Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?
Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.
October 25th, 2014
Celebrities undergoing plastic surgery is certainly not new whether they own up to it or not. Any slight change in their well known faces or bodies is subject to immediate scrutiny and speculation. Most of the time the criticism of these changes is rarely complementary as what was once familiar is now different.
Such is the case with the most recent alleged celebrity poster child for plastic surgery, Renee Zellweger. When seen recently there is little question that something has changed. Her familiar deep-set eyes and heavy upper eyelids are gone and replaced with eyes that are much more wide open with fuller cheeks. This has immediately come with criticism as some of the facial features for which she is well known and even perhaps famous have been changed. Such a change has seemingly made her look more generic rather than unique. She of course has denied changing anything and attributes her new look to an improved lifestyle…but such an explanation is fooling no one.
While it is tempting to attribute this change in her facial appearance to plastic surgery gone awry or overdone, such judgments are a bit hasty. The eye area is one of the most important facial areas of personal identity. Most people know more about how one looks around the eyes (or at least has a very recognizeable gestalt) than any other facial area. After all that is the area of unwavering focus in human conversation. Even the slightest change about the eyes is easily recognizeable as different. That does not always mean it is unattractive or even an undesireable change but just that it is different.
Often times different is equated with being a bad change but that is not always so. It only seems ‘bad’ because it is unfamiliar. There is nothing distorted or overdone with Renee Zellweger’s result. We have just all become familiar with her heavy hooded eye look which was distinctly hers and is uncommon for such a young person. With the upper eyelid hooding removed she actually looks better…if you can forget her familiar famous look. Her previous eye look did not make her famous, her talent did, but her heavy eye look became a familiar feature as she became more well known.
Dr. Barry Eppley
October 23rd, 2014
The benefits of bariatric surgery are well known and weight losses of 100lbs or more are not uncommon. While the weight loss has tremendous medical and functional benefits, patients often do not necessarily feel better about their body. Once deflated by the weight loss the excess skin results in extensive skin excesses and rolls. It can literally affect the whole body from the neck to the knees but always the stomach and waistline areas are the biggest concerns and the first for surgical removal.
While the body contouring benefits from such large skin removals are obvious, a recent study suggested that there are other long term benefits as well. At the recent annual American Society of Plastic Surgeons meeting earlier this month, a presentation presented data that morbidly obese patients who have excess skin removed after bariatric surgery are more prone to keep the weight off than those who don’t. Out of Henry Ford Hospital in Detroit, plastic surgeons followed almost 100 patients who had bariatric surgery over a ten year period of which almost half had subsequent body recontouring plastic surgery procedures. The patients that had the plastic surgery had an average decrease in their BMI of just over 18 two and half years later. That compared to an average decrease in BMI of over 12 for those that did not have the body contouring surgery.
While bariatric surgery can have great short-term results, it is well know to have a relatively high rate of relapse with partial or full weight return in some patients. It is perhaps no surprise that those massive weight loss patients that feel the need and make the sacrifice to have body contouring have better long-term maintenance of their initial weight loss. There are numerous explanations as to why this is so but the most compelling would be their body image perception. Once you see yourself in a ‘new body’ that truly reflects what has been accomplished by weight measurements, you are more motivated to exercise and even lose more weight is some cases.
What this study shows is that many bariatric surgery patients who have excess skin should have body contouring surgery if they can. Economics is the ultimate barrier for many of these bariatric patients. While some insurance companies provide coverage for certain body contouring procedures (e.g., abdominal panniculectomy), the approval process can be arduous and often disheartening. The criteria for insurance coverage for such bariatric plastic surgeries are a large amount of weight loss (greater than 100lbs), a stable weight for six months and a documented history of chronic skin irritation or rashes. Even if approved it can be hard to find a plastic surgeon to do the procedure because of the very low insurance reimbursement rates given the amount of surgical work needed and the potential risk exposure.
But in almost any community plastic surgery care can be found to help get this reconstructive body contouring done. As this study shows, improved function and body image plays an important role in helping maintain the weight loss from bariatric surgery.
Dr. Barry Eppley
October 21st, 2014
Background: The desirable features and shape of the male forehead is well known. It consists of a brow bone prominence, a superior brow bone break and a smooth slightly convex shape of the upper forehead to the hairline. A wider or more square forehead shape is often seen as an asset as well. Some put great stock in the appearance of the forehead in a man and it certainly can have a strong or weak appearance depending on the shape of the frontal and brow bones which make up its bone structure.
Regardless of gender, one of the desireable features of an attractive forehead is having a smooth contour. Irregularities or indentations are easily seen on the forehead given its broad surface area. This is particularly true in men who do not commonly have a hairstyle that can completely obscure the forehead.
Central indentations of the forehead are not rare in men and are the result of natural development. When present they often create the appearance of upper forehead prominences or horns. This is an artificial appearance that exists mainly because of the depression between them and the lower brow bones. Those who have these forehead horns often feel they make one look older and cast a shadow on the forehead which makes it look uneven even thought the forehead horns aren’t really that raised.
Case Study: This is a 17 year-old male teenager who was bothered by the appearance of his forehead. It had an irregular uneven appearance and he was teased about how it looked. His forehead had a central horizontal depression between the upper forehead and the brow bones that made it look like he had two forehead horns.
Under general anesthesia a coronal scalp incision was used to access the entire forehead. The forehead was built up with hydroxyapatite cement, filling in the depressed area in the center of the forehead. This created a smoother frontal bone shape which also eliminated his superior brow bone break.
His results showed a much improved forehead shape with complete elimination of his forehead horns and any shadowing effect. His scalp scar was essentially undetectable across the entire length of the incision.
1) In some men, a depressed upper forehead accentuates their brow bone prominence and can even create the appearance of forehead ‘horns’ or prominences.
2) Forehead augmentation through hydroxyapatite cement can effectively smooth out indented forehead contours.
3) Forehead augmentation with bone cement needs to be done through an open scalp approach and can have very acceptable scar outcomes.
Dr. Barry Eppley
October 20th, 2014
As the U.S. population ages and the growing acceptance of plastic surgery extends to all ages, older patients are now undergoing procedures more frequently than ever before. This raises the question of whether this is safe practice and are these older patients at an increased risk of complications because of their age. On the surface, age is associated with a perception of being weaker and more susceptible to disease and injuries.
At the annual meeting of the American Society of Plastic Surgeons in Chicago last week, a study was presented evaluating the rate of complications rate amongst younger vs older plastic surgery patients. In this paper, the CosmetAssuree company (independent insurance company that offers protection from the costs of medical complications for certain cosmetic surgery procedures) provided data over a five year period (2008 to 2013) of their reported complications and their ages. Patients over 65 years old (mena age 69 years old) had a complication rate of 1.94% which was not statistically different than the 1.84% complication rate amongst younger patients. (mean age 39 years old) No differences in complication rates occurred despite the higher number of medical issues and weights in the older patient group. Even with looking at the upper ranges of the older group (80 years or older), the complication rate only rose slightly to 2.2%.
This study also showed that the proportion of facial procedures amongst the older group was much higher than in the younger group. (63% vs. 12%) It is no surprise that the older patients had more facial procedures than body contouring which is well known to tail off from age 60 and older. So to some degree the decreased rate of complications may have been partially altered by the procedural bias that happens with age. Despite that the length of a facelift may be just as long or longer than a tummy tuck for example, there are natural big differences in the rate and type of complications that can occur between a smaller face than the larger abdominal area.
But even looking at facial procedures, the older patients fared just as well. This has been previously reported in the June 2011 issue of the journal Plastic and Reconstructive Surgery in the paper entitled ‘The Safety of Rhytidectomy in the Elderly’. In looking at over 200 patients (divided into over or under age 65) over a three year period by a single surgeon, the complication rates were comparable between the two age groups. (3% vs 2% for major complications, 6% vs 6% for minor complications) Thus indicating that age alone is not an independent risk factor in facelift surgery.
While these studies show that cosmetic surgery is just as safe in the elderly as in the young, it is important to remain vigilant in the planning and workup of the older patient. A good medical workup including laboratory studies and EKG should have been done in the previous six months before the surgery. Specific attention should be paid to their cardiopulmonary history and clearance from their physician. Operative times and the number of procedures should be ‘reasonable’ and not require prolonged recovery times or extended periods of immobilization. Safety and a low rate of complications in the elderly is dependent as much on what their plastic surgeon does as much as their own remarkable tolerance to surgical insult.
Dr. Barry Eppley
October 18th, 2014
Background: Otoplasty, known as ear reshaping, is a commonly performed cosmetic procedure whose intent is to make the ears less conspicuous. An aesthetically pleasing ear is one which blends into the side of the head and has no feature that makes it an ‘eye catcher’. The best looking ear is really one that is not noticed.
The typical cosmetic otoplasty involves the classic setback or ear pinning procedure. This cartilage reshaping technique creates a more pronounced antihelical fold, reduces the prominence of the inner concha or both. This moves the protruding ear back into a less conspicuous position by changing a portion of its shape.
The earlobe is the lone non-cartilaginous structure of the ear. It is often forgotten in otoplasty because it is not part of the cartilage framework. But it can have its own unique set of deformities that if overlooked can mar an otherwise good cartilage reshaping effort. Earlobes can become conspicuous because they stick out or are too long.
Case Study: This 20 year-old female was bothered by the appearance of her ears. As a result she never wore her hair pulled back to reveal them. Her ears showed a deformity consisting of a combination of the upper 1/3 of the ear which stuck out and her earlobes which were unusually long for her age.
Under general anesthesia she had an initial cartilage reshaping of the upper ear. Horizontal mattress sutures were placed to make the antihelical fold more prominent and pull back the upper helix through a postauricular incision. The earlobes were then reduced using a helical rim excision technique.
Her ear results showed a much better ear shape from top to bottom. The protruding upper ear was less obvious and the reduction in the vertical length of the earlobes made a huge difference. A shorter and more proportioned earlobe even made her ears look ‘younger’.
1) Numerous changes can be made to the ear during an otoplasty procedure besides just pinning the ears back.
2) It is common that repositioning of the protruding earlobe is also done with reshaping of the ear cartilage.
3) Reduction of the long earlobe is usually best done by a helical rim excision technique. It is most commonly done in older patients who may naturally have developed longer earlobes with aging or ear ring wear.
Dr. Barry Eppley
October 17th, 2014
Brazil is the largest country in South America and is the fifth largest country in the world. It occupies in land mass almost half of all of South America and has more land than that of the continental United States. (minus Alaska and Hawaii) It is unique in many ways from its Portugese language to being situated along the equator. Of the many things it is known for one of those is the large number of plastic surgery procedures performed within its borders.
While people feel that the U.S. is obsessed with body image and undergoing plastic surgery, it runs a distant second compared to the country of Brazil. According to statistics from the International Society of Aesthetic Plastic Surgery, Brazil has now surpassed the U.S. with the most cosmetic surgeries performed in the world. This is impressive given that the population of Brazil is less than that of the U.S. (203 million vs. 317 million) and with a far less GDP. (2.5 trillion vs 17 trillion) A total of over 1.5 million cosmetic surgeries were done in Brazil, a number that is well over 10% of all elective cosmetic surgeries done in the world. The statistics also show that Brazilian patients are more prone to having actual surgery while the U.S. patients partake of many more non-surgical procedures. (e.g., Botox, injectable fillers and lasers)
Such numbers raise the question as to why Brazil is so profoundly different when it comes to cosmetic surgery. The main reasons are two-fold and synergistic. First, Brazil has the highest number of plastic surgeons per capita than anywhere else in the world. While it struggles to find doctors to service even the most basic needs in remote and poor areas of its vast country, there is a disproportionate number of plastic surgeons. The other reason is that the economy of Brazil has grown considerably and, as such, disposable income has also increased. As part of its unique culture, women are particularly predisposed to spend their disposable resources on improving their appearance. It is so prevalent that having plastic surgery is a status symbol and is something of which to be proud.
