Explore Plastic Surgery

Saline-filled breast implants typically have some amount of rippling or wrinkling which is not usually seen with silicone gel breast implants. (although it can still occur) This is particularly evident in women with thin skin and very little breast tissue. Implant wrinkling is felt on the bottom and sides of the breasts and can be seen as patterned set of lines visible through the breast skin. Breast implant wrinkling is usually most visible in certain positions, particularly when one is leaning forward or lying on your back. Wrinkles on a saline breast implant may be only a minor cosmetic issue (if you were informed before surgery) or might be a source of major unhappiness and be the reason to undergo revision surgery.
Rippling occurs as a result of the physical interface between the saline and the elastic silicone polymer shell . The exact reason wrinkling of the breast implant occurs has to do with how well the filler material coats the inside of the implant and bonds to it as well as its own viscosity. Water (or saltwater) flows easily and does not ’stick’ well to the inside wall of the breast implant shell, resulting in implant buckling and folding. This is a normal finding with saline breast implants and its presence is not abnormal or the plastic surgeon’s fault. Placement of saline breast implants above the muscle is also much more likely to lead to visible implant wrinkling in thin individuals as there is little breast tissue to cover the visible ripples and there is no pressure on the implant from the overlying muscle. Textured saline implants are particularly prone to rippling due to their thicker shell (harder for the water to push it out) and due to traction from the implant grabbing the thicker non-stretchable surrounding scar that it creates. The combination of textured saline breast implants above the muscle has the highest incidence of significant wrinkling issues.
Established ways to diminish the amount of wrinkling which can occur are to overfill the breast implant with more saline than the implant base size (increase the internal fluid pressure) and to place the saline breast implants under the muscle. (which puts more pressure on the outside of the implant). Both of these methods do lead to less wrinkling, but neither can completely prevent it. Overfilling a breast implant with too much saline will make it feel more firm than normal breast tissue, although this is generally well accepted by most patients. The best approach for prevention is to use non-textured saline implants placed under the muscle which are then filled 25 to 50cc more than its base size. While all implant wrinkling can not be prevented with saline fills, a significant reduction can be seen in most patients with this approach.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

The development of dark circles under one’s eyes makes you look tired. Some people develop dark circles with aging, while others have had them from when they were young. Dark circles occur just as frequently in Caucasians as they do in more darkly pigmented people. Dark circles, contrary to popular thought, is not due to being tired, stressed, or worn out. (no matter how you feel!) Dark circles develop due to staining of the thin eyelid skin from pigments that have leaked out from your blood cells. The blood cell pigment, known as hemoglobin, oxidizes when it gets close to the skin’s surface due to light exposure and turns a bluish red color. (the hemoglobin turns to hemosiderin, an iron-based pigment) This discoloration subsequently looks like a bruise and is easily seen since the lower eyelid skin is very thin and almost transparent. Once the dark circles appear from the pigment deposits, they may likely be permanent.
What can one do for dark circles? First and foremost, eyelid surgery will not get rid of dark circles. Lower blepharoplasty, which removes excess lower eyelid skin and fat, does not directly target the pigment-staining problem. In the short-term, it may actually make it look worse due to the bruising from surgery and has the potential to place more blood products near the skin to be broken down. In some cases, there is some improvement in the appearance of the dark circles as the lower eyelid is tightened and there is less of an undereye hollow for shadowing to appear in. But one should never undergo lower blpeharoplasty if your main objective is to get rid of the darl circles. Any improvement in the dark circles should be considered a bonus but not the main objective of the surgery.
Secondly, peeling, burning, or exfoliation of the lower eyelid skin does not usually work well either. Whether it is done by a chemical peel or laser resurfacing, the removal of the outer layer of the lower eyelid skin does not reach the area where the pigment deposition lies. Resurfacing removes the outer epithelium of the skin but does not, or should not, reach the deeper dermis or the underside of the skin. (if it does, the lower eyelid will scar) While I don’t think there is much harm to a lower eyelid peel, with a 25% or 35% TCA solution, it is not particularly effective in most cases. And runs the risk of an additive problem known as hyperpigmentation which can contribute to the darkness of the lower eyelid skin.
Potential leaching of the skin through hydroquinone topical preparations seems like a reasonably safe approach, although how it works doesn’t necessarily specifically target the pigment issue. Hydroquinone works by suppressing the melanin or color production of the skin so it is easy to see how this may be effective for hyperpigmentation or age-related (sun exposure) brown spots. But this bleaching chemical is not known to specifically break down and clear hemosiderin pigments stains. So bleaching the skin sounds like it would work, but the chemistry behind it would suggest otherwise.
Lastly, many topical skin creams claim dark circle improvement and some are even labeled as dark circle repair serums. These contain agents such as arnica, haloxyl, and other enzymes that purportedly break down the pigments and help the dark circles fade. While theoretically appealing, there is very little good clinical or study information that would support these claims. Even if effective, it would be a slow process in which it would takes months to begin to see improvement. (which is ok if improvement actually occurs)
My frustration with dark circles has led me to try another approach. I currently am using light therapy (intense pulsed therapy, specifically broad band light) with vascular filters in combination with topical dark circle serums. It strikes me that something is needed to intiate the pigment break-up and light therapy can specifically target that without injuring the overlying skin. And without any recovery for the patient. I currently am doing a series of 3 light treatments spaced one month apart with nightly applications of the topical serum.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

