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Archive for the ‘scar revision’ Category

Mini-Mommy Makeover Procedures

Sunday, May 19th, 2013

The concept of a Mommy Makeover plastic surgery procedure is about combining abdominal and breast reshaping in one operation. The breast and abdominal components are not new and include many well known procedures such as tummy tucks, breast implants, liposuction and breast lifts in whatever combination each individual women needs. While the effects of a Mommy Makeover can be dramatic, breast and abdominal procedures are major surgery with significant recovery as well.

But there are numerous other procedures of lesser magnitude that could also be lumped into the Mommy Makeover category and consist of a variety of ‘nips, tucks and sticks’ that create effects that mothers would also like. Here are some of the most noteworthy.

BOTOX  For reduction of those facial expression lines that come from the stress of balancing mother and wife roles, Botox injections are probably the most common injectable Mommy procedure.

Vi/PERFECT PEELS With only a few days of redness and flaking, these medium-depth facial peels are essentially painless to go through and provide a real boost to one’s complexion. A few of these a year will keep a mother’s skin radiant and glowing.

C-SECTION SCAR REVISION For those women that don’t need a tummy tuck and have a noticeable c-section scar with just a little pooch above it, widely cutting out the scar can produce a flatter upper pubic area. This scar revision can be combined with some lower abdominal liposuction for an additional and wider flattening effect.

UPPER LIP PLUMPING Some well placed Restylane or Juvederm injections into the upper lip has an instant youthful volumizing effect. This is particularly evident if the cupid’s bow and philtral columns are accentuated.

NIPPLE REDUCTION Breast feeding can elongate the nipple which can be a source of embarrassment and out of proportion to the size of the areola. Under local anesthesia, the nipple length can be reduced by half or more.

EARLOBE REPAIR Fixing stretched out ear ring holes or complete tears through the lobe can allow old or new ear rings to be comfortably worn again.

BELLY BUTTON REPAIR (Umbilicoplasty) Pregnancies can change an innie belly button to an outie due to a small hernia through the umbilical stalk attachment. Tucking the peritoneal fat back through the hole and reattaching the stalk of the belly button back down to the abdominal wall will recreate that an old inne look again.

EXILIS For those stubborn fat areas that just won’t go away despite some diet and exercise, this non-surgical fat treatment can easily fit into a busy mom’s schedule. It takes a series of treatments to see the effects but there is no downtime with 30 minute in-office treatment sessions.

These mini-Mommy Makeovers provide changes that do not require major surgery or recovery and can fit into anyone’s hectic schedule.

Dr. Barry Eppley

Indianapolis, Indiana

Scar Revisions of Dogbite Injuries in Children

Monday, April 29th, 2013

 

One of the most common traumatic facial injuries to deal with in children as a plastic surgeon are dogbites. There are a lot more common than most people think and, fortunately, are usually minor and result in no significant scarring. They often are just ‘nips’ and don’t require any major reconstructive surgery.

But having been at a University for many years before entering private plastic surgery practice, I had the unfortunate opportunity to see more than my share of major dogbite injuries to the face…the vast majority being in children. I reported my pediatric dogbite experience in the March 2013 issue of the Journal of Craniofacial Surgery over a ten year period while covering a major children’s hospital. From 1995 to 2005, I treated over 100 major dogbites the face, scalp and neck in children that required surgical repair in the operating room. The average age of the patients was 6 years old and was fairly evenly split between boys and girls. In most cases the dog was known to the patient or family and was classified as ‘provoked’. The most common dog breeds were Pit Bull, Chow, German Shephard and Doberman Pinscher. Most injuries could be primarily closed but a few did need skin grafts or other reconstructive surgery.

Contrary to popular perception, only one patient developed an infection. Surprisingly, only one patients was left with a permanent facial nerve weakness. In more than three-fourths of the patients, scar revisions were needed and another third needed more than one scar revision.

More than one-third of these dogbite cases involved legal action, either against the dog’s owner or their insurance companies. Because of the high litigation rate and possible denial of insurance claims for subsequent reconstructive procedures, I would advise all plastic surgeons and the families to keep meticulous records, including photographs, of the dog bite injuries.

Like many traumatic injuries dog bites to the face often require repeated plastic surgery procedures to obtain the optimal aesthetic outcome. One should not try and be too clever at the time of initial injury repair with complex closure decisions as the tissue quality often precludes the optimal aesthetic result from the primary repair.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Scar Healing – Patient Education and Expectations

Tuesday, March 19th, 2013

 

Scars are by far and away the concern of most plastic surgery patients, either before or after surgery. They are keenly interested in how to diminish their appearance and or what specific preventative or treatment strategies would be most effective. Scars can also be a source of tremendous dissatisfaction if they become exaggerated due to poor healing or inadvertent misplacement for their ideal location when seen after surgery.

