Newspaper Articles

The eyes may be the window to the soul, but they also create a strong impression of how we look. So many people comment to and about others based on how their eyes look. We all have had the experience of someone asking us if we are tired or have been up late. You can be certain their question is not probably based on how we were dressed or what we were eating.

But it is not the eyes per se that give these impressions, it is what is around them. The drapes of the eyes, the lids or window shades, are largely responsible for their appearance. Too much skin, deepening wrinkles, and bulging fat creates a tired and aging appearance. When combined with falling eyebrows, the amount of eye we see gets smaller and one really does look older. All this excess lid tissue is also prone to collect and retain fluid, hence those swollen eyes in the morning.

Because of the impact of how our eye area looks, eyelid surgery (blepharoplasty) is the best value in all of facial rejuvenation surgery. This is certainly true based on the size of the treated surface area. But more importantly, changing the look of the eyes does exactly what one is after…to look more refreshed. Few want to look different, but all want to look like themselves, only better.

While there are some non-surgical treatments that can make some areas around the eyes look better, none of them can improve the way the eyelids look. Botox can decrease wrinkling between the eyebrows and around the sides of the eyes, and that can be a great benefit for sure, but that affects expression only. If you look in the mirror without your face smiling or moving and your eyes still look tired, eyelid surgery is the only option.

By the way, forget about some magical cream making your eyelids look better. Amongst the many hundreds that exist, a few can make some minor reduction in fine wrinkles and puffiness. But really visible differences require removal of what makes them look that way, too much skin and fat.

While blepharoplasty surgery works on the lid skin, there are differences between what is done on the upper versus the lowers. The upper eyelids are largely about skin removal and re-creating an upper eyelid crease. Having a well defined eyelid crease is more important than trying to remove all excess skin. In the lower eyelid, more focus is on fat removal and skin tightening and making it as smooth as possible. There is no lower eyelid crease that needs to be made.

Many potential patients fear that blepharoplasty surgery will make them look unnatural. While this is possible if too much skin is removed from the eyelids, most overdone results come from browlifting not blepharoplasty. While browlifting can be a valuable addition to eyelid tucks, it is a procedure that is easily overdone. High eyebrows can easily change the appearance of the eye area and not favorably. Consider browlifting very carefully. It is not a cavalier addition to eyelid surgery.

If you are tired of looking tired, blepharoplasty may be a good choice to get a more youthful look back.     

Dr. Barry Eppley

Plastic surgery continues to grow in popularity as evidenced by the statistics from the American Society of Plastic Surgery over the past decade. Surgical procedures as well as non-surgical cosmetic office treatments have increased every year since 2000. With the explosion of the internet and other communication mediums, a tremendous amount of information about plastic surgery is available at the click of a mouse from anywhere in the world.

But like much on the internet, news magazines, and product brochures, what can you believe? How do you separate reality from the marketing hype? How can you decide what are the best treatment options for your facial concerns?

Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a tour of facial plastic surgery. Covering dozens of the most popular cosmetic surgeries and treatments of the face, Dr. Eppley talks plainly about his experience and observations. From facelifts and nosejobs to injectable fillers, Dr. Eppley writes from his own extensive plastic surgery experience of the face, and provides insights into what many cosmetic procedures are, and what they actually do.

The desire to feel beautifully confident at any age is a natural one. Seeking plastic surgery ‘assistance’  is not vain or trivial. It is a major decision that requires forethought and preparation. Whether you are still considering  if plastic surgery is right for your face, have an upcoming consultation with a plastic surgeon, or are planning a procedure in the future, Dr. Eppley prepares you to ask better questions and Face The Facts!

This book has been written to provide a basic education and awareness of the surgical specialty of Maxillofacial Surgery.  It is not designed to be an all- inclusive text, but an outline of the terminology, anatomy, diagnosis, and treatment of the broad and complex array of maxillofacial and craniofacial problems. It is intended to serve as a pocket guide that is visually- oriented, can be quickly used as a reference, and read from cover to cover in a short period of time.

Maxillofacial surgery, a long-standing subspecialty of Plastic Surgery, had its beginnings in the early part of the 20^th century during World War I when trench warfare created a large number of severe facial injuries. Their treatment required  the development of an integrated approach of reconstructive surgery and dentistry which remains the guiding principles of Maxillofacial Surgery today. It has grown from its beginnings in facial trauma to include congenital cleft and craniofacial deformities, jaw surgery, reconstruction of extirpated tumor defects, to aesthetic facial surgery.