By the mid- to late 1990s, the impact of the less-invasive laparoscopic approaches to general surgery (particularly that of gall bladder removal) had reached plastic surgery. A wave of endoscopic (laparoscopic approaches infuse a lot of air to make the cavity, endoscopic just uses a camera without the extra air) approaches to a variety of facial (mainly) and other breast and abdominal procedures in plastic surgery had been caught up in adopting this technologic approach. The biggest benefit to any endoscopic approach is the simple fact of having less of an incision to do the surgery, which in plastic surgery is a big deal. By the time the dust settled from this enthusiastic push years later, the one plastic surgery procedure that has really benefited is the browlift. The endoscopic browlift is the one procedure that has stood the test of time and remains as one of the few remnants of the attempts at endoscopic adoption in plastic surgery.
It is easy to understand why the endoscopic approach to browlifting has stuck. The traditional open approaches, while tremendously effective, require an incision across the top of the head either way back in the hairline or at the hairline. That is a scary thought for some patients and some patients simply are not good candidates for that approach given the style and thickness of their hair density. Also, the endoscopic approach is not anatomically complex, you are sliding instruments and a camera done along the front part of the bony forehead. There is little in the way and it is hard to get lost and end up in the wrong place.
The endoscopic browlift, however, is not a perfect operation. It is not as effective at removing muscle between the eyebrows and up underneath the forehead skin as an open approach can do. And it can not lift the brow as well as open approaches where more aggressive brow release and actual skin removal is done. But for some patients, particularly younger women who do not have a lot of brow sagging and deep forehead wrinkles, the endoscopic approach is a nice option where the ‘solution matches the problem’.
There is one other consideration about endoscopic browlifting that receives little attention. The endoscopic browlift really works by what is known as an ‘epicranial shift’. This is a fancy term meaning the brow is lifted because the whole forehead and scalp is loosened and moves backward. This means the frontal hairline will move back as much, if not more, than the brows themselves with the lift. For those women with an already long forehead and high hairline, this may be too much of a hair-raising experience.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