There are many variables that affect how well a scar heals and its subsequent appearance. All other factors beinjg equal, the most signfiicant one is skin color or the degree of natural pigmentation. The more pigment that is in the skin (thicker dermis) the higher the risk is for more reactive scarring appearing as hypertrophic or wide scarring and potentially even keloids. At the least, darker skin will almost always hyperpigment, and sometimes even hypopigment, even if the scar line is very narrow. One of the best indicators of how well any patient will scar is to look ar their previous scars, particularly those created by surgery. But don’t confuse how a traumatic leg scar looks with what their facelift scars will do. Location of scars is almost as important as skin pigmentation and thickness.

The single most effective method to minimize scars is what the plastic surgeon does…careful placement and a meticulous layered wound closure. Plastic surgery often takes longer because more attentioin is paid to getting the scar closed as well as possible. One of the great misconceptions is that the use of a laser to make an incision will result in a better scar. It makes for better marketing but not better scars. Lasers, as opposed to the cold steel of a scalpel blade, always increases the risk of adverse pigment changes due to its heat…and they also cause delayed wound healing .

Patient education on how scars heal is important as often they will look worse with a long time befoer they get better. The initial appearance of a scar will usually be slightly raised and this is always a concern for many patients. But because there is tension on the wound closure in the vast manjority of plastic surgery procedures, the raised scar line will settle in the first month or two after surgery. The other natural healing process of scars is they initially appear very fine and colorless and then start to turn red weeks after surgery. Patients often think that something is wrong but this just represents blood vessels growing into the scar to help it heal. This is also why scar redness fades naturally many months laters as the blood vessels recede once good healing has occurred.

While patients  can’t wait to see how their scars look after the dressings or tapes are removed, the initial appearance of a scar is just the beginning of a cycle. All scars go through a life cycle of healing and then maturation which is different for various body locations and procedures. In general, scars will usually look worse before they get better.

Dr. Barry Eppley

Indianapolis, Indiana

 

Postoperative Instructions for Scar Revision

Wednesday, February 6th, 2013

 

Scar revision is most commonly done by surgical excision of the scar and putting it back together as either a straight line or a geometric or broken line closure pattern. The type of scar revision used depends on the location of the scar, its size and dimensions and the patient’s skin characteristics.

The following postoperative instructions for scar revision are as follows:

1.  Most scar revision have little if any discomfort. Most patients only use Tylenol or Ibuprofen for just a few days after the procedure. You may also feel free to use ice packs on the scar revision area for discomfort relief if you desire as long as they do not directly contact the skin to avoid a thermal injury.

2. In most cases of scar revision, the area will be covered with glued-on flesh-colored tapes. These are to be left on until Dr. Eppley removes them during your first postoperative visit. Some spotting of blood may appear on the tapes and this is normal.

3. In some cases, the area will not be taped and left open. Antibiotic ointment may be used three times a day to keep the sutures soft and moist.

4. Whether you have tapes or visible sutures, it is also ok to have them get wet when you shower. You may shower as normal the following day.

5. If the scar revision is on your face, you may wash your face and get the tapes or suture lines wet. Shaving and make-up application may be done around the area.

6. Physical activities after scar revision depend on where the scar is located. If it is on your scalp, face or neck, you should be able to do any activity that feels comfortable afterwards. If it is on your body, then just think carefully about whatever you are planning does not put undue stress or pulling on the incision lines for up to a month after surgery.

7. You may eat and drink whatever you like right after surgery.

8.  The application of topical scar therapies such as ointments and tapes can begin three weeks after the procedure.

9.   Avoid extreme sun exposure or the risk of sunburn on the scar revision areas for up to six months after the procedure.

10. If any scar revision redness, increased tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery: Scar Revision

Wednesday, February 6th, 2013

 

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of surgical scar revision. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

Alternatives for improving the appearance of a scar could include more time for scar maturation, dermabrasion, laser resurfacing, injectable fillers, fat injections, collagen and stem cell injections and the use of make-up for camouflage.

GOALS

The goal of scar revision is to improve the appearance of the scar(s). This could include physical changes such as narrowing, correction of depressed or elevated surface contour, red or brown color reduction, or line of scar direction.

LIMITATIONS

The limitations of scar revision is in how much the appearance of the scar can be actually improved. Age of the scar, the scar pattern, where on the face or body the scar is located and the patient’s skin color and elasticity all play a factor in limiting how well the appearance of the scar can be improved.

EXPECTED OUTCOME

Expected outcomes include the following: temporary swelling and bruising around the scar revision site, temporary numbness of the surrounding skin, temporary increased redness or discoloration of the scar, elevation/firmness of the scar, and that it can take up to one year after scar revision to see the final result. It is important to understand that no scar can be completely removed and scar revision is about scar reduction not scar elimination.

RISKS

Significant complications from scar revision are very rare. More likely risks include infection, wound separation, suture reactions, worsening of the appearance of the scar, and failure of long-term scar improvement. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY

Should additional surgery/therapies be required to do additional surgical scar revision, laser resurfacing, pulsed light treatments or topical scar therapies, these will generate additional costs

Treatment Options for Facial Acne Scars

Saturday, January 5th, 2013

 

Acne is a common skin condition that results in a wide variety of scars types and patterns. Even though there are a number of available treatments for acne scars, they are not always universally successful. Acne scars represent a difficult challenge for improvement and every option must be considered in each patient. Often different treatment approaches may be used on the same patient based on the type of acne scars that they have.

When evaluating acne scars, there are three main types based on their shapes. Ice pick scars are the most common acne scar and are semi-round in shape but narrow and deep. They occur most commonly on the nose and cheeks. Rolling hill scars are wide deep scars that roll into the skin. They often occur in bunches and are the result of large and deep cysts. Boxcar (atrophic) scars are somewhat similar to ice pick scars but are not as deep and are wider. The morphology of acne scars goes a long way in determining the correct treatment choice.

The options available for acne scar treatments include injectable fillers, subcutaneous incision/subcision, punch excision, punch elevation and fractional laser resurfacing. Which of these approaches is best? Again, the shape and depth of the acne scar is the determinant.

Hyaluronic acid injectable fillers work by lifting up the depth of the scar depression and trying to make it more level with the surrounding unscarred skin.  In essence, try and raise the valley to get closer to height of the surrounding mountains. Fillers may stimulate collagen regeneration in the skin but this is more theoretical than ever actually seen on a consistent basis. This acne scar technique works best for broad and shallow scars. Deep pitted scars are too fibrotic to be elevated by the push of a filler. While the improvement occurs immediately with injectable fillers, it is a temporary effect that will last as long as the composition of the filler.

Subcision is a technique that inflicts injury to the skin at the base of the scar. This causes the scar to release and accumulate blood underneath it. This is done by using the beveled edge of a small needle like a miniature scalpel. This will result in some bruising and swelling. The dermal collagen injury and bleeding may act as a stimulant for new collagen growth. This technique works best in rolling hill type scars. Multiple sessions are often needed for the best results.

Punch excision is a very well known acne scar technique that does exactly what it describes, it cuts the scar out in a circular pattern. This is done using punches which are small cooker-cutter tools with varying diameters. (1 to5mms) Once the scar is removed, the circular hole is then treated by one of two closure techniques, small suture closure or the hole is filled in with a full-thickness skin graft of the exact size usually cut with the same tool. (punch elevation) Once healed, laser treatments are often done for the smaller scars left behind from excision and closure or the raised scars from the punch graft.  Punch excision works best for ice pick and boxcar scars.

Laser resurfacing works best for the most number of acne scar types. The laser fundamentally works by removing the top layer of skin so that shallow scars may be eliminated and deeper scars appear more shallow. But in a 100% ablative laser, where top layers of skin are removed in even unscarred skin, no net gain may often be seen. The better technique for acne scars is fractional laser resurfacing where just a portion of the skin is treated but the penetration is much deeper. The deep skin channels cut by the fractional laser stimulates the skin to contract and get tighter, narrowing the diameter of the scar. Multiple fractional laser treatments are almost always needed.

The challenge of improving facial acne scars is met with a variety of treatment techniques. While perfectly smooth skin is never possible, mixing and matching  several of these treatment techniques almost always provides visible improvement for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Scar Treatments

Monday, November 26th, 2012

 

Scars are a common problem that occur from a variety of events including injury, various skin conditions and surgical procedures. Removal of these scars is a frequent patient request from plastic surgeons. While scar treatments have been a part of plastic surgery for a very long time, one thing about them has always been true… scars can be reduced in appearance but they can never be completely removed. There is no such thing as scar removal. Every strategy for scar treatments is about reducing their appearance and how to make them less visible. Plastic surgeons wish they had a magical technique that could simply wipe away scars but that does not exist. The emergence of laser technologies makes it seem like this would be the definitive solution. While in some cases lasers can be helpful for scar treatment, they do not eliminate them and are frequently overpromoted for what they can achieve. Compared to surgical scar revision, lasers (and its distant cousin dermabrasion) actually plays only a secondary role in effective scar reduction. The actual cutting out of scars, if possible based on scar type, and the rearrangement of surrounding healthy tissues still remains the cornerstone of effective scar reduction therapies. Surgical scar revisions may include simple linear excisions or more complex forms such as z-plasties  and a wide variety of geometric tissue rearrangements. Once these are done, the use of lasers may put the finishing touches for maximal scar appearance improvement.

Treatment of Self-Inflicted Cutter Scars

Saturday, November 17th, 2012

 

Scars come in a wide variety of patterns that often identify the cause of the original injury. One of the most identifiable scar patterns is that from cutting. Most commonly seen on the arms, cutting is a form of self-mutilation that is almost exclusively seen in teenagers and young men and women. Using sharp objects such as razor blades and knives, self-harm is done by making a series of superficial to medium-depth skin cuts on the arms or legs. Psychologists state that this behavior is an outward expression of inward torment and even suicidal thoughts. Clearly it is self-destructive behavior.

What was once a very rare scar pattern for a plastic surgeon to see, it is now becoming more common. According to recent estimates in the U.S., one in every 200 teenage girls between ages 13 and 19 have cut themselves…a rather startling statistic even if it is only a half percent. More females do this behavior than men in a 60:40 ratio and my experience confirms that with more young females seen.

The injury patterns seen in cutting pose unique challenges for potential scar revision. It is the forearm and upper arm scars that bring young people in as they are hard to explain and impossible to hide in many cases. The sheer number of cuts can easily number in the dozens to even hundreds. They often are very fine, many of which parallel each other or have criss-crotching patterns. While a few may be wide because they were deeper cuts, most are much finer because the initial cuts barely passed into the dermis of the skin.

The revision options for most scars almost exclusively include excision and laser resurfacing. But cutter scars can not really be improved by either. The scars are usually too fine to result in much change by excision and re-closure. Even if a few of the bigger ones can be improved by being narrowed, that does little to change the look of the overall scar pattern. Laser resurfacing seems like such an obvious method of improvement but it is not as simple as wiping the scars away. Laser resurfacing only goes so deep but never as deep as the scar tissue. Even though the scar may appear fine line, they go all the way into the dermis. No matter how many of the top layers of the skin that are removed by the laser, it just unmasks more of the scar.

What does work for cutter arm scars if traditional methods of scar revision will not? I have found only two methods that can change the entire look of most or all of the scar area. These are dramatic scar treatment methods that are not appropriate for most patients, but for the right person they may be acceptable. One approach is a full-thickness excision of the scarred area and replacement with a thick split-thickness skin graft. This will leave an eventual patch appearance but that certainly changes the way it looks and is more explainable to public scrutiny. (I had an injury and needed a skin graft) The other approach is to use the laser to create a deep burn over the area. This will replace all the fine line scars with one large hypertrophic burn scar. This creates a lot more scar but does offer another more explainable injury pattern.

Both treatment approaches certainly do remove the emotional and psychological memories of the cutter scars…even if their replacements would be judged as ‘worse’ scars.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review: Embrace Scar Device

Tuesday, August 14th, 2012

 

Scars remain a challenging problem. This is demonstrated by the sheer number of scar treatment products and strategies that exist, all of which claim to offer improved scar outcomes. A new scar device, called Embrace by Neodyne Biosciences, has released study results which show improvement in abdominoplasty scars. The Embrace device is an FDA-approved single-use adhesive silicone sheet which is applied to the incision/scar with a disposable applicator that transfers a predetermined amount of strain to the sheet. This device employs the concept of mechano-modulation (active compressive strain) to the injury site. This unique method of action provides a uniform compressive strain or stress-shield around the wound closure which can minimize collagen formation and scar widening. Abdominoplasty scars were used for the study because of the large amount of tension that is known to exist across the closure site. This is a good test for a scar device whose purpose is to offload the tension on the healing scar. In 28 abdominoplasty patients studied for six months after surgery, expert blinded evaluations of the scar appearance between the Embrace-treated vs the standard-of-care treated incision sites showed consistently better results with the Embrace treatment.

This device has already received FDA-approval in September 2011 and this released study is done in preparation for market release later this year. While this scar device has demonstrated benefit in high-tension scars, it is interesting as to whether it offers similar benefit in scars exposed to less tension. But what really matters in effective scar treatment is those wound closures that are predisposed to hypertrophic scarring or those scars undergoing surgical revision.

Plastic Surgery’s Did You Know? The Myth of Laser Scar Removal

Monday, August 6th, 2012

 

When most people think of scar revision they usually think of two things; elimination of the scar and the use of lasers to do it. The reality is that both of these perceived principles of scar revision are wrong. Scars may be able to be improved but they can almost never be removed. Plastic surgeons wish this was possible but it is not. Once the skin has been injured and healed by scar, it will be forever changed. It is merely a question of how much reduction can be obtained and how much less visible it can be. Secondly, while lasers have a role to play in scar revision it is less significant than excisional techniques. Lasers are not magical wands that work like erasers. They are most effective in prophylactic treatment of early scars and incisions. They will make little difference in well-established mature scars, particularly those that have visible surface contour issues. (wide, deep, raised) Revision of significant scars requires excision and closure, often using geometric rearrangement techniques. Laser resurfacing may then be done after to get the best camouflaged appearance.


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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