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

One of the most common concerns from many before surgery patients is that they don’t want to look like they have had plastic surgery. In theory, what patient does? But yet many do and one only has to look to Hollywood to see many examples. Patients point them out all the time and often it is the same collection of well known names that are used as illustrations of ‘bad plastic surgery’.

Patients wonder why such celebrities who have no financial limitations and access to the presumed best of plastic surgery care can end up looking like they do. This perception is magnified when any of the reality shows that focus on plastic surgery in Beverly Hills and southern California show extreme and often overdone changes. (there is a reason it is a TV show…natural looking results or even ‘normal’ patients does not make good TV) It is important to remember that there are many more, thousands no doubt, of patients from these areas that have superb results and are virtually undetectable. It is just a small percentage that can distort the perception of the whole industry.

The answer as to why unnatural or obvious plastic surgery results exists is not a simple one. The most obvious answer and one that is often cited is that celebrities have to keep up their youthful appearance if they want to continue to find work. It is therefore very easy for one to keep getting a nip or tuck with some frequency to keep up the look audiences have come to know and to fight back the continuous effects of aging. If you add enough of these procedures over time, the balance between natural and unnatural looking can be crossed. Knowing when to say when is harder than most people think….particularly when you remove the money barrier and the lifestyle that you have come to know is threatened.

Anyone that appears on film or TV is exposed to an incredible amount of visual scrutiny. The lighting and camera angles are brutally revealing. This has been taken to a completely different level now with high definition. While make-up and editing can hide most flaws, computer-generated imaging (CGI) can hide anything. Even when not on the big screen or TV, celebrities are constantly being photographed at almost every hour of the day. These more natural photos can contrast with what is seen on film, TV or in magazines and the differences can be downright striking. (and not in a good way)

Even well done plastic surgery can be look a bit overdone or unnatural when exposed to this type of contrast. I suspect that many cases of plastic surgery, which look very natural and well done, might be exposed if the non-celebrity patient had tro endure the same level of scrutiny as that of the celebrity.

It is important for the typical patient considering plastic surgery that what happens in Hollywood and in celebrities should not be applied to them. While most patients are worried that their result may be overdone or look very obvious, the reality is that exactly the opposite is usually the more appropriate concern. Getting a satisfactory result that does enough is what most plastic surgeons are thinking and worried about for their patients. There are many more dissatiisfied patients because their results did not meet their expectations than in those that got ‘overdone’ surgery.

To achieve the most natural result from any plastic surgery procedure, it is important that the patient establish a good dialogue with their plastic surgeon. While your plastic surgeon may fully understand what you want, don’t assume. The perception of a good surgical result is open to a variety of interpretations. Explain what your concerns are and describe what you mean by an unnatural result. Show pictures that illustrate what you don’t want from the procedure. While every patient wants the best value for their money, most natural results are usually less rather then more.  

Dr. Barry Eppley

Indianapolis, Indiana

The 2012 annual statistics on the cosmetic procedures performed was recently published by the American Society of Plastic Surgeons. These numbers come from members of the society who are board-certified plastic surgeons and who voluntarily submitted their annual procedural numbers. Over 14 million surgical and non-surgical procedures were performed which represents a small increase (5%) over that of 2011. On balance, the number of cosmetic surgeries were down slightly (2%) but this was more than made up by an increase in non-surgical procedures. (6%) This is no surprise as the number of non-surgical procedures continues to climb as new options in topical,  injectable, laser, and numerous other energy therapies emerge.

The largest increases were seen in both surgical and non-surgical facial procedures. This is partially because the options for facial rejuvenation are far greater than that of the body. But it is also reflective of changes in society where people are in the work force longer, there is a desire to look better at any age, and the internet and other media is driving the ‘need for looking young’. Some might say that the increase in procedures is reflective of a stable and improving economy. Conversely, the employment and other social forces help drive the need for appearance improvement/maintenance regardless of the state of the economy.

But while such surgeries as blepharoplasty (eyelid lifts) and facelifts have increased, the big winner is the non-surgical procedures. More people are discovering the benefits of neurotoxins (Botox, Dysport) and the wide array of injectable fillers (e.g., Juvederm, Restylane) for their immediate and often dramatic facial benefits. Only a minority of people who partake of these injectables does not come back for at least one more treatment. The old standbys such as chemical peels and microdermabrasion remain steady and laser and light-based therapies (e.g., laser hair removal) continue to increase in popularity.