While liposuction can be performed on almost any body area below the neck, little mention is ever made of fat removal from the knee. Yet, in my practice, I regularly perform knee liposuction particularly when the inner thighs are being treated. Most female patients can benefit from knee liposuction if it is done judiciously and in consideration of the line and flow of the inner thigh down into the calf area. Knee liposuction can produce very rewarding results that can make patients more comfortable in shorts and above the knee dresses and skirts.
The knee sits at an important esthetic juncture between the thigh and the calfs. The most important esthetic line is in the inner aspect in which a straight or mildly curving line should run from the inner thighs down to the top of the calf before it bows out again. If the inner knee fat bulges outward, it disrupts this esthetic line giving one the appearance of knobby or chunky knees.While the top and outer aspect of the knee also makes up the knee unit, little can be successfully done with those areas compared to the inside of the knee.
Liposuction of the knee is very straightforward to do. But the technique is critical if too much fat is not to be removed or irregularities and indentation of the overlying skin is not the result. A very small cannula is used with a small stab incision just behind the inner aspect of the knee in the popliteal crease. While the knee must be bent to do the procedure, it is important to regularly check the progress of fat removal by re-straightening the leg and checking how the inner esthetic line is progressing. When done as a stand alone procedure, it is important to make a gradual transition up into the inner thigh so there is not a demarcation line between the inner knee and the inner thigh. I find it esthetically important to also make sure that the liposuction is carried down into the upper calf area so I slight inward curve is placed before it bows back out again into the upper calf area.
I have found that knee liposuction can make a dramatic difference in the knee area and can get rid of the handful of fat in the inner knee that many women have. Even somw women with thin thighs and shapely calfs can still have a slight inner knee bulge. This area is clearly not metabolically active no no amount of diet and exercise can remove it. I usually have my patients wear a knee wrap or knee brace for a week or so until they feel comfottable without wearing it. The biggest issue with knee liposuction is that, because it is a flexion area, stiffness in the knee can be expected for 4 to 6 weeks after surgery when bending. Normal physical activities, including running, can be resumed three weeks after surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com/

http://www.ologymd.com/

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Men pose uniquely different challenges than women when it comes to the consideration of facelift surgery. Men age just like women but usually are only concerned with their neck when becomes more of a waddle. As a result, they often are seen in plastic surgery consultation with more advanced facial aging concerns than what one sees in women. Because of their more advanced neck issues and the heaviness of the male skin, minor or more minimally invasive procedures are not going to be effective at making a significant difference in their neck. Only a real facelift procedure will do the trick.

But the typical facelift operation is more difficult in men because of two hair issues….their beard skin and the hairline and quality of hair density (or lack thereof) around their ear area. As the conventional facelift procedure uses incisions in and around the ears, with a subsequent redraping of skin back and over the ear, men will often end up with beard skin behind their ear and potentially even inside their ear after the skin excess is trimmed. For this reason, the male facelift must often use an incision in front of the ear at the junction of the beard and non-hearing skin just in front of the ear to keep hair out of the ear after the operation. Keeping beard skin from ending up behind the ear is difficult and most men should expect that they will have to shave behind their ears after a facelift procedure. ( at least for an inch or behind the ear lobe)

For some men, their sparse hair over the temple areas and around the ear may make a conventional facelift very difficult to do to end up with good camouflaged scars. This is rarely a problem in women. Usually the scar ends up above the ear in the hairline, but with todays’ very short hairstyles particularly in men with thin or little hair,  it may not be very camouflaged and this is a very real consideration and concern. No male wants any area of the facelift scar to be visible so where to end the scar, and how that may affect the outcome of the procedure, must be thoroughly discussed prior to facelift surgery.

Me also will not get as dramatic a change in the neck as women will with a facelift. The heaviness and thickness of male facial skin does not allow it to tightened as much. And the way the facelift must be done in consideration of their hairline will also play a role in the outcome. Men are also prone to more ‘rebound relaxation’ in the jowl and neck area after surgery due to the quality of their skin, another factor that plays into the long-term outcome. Fortunately, men do not usually want a dramatic change anyway from any facial procedure so all of these issues usually add up to a good result that will please most men.