Maxillofacial surgery requires an understanding and assimilation of medical and dental principles involving anatomy, biomaterials, and manual dexterity. Surgical manipulation of facial anatomy is unforegiving in its visible outcome to the patient and society.

The specialty of Maxillofacial Surgery combines a knowledge base and techniques drawn from all of the head and neck disciplines with particular emphasis coming from plastic surgery. The field has expanded greatly over the latter half of the 20^th century, led primarily by the interest and innovations established by the tenets of contemporary craniofacial surgery where maxillofacial surgery was expanded to the orbits, forehead, and the cranial cavity to make a better life possible for many congenitally deformed but intelligent human beings.

The specialty of Maxillofacial Surgery is designed to provide the highest standards of care for all surgery performed in the face and skull, whether it’s origin be of bone, soft tissue, or  both. It can be difficult work in an anatomic area where many essential functional and aesthetic structures intermingle and proper training of the surgeon is paramount to achieve the desired end result, a patient with a more normal face and smile. It endeavors to achieve these aims through education, research, and awareness amongst the general public and medical field about the specialty.  This handbook, in its own small way, is another brick for that building. May its reading provide insight into the astonishing work possible from Maxillofacial Surgery.

Dr. Barry Eppley

Q: I’ve lost about 90 lbs and now I have excess skin that hangs on my upper arms that I want to have fixed.

A: One of the many skin problems that develops after large amounts of weight loss is that of loose hanging arms. The skin on the back of the upper arm in the triceps area hangs down, creating what is often called ‘bat wings’.  The excess skin frequently extends into the armpit (axillary) area and down into the side of the chest wall. Such large amounts of upper arm skin are a unique finding amongst extreme weight loss patients, particularly after bariatric surgery. Interestingly, this arm problem occurs overwhelmingly in women and not usually in men. (I have never performed an armlift in men) It may be that men’s skin shrinks down better after weight loss.

An armlift, known in plastic surgery as a brachioplasty, is an extremely effective procedure for reducing the size of the upper arms and getting rid of this loose floppy skin. While it accomplishes this result with the trade-off of a long arm scar, patients with this amount of loose arm skin consider that scar better than the excess skin. Armlifts are one of the most satisfying of all weight loss body contouring surgeries.

Armlifts traditionally have either placed the scar running down the middle of the inside of the arm or on the back of the arm. Recently, I am using a new technique during surgery that places the scar between the middle and the back of the arm with significantly better results.  The scar is not only better hidden but the common postoperative wound healing problems that used to occur (particularly when using the inside of the arm location) have been largely eliminated.

Dr. Barry Eppley

Breast implants are a very common plastic surgery procedure that has not waned in popularity despite the recession. While they are unparalleled in making an instant body change, they have also make news for other interesting and unfortunate reasons. In the past year, these are the noteworthy breast implant stories you may not have read.

This week a California woman was sentenced to six months in jail and required to pay monetary reimbursement for ‘stealing’ breast implants as well as other cosmetic surgery back in 2008. Under an assumed name, the 30 year-old woman used a credit line in someone else’s name to obtain $12,000 in plastic surgery which included breast implants and liposuction at a plastic surgery center in Huntingdon Beach California. She pleaded guilty to burglary, grand theft and identity theft for using another woman’s personal information to obtain the surgery. How did she get caught you may ask? Police tracked her down using the serial numbers from her old implants, which she had removed when the new ones were put in.

In a similar scenario, but much more tragic, you may remember the murder of model Jasmine Fiore last August in California. The Playboy model mysteriously disappeared and was later found mutilated. With missing teeth and fingertips, she was initially unable to be identified as was the intent of the murderer. She was later identified by something her assailant had overlooked…literally…the serial numbers on her breast implants.

Proving that many criminals are dumb, most implantable medical devices today have serial numbers for tracking purposes as an FDA requirement. Usually the benefit of them on breast implants is for replacement and warranty reasons, but they also serve nicely as a human identification method that is more precise than fingerprints or dental records.