While men still make up a minority of cosmetic patients, one surgical area of increase is that in the treatment for gynecomastia. With an increase of over 5% from last year, this is one of the fastest increasing body contouring procedures in either men or women. My guess is that much of this is not the historic adolescent type of gynecomastia but is that now seen in middle-aged and older men with smaller areolar protrusions and sagging chests.

The annual statistical numbers in plastic surgery in some ways provides an overview or state-of-the-art assessment in what is transpiring in the field. From a pure procedural standpoint, the cosmetic surgery business is stable. But within the numbers, non-surgical treatments are the only real movers precisely becasue they aren’t surgery….easier to do, cost less, have minimal recovery and involve less risk.

Dr. Barry Eppley

Indianapolis, Indiana

The incidence of smoking in the general U.S. population over the age of 18 is estimated to be close to 20%. With one in five adults that smoke, it is inevitable that actively smoking patients will appear in any plastic surgery practice for elective surgery with great regularity. As smoking has a well chronicled negative effect on healing and patient recovery, every surgery candidate is counseled to quit smoking for a period of time before and after surgery to lessen the risks of complications.

Despite these smoking precautions, plastic surgeons know that not every smoker abides by them. A few plastic surgeons will go as far as nicotine testing of their patients before surgery but most hope that their recommendations are followed…for the patient’s sake. An interesting question is how many smokers ‘cheat’ and does it affect the incidence of after surgery complication rates?

In the February 2013 issue of Plastic and Reconstructive Surgery, a study entitled ‘Plastic Surgery and Smoking: A Prospective Analysis of Incidence, Compliance and Complications’ was published. In it the authors examined nicotine use and how it affected plastic surgery outcomes. A total of 415 patients in a single plastic surgeon’s practice undergoing elective surgery under general anesthesis were studied over a two year period. Before surgery, urine samples were taken for nicotine metabolites and complications recorded for up to three months after surgery. Just over 1/3 of them had stated they quit smoking and just under 10% were admitted active smokers.

The study results showed that urine nicotine analysis demonstrated that 54/362 patients showed active smoking. Fifteen of these patients (4%) denied they were currently smoking. Patients who stated they had quit smoking were more likely to be falsify they were currently smoking than those who had never smoked. The smokers had higher overall complication rates and were more likely to undergo revisional surgery.

While this is a well-crafted and executed study, and the first time such a study has ever been conducted in plastic surgery, its results are not surprising. Most plastic surgeons have long surmised that patients do not always tell the truth about their smoking history even though it is in their best interest to do so. Nicotine does lead to a higher number of adverse outcomes of which wound healing issues is just the most notable one.

This study raises the question of what is a plastic surgeon to do. Should every patient be tested right before surgery and the surgery cancelled if the test is positive? If this was a practice policy and well known to the patient beforehand, I suspect the number of positive testers would go down

Dr. Barry Eppley

Indianapolis, Indiana

Background: The nipple-areolar complex has both a significant functional and aesthetic contribution to the breast mound. Ideally the nipple-areolar complex should sit in the center of the breast mound and has a reasonable size that is not too big or too small. The concept of reasonable nipple-areolar size is a relative one and each person makes that judgment on their own. In general, diameters in the range of 38mm to 42mm are often cited as being a normal areolar size.

A reasonably-sized areola (the outer ring that makes up most of its diameter) will be highly influenced by the size of the breast mound onto which it sits. And most of the time there is a good correlation between the size of the two. But that is not always true and it is not rare to have a really large areola on a small breast mound. This disproportion between areolar size and breast mound is often called a mega-areolar deformity. Within these areolar deformities is a range of manifestations from just slightly too large to extremely so.

The size of the areola can be circumferentially reduced by a periareolar reduction technique. The larger outer ring of the areola is removed and downsized to the desired diameter. While a periareolar technique is more commonly associated with breast lifting through the removal of a ‘donut’ of skin, it works even better for reduction of the large areola. This is because the amount of areolar reduction needed is frequently less than the skin that would be removed in a breast lift. Less tissue removed translates to less tension on the wound closure, resulting in less risk of eventual scar widening

Case Study: This 22 year-old female had long been bothered by the size of her areolas. She felt they were too big and this was embarrassing for her. She was happy with the size of her breasts but felt the size of her areolas was too much for her smaller-sized breasts.

