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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘laser liposuction’

Myths and Misconceptions about Laser Liposuction (Smartlipo)

Wednesday, April 20th, 2011

Smartlipo has become a very popular body contouring procedure that attracts the interest of many people with fat deposits that have proven refractory to their best efforts. As a technologic advance and with a very trendy name, Smartlipo does offer certain advantages in the reduction/removal of stubborn and unsightly fat. The internet is full of much information about Smartlipo, much of which is highly promotional. Having used this device for the past two years, I have consulted with many body contouring patients. From these discussions, it has become very clear that there are many myths and misconceptions about Smartlipo that merit a detailed discussion. They can be summarized into the following:

SmartLipo is not surgery. While it is a laser device, it must be inserted into the body to be effective. It is not an external treatment. It should not be confused with non-surgical fat treatments such as Zerona, Zeltiq or even Lipodissolve. It is a liposuction procedure that is associated with all of its potential risks and complications.

It is less invasive than traditional liposuction. Smartlipo is liposuction and is just as invasive as this traditional method of surgical fat removal. Whether it is a metal cannula that is being thrust back and forth through a small incision or it is a laser fiberoptic cable that is run back and forth with less obvious elbow grease, it is equally invasive and traumatic to the tissues.

Smartlipo does not use suction. While Smartlipo uses a laser to help loosen the fat tissue, it shares the need with all forms of liposuction for actual vacuuming or suctioning to remove the mobilized fat. There are some practitioners that do not suction out the fat after laser treating fatty areas, relying on the body to absorb any liquefied fat. This is not what should be done. I have seen many patients who have had such an approach and they wonder why they don’t look any different weeks to months later…or have noticed very little improvement. Smartlipo requires suctioning to be effective.

Smartlipo zaps fat cells to eliminate them. While lasers are focused light, it is not like a video game. The real objective with the laser is to heat up the treated area to a temperature that causes fat cells to break down, roughly 46 to 48 degrees C. Some fat cells do get ‘killed’ by direct contact with the laser probe but the real objective is to heat up the room, so to speak, to a temperature that the sensitive fat cells do not like.

Smartlipo effectively treats cellulite and stretch marks. It does not. There is no evidence that the heat generated from a laser improves skin irregularities or imperfections. It is a good theory and it seems like it should, but it is not a reliable outcome. I have certainly seen some patients who do have sustained improvement in the appearance of their cellulite but this should be viewed as an unexpected bonus not an assured result.

Smartlipo does not require general anesthesia. This is by far the biggest misconception and that is because it is a half-truth. It can be done under local anesthesia, and can get comparable results to liposuction performed under general anesthesia, if the area is small enough. The key is the size of the area to be treated. When multiple areas are involved, local anesthesia alone may not make it a comfortable enough experience to do a thorough fat reduction effort. It is important for patients to understand that the type of anesthesia used can affect the final result.

Smartlipo tightens loose skin. This is a true statement but it is a matter of perspective. From a scientific standpoint and based on my clinical experience, skin tightening can be achieved as measured in millimeters. (mms) A patient’s expectation, however, is viewed as in centimeters (cms) or inches. Many patients come in thinking that the inches of skin hanging over their waistline will be tightened by the laser. The hope of substantial skin tightening has many patients thinking that liposuction is the answer when some form of excisional surgery is needed as well.

Smartlipo has numerous benefits over traditional liposuction in my experience including better long-term results, less bruising, less discomfort and some small degree of skin tightening. But it is not magic and it is real surgery. It is not a lunchtime procedure and it is associated with real recovery and risks.

Dr. Barry Eppley

Indianapolis, Indiana

Smartlipo Treatment of Axillary Hyperhidrosis

Monday, April 26th, 2010

While many people regularly sweat during exercise and exposure to high heat conditions, there are some people that do so under completely normal conditions. It is estimated that about 1% of the American population suffers from such excessive sweating known as axillary hyperhidrosis. It is both a source of embarrassment and clothing inconvenience.