In rare cases of the much older male (usually greater than 65) who has a large neck waddle and does not want or can not undergo a significant operation, the direct neck lift can be an option. Rather than using any incisions around the ears, the loose skin is cut out directly in the neck. This produces a pretty significant change that offers a much more limited recovery. And can be a consideration if the man can accept a scar running vertically down from the chin to the adam’s apple. Surprisingly that scar can heal very nicely due to it being in beard skin which scars less than non-beard skin most of the time. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Whether you are young or old, some people end up with that annoying double chin even if they are not overweight. And while there are some ways to camouflage it, like wearing a turtleneck, that often is not practical or desired. Many times, that double chin or extra ‘neck’ is not seen or fully appreciated until one sees themselves in profile in a photograph. I have had many patients tell me that want initiated the consult was that they saw themselves in a school reunion, family picture, etc and they were surprised how they looked. Almost always, the surprise is the appearance of the jowl line and neck.
Double chins or neck waddles are the result of excess fat and hanging loose skin for some. In the younger patient, it may be a lot of extra fat and not so much extra skin although the weight of the fat pulls it down, making it look like there is more extra skin than there is. That distinction is important as it changes the strategy for what will be the most effective treatment.
If extra neck skin is not the dominant problem (usually the younger patient), then a fat-based treatment method shoudl be fairly effective. If the amount of fat or the double chin is small, then office-based Lipodissolve injections could be very effective. This is a slow process that takes months for maximal results to be seen. The biggest issue with Lipodissolve, however, is not the series of treatments but the swelling that will occur after each treatment session. It may only last for 4 or 5 days but the neck will essentially double in size for that time period. The most efficient treatment method for the fat neck would be liposuction. While that is surgery, it is both more efficient and effective and one only has to go through swelling and bruising of the neck one time.
When extra skin is a more significant issue, then a fat treatment alone will not work well and one will likely end up with even more loose sagging neck skin. In these cases, some type of neck lift (aka a facelift) must be done to remove the loose skin by lifting and working it out around the ear area where incisions can be placed more discreetly. In the older man, a direct neck lift can be done which is much simpler and highly effective although one has to be able to accept a fine line scar running from under the chin down to the adam’s apple.
Double chin reduction can be a very gratifying procedure and can be approached with Lipodissolve injections, liposuction, or some form of a facelift. The best procedure is the one that matches the cause of the double chin…too much fat, too much skin, or both.
Dr. Barry Eppley
http://www.eppleyoplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Despite the many off-the-shelf injectable fillers which currently exist, none of them can promise permanent results or complete biocompatibility and lack of any type of foreign-body reaction in everyone. Only one’s own fat, when done as an injection, can potentially fulfill those promises. But fat has another problem…..its survival after injection is unpredictable and it can not be injected very easily into small places or directly into the skin due to its irregular thick flow and the need for a large-bore needle from which it is introduced. But despite these drawbacks, the allure of fat as a filler material continues and its ample donor source (for most patients) perpetuates the mystique of a simple transfer from someplace undesired to a more desireable one.
There is no getting around the fact that fat injections are unpredictable. While there are some that blame a surgeon’s outcomes on their methods, an honest assessment of results will show that, even in the best of hands, the fate of fat transfer is not technique dependent alone. There is still much about fat biology that we do not know or understand. Many factors other than method of harvest and preparation influences its transplantation outcome including source, patient age, and the recipient site. It is naive to think that the important but relatively simple step of concentration after harvest is the dominant step that controls how much fat survives later. It is important for sure but it can be only one of the contributing factors. Much active research work is going on right now to study many of these other factors including how fat differs between donor sites and what other factors may be added to fat to improve its survival after injection.
The face is a fortunate site for fat injections in that the relatively small volumes needed have a better chance of survival. The smaller volume to surface area caused by linear injection patterns favors a quicker ingrowth of blood vessels which provides nourishment to traumatized and starving fat cells. As a result, fat does better in the face than any other bodily area. I currently strain all harvested fat and/or do a few minutes of centrifugation to get out most of the liquid debris and pack presumably good fat material into a syringe. Using 1cc syringes and a 16 gauge needle provides a relatively smooth outflow of fat into the desired facial areas.
One biologic approach that I am currently looking at is the addition of PRP or platelet-rich plasma to a fat graft concentrate. PRP is derived from the patient’s blood and is a spin down of concentrated platelets which can be easily added to any fat graft mixture. The dosing (amount of PRP) per fat graft that is necessary is unknown and must be studied further, but I am empirically using 1cc of PRP per 10cc of fat. Early results, particularly in the lips which can be easily followed and assessed, are promising.At the least, PRP is not harmful in any way as it is derived from each individual patient.
The conceptual allure and simplicity of the fat injection makes it a useful facial augmentation technique. It may not have guaranteed survival and is ideally a procedure best done in the operating room at the time of other more major interventions. The future will undoubtably make its use more widespread as a better understanding of fat biology is realized.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.como/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