Under IV anesthesia and the injection of local anesthesia, her existing 52mm diameter areolas were reduced to 40mms by a circumferential excision of areola between the two markings. The areolas were closed in two layers with multiple deep dermal sutures with an overlying barbed suture subcuticular layer.

She had her incisions taped for a week and they were then removed. When seen one month later the areolar reduction was evident and she felt she had a bit of a breast lift as well. She felt that her entire breast mound had changed and she was very pleased.

While the short-term benefits of areolar reduction are obvious, the long-term question is how well will the scars do. Will they have any widening? And if so, how much? Final judgment of the periareolar scars will await a minimum of six months and possibly up to a year to see the final result after complete collagen maturation.

Case Highlights:

1)      Large areolas (mega-areolar deformity) can be downsized  through a periareolar reduction technique.

2)      Periareolar reduction produces a very modest breast lifting effect.

3)      Smaller areolas can make the breast mound look slightly bigger as the areolar-mound size ratio changes.

Dr. Barry Eppley

Indianapolis, Indiana

High-intensity pulsed light has become a very popular method of treating a wide variety of skin conditions. From pigmentation issues to rosacea, the beneficial effects of pulsed light have shown great clinical benefits. One of the its even more widespread uses has been in the overall improvement of aging skin. Numerous clinical and histological studies have shown significant skin rejuvenation effects from repeated broad band light (BBL) treatments.

While visible skin improvements are seen in such treated skin, the question becomes why. What about the light that causes the skin to change? In the October 2012 issue of the Journal of Investigative Dermatology, a study entitled ‘Rejuvenation of Gene Expression Pattern of Aged Human Skin by Broad Band Light’ reported on this very question. Using the left forearms of female patients who were treated three times at four week intervals, skin biopsies were compared between these treated areas and adjacent skin. The skin biopsies were used to obtain genetic material. Biopsies were also taken at a handful of untreated females under the age of 30 to serve as a baseline comparison of youthful skin.

 The study results showed that the treated skin had changes in a number of genes that are linked to the aging process. They specifically called these changes gene ‘rejuvenation’. It appears that BBL treatments affect gene function to create an anti-aging effect. It is important to point out that this is a preliminary study and it is not known whether the effects seen persist or are just short-term changes from the treatments. My suspicion is that it will take some regular maintenance treatments for persistent gene alterations. It is also not clear as to what causes these effects, the light or the heat from the treatments.

This study is very relevant as it is one of the few studies that show genetic alterations in the skin from BBL therapy. We know from clinical experience that regular BBL treatments do reduce the signs of skin aging. Now we have a peak into understanding why. Whether similar results are seen with other energy therapies such as ultrasound and radiofrequency is not known as they have not been studied.

Dr. Barry Eppley

Indianapolis, Indiana

Repositioning of an aesthetically low eyebrow can be done by a variety of browlift procedures. Historically and most commonly, an approach from the scalp (coronal, hairline or endoscopic) is how many browlifts have and are done. This is the most logical approach because lifting up or pulling back seems the right direction for an eyebrow that is too low. A more recent and diametrically opposite approach to lifting the low brow is to push from below. This is known as the transpalpebral (through the upper eyelid) browlift technique that uses a device (endotine) to achieve its effect.

The origin of the transpalpebral browlift is based on three issues.  First, browlifting in men poses a unique challenge because of the dubious nature of their hairlines. Scalp approaches in men are usually unacceptable because of visible scar concerns. Coming from below through an eyelid incision is the only acceptable option for most men. Secondly, there are some women who may feel that the standard browlift approach is more than they want or need. They may desire a little browlifting but feel a scalp approach is too aggressive. Lastly, the sheer proximity of the upper eyelid to the brow bone makes the addition of a browlift through an upper blepharoplasty very convenient with very little additional risk and no extra incision.

An interesting question is  how similar are the results from these two very different approaches to browlifting. In the December 2012 issue of Plastic and Reconstructive Surgery, a paper entitled ‘Morphometric Long-Term Evaluation And Comparison Of Brow Position And Shape After Endoscopic Forehead Lift And Transpalpebral Browpexy’. Photographs of patients who had received either an endoscopic browlift or a transpalpebral browpexy were morphometrically evaluated for brow height and brow shape up to five years after surgery. Their results show a significant elevation of the brow done through the endoscopic approach is both higher and more sustained than the transpalpebral technique. The descent of the eyebrow after the transpalpebral browpexy is felt to be caused by a decrease of frontal hyperactivity after the simultaneously performed blepharoplasty.