While mild cases of axillary hyperhidrosis responds to strong antiperspirants, more significant and persistent conditions require other forms of treatment. The well known neurologic injections of Botox and Dysport  provide profound and sustained reduction in axillary sweating. The injection treatments are quick to do but not inexpensive, often ranging in cost of between $750 to $1,000 for treatment of both armpits. While the results are temporary and must be repeated to be sustained, they will often last for up to one year.

Numerous surgical approaches have been advocated over the years, all of which try to destroy the offending sweat glands which are largely situated underneath and around the axillary hair follicles. No single technique has been shown to be consistently effective. But the use of  heat (thermal destruction) is a logical method to permanently damage the sweat glands and hair follicles. The issue has always been how to deliver the heat to the underside of the skin without creating a full-thickness burn to the skin.

The use of laser liposuction (Smartlipo) is now a well accepted and effective method of liposuction. By introducing a small 1mm fiberoptic probe under the skin, heat energy is delivered to the fatty target tissues. When the laser probe is under the skin, it may not look like it is doing much but feeling the outer skin will soon dispel that perception. The tip of the laser probe can deliver a very significant amount of heat. While the tip energy is not as much as an electrocautery, it is still significant enough to thermally damage whatever it contacts.

The use of Smartlipo can be used in the treatment of axillary hyperhidrosis through the introduction of the laser probe. Running the probe underneath the axillary skin delivers heat exactly where the glands lie, causing either their vaporization and disruption of the ducts up into the skin.While complete elimination of sweating may not occur, reduction is significant and is reportedly maintained for up to several years after a single treatment. Using power settings of 30 watts with wavelengths blends of 1064nm and 1360nm, a high amount of heat can be selectively delivered.

This treatment can be done under local anesthesia or IV sedation, whichever the patient prefers. There are no dressings and any special care needed afterwards. The armpits will be a little sore and tender for a few days but there are no physical restrictions. One can return to work the following day in most cases. Very physical jobs may require a few days until the axillary soreness improves. I have seen a few partial skin burns which appear as blisters the following day. These will go on and heal on their own uneventfully. While on the one hand I don’t like to see blistering, those healed blistered areas will likely never sweat again.

The use of the Smartlipo laser probe  is a more contemporary approach to the concept of subdermal shaving in the treatment of axillary hyperhidrosis.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction – An Evolving Science but still an Imprecise Art

Wednesday, November 11th, 2009

continues to be the most commonly performed of all body contouring plastic surgery procedures. The large surface areas that can be treated make for significant changes in the contours of one’s body. The marketing and promotion of liposuction across all types of media strongly suggest that it is a precise surgical procedure. Inferences are not subtle that surgical fat removal is able to achieve results that are comparable to ‘sculpting’ or the chiseling out of body parts.

While there are some body areas that truly can be sculpted, most liposuction results are relatively imprecise. At the least, they are not usually like the model that appears in an advertisement. The outcome of a liposuction procedure is certainly influenced by the surgeon performing it and the tools that are used. But there are numerous logistical factors that will always limit the quality of the results that can be achieved.

The topography of the treated area is one important factor. Most of the body is not flat but rather a curved surface that has different thicknesses of fat as it curves around from area to another.  This certainly makes it difficult to ensure evenness of fat removal, particularly when the aspiration is done with a straight cannula.

Liposuction surgery is almost always done with the patient in the supine or horizontal position.  While this does not significantly affect some body areas, such positioning allows most fat collections to shift backward and become distorted as they lie or are pressed up against the operating table. The concept of ‘standing up’ liposuction is theoretically appealing but currently impractical.

Skin quality remains a very important determinant of liposuction outcomes. Looseness of skin, stretch marks, and cellulite over a treated area does not bode well for needed skin contraction of deflated areas. One must appreciate that it is highly likely that the smoothness of overlying skin will never be better after liposuction and, in some cases, can be made worse. Liposuction, by any method, is not a treatment method for cellulite as some patients mistakenly believe.