One of the most common facial areas that bothers many patients is the development of the nasolabial folds, also referred to as the lip-cheek groove, or in a recent television commercial known as the parentheses. You can argue whether it is a fold or a groove but it is probably closer to a fold. It develops as the cheek tissue from above ages and begins to sag….falling over its border with the upper lip. The upper lip is ‘fixed’ so the overhanging cheek tissue creates the appearance of a deepening fold. With time, aging, and the anatomy of one’s face, this nasolabial fold extends south past the corner of the mouth and sometimes nearing the lower border of the jaw in extreme cases of skin laxity.This area is commonly treated by injectable fillers and in my practice as many patients wants their nasolabial folds treated as they want their lips enlarged.
The most common method for nasolabial fold reduction is with injectable fillers. Like all filling procedures by injection, the results from nasolabial fold reduction is quick, easy to do, and the results are immediate. I usually perform them under a local anesthetic block so the treatment is as comfortable as possible. While all of the injectable fillers will work, I think some are better for this area than others. And the ones that I think are best are those that last the longest and have the greatest ‘push’.
While all of the hyaluronic acid fillers such as Restylane or Juvaderm will work, they do not last as long as any of the particulated injectable fillers. Currently Radiesse (ceramic beads) and Artefill (plastic beads) are the only two particulated fillers currently available. The evidence is clear, not surprisingly because of their solid bead component, that they consistently last longer than any of the hyaluronic acid fillers. While beaded injections can cause lumpiness and irregularities, this is not a significant cosmetic issue (nor can it usually be seen) in the forgiving area of the nasolabial fold. Conversely, in the lips this is a different matter. Also, because the bead composition makes the injectable material more thick and viscous, I think it provides more push as it goes in resulting in a better cosmetic effect and having to use less injectable filler. Because of particulated fillers longevity and thicker volume, it is my preferred injectable approach to the nasolabial folds. This injectable treatment will give a 9 to 12 month result.
There are other treatment options for the nasolabial fold as well. The best way to eliminate them is the one way which is almost never done….cut them out. That gets rid of the fold immediately but also leaves a fine line scar which may only be acceptable in an older patient. The other more commonly done alternative is to use an implant. I specifically use an Advanta implant for those patients that want a permanent volume solution. A very small incision is made in the nose crease and at the end of the lower fold line. The implant is slide into place from one end to the other. This is a procedure that can be done in the office under local anesthesia. An implant approach to the nasolabial fold is a good solution for someone who no longer wants to do injections, doesn’t mind the concept of an implant in their face, or has very deep nasolabial folds which would take a lot of injectable filler volume. My experience with an implant in this area has been quite good but it is not a first line approach for most patients.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