It should be no surprise that an endoscopic browlift causes a greater change in the brow’s position and shape as it is a bigger and much more powerful procedure. By comparison, the transpalpebral technique is much more limited in subperiosteal elevation and forehead flap movement. In an endoscopic method the entire forehead is mobilized and moved in one large tissue flap. The transpalpebral approach only mobilizes the brow. This study merely confirms what is intuitively obvious that a bigger operation is more effective and sustained than a smaller one.

While the transpalpebral browlift is less effective than other browlift methods does not mean it has no periorbital rejuvenation value. Its very simplicity and more subtle effects makes it well suited for those who need just a little browlifting or want a less invasive method of doing it. This particularly applies to many male patients who desire a browlift result that does not look overdone with too much brow elevation change.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The chin is composed of various tissues that simplistically is a ball of soft tissue sitting on top of a prominent bony ledge. At the top of this ball is a horizontal groove or indentation that sits between the lower lip and chin about 2/3s the way up from the very bottom of the chin bone. Known as the labiomental fold, sulcus or groove, it is a natural feature of most chins. It is caused by the underlying attachments of the mentalis muscle as it comes superiorly and inserts into the underside of the skin below the lower lip. It forms an angle between the lower lip and a line tangent to the superior convexity of the chin and is purported to be most aesthetic at around +/- 130 degrees.

Unlike the nasolabial fold which deepens with aging, the labiomental fold is a fixed structure that is established early in life and does not change thereafter. The depth of the labiomental fold is affected by numerous factors and can become excessively deep when the lower jaw is shorter. When the lower teeth are retropositioned (class II malocclusion), the lower lip folds under the upper teeth making the labiomental fold deeper.  When the lower teeth protrude beyond the upper teeth (class III malocclusion), the fold is flattened or non-existant. Short of these jaw deficiencies, the depth of the labiomental fold is genetically determined and appears to be a function of the size of the entire chin pad more than anything else.

The labiomental fold is not a very common aesthetic facial concern. But occasionally requests are made to treat a deep one. The most common treatment method is by injection and it can be augmented like any other facial fold. It requires smaller volumes of injectable fillers than other facial sites and any of the commercially available fillers can be used. Synthetic fillers can last up to a year in the fold. Fat injections can also be used but there is no documentation that it persists any longer.

Case Study: This 48 year-old male was going to undergo multiple aesthetic procedures including rhinoplasty, submentoplasty and lip and nasolabial augmentation with implants. He also wanted an implant to lessen his labiomental fold as well. He has always felt it was too deep.

Under general anesthesia, he had all of his implants placed first to decrease infection risk. Using Permalip silicone implants a 4mm x 65mm implant was placed in the upper lip and a 3mm x 60mm implant in the lower lip. For the labiomental fold, small stab incisions were made at each end. A 5mm diameter Permalip implant was slide into place right under the skin and the ends trimmed off as only about 35mm of length was needed.

There was no bruising in the chin from the labiomental fold implant placement and the incisions healed inconspicuously. There was a moderate reduction in the depth of the fold that was maintained.

Labiomental fold reduction can be achieved permanently with the placement of a subcutaneous implant. Most reductions are modest in nature and deeper V-shaped folds respond less significantly than those that are more shallow with a rounder indentation.

Case Highlights:

1)      The labiomental fold is natural line between the lip and chin whose depth is genetically determined.

2)      Injection therapies provide an immediate but temporary improvement in lessening the depth of the fold. Synthetic implants provide a permanent result.

3)      Soft silicone tube-shaped implants (Permalip) can be easily placed to soften the fold under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Aging may have more negative effects than just on one’s appearance. A recent study from the American Heart Association indicates that it may be a sign of heart disease as well. This is not heart disease that could occur in anyone if they simply live long enough but an indicator of a predisposition to heart problems.