To work around these limitations, there are some presurgical and intraoperative  techniques that are used to get the best results possible. Marking the surgical sites immediately prior to surgery is critical. One must look at the planned treatment areas like a topographic map. The marks will indicate how far one has to go as the body areas shift and distort when one lies down. Marking the high and low spots also indicates how much time should be spent or tissue removed from one encircled area to another. Positioning the patient on the table can help tremendously with seeing the marked areas more ‘three-dimensionally’. For example, it is better to treat the lateral thighs or the flanks with the patient turned on one side. While this is more difficult for the surgical team, it is the best way to avoid seeing irregularities and missed areas of fat when the patient is seen standing weeks later in the office.

While new liposuction technologies appear fully capable of improving how well and even fat is removed, they are not magical devices. The use of laser liposuction (a.k.a. Smartlipo) is one example of how using a thermal approach (melting and liquefaction) may produce more consistent and even fat removal. The heat that it creates is promising for helping skin contraction, but it will not transform skin that is already damaged.

Liposuction is an improving plastic surgery technique but it is not yet an absolutely precise science. Its results are still somewhat of an art form. Patients should appreciate that perfect symmetry and evenness throughout a treated area can not be guaranteed and the desire for secondary improvement through touch-up procedures is not rare.

Dr. Barry Eppley

Indianapolis, Indiana




Postoperative Drainage after Smartlipo (Laser Liposuction)

Wednesday, October 7th, 2009

, also known as laser liposuction, uses heat to breakdown fat. Through the joint concepts of direct fat destruction by contact with a 1mm probe which emits laser energy to raising the internal temperature of the zone of treatment to above 45 degrees C, fat cells are thermally disrupted. The heat either directly breaks open the cell walls and the internal lipids leak out or the intracellular fluids boil and explode open the cell walls. This is clearly visible during the procedure as yellowish-colored fluid drains from the skin entrance site where the laser probe is inserted.

By either heating mechanism, fatty oils are released. When the suctioning phase after laser heating is done, these oils become part of the mixture of particulate fat, blood, and tumescent solution which makes up the aspirate. While suctioning removes a lot of these fluids, some fatty oils are either left behind or will be created afterwards as additional fat cells die and leak additional oil.

This process creates a unique postoperative finding that is unique to laser liposuction procedures. That is the draining of fluids for several days after surgery out of the skin entrance sites. The amount and duration of the drainage is higher and more extensive than with any other liposuction procedure. The drainage is the combination of these residual fatty oils and other fluids and the compression garments applied and worn after surgery.

In my Indianapolis plastic surgery practice, our presurgical education and postoperative instructions point out this perfectly normal drainage. We supply absorbent pads to be used under your compression garments to help absorb much of this fluid. They should be worn as long as any of the skin holes are draining. If hips and thighs are done, for example, do not be alarmed that fluid comes running out of the holes the next day when you change your garments.

While this fluid drainage is temporarily annoying, it is very beneficial. It is far better that these fluids are out of the body, otherwise they will take days to weeks to be absorbed. This will result in greater swelling and bruising and a longer time to get to the final contoured shape.  

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Smartlipo (Laser Liposuction): It’s All About The Heat

Wednesday, August 19th, 2009

The  most simplistic understanding of Smartlipo (laser liposuction) is that it induces thermal lipolysis. This accomplished by the direct destruction of fat cells through heat energy delivered by a fine laser probe. A secondary effect of the use of laser energy is that there is a build-up of heat throughout the treatment zone which also disrupts the walls of fat cells.  (that are not directly contacted by the laser probe) This results in liquid fat being released from the broken down fat cells which can then be removed by intraoperative suction or can be absorbed and eliminated by the body days to weeks after surgery.

 In reality, fewer fat cells are destroyed by the laser probe (mechanical destruction) than by the general heating process. (thermal cell destruction) The laser probe, being only 1mm in size, cannot directly contact every fat cell in the treatment area. Rather the internal tissue temperature is driven to a level that the fat cells can no longer stay intact. While normal tissue temperatures in which fat resides is around 37 degrees C, the goal in Smartlipo is to drive up the temperatures to 50 degrees C or greater. Running the laser probe around enough times in a given area will achieve high internal tissue temperatures. This is the real goal of any form of laser liposuction….collateral fat cell damage.

By bulk heating the treatment area, not only will fat cells be destroyed at the time of surgery, but the thermal damage affects cells after surgery as well. Some fat cell walls remain intact but the internal damage induces deterioration and cell death afterwards. Therefore, those fat cells will release their contents days or weeks later. This translates to the clinical effect that the final result (amount of fat loss and shaping) will take months to completely see. During the early postoperative period, the released fat (triglycerides) is taken up and removed by the body’s natural processes. This removal process is not fast and can only handle so much at a time which is why it takes such a long time to get to the final result.

A side benefit to this internal heating process is the potential for postoperative skin retraction. Much has been made of this benefit and it is real. But a patient’perception of skin shrinkage and that of a plastic surgeon is usually quite different. To put it in a patient’s viewpoint, I would say that the amount of skin shrinkage is mild and sometimes moderate…but never dramatic. In short, it will not avoid the need for a tummy tuck, for example, if a lot of loose skin exists in the stomach area.

Dr. Barry Eppley
Indianapolis, Indiana


Smartlipo – Melting Fat Through Controlled Heating with the Thermaguide

Tuesday, July 28th, 2009

represents a paradigm shift in liposuction technology. Using a laser probe and the emitting of pulsed energy from its tip, it is used to directly and indirectly destroy fat cells. Whether it is by direct contact with the laser probe through multiple passes or the build-up of sufficient heat energy by working continuously in one area, fat is more effectively removed by the combined direct and field effect.

From the outside and to the patient or novice user, one would believe that the benefits of Smartlipo are primarily the result of the probe’s direct contact on fat. In reality, raising the temperature in the subcutaneous fat area is very important also. It is currently acknowledged that the death or rupture of fat cells will occur at temperatures around 42 to 45 degrees centigrade. But how does one know when that temperature is reached as the laser probe is under the skin?

In the past few years since the introduction of higher powered laser machines, which are now capable of delivering much more heat quicker,  one could only estimate the fat temperatures by how the skin feels by touch. While this is a rough guide, it is not as accurate as one would like and it is possible to actually create too much heat which can be destructive and cause substantial fat necrosis and indentations.

The more recent introduction of the thermaguide to the Smartlipo machine really brings a much greater precision to the procedure. The thermaguide is a special cannula, through which the laser probe is inserted, that reads the temperature of the area you are in and puts it in real time on the computer screen. In addition, the thermaguide requires the use of a 1mm (1000 micron) probe as opposed to the smaller 600 micron probe. This not only makes it more stiff for easier tissue passage but also delivers more heat energy due to its larger cross-sectional surface area. This helps heat each fat area faster.

The thermaguide represents a real advance for laser liposuction. While initially ridiculed when it first came out due to its low powers and slow and ineffective treatment times, a 30 or 46 watt machine with the thermaguide now makes laser liposuction a really effective procedure. I now believe that Smartlipo rivals traditional or ultrasonic liposuction in operative speed but with more effective fat reduction. Heating up the subcutaneous fat layer before suctioning provides good fat removal, less pain, and the potential for some small amount of skin retraction.

 Dr. Barry Eppley
Indianapolis, Indiana


Love Handle/Muffin Top Reduction with Smartlipo (Laser Liposuction)

Monday, June 29th, 2009

Love handles, a well known slang term, refers to a layer of fat that develops around one’s midsection, especially apparent on the sides over the abdominal external oblique muscles. I assume they are called love handles because they can be grabbed or rested on while one’s arm is around another person. But I don’t know anyone that really loves them. Love handles are also called a spare tire, midriff bulge and muffin tops. (my personal favorite)

While there is no doubt that diet and exercise are the first line of offense to reduce love handles, this is often not that effective. I have talked to many patients, both men and women, in my Indianapolis plastic surgery practice who have made gallant efforts and are still stuck with love handles. They may have lost it most everywhere else, but the love handle area is often quite resistant. Perhaps they weren’t doing the right exercises or weren’t really trying hard enough, but they remained with love handles nonetheless. I do not believe that most people can lose spot areas of fat by exercise.