Given the warmer weather, Brazil is well known for its body contouring procedures such as breast augmentation, breast reductions, liposuction and in particularly buttock enhancements. While breast augmentation is very popular in North America, buttock augmentation is more popular in South America. Brazil is the home and origin of the well known and highly performed Brazilian Butt Lift where fat harvested by liposuction is injected into the buttocks for enlargement.
Brazil’s most famous contribution to plastic surgery, however, is it own world famous plastic surgeon, Dr. Ivo Pitanguy. Practicing in the Brazilian capital of Rio de Janiero since the 1950s, he established his own clinic where be both operated on patients and trained surgeons. In a public hospital, he created his own ward where he has provided plastic surgery for free for decades. This epitomizes his philosophy that everyone has the right to look better physically.
Dr. Barry Eppley
October 14th, 2014
While there are numerous body areas that can be changed through excisional lifts, particularly after large amounts of weight loss, the most common area treated is that of the waistline. Tummy tucks and body lifts (circumferential lipectomy) make up the most well known and largest surface area removal procedures. Often overlooked (but ultimately not by that of the patient) is the smaller pubic region which lies just below the waistline and may often be hidden by overlying abdominal tissues.
The mons pubis is a skin and fat mound that is located directly above a woman’s pubic bone. This pad of tissue is thought to provide protection of the underlying bones during intercourse. With a predominantly fat composed mound, it is easy to see how it could act as a cushion. But with weight gain (and loss) the fatty pubic mound can sag and remain full of fat that can have a contour that becomes protrusive when what lies above it becomes flattened. It has been well described by patients of how a prominent mons pubis has become ‘unmasked’ by tummy tuck surgery. With a tight and flat horizontal scar line above it, the rounder and more convex pubic mound can stick out further than a flat stomach after tummy tuck surgery. It is thus well known amongst plastic surgeons to check carefully for the pubic mound contour and incorporate it into the excisional design of the tummy tuck surgery
In the November 2014 issue of the Annals of Plastic Surgery journal, an article appeared entitled ‘Using Superficial Fascial System Suspension for the Management of the Mons Pubis After Massive Weight Loss’. In this paper, fifty (50) patients who underwent a lower body lift had a simultaneous mons pubic lift using a superficial fascial suspension technique. After an average follow-up of nearly 18 months, they were evaluated by before and after pictures as well as a satisfaction survey. Satisfaction of their mons pubic appearance improved significantly. One-third of the patients described the look of their pubic region as very good while half of them described it as good. Eight patients developed prolonged swelling of the mons pubis and a single patient developed an infected fascia suture which had to be removed.
In the extreme weight loss patient, an unshapely pubic mound always exists even in men. But unlike the fat and more convex mound shape in a more traditional tummy tuck patient, the weight loss patient’s pubic mound is deflated and has substantial skin sag. Thus a significant pubis lift is needed with their tummy tuck/lower body lift and fascial suspension along with skin excision is a logical and stable approach to doing it.
Dr. Barry Eppley
October 12th, 2014
Jaw angle augmentation has become an increasingly popular facial implant procedure. While done more in men to enhance an overall weak jawline, it is even done in females who have thin lower faces and lack of any jaw angle width. While historically jaw angle implants only added width to the back part of the jaw, it is now recognized that vertical lengthening of the jaw angles is often needed as well in many patients. This has led to two jaw angle implant types, width only and combined width and vertical lengthening styles.
Regardless of jaw angle implant type, they are usually placed as pairs and their positional symmetry becomes an important part of the aesthetic result. Because the implants are usually smooth (silicone), assuring their position on the bone (and often partly off it to length the angle) is important as any instability can lead to displacement. One simple technique to secure implant position, and the most common one that I use, is single screw fixation. Placed percutaneously, a single 1.5mm screw placed through the implant into just the outer cortex of jaw angle bone is usually sufficient to secure its position.