On a happier note, it was reported that a silicone breast implant saved the life of a California woman who was shot in the chest.  A woman working in a Beverly Hills dental office last July was struck by a bullet after one of the employee’s estranged husband entered the office and killed her with a handgun. On exiting, the gunman ran into another employee and shot her in the chest. Unlike her co-worker, she miraculously survived. According to the Los Angeles Times, one of her breast implants stopped the bullet and prevented any fragments from getting as far as her heart. A physician who took care of her at the hospital stated that the bullet fragments were just millimeters from her heart.

A forearms expert was later quoted as saying that the breast implant probably slowed down the bullet enough that it caused it to stop short of the heart. While its an appealing story, that is not likely. A silicone gel or saline breast implant would not slow any bullet fired at close range. Breast implants have the stopping power similar to that of Jell-O. More likely her sternum or ribs was the reason that the bullet was deterred from going any deeper. The intervening breast implant, however,  is happy no doubt to take the credit.

Breast augmentation and the implants needed to do them have weaved their way into the mainstream of American society, sometimes in ways not exactly as intended.

Dr. Barry Eppley

Published in 2003 with co-authors Dr. Peter Ward-Booth (United Kingdom) and Dr. Rainer Schmelzeisen (Germany), Dr. Eppley co-authored this now classic textbook entitled Maxillofacial Trauma and Esthetic Reconstruction. In a single volume, the comprehensive topic of the management of bone and soft tissue injuries to the face was done in just over 650 pages with 33 chapters and more than 500 color illustrations.

Bone and soft tissue facial trauma is one of the three major areas in the field of maxillofacial surgery. Having its origins in World War I and II from the last century where many facial injuries occurred, the need for specialized surgery methods for facial reconstruction began. It has now evolved into very sophisticated technologies for bone fixation and movement (plates and screws) as well as replacement of missing soft tissues. (pedicled and free flap transfers) The ‘high-rent’ district of the face allows the need for numerous medical specialities to participate including ophthalmology, neurosurgery, radiology, and dentistry in addition to the classic three surgical specialities of maxillofacial, plastic and otolaryngologic surgery. This book does an excellent job of bringing the knowledge base of all such disciplines together in a single concise volume.

One of the real strong points and emphasis in the book is what most facial trauma books historically lack, reconstruction of secondary facial defects. Despite the best surgical techniques and equipment, not all facial trauma patients end up with perfect results. Beyond simple lacerations and isolated bone fractures, the injury pattern of many facial trauma patients is complex and the best outcome will usually defy a single surgical effort. From scar revisions to occlusal discrepancies to soft tissue deficiences, secondary reconstruction of facial trauma is not rare and the book spends about as much time on those topics as that of primary repair.

This book is now undergoing a 2nd edition which should be forthcoming in the fall of 2011.

Too much fat is a near ubiquitous problem. The sheer number of weight loss diets, medications, and exercise programs that we are inundated with each day is a testament to their ‘popularity’. Accompanying these fat concerns, to no surprise, is the desire for liposuction as a surgical fat removal method. Liposuction is by both number and surface area the most common cosmetic plastic surgery procedure in the United States.

Contrary to the perception of some is that most liposuction patients are not trying to use it as a weight loss method. Almost every liposuction patient that I have ever seen in my Indianapolis plastic surgery practice has come in with a history of diet and exercise efforts. Whether it is the 35 year-old mother who can’t get that stomach pouch off after her second child or the very trim 42 year-old male who just can’t get rid of those stubborn love handles, liposuction is usually sought out for the right reason…as a spot method of body contouring.

As potential patients seek out liposuction today, they are surrounded by an array of technology that did not exist just ten years ago. And such information is freely available for their assessment on the internet. Between marketing ads and alleged patient testimonials, every manufacturer and many doctor’s practices tout one liposuction method over another. Whether it is tumescent, ultrasonic, laser, water jet or cold liposuction, they all seem to be the ‘best’. At the least, many are relatively new and after all newer is better…isn’t it?

To understand this maze of liposuction technology, it is important to appreciate how the liposuction process actually works. Essentially, it is a two-part process. Simplistically, the first part of liposuction requires that the fat be loosened by some method. The second part is that the loosened fat is then suctioned out. All the different liposuction techniologies need to use the second phase, suctioning. The difference between all of them is in the first part, the method they use to loosen up the fat.