The love handles happen to be a particularly good area to be reduced by liposuction. I consider it the most ‘responsive’ area on which to do liposuction because the results are always significant and there is very little risk of contour or shaping problems. It is an area which can be treated very aggressively with liposuction techniques because of the thickness of skin and the acceptance of an overall ‘indentation’.  If the side of the waist ends up either straight up and down or becomes more like an hourglass, all patients would consider that a good result. In short, maximal removal of subcutaneous fat around the waistline into the back is the approach for love handle removal.

The newest laser liposuction method, Smartlipo, works particularly well for this waistline problem. It appears that the heat build-up in the love handle area helps to create significant collateral damage to fat, beyond what is liquified and melted, to optimize the results. Suctioning the love handle area traditionally creates very noticeable bruising and pain in the back area around the waistline, but that seems to be reduced with Smartlipo. I didn’t say eliminated but definitely reduced.

I like to leave the small entrance skin sites for the laser probe and suction cannula open to drain after surgery. This drainage is easily caught in dressings that are placed against the skin over which a circumferential abdominal binder is placed. This drainage will stop in 24 to 36 hours. It is better to have this fluid out, rather than in, so there is less blood and fluid for the body to have to clear afterwards. Love handle liposuction results are immediately apparent, even the next day when the dressings are removed. The results continue to improve as swelling and bruising resolves.

Be aware that love handle reduction is only as permanent as the stability of your weight permits. Like the abdomen, it is an area of preferential fat deposition (particularly in men) and treating it with liposuction will not change this biologic predisposition. Keep working on those exercises after surgery!

Dr. Barry Eppley
Indianapolis, Indiana


Smartlipo and Tummy Tuck Surgery on Indianapolis Doc Chat Radio Show

Sunday, June 28th, 2009

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by plastic surgeon Dr. Barry Eppley, an encore show in which the topics of Smartlipo (laser liposuction) and tummy tucks were discussed. An open discussion on reshaping the abdomen and waistline and laser lipolysis for fat removal were reviewed over the hour. What a tummy tuck is, how it is done, what the different types are, how do they differ in men vs. women, and what recovery is involved was reviewed.


The newest version of liposuction, Smartlipo which uses laser energy to melt fat and tighten skin, was reviewed for what its advantages were, how it works, and what type of patient would best benefit by it. Its use in combination with tummy tuck surgery was highlighted.

Cellulite – What is It and What To Do With It?

Wednesday, June 3rd, 2009

Everyone knows what the dimpling appearance of cellulite looks like.  The vast majority of women will experience cellulite at some time in their life and, once it appears, it is likely there  forever.  While some choose to ignore it, many women  are interested in pursuing treatment, whether it be through surgical or non-invasive options.

While its appearance is well known, few understand why it is there and what causes it. Cellulite is not really based on being overweight (although thinner people usually have less of it), but rather genetics, hormones, and age play the dominant causes. It clearly appears much more often in women than men due to the different subcutaneous anatomies of the way fat is stored.

From an anatomical standpoint, cellulite refers to the fatty deposits that form uneven and dimpled skin found mainly on the thighs, hips and buttocks of many women. Cellulite is not caused by being overweight. The subcutaneous connective tissue that holds fat is made up of fibers and these fibers act as anchors between the muscles and the skin. Between these fibers are chambers that hold fat cells. Cellulite develops when, for unknown reasons,  these connective tissue fibers beneath the skin that compartmentalize the fat shrink and stiffen. This results in areas where the skin is held down while other sections bulge out, resulting in that lumpy “cottage-cheese” appearance. Men are very much less prone to this problem because their connective tissue fibers run more diagonally rather than completely vertical.

The burning and never-ending question is…what can you do for cellulite?  What I can say is that there is nothing that you can buy on the internet and slather on the affected areas that will produce a miracle cure. Of course, there are many creams, oils, and lotions promoted  to improve cellulite.  Time and again these products are proven ineffective, yet millions of consumers still purchase them in hopes of an easy answer.  But there are newer and promising treatments that can provide some improvement although most results are not permanent. The search for more permanent solutions, like the Loch Ness monster,  is ongoing.

