While the wearing of earrings for both women and men has a long history, the more recent phenomenon of stretching the earlobe with plug inserts is more recent. This current ear adornment statement is often referred to as gauging, although the more accurate term would be stretching.

From a plastic surgery standpoint, this is really tissue expansion of the earlobe. It is a different twist on our concept of tissue expansion in that it is done as an external method of tissue expansion as opposed to what we do in plastic surgery which is internal. (e.g., tissue expansion for breast reconstruction)

 
From a cultural and aesthetic standpoint, I can not comment on this current practice. To each his own so to speak. From a plastic surgery standpoint, however, I must say that it may have very negative long-term effects on the earlobe. This is not like wearing a piercing and simply removing it later with the tradeoff of a near negligible hole(s). This practice creates permanent damage to the earlobe by altering its shape, the quality of earlobe left, and the real possibility of significant scarring, even keloids. I am now getting request and seeing patients who want their ‘gauged’ earlobes reconstructed.
As you might imagine, there is a great diversity to the type of earlobe problems that stretching/gauging can cause. I have seen relatively small holes that have shrink back down to a patient with large keloid formation. In every case, however, the earlobe tissue is not really normal and can either be quite thin or thick and scarred. Just as the practice of earlobe stretching is variably done, the resultant problems if they occur are also quite diverse.

 
The reconstruction of the stretched earlobe, fortunately, is not as difficult as patient who has no earlobe. Having cut my teeth on ear reconstruction in the microtia patient, it is always better to have something to work with, even if it is not completely normal. Usually the stretched earlobe hole is opened up and the two bivalved earlobe remnants brought back together in a near straight line fashion. This is a simple procedure that can be done in the office under local anesthesia. Sometimes I will place a small V or Z at the rim of the earlobe in an attempt to avoid notching as it scars down and heals. This procedure will, in many cases, result in an earlobe that is smaller than what one had prior to the stretching experience.

 
I have had only one experience so far with true keloid formation from earlobe stretching. Keloids anywhere are very prone to recurrence and may eventually require steroid injections or even radiation in addition to surgical excision and reconstruction. Many times, even with everything we know how to do, keloids still recur. I have seen this occur even from simple earlobe piercings so I am certain stretching the earlobe will cause as many, if not more, of this problem.

 
While I can not condone the potentially deleterious practice of earlobe stretching, earlobe reconstruction can always be done and most patients will have a reasonable outcome.

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

Breast augmentation remains one of the most popular plastic surgery procedures overall and one of the most commonly performed plastic surgery procedures for women under the age of 35. Breast augmentation is a fairly ‘standard’ procedure in terms of how it is performed and the time it takes to perform it. In my hands, a primary breast augmentation procedure takes one hour to complete, from entering the operating room to being awake headed to the recovery room. Much of the cost of breast augmentation is, therefore, fixed including the cost of the breast implants themselves (silicone gel breast implants cost more to purchase than saline breast implants) and the use of the operating room and the anesthesiologist’s charges.

 
Because breast augmentation costs are predictable, many plastic surgeons freely publicize their fees to perform the procedure. When seeing a breast augmentation fee stated, make sure the fee you are seeing is all-inclusive. Often times, touted breast augmentation fees only list the surgeon’s fee and you have to read the fine print to see the additional costs of the breast implants, operating room, and anesthesia. If the fee has an asterik (*) by it, you automatically know that the listed fee is only a tease and misleading.

 
Because breast augmentation is a very predictable operation in terms of costs and execution, unlike most other plastic surgery procedures such as facelift, liposuction, etc., the listing of breast augmentation costs for any practice is not unreasonable. Also, one of the most common questions that patients have about breast augmentation surgery is the cost. It is often the first and only question they may have when making a phone call to your office or an e-mail inquiry to your website. For these reasons I, like many plastic surgery practices, prefer to publicize my fees for breast augmentation. In my practice, the all-inclusive costs for silicone gel breast augmentation is $5,999 and $4,799 for saline breast augmentation.

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

There are two good reasons why patients choose silicone gel breast implants over saline…and one of those is that silicone breast implants have significantly less rippling or wrinkling than saline. This is of great aesthetic importance to those women with very little breast tissue and thin or stretched out skin where the outline of the breast implant can clearly be felt and often even seen. This is most evident in the inferior (lower) and lateral (side) poles of the breast implant where the chest muscle does not provide coverage.

 
The phenomenon of breast implant rippling is actually present in both saline and silicone filled implants. 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. This is why we usually overfill the saline breast implant to generate increased pressure on the inside which lessens the amount of wrinkling that can occur. In the short-term this works but, over time, the plastic bag of the implant stretches a little and relaxes, creating some rebound wrinkling if you will. Silicone gel, a much thicker (viscous) material and with slightly more weight, coats the inside of the implant shell better and is more effective at lessening wrinkling.

 
The point is….silicone gel breast implants have less wrinkling, usually substantially less, but it may not always be zero. I have had several women who have small amounts of rippling in the lateral (side) pole of the breast. Usually it is only one or two small ripples, which would be less than that which would have been present had they been saline implants instead. I can’t say at this point whether this subtle rippling phenomenon in silicone implants is less evident in high profile (projection) versus medium or low profile style implants. I think it is more reflective of the lack of breast tissue between the overlying skin and the breast implant, an anatomic issue in which no type of breast implant can completely overcome.

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

Many female patients today seek rejuvenation procedures which involve making the mouth area look better or less aged. As women age, some will lose lip volume, develop upper and lower lip wrinkles, and have the corners of the mouth draw down. This often creates a sad, mad, or unhappy appearance to the lip area. Most commonly, lip injections with hyaluronic fillers such as Juvaderm, Restylane, or Perlane are done to enhance the size of the lips, help fill out some of the fine wrinkles which are around the pink part of the lips, and raise up the mouth corners to some degree. While these forms of injectable treatments are effective and non-invasive, they are not permanent.

 
The corner of the mouth lift is a surgical option that has lasting effects. It is an old procedure that has been around for many decades. The corner of the mouth lift should be more popular than it is given that it is a minor procedure that can be performed alone in the office or as part of many other facial rejuvenation procedures. By taking a small triangle of skin from just above the drooping mouth corner, the downhanging mouth corner can be turned up quickly and easily. It is a very powerful procedure for such a small removal of skin and one must be careful not to overdo it by raising the corner of the mouth too far up and having too long of a scar. It does create a very small scar at the corner of the mouth but it is nearly indetectable if done right.

 
The key to a good corner of the mouth lift result is making the mouth corner level, and not more, and keeping the scar small that does not wander far from the corner of the mouth. Many facelift patients mistakenly think that the facelift will pull up the corner which is a misunderstanding. That is why some facelift patients with ‘frowns’ needs a concurrent corner of the mouth lift procedure.

 
I have found this procedure to be well accepted and most patients are surprised when I mention it as they have never heard of it. As an in-office procedure, it works well with lip injections and lip lifts and advancements. The frown that runs down into the ‘marionette lines’ will usually need filling of the deeper marionette line with injectable synthetic fillers, fat grafts, or a soft gore-tex implant, depending upon whether the procedure is done in the office or the operating room. For those patients with chronic irritation due to salivary overflow (a condition known as angular cheilitis), a corner of the mouth may even be curative as it rearranges the angulation of the ‘spout’ and creating a more competent lip dam effect.

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

Scar revision is both a frequently performed and a common consultation in plastic surgery. Scars can occur from trauma or surgery and can be very distressing for some patients. While time makes many scar better, some scars go on to be raised, wide, or stay very red without improving. On the face, scars can be quite conspicuous if their orientation does not parallel the relaxed skin tension lines of the face. While many scars can be improved by plastic surgery techniques, there are some fundamental principles of scar revision that every patient must understans and be willing to accept.
First and foremost, no scar can be completely removed, there will always be some telltale signs of its existence. In plastic surgery, we don’t have any erasers that can completely make it go away. I don’t care what you see on the internet or on any doctor’s website. (the overexposed or picture with bright lights can make it look washed out and absent) Or to put it another way, we are physicians not magicians! Scar revision, no matter how it is done, is about lessening its appearance, not complete elimination. Whether a scar revision procedure is worth it depends on if the patient can accept some degree of improvement only. I usually think it is worthwhile if the scar can be improved by 50%, anything over that is a bonus and a fortunate development.

 Secondly, getting the final result in scar revision takes time. Usually much more time than one would prefer to spend, but this fact is inescapable. I always tell patients, think of stepping back a step to eventually move forward two steps. One step back…six to 9 months to step forward…and in children this will usually be longer. I have no celebration about scar revision results until we are out close to a year. If it really looks better then, call the band for the victory parade!

 Thirdly, scars are all different and not every scar can be improved. Scars that are very wide, raised, or persistently red after some time have a better chance for improvement than others. While many different types of scar revision treatments exist (visit http://www.scarscription.com for an overview of scar treatments), the reality is that most scar revisions involve some form of cutting them out and reclosing them. Many of the other methods of scar revision, such as the laser, are adjunctive treatment methods that complement surgical excision but are not primary treatment methods.

 Lastly, all bets are off when it comes to the nastiest of scars….keloids! Many patients think they have keloids but they do not. Keloids are raised overflowing scars which keep on growing and cause significant pain and distortion. They are bad actors and few treatments even work, let alone work well. This doesn’t mean we don’t try, but the failure rates are horrendously high.
It is my job as a plastic surgeon to guide each patient and help them determine if scar revision is worth the effort. Sometimes it is…and sometimes it is not. The consideration for scar revision must be done on an individual basis.

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

Plastic surgery encompasses a wide variety of procedures for the face and body. From nose jobs to breast implants, we perform a broad scope of body changes. While the vast majority of these procedures do very well and patients have an uncomplicated after surgery course, some patients will experience complications. The occurrence of complications in plastic surgery, of the minor variety, are not rare. Major complications in plastic surgery, fortunately, are very rare.

Interestingly, there is a vast difference in the occurrence rate and types of complications between plastic surgery of the face and that of the body. While patients understandably place a greater emphasis on procedures done to their face, the actual rate of significant complications from facial plastic surgery is quite low. There are several reasons for this that include; the tremendous blood supply to facial tissues which is quite resistant to infection and allows most wounds to heal quite quickly (including the clearing of bruising and swelling), cosmetic surgery of the face is really ‘superficial’ surgery and does not enter any major body cavities or cause major pain and surgery on the face does not disrupt the body’s physiologic functions (like temperature control and fluid shifts) like body plastic surgery does. For these reasons, facial plastic surgery procedures do not pose the same systemic risks as body plastic surgery such as deep vein thromboses, pulmonary embolisms, and infection. Most complications in the face, short of bleeding and hematomas, are mainly about appearance, symmetry, and scarring. Not that these are not significant, but they rarely are life-threatening or invoke major medical problems.

Body plastic surgery, conversely, carries with it bigger risks in my opinion. First, body plastic surgery is ‘bigger’ and involves more surface area of the body than the face. Whether it be liposuction or a tummy tuck, large body areas are being opened or manipulated. As a result, the issues of blood loss, adverse temperature changes, and fluid shifts are real potential issues and expose the patient to greater medical risks such as fluid collections (seromas) and blood clots. Second, the blood supply below the neck to any one body part is not as great as any part of the face. Therefore, infection rates for body plastic surgery are definitely greater than that of the face. While patients are more tolerant to small differences or asymmetries on the body as opposed to the face, the chances of more significant differences is also likely because the surgery site is much bigger and the changes being made are bigger. No where are these issues more evident than in bariatric plastic surgery, the extreme end of body plastic surgery,  where big skin cutouts, long incisions, and extended operating times test the ability of any patient to heal in an uncomplicated manner.

Potential complications are part of any form of plastic surgery and fortunately most are relatively minor and are often just a bump (aggravating as that is) along the way of recovery. However, body plastic surgery is associated with longer recoveries (for many of the procedures) and higher rates of complications such as wound dehiscences, seromas, and asymmetry between body parts. This is in contrast to plastic surgery of the face where the surgical sites by comparison are smaller and healing is much quicker and less complicated.

 Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Next to orthopedic surgery, plastic surgery as a medical specialty uses a significant number of implants and implant materials to help achieve its surgical outcomes. Whether it is breast implants or an injectable filler, the use of synthetic or foreign materials is common in plastic surgery. Often when a plastic surgery patient needs an implant for their procedure, they will ask the question….’What if my body rejects the implant?’…..or…..’What are my chances that I will react (adversely) to the implant?’ This understandable concern is reflective of a basic misunderstanding of how the body reacts to implanted foreign materials and what type of complications can develop.
In reality, the rejection of an implanted synthetic material (that has been evaluated and approved for human implantation by the FDA), in the most scientific sense, does not happen. A true rejection reaction in humans is an autoimmune response to an ‘implant’ that is composed of live or organic material. Therefore, you will develop a rejection or autoimmune reaction, for example, in any type of organ transplant which is from other human or animal origins. Your body’s cells mount a massive response to what it recognizes as foreign or an invading organic source. The body is quite smart and protective as this type of response is necessary for survival.
Synthetic implants are composed of inorganic materials, which do not cause a true allergic or autoimmune response. These are not live materials and were never composed of living organic materials. As a result, they can not elicit an allergic response. They may never become part of you or integrate into your body’s tissues, but they can safely occupy a space to do their job. Synthetic implants, while not causing allergic responses, can cause a different set of problems which patients mistakenly interpret as ‘rejection’.
Synthetic implants can get infected, exposed, or migrate, all of which are complications of the surgical implantation process not due to rejection. If bacteria inadvertently get on the surface of the implant, an infection can later develop. Most implant infections occur within weeks of the surgery as it takes time for the bacteria to multiply and become evident. Synthetic implants can migrate or move from their location where they were surgically placed if the implant material is very smooth or the tissue pocket into which it is placed is very big. This potential migration can be eliminated if the implant is secured into its desired location by some method such as sutures or metal screws. Implant exposure can result from migration of the implant, getting close to the original incision through which it is placed. Or implant exposure can result from not having enough good tissue closed over it or tissue that breaks down over the implant due to too much pressure that the implant exerted on it or the overlying tissue is of poor quality and it doesn’t heal well and then breaks down, thus exposing the implant.
The patient will understandably interpret these synthetic implant complications as ‘rejecting the implant’. In reality, the patient’s body has little to do with the development of these complications. They are more a function of surgical technique and not due to a patient’s immune response to them. The risk of these potential implant complications can be reduced by pre-surgery antibiotics, a properly sized implant that does not stress the surrounding tissues, and careful surgical implantation technique.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Anatomy of the Skin

The epidermis is the most superficial layer of the skin and provides the first barrier or protection from the invasion of foreign substances into the body. The principle cell of the epidermis is called a keratinocyte. The epidermis is subdivided into five layers or strata, the stratum germinativum (SG), the stratum spinosum (SS), the stratum granulosum (SGR), the stratum lucidum (not seen in this photomicrograph) and the stratum corneum (SC) in which a keratinocye gradually migates to the surface and is sloughed off in a process called desquamation.

The condition of the epidermis determines how “fresh” your skin looks and also how well your skin absorbs and holds moisture. Spots, pores, evenness, porphyrins, and UV spots all manifest themselves in our epidermis.

Wrinkles, however, are formed from changes in the dermis.

The dermis assumes the important functions of thermoregulation and supports the vascular network to supply the avascular epidermis with nutrients. The dermis is typically subdivided into two zones, a papillary layer and a reticular layer. The dermis contains mostly fibroblasts which are responsible for secreting collagen, elastin and ground substance that give the support and elasticity of the skin. Also present are immune cells that are involved in defense against foreign invaders passing through the epidermis.

The papillary dermis (PD) contains vascular networks that have two important functions. The first being to support the avascular epidermis with vital nutrients and secondly to provide a network for thermoregulation. The vasculature is organized so that by increasing or decreasing blood flow, heat can either be conserved or dissipated. The vasculature interdigitates in areas called dermal papillae (DP). The papillary dermis also contains the free sensory nerve endings and structures called Meissner’s corpuscles in highly sensitive areas.

The reticular layer of the dermis (RD) consists of dense irregular connective tissue, this differs from the papillary layer, which is made up of mainly loose connective tissue (note the difference in the number of cells). The reticular layer of the dermis is important in giving the skin its overall strength and elasticity, as well as housing other important epithelial derived structures such as glands and hair follicles. This reticular layer is our target for collagen production.

Collagen

Collagen is a member of the connective tissues: cartilage, bone, tendons, fascia, ligaments, and blood vessels. The character of any connective tissue is determined by the function of the specific cells that compromise that tissue. The major fibrous proteins are collagen and elastin. The predominant nonfibrous components are the complex carbohydrates mainly: hyaluronic acid, the proteoglycans, and glycoproteins. Collagens are a class of proteins, members of which have chemical and structural features in common, but each is a product of a specific gene (hence, the specific connective tissue disorders). One property of all collagen molecules is the unique triple helix, a particular conformation of the three component polypeptide (alpha) chains, each containing approximately 1000 amino acids. The conformation of the chains is determined by the amino acid content, with glycine constituting a third of the total and occurring at every third position in the amino acid sequence. Thare are two major classes of collagen: interstitial and pericellular. Interstitial collagens are the major collagen of the skin and essentially exclusive type of bone (type I); articular cartilage and nucleus pulposus (type II); and the collagen present in the skin, blood vessel walls, and the matrix of parenchymal organs (type III). Pericellular collagens are types of IV and V and predominate in basement membranes.

Biosynthesis

Biosynthesis of the collagen chains is a multistep process in which a precursor form (procollagen) is first synthesized, with peptide extensions at either end. During synthesis, several amino acids are uniquely modified post-translationally (after incorporation into the polypeptide chains). These post-translational modifications include hydrozylation of praline residues (hydroxyproline) and lysine residues (hydroxylysine) and addition of sugars (glucose and galactose) to the hydroxylysines, and formation of the hydroxylysing and lysine aldehydes. Specific proteases act to cleave off the extensions of the procollagens to produce the processed collagen molecules, which can then polymerize to form fibrils and fibers. Our lasers target the cell mediators which stimulate the production of procollagen I & III.

Aging

Cutaneous (skin) aging is a complex biological phenomenon. Disorders in aged skin are more the result of photoaging (UVR) than from chronological aging. There is gradual atrophy of the dermis and epidermis and a massive accumulation of abnormal elastic tissue with its associated microfibrils and proteoglycans. These elements replace the normal collagen rich dermal foundation, leading to a weakened and thinner dermal layer. UVR consists of UVA (320-400nm) + UVB (280-320nm) and UVC which at the present time does not penetrate our atmosphere. UVA light is the prime offending agent for collagen loss and subsequent wrinkles. UVB’s shorter wavelength only affects the epidermis. As the dermal layer “sags” so then follows the epidermis, and wrinkles appear. This decrease in collagen results more from increased deterioration (UVA) rather than from a significant decrease in production (age). The term solar elastosis is used to describe photodamaged skin.

The thickness of the skin changes with age: young skin gradually gets thicker until the age of about 20 years, after which there is a gradual atrophy of the dermis. At the level of the papillary dermis, a relatively nonechogenic band appears and develops with age. The exact reasons for the appearance of this shadow are unknown, but it corresponds to a homogenization of the papillary dermis, the local disappearance of elastic and collagen fibers, and their replacement with an undifferentiated matrix of hydrated gycosaminoglycans (elastotic tissue). The extent of this shadow steadily increases with age and is a reliable marker for skin aging (loss of collagen density). This shadow is found in both types of aging skin: photo and chronological. An increase in dermal thickness from laser therapy is found in the upper dermis and is due to an increase in the collagen fibers and not the other components of the matrix. The laser heat causes a partial denaturation of the older collagen and accelerates the new collagen synthesis process by the fibroblasts and the deposition of new glycosominoglycans and leads to a reabsorption of elastotic material. An increase in the echogenic band in the upper dermis is easily visualized with ultrasound and is directly attributable to an increase in collagen. Two possible benefits occur with laser collagen remodeling therapy. The thickness of the dermis increases and/or the density of the collagen increases.

Anti-Aging

Anti-aging modalities are classified by type:

Type I therapy is directed at the epidermis (microdermabrasion/chemical
peels/laser)

Type II therapy is directed at the dermis (laser/chemical peels/ultrasound)

Type III therapy is surgical or injectable (facelift, botox, fillers).

Dr Barry Eppley

Indianapolis