In traditional ‘old-style’ liposuction, good old elbow grease is how the fat is gotten free. Most everyone has a good vision of how that is done by the in and out motion of a cannula that looks like a good beating up, to quote quite a few patients. In ultrasonic liposuction, it is the high intensity sound waves that do it. With laser, it is the heat and melting of the fat. With water jet, it is the high pressure of water. With cold, it is the reverse thermal effect of heat that does it.

I have left out the tumescent method as it is not really a liposuction method per se. Every liposuction technique first infuses a fluid to make the suctioning part easier, to make the treated site numb, and to lessen bleeding. It is called tumescence because it inflates or tumesces the planned treated area. It is necessary to do this first for all liposuction methods. While this may have been a liposuction advance by the late 1980s and early 90s, it is standard today and not a novel liposuction approach.

While great and appealing arguments can be made for each of these liposuction technologies, the reality is that none of these methods have been proven or shown to be better than another. They are accepted techniques that can make for an acceptable liposuction outcome. The most important technology or technique, however, remains that of the hands and the experience of the plastic surgeon wielding the device. The greatest tool ever made is only as good as the person using it. Conversely, skill and experience can make  an average tool do a great job.  More focus should be placed on that assessment by potential patients, if possible, than the allure of the next great liposuction wand.

 Dr. Barry Eppley

Almost everyone has now heard of the facial wrinkle treatment, Botox. While some may not know exactly what it is really good for, its recognition and popularity is because it simply works. When it comes to softening facial expressions, it does something that even surgery can’t do.

Many misconceptions exist, however, about Botox (and now Dysport) and it is time to reveal some of its secrets. Here are some facts about its use that are not commonly known.

Botox is a poison and can be quite lethal if the dose is high enough. It is administered in units which originally stood for mouse units. A unit was the dose of Botox that could kill a mouse. Fortunately, there is a big difference in size between a mouse and a human. To poison a human, it is estimated that it would take about 25,000 or more units to do so. The average dose for wrinkles is around 20 to 30 units, so it is well within the margin of safety. (mathematically, cosmetic dose units are a mere 0.001% of the doses that could be fatal). Cosmetic injections are precisely placed 2 to 4 unit doses in select facial area.

While Botox is touted for a lot of facial uses, it is largely a ‘northern’ face procedure. The areas of the forehead and around the eyes accounts for much of its use. Weakening of the muscles between the eyebrows, in the forehead, and at the sides of the eyes produces the desired effect of less frowning, a more relaxed forehead, and less lines around the eyes. While some do use it down south around the mouth, it is not effective as a primary wrinkle reducer in that area. A little too much Botox there can affect the way you smile.

Botox injections do not produce immediate results. It usually takes one week or more to see its effects. This is because it blocks the release of chemicals from the nerve endings that cross over to stimulate the muscle fibers to which it is attached. Because there is a supply of chemicals in the nerve endings to start, they must first be depleted. As a result, the muscle will work normally for a few days before it begins to weaken as its ‘gas supply’ diminishes.

The effectiveness of Botox can vary from one doctor to another or from one treatment center to another. This seems initially unusual because one of the benefits of a prescription drug is that it has been tested and approved for the uniformity of its effects. But Botox differs from a pill and many other prescription medications. It comes as a dry powder and must be formulated or reconstituted prior to treatment. How well it works, therefore, is affected by how it is mixed and how long ago it was prepared. It is designed to be mixed according to the manufacturers recommendation in a very specific way. (2.5ml of saline per vial) and it should be used either immediately or within a few days after preparation. But treatment centers vary on how they mix it and how quickly they can use it. You have no way of knowing if you are getting diluted or old Botox. If it doesn’t seem to be working well or lasting very long, this could be the reason.

Like all drugs, there is an effective dose to Botox or a ‘sweet spot’ at which it works well. What you want as a patient is to find the Minimum Effective Dose as well as the right injection spots. You may regularly be getting 40 units in the forehead are, for example, when 32 may work just as well. More Botox than necessary does not make it work better or any longer. Don’t be afraid to ask your injector to adjust the does or injection locations to see if the results improve…or become less.

Botox and Dysport have a very consistent duration of effect of around 4 months. Repeat treatments, unfortunately, do not make it last longer. But some patients feel that it does. This is likely an effect of muscle re-education, a chemical training if you will. It may take your body awhile to begin using those muscles again if they have been weakened repeatedly. Conversely, most people will not build up tolerance or immunity to Botox. But a few patients say that they have and resistance to any drug is always possible. One can than switch to Dysport which has a slightly different molecular structure.