The study reports that those patients who had a number of visible signs of aging had increased rates of heart attacks and of developing heart disease. The markers of aging included hair loss with recession at the temples and baldness at the crown, skin creases in the earlobes and fatty deposits around the eyelids known as xanthelasmas. It is no surprise to me that xanthalasmas suggest an increased risk of heart disease given that they represent cholesterol deposits from elevated levels of lipids in the blood. They were also the strongest predictors of heart disease risk. Hair loss and earlobe creases are bit harder to make an obvious connection to heart disease.

What is impressive about this report and study is the large number of patients followed for a long period of time. In this Danish study, over 11,000 patients  age 40 years or older were studied for over 35 years beginning in 1976. These aging signs predicted heart attacks and disease independent of traditional risk factors such as elevated cholesterol levels, high blood pressure and smoking. Also the common aging signs of gray hair and skin wrinkles were ruled out as predictors of heart disease and are reflective of chronological aging but not a risky heart condition.

This study is of medical importance in that internists and family practitioners should look for these physical signs and consider lifestyle changes and lipid lower therapies for those patients who have them.  But these aging signs can also be treated directly through various common plastic surgery procedures. Hair transplantation is a well known treatment for temporal recession and loss of hair at the crown. Usually earlobe creases represent an excess of earlobe tissue and larger earlobes. These creases can be removed through a simple earlobe reduction done through a wedge resection technique. Xanthalasmas are a common condition that plastic surgeons see and are challenging in terms of removal. Usually appearing on the lower eyelids and cheek, they are often dozens of small yellow white plaques located just under the skin. Numerous techniques have been described but I find micro-excision (making a small slit and pushing out the plaque) to be most successful for larger ones.

While the numerous physical signs of aging can be improved or reduced by plastic surgery, this unfortunately does not reduce the risk of heart attacks and disease as well. Their outward appearance can be modified but the underlying genetic code can not be so favorably manipulated.

Dr. Barry Eppley

Indianapolis, Indiana

For many patients undergoing surgery, even plastic surgery, there can be a requirement for some form of preoperative testing. While the indications for laboratory tests has become more selective and less of a shotgun approach than when I first started in medicine, patients over 50 years of age are recommended to have some basic blood work and an EKG. Younger patients generally only get selective tests based on whether they have a specific medical condition or inherited disease.

In the vast majority of cases, this preoperative testing is normal and does cause any change in the surgical or anesthetic plan. Such normal findings can call into question the value, particularly the economic value, of such testing in elective plastic surgery. Some patients even vocalize these concerns. It takes time out of their schedule to get them and adds to the overall cost of surgery. Some patients have the good fortune to have annual medical checkups and getting testing results is as easy as their doctor faxing over the information. But well over half the patients who need them must make the effort to get new test results.

But are these tests really necessary if the patient looks good and feels fine? The unequivocal answer is yes. Because every great now and then these preoperative tests reveal a relevant piece of medical information that can be life-saving. The percentages are not high, maybe less than 1%, but that is fairly standard for screening tests of almost any sort.

For plastic surgeons, the most likely medical disease to be ‘discovered’ is breast cancer due to the large number of breast reshaping operations that are performed. Mammograms before elective breast surgery in anyone over age 35 or 40 can reveal suspicious masses or lesions that had not been previously detected.  Finding malignant lesions during breast surgery is well known but it is far better to find them before surgery.

Such testing for me has revealed a wide variety of other medical diseases such as ovarian cancer, cardiac rhythm disturbances, blood clotting disorders and reduced kidney function. In each case the patient was completely unaware that they had any problems and further work-up by their own doctors lead to either delayed surgical times or eliminated the proposed procedure altogether. I even had one case where the heart monitors placed on the patient when they went into the operating room before she went to sleep revealed the real source of her left chest pain… an evolving heart attack and not her ruptured left silicone breast implant that everyone thought it was.

In each of these cases, presurgical testing may have saved their lives or at least allowed them to receive earlier and hopefully more effective treatments. In a round about way their decision to undergo elective plastic surgery was a potentially life-saving one even if they did not know it at the time. While such plastic surgery ‘screenings’ have low yields, mine is less than a dozen cases over thousands of surgeries, the medical benefits were undoubtably far greater than any aesthetic change that I could have done for them.

While presurgical testing may seem unnecessary and costly to some patients, it is important to remember that it is a valuable medical service to those patients who may not receive regular medical evaluations. Plastic surgeons are first physicians and making sure everything is working well on the inside always takes precedence over changing the outside.

Dr. Barry Eppley

Indianapolis, Indiana