But in some jaw angle implant cases, particularly those which have suffered implant displacement, an even more secure form of fixation is needed. Jaw angle implant displacement is always superiorly, up and away from its lower desired position over the angle. With healing an enveloping capsule develops around the implant which must be opened or removed to permit it to be positioned in its lower desired position during a revisional procedure This leaves a large upper space into which an unsecured implant can become displaced back into it during the healing phase.
One absolute secure fixation method for jaw angle implant revision is the ‘flange’ technique using a matrix or grid type fixation plate. By securing the upper end of the metal plate just above the implant with 1.5mms screws, the lower end of the plate overlaps the jaw angle implant essentially pinching against the bone. The upper end of the plate prevents the implant from ever riding up again out of place.
Dr. Barry Eppley
October 11th, 2014
Buttock implant augmentation has historically been plagued by a high rate of complications. Since the intramuscular technique for implant location was introduced in the mid-1990s, the rate of complications has decreased and more natural and long-term results have been obtained. Its advantages over the subfascial location has led to more patients considering the procedure although it is important to realize there are size limitations of the implants that can be placed (300cc to 350ccs) due to the greater restriction of the intramuscular pocket space.
But with the increase in the numbers of such buttock implant surgeries being performed has come a new set of complications unique to the procedure. While incisional dehiscence and seroma are still the most common postoperative problems that can occur, implant displacement out of the intramuscular pocket (herniation) is now being recognized as another potential complication that can occur.
In the October 2014 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Gluteal Implant Displacement: Diagnosis and Treatment’. The purpose of this paper was to describe, classify and standardize the treatment of buttock implant displacement. A cadaver study was done to determine the least intramuscular overlying muscle thickness needed for safe intramuscular dissection. This was shown to be a minimum of 2 cms. Over a three year period, 24 patients were treated for visible buttock implants. Treatment consisted of implant removal, radial capsulotomies, capsular pocket plication, and intramuscular pocket dissection. An anchoring suture was placed at the lateral edge of the muscle incision to prevent muscle rupture during implant insertion. This one-stage approach for implant relocation resulted in only one implant (3%) out of 47 patients that subsequently developed displacement back into the more superficial pocket.
Buttock implant complications in the subfascial space (usually seroma) or the intramuscular space (herniation) can be difficult problems to correct. Herniation out of an intramuscular pocket can be associated with implant visibility, pain and recurrent seroma formation. Very much like relocating subglandular breast implants into the submuscular pocket, slipping back into the old pocket is always a possibility. Keeping a limited incisional approach to the intramuscular space is critical and this suture placement is one method to do so. This study shows that successful resolution of buttock implant herniation can be done with a high success rate.
Dr. Barry Eppley
October 10th, 2014
Chin augmentation can be done by a variety of surgical methods including a chin implant and a sliding genioplasty. Each of these aesthetic chin techniques has a role to play and they have their own advantages and disadvantages. But both have the same limitation…a limit to how much the chin can be horizontally projected. Chin implants are not made with standard thicknesses that are greater than 10 to 12mms. A sliding genioplasty can only be moved as far as the thickness of the bone will allow which can vary between 10mm to 16mms.
The horizontal movements provided by standard chin implants and sliding genioplasties are sufficient for the vast majority of patients with chin/jaw deficiencies. But they can be inadequate for the few patients that have horizontal chin projection deficiencies that exceed 15mm and may be as significant as 25mms.
Combining a sliding genioplasty with an implant is a novel method to achieve larger amounts of chin projection that I have done for years. Through an intraoral approach, which is needed for a sliding genioplasty, the implant is placed on the chin bone just one would normally do. It does need to be secured into placed by screw fixation otherwise it would easily become displaced. A chin implant with long wings also has the advantage of covering over the bony step-off that often occurs at the back end of the osteotomy.
Very large chin deficiences can be managed by the creation of a custom implant but combining an implant and a sliding geniplasty may be sufficient in some of these cases. In my experience there has been no higher infection risk when placing an implant on top of a sliding genioplasty than when using a chin implant alone.
Dr. Barry Eppley