Dr. Barry Eppley

Of the very large number of cosmetic surgery procedures that are performed each year in the United States, a certain number will undergo subsequent revision. While this is a concept explained to patients by their plastic surgeon beforehand, it is understandable that it falls on deaf ears for the most part. The euphoria of the upcoming outcome blocks any realistic consideration that anything but the best will happen. The decision to undergo cosmetic surgery is both emotional and optimistic.

Why does surgery not always turn out to be exactly as desired? While there can be numerous reasons, including the wrong operation for the problem or that the operation was not done well, but the most common reasons for these undesired outcomes are less obvious. How the body responds to the trauma of surgery and the not always predictable events of wound healing account for much of the need for revisional surgery. The occurrence of complications in cosmetic plastic surgery is uniquely different from that of most other types of surgeries. Unlike common surgical problems, such as infection or bleeding, the healing of a cosmetic surgery site may be perfect but the aesthetics of the healed site may still not be what was desired. Cosmetic surgery results are judged by a higher standard, they must both heal and look good as well. Even the avoidance of common wound healing problems is not enough in cosmetic surgery.

While the real number of the incidence or need for revision in cosmetic surgery will never be known, estimates are thrown around of around 15% on a national average. This estimated number will be quite different depending upon the type of procedure being performed. For example, any form of breast surgery carries a higher revisional risk than that of a facelift. Any operation that relies on an implantable device to achieve the outcome will always have more potential problems than those operations that don’t. While revisional surgery in most cases is minor and nothing in comparison to the original operation, potential patients need to appreciate that the need for secondary surgery in cosmetic procedures is not rare.

When postoperative complications occur and revisional surgery is needed, there is unhappiness on the part of both patient and plastic surgeon. The cosmetic patient is understandablely unhappy as they never really believe it would happen to them no matter how it was disclosed or what forms they signed. Such surgical problems happen to other people, no one thinks or hopes that it will happen to them. Other people make up statistics but not themselves. Patient naivety in this regard has been promoted, inadvertently, by cosmetic surgeon’s themselves through countless promotional efforts. Advertising ‘lunchtime facelifts’, ‘weekend recovery’, and other seemingly too good to be true procedures has only added to dumbing down that fact that it is real surgery with associated risks.

Like the patient, plastic surgeons are equally not pleased about the need for revisional surgery. There are many reasons for such a response by the surgeon from facing a patient’s disappointment, a perceived failure of their own skills and expertise, and how this result reflects on their own reputation and image. Sometimes, a difference in opinion may develop between the patient and surgeon as to the need and advisability of revisional surgery. In these circumstances, patients often seek out other surgeons to undergo their revisional surgery, getting a fresh perspective on their adverse outcome. When needed, however, surgical revisions should be done in the proper setting and under the appropriate circumstances. Certain minor revisions can be reasonably performed under local anesthesia in the office. This approach is simple and avoids the use of the operating room. Many times, however, this office approach to revisional surgery is overused in an effort to save the patient further expense. As a result, the desired outcome may still be suboptimal. In many cases of revisional surgery, the patient and surgeon needs to be willing to accept the additional arrangement and expense of an operating room to put themselves in a position where the procedure can be carried out properly.

The potential need for revisional surgery after a cosmetic procedure is a statistical reality. Revisional cosmetic surgery has associated physical, emotional, and economic consequences. It will often test the depth of the relationship and preoperative dialogue between plastic surgeon and patient.

Dr. Barry Eppley

You wouldn’t normally consider the concepts of plastic surgery and terrorism in the same sentence. If you did, you would assume that it had something to do with surgical changes of a terrorist’s face to alter their identity. Plastic surgery amongst drug dealers in different parts of the world, for example, is well known. Why wouldn’t it be the same for terrorists?

Perhaps terrorists are getting their noses reshaped and other facial reshaping surgeries, but that is not the association that is currently news worthy. It is now reported that female suicide bombers are being fitted with breast implants containing explosives which are all but impossible to detect by current airport scanning machines. Similar approaches are apparently being also considered for men by using buttock implants The discovery of these methods was made after the recent airliner incident on Christmas Day where a Nigerian had stuffed explosives inside his underpants.MI5, the famous British spy unit, has reported that such movie-like plots for bringing down airliners do really exist.

While breast implants do have  a controversial material history, it has never been one of a lethal and nefarious nature. Explosive experts say that an implant containing as little as five ounces of certain explosives (a B cup breast size) can open a hole in the skin of an airplane that can take it down.

While an exploding breast implant is not a concern for the typical woman in the U.S.  who undergoes breast augmentation, understanding implant rupture is. Implant rupture is not the same as an ‘exploding breast implant’. This is the one lifelong implant-related risk which every breast implant patient should know. While the bag or shell of a breast implant does not explode, it can develop a tear or hole in it over time. Such an implant defect is not the result of anything the patient does, it is the result of natural fatigue of the implant material as it flexes and folds over time from external displacement forces. It is always best to not think of breast implants as permanent although we all hope that they are.

Patients of course want to know how likely is implant rupture and what happens if it does. The true incidence of breast implant failure is really only known from past history with older device designs that are no longer used. While the manufacturers provide statistics of a 1% risk per year for the lifetime of the implant, numbers are just…numbers. That statistic is meaningless when it happens to you. You just have to know that it can happen and the longer they are in place, the more likely it can occur. Rupture of saline implants are immediately obvious, like a flat tire. Silicone implant failure usually never results in any external change and may only be found on a routine mammogram.

The good news is that breast implant rupture is medically harmless, no scientific evidence has ever linked a medical disease with implant filler materials. Rupture is an issue of inconvenience and economics. For saline implants, it will be a cosmetic ‘emergency’. For silicone implants, it is more of a dilemma of whether anything needs to be done at all if the breast feels and looks fine.

While terrorists might come up with lots of different ways to try and kill US citizens, using breast implants against us is definitely not one that we might have expected.

Dr. Barry Eppley

Spring brings forth many new growths as we emerge from winter. Warmer temperatures with rain and gusty winds fuel this growth. As the season changes into this rebirth time of the year, certain plastic surgery procedures emerge as well. Often called seasonal plastic surgery in this part of the country, one would most likely think of breast augmentation or liposuction as one prepares for greater summer exposure of one’s body. While the frequency of these procedures increases for sure, correction of prominent ears (otoplasty) also increases. (a common plastic surgery joke is the risk of flying away with the spring winds)

Protruding ears affects both children and adults alike. But otoplasties are done disproportionately more in children. This is likely because an adult has lived with their ears for a long time and may be less psychologically bothered by them. Or they have had them for so long that changing them may be emotionally disturbing. (as part of the theory that change is scary and that hanging on to the more familiar is less ‘risky’ than the potential benefit of the unknown) But the child’s self-image is still being developed and eliminating protruding ears is one simple and quick way to eliminate some potential psychological baggage.

Ear pinning, medically known as otoplasty, is one of the most satisfying of all facial plastic surgery procedures. When you factor in a very low risk of any problems after surgery, a dramatic improvement in appearance and when done early in life as a child or teenager, it offers some of the best value of any plastic surgery procedure that I know. Low risk, dramatic improvement, and permanent benefits is always a sure sign of a plastic surgery winner.

A fundamental principal of otoplasty surgery is to identify the cartilage problem that makes the ears protrude.  In most cases, the absence of the fold between concha and the helix, known as the antihelical fold, is the main cause. When this backward fold is not there, the helical rim sticks way out.  Bringing back the helical rim, through sutures placed from the backside of the ear, brings  the protruding ear back in an immediate fashion.

But there are other cartilage deformities in the ear that can make them stick out. The concha or bowl that surrounds the ear hole can be too big, pushing the entire ear out too far. The concha helps capture sound to direct it into the ear canal down to the ear drum. It provides the foundation onto which the helix and antihelical fold sits. A big concha and the lack of an antihelical fold make for an ear that really sticks out.Without reduction of the large concha, other suturing methods will be unsuccessful. Removing a wedge of conchal cartilage and using sutures that pull back the concha towards the mastoid are needed to make the ear sit closer to the side of the head. Many otoplasty procedures require a combination of antihelical and conchal manipulations to create the best ear shape and position after surgery.

Otoplasty plastic surgery is a simple outpatient procedure that can be completed in just one hour. Most of the time it is done under anesthesia but some cases in adults can be completed with just local anesthesia. Dissolveable sutures are used on the back of the ear so suture removal is not necessary. A head wrap is used for just one day and one can shower the next day after surgery. Even in the face of some mild swelling and soreness, the change  in the ears is immediate and quite dramatic.

Spring is a time when many parents begin to think about otoplasty for their child or teenager, planning for a summer surgery when out of school. But the simplicity of the procedure allows it to be done over winter or spring break as well without missing school. It is prudent, however, to avoid contact sports for the first month after surgery.

Dr. Barry Eppley

The greatest trend in plastic surgery in the past decade has been, ironically,  the explosion of procedures that don’t involve actual surgery. Comprised largely of injectable therapies, such as Botox and fillers, and laser and light treatments, making the face look rested, supple and youthful  has become as easy as a quick visit to the doctor’s office. By sheers numbers, non-surgical facial enhancement far exceeds the actual number of cosmetic surgeries performed per year.

Such ‘beauty treatments’ have been very successful for concerns of facial aging but the same approach has not seen the same successes for body concerns. The search for an effective non-surgical method for the reduction and removal of fat remains as elusive as finding the magic pill or diet for weight loss. Much has been promised, but little has been delivered so far.

The allure of ‘non-surgical’ is always a compelling one and any device or product that offers it always attracts a large amount of public interest. But within that appeal lies the often ignored fact that non-surgical treatments are not equivalent to surgery. They produce results that are far less and should be of thought as a delaying tactic or a complement to what surgery can do, not a substitute.

Non-surgical facial methods should never be equated to what actual surgery can do. You can reduce a few wrinkles, plump up some thin tissues, and get your skin to look fresher. And, to be sure, those are great changes for many people, but many patients often expect or believe much more will occur. This is unfortunately not helped by the sometimes very ‘broad’ promotional claims of product manufacturers and doctors alike. Unless properly advised, it is easy for one to undergo some form of office treatment, often not inexpensive, and be disappointed with the results. This is especially seen when it comes to a wide variety of ‘facelift-like’ methods. I have seen many such patients, all of whom in the search for something less, did indeed end up with less.

While seriously ‘injurious’ complications are rare with underperforming and overpromised cosmetic treatments, there is always the economic loss. Wasted money may prevent someone from contributing to and having a more significant procedure that would provide much better long-term benefit. The point being is that one must keep an eye on the concept of value when comparing non-surgical versus surgical cosmetic procedures.

One good illustration of this concept  is in the highly promoted ‘Liquid Facelift’ procedure. Plumping your face up with injectable fillers does create some more fullness in the face and it could  be called  a lift of some sort (it does nothing for the neck which is why most people seek a facelift).  But its effects last perhaps six months and costs several thousand dollars. Some form of a real facelift (and there are many variations) may cost two or three times more but the results are much more significant and could easily last a decade or more. Is either one wrong? No. Each person has their own objective and needs and either approach could be right for different people.  But from the concept of value, removing, lifting and tightening is actually more economical in the long-run than plumping and a little smoothing.

Most non-surgical office treatments have no recovery, a near instant result, and cost less …and do so at the ‘price’ of being less effective as well. Expectations are the key to any plastic surgery procedure and simple office treatments should be judged more for their contribution to value than their ease of doing them.  

Dr. Barry Eppley

As an appreciation of what our military does around the world, our Patriot Program exists to help make plastic surgery more affordable to them. Having seen and talked to many of these military patients, I have become aware that elective plastic surgery is often done at Armed Services facilities. In addition, one of my plastic surgery techs spent nearly a decade in the military and he often speaks of the cosmetic surgeries that he knows where done or participated in.

According to a recent article in Stars and Stripes (passed along to me by one of my military patients…he thought I might be interested), the military says it does not pay for unnecessary plastic surgery. But an audit of patient records released in February by the Pentagon says this is not so. The audit found that military doctors were regularly performing breast augmentations, tummy tucks, liposuction and other cosmetic surgery without charging the patients as they are supposed to do.

Plastic surgeons exist in the military to perform reconstruction of many injuries that are sustained from war, accidents and disease. The very existence of plastic surgery as we know it today is the result of the experience gained in the first two World Wars in the first half of the last century. Because military plastic surgeons need to keep their skills up for when they get out (and to encourage them to enter the military in the first place), they are allowed to perform cosmetic plastic surgery for patients as long as they pay for it…just what people have to do in the civilian world. Such requirements have been in place for the military for some time. Troops have had to do so since 2005 and dependents and retirees have been required to pay since 1992.