Liposuction is still widely perceived as a cellulite treatment since it removes fat. However, it has proven to not be an effective treatment and can even make it look worse if too much fat is removed or removed too close to the skin. In my Indianapolis plastic surgery practice, I emphasize this point to patients and how we must be careful in performing liposuction in areas underneath cellulite-laden skin.

Pickling or subcision is a procedure that has been used for decades to alleviate scarring from acne and has a more recent history of use in cellulite. The procedure is done by special long instruments that have a cutting edge to them, like a pickle fork. They work by detaching the tight fibers that run beneath the skin that cause cellulite. Unfortunately the initial smoothing benefits are not usually maintained once all swelling has subsided months later. For this reason, cellulite pickling has largely been abandoned. I have recently applied the Smartlipo technology as a ‘laser pickling’ method. The heat from the laser may yield better results in causing a more permanent cellulite improvement but more patient treatments and follow-up are needed.

Several ultrasound and laser external machines, such as TriActive and VelaShape, are FDA-approved and do produce some cellulite reduction benefits. They both use the concept of different energies being driven into the skin toincrease blood flow, improve  lymphatic drainage, and tighten a little skin. Their benefits are real but, again, only temporary for many. Maintenance treatments are necessary for sustained benefits.

In conclusion, an effective and permanent solution for reducing the appearance of cellulite does not yet exist. Superficial subcutaneous laser treatments are promising but that still requires an invasive approach. Non-invasive device-driven technologies do work but results require long-term maintenance. If it comes out of a bottle or jar…save your money (and hope) for more proven methods.

Dr. Barry Eppley

Indianapolis, Indiana

Smartlipo (Laser Liposuction) – Evaluation of the Aspirate

Tuesday, June 2nd, 2009

Smartlipo has brought a new dimension to liposuction surgery principally through its introduction of high heat levels into the fat location.  Between the very hot probe tip and heat generated in the fat tissue, significant liquefaction of fat can be obtained. This makes the zone of ‘collateral fat damage’ much higher than that which is seen with traditional liposuction techniques.

The sequelae of Smartlipo or laser liposuction can be readily seen in the collection canister or what is known as the aspirate. There are, however, many misconceptions of what exactly is in the aspirate. When a patient asks how much fat was removed or the plastic surgeon notes in the chart how much fat was removed, this really refers to the aspirate. The aspirate is essentially comprised of three main components, fat, blood, and tumescent fluid. Remember that all liposuction is done with the initial infiltration of a tumescent fluid which provides pain and bleeding control. So some of that infiltration fluid is what is being sucked out. If one waits long enough, the aspirate will traditionally settle out into two main layers, fluid (including blood) at the bottom and fat (which is lighter than water) which floats on top. The ratio between the two varies with each patient but is generally 10% to 30% fluid and 70% to 90% actual fat. So if you had one liter of fat aspirate removed, the actual amount of true fat is a percent of that total.

The aspirate of Smartlipo actually shows three distinct layers, fluid, more solid fat, and fat oil on top. This can clearly be seen in the canister. This demonstrates that a portion of the fat removed has been liquefied while more solid or particulated fat has also been suctioned. The ratio between particulated fat and fat oil will vary depending upon how much time was spent using the laser to build up the heat in the area. The oil ratio  increases based on time spent lasering. The goal is not to have a complete oil aspirate as that would indicate that too much heat has been applied to the area. While no exact amount of time or oil ratio has been established as of yet, it is important to see some oil layering or too little time was spent lasering and the benefits of Smartlipo will not really be seen.

This liquefaction of fat by laser liposuction also accounts for why there is persistent drainage from the entrance sites for a few days after surgery. The oil (and fluid) continues to drain out which is actually a good thing. This means that one will have less swelling as the body will not need to absorb the oil from the fat cells that have been ‘melted down’.

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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