the skin is radically removed and reshaped but the breast tissue and nipple is merely ‘re-wrapped’ so to speak. Because of the large wedge of skin that is removed, this results in the classic anchor or invert T scars. A scar runs around the new position of the nipple then down vertically to the lower breast crease which connects with a long horizontal scar in the lower breast crease.

At no time is the nipple actually removed. It remains attached to the breast tissue and is moved up as the entire breast mound is lifted and reshaped from the skin portion of the operation. It is brought out through a new hole cut in the skin at a much elevated and more centrally located position on the newly shaped breast. That is why the nipple stays alive and in most patients will still have feeling after surgery. (although the risk of losing feeling is one of the surgical risks)

A full breast lift is the foundation for reshaping the female breast after extreme weight loss. Because of the breast tissue loss, many such breast lifts require an implant for more volume also.

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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