However, it appears that some service members and their dependents are having cosmetic surgery on the military’s (your) dime according to the audit. Arguments can be made that they deserve it or it doesn’t really matter since most of the costs are already built-in anyway. The basic costs of the facilities and doctor’s and operating room staff salaries is an ongoing expense, it is really just a supply issue to perform the surgery.

One of the real interesting sides to this story, and one that we face every day in the civilian world with medical insurance, is what is the difference between medically necessary (reconstructive) and cosmetic plastic surgery. From the military’s standpoint, what should they be paying for and what should patients be paying for?  By definition, plastic surgery is reconstructive if it restores or repairs appearance or function from trauma, disease, or birth defects. Cosmetic plastic surgery is changing what is not deformed, injured, or diseased. That seems like a simple differentiation…but it often is not.   

In the Stars and Stripes article, for example, they discussed male breast reduction or gynecomastia surgery. This is a source of embarrassment for many young men but is often viewed as a cosmetic problem in the civilian world and is not often covered by medical insurance. But in the military, male breast enlargement can make wearing body armor difficult and that can make it medically necessary. Similar situations may exist for rhinoplasty (breathing problems), otoplasty (helmet wearing), and even tummy tucks. (hernia repair)

One of the side, but important, issues is being able to recruit or retain plastic surgeons in the military. Outside of being close to a war zone, plastic surgeons in the military may encounter few combat casualties and may not do enough reconstructive surgery to keep their skills and board-certification current. (in some ways, this is thankful) Cosmetic surgery techniques are an extension of those used in reconstruction. A midface lift, for example, is a cosmetic procedure developed from repairing cheek bone fractures and lower eyelid deformities. There are many connections between cosmetic and reconstructive plastic surgery and their differences in technique are often more gray than trying to determine the medically necessary basis of the procedure.

Of significance, the military report suggests that plastic surgeons are increasingly leaving the military because of their inability to keep up their cosmetic surgery skills due to the 2005 patient payment policy. That is unfortunate as plastic surgeons have  a lot to offer our military service members. Perhaps continuing to provide cosmetic surgery is a retention factor for both plastic surgeons and our military alike.

Dr. Barry Eppley

While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.

Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.

Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer.  These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.

But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.

Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.      

Dr. Barry Eppley

While the way and the changes that a face undergoes as it ages may not have changed since time began, the treatment of it has. Facelift surgery used to be an extensive operation largely because it was done on older people. (who needed a lot of work!) In a generation past, most people (primarily women) underwent a facelift when they retired, rewarding themselves for a lifetime of work and when they can most afford it.

But today’s approach to facial aging is different and reflects changes in both society’s attitudes and plastic surgical techniques. People now want to age less obviously and remain youthful appearing in middle-age as they participate in the ever competitive workplace. As a result, facelift surgery has adapted to these needs becoming less invasive and suited for less severe signs of aging that exist in the 40 and 50 year-old ages.

Besides the common misconception of what a facelift really, most people perceive that it is a highly invasive procedure that requires a long recovery.  These two perceptions are tied together under the belief that a facelift is a ‘scalp to neck’ lift. In reality, a facelift only changes the lower third of the face…a neck and jowl improvement. It does not change the mouth, cheek, eye or forehead area. These require separate and often combined procedures with a facelift to create a complete facial makeover. When one understands the more limited scope of what a facelift is, it becomes less scary and intimidating.

Facelifts have evolved into two different types, complete and limited. The difference is in the amount of neck improvement that is obtained. Since many younger patients have more jowling than sagging neck issues, the limited facelift has become widely used. The surge in the number of facelifts has been because of this scaled down version and accounts for at least half of all facelifts now performed.

The  popularity of the limited facelift can be seen by the numerous marketing approaches taken by both plastic surgeons and franchises alike. Catchy names that imply the ease of recovery, such as Swiftlift and SimpleLift to name a few, are used to differentiate this technique from that of the historic facelift perception. Promoting surgery under local anesthetics, one hour procedure times, and a few days of recovery, it can make it seem that it is hardly surgery at all. I have seen numerous