The most common method for lip augmentation is with injectable fillers. While other more surgical options exist such as lifts and implants, making the lip bigger by injections are quick, easy to do, and have instantaneous results. (notice that I did not say painless!) While five years ago, only two injectable filler options existed (collagen and a first-generation hyaluronic acid filler, Restylane), the choice between them was pretty clear. But as of today, there are now eight commerically-available injectable filler options and more are sure to come in 2009. With so many choices, it is impossible for any patient to know which injectable filler is best for the lips and certainly some physicians are in a quandry as well.
The simple answer is…..none of the injectable fillers is the best. Each has their own individual advantages and disadvantages although certain trends amongst them are clear. First, understand that no injectable filler has ever been FDA-approved for use in the lips in the United States although it is common practice. Technically, the use of injectable fillers in the lips is ‘off-label’ use. Why it has never been approved by the FDA is a regulatory technicality and processing issue from the manufacturer, not one of safety. Lip augmentation probably accounts for nearly half of all injectable filler use for many years so its safety track record is well established. Secondly, the composition of the injectable filler is critical to understanding its effectiveness and safety in the lip. Lip tissue is different from skin as lips are like fingers, we use them alot and they are very sensitive to touch and feel. For this reason, non-particulated fillers such as collagen and hyaluronic acid fillers are best suited for the lips. Those injectable fillers with particles (Radiesse and Artefill) should not be placed in the lip as their risk of irregularities and nodules (foreigh-body reactions) is definitely higher.
I would say that the hyaluronic acid fillers ( boned sugar molecules) are the gold standard for lip augmentation. All of them will work and their effectiveness is the same no matter the marketing name or manufacturer. The only difference between them is……how long do they last and how much do they cost? In short, the question is an issue of value with their use. The only way to figure out how long hyaluronic acid lip injections will last is to know the concentration of hyaluronic acid in the product and how well it is cross-linked together. Both issues which a patient can not determine. As there are no studies that directly compare one hyaluronic acid product to another in a prospective lip augmentation study (someday there will be but none exist as of now), patients have to guided by what their physician injector tells them.
In my experience, some hyaluronic acid (HA) fillers last longer in the lips than others. The range of persistence is anywhere from 4 to 12 months. For the sake of simplicity, for example, the newest hyaluronic acid filler Prevelle (HA concentration of 5 mg/ml) lasts about 3 to 4 months while Juvaderm (HA concentration 24 mg/ml) lasts around 8 to 9 months in my experience. And, not surprising, the cost in my practice is also different with the longer lasting one priced higher. (as it should be) With such an array of HA injectable fillers, I have found that it is now possible to ‘get what you pay for’. You can now choose your injectable lip augmentation result pretty much on the price you want to pay. Some HA injectable fillers cost more than others but they last longer too.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

The concept of a facelift for many patients, initially, seems extreme. Prospective patients often have a vision of being swollen and bruised for weeks over their entire face. Such thoughts have driven some patients to other less or minimally-invasive procedures which are often inappropriate for their facial aging problem. They may have been less invasive and may have cost less, but the end result may have also been disappointing.

Some potential patients suffer two fundamental misconceptions about facelifts…what they are and what the recovery may be. Over half of the facelifts that I do are done in isolation without any other facial procedures. Some patients are only concerned about the appearance of their neck and are not concerned about their eyes, for example. If that is only what concerns the patient, then that is the only issue that needs to be addressed.

An isolated facelift, or a neck-jowl lift, causes none of the issues that many patients fear. There would be no swelling or bruising around the eyes. The neck and jowl line will have some mild swelling and bruising…but it will be painless as the neck and jowl skin are numb for several months after surgery anyway. The only discomfort will be around the ears where the incisions are placed. The ears will be tender for a week or two as these incisions heal. While I use a head dressing that wraps around the neck for the first night….with surgical drains… all of this gets removed the following morning. In limited facelifts, there is no further dressing needed. In full facelifts, a small neck strap is used for a few more days. Showering and washing one’s hair can be done the next morning. There is no concern about getting the incision lines wet. Once can style and blow-dry their hair as they wish. Even with some mild swelling and bruising the neck and jowl

Patuent fears about facelift surgery are often unfounded. When done as the only facial procedure, a facelift is much easier to go through than most envision. An improved understanding of a facelift and its recovery is helpful for patients to make better decisions and ensure a good return on their investment.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com/

http://www.ologyspa.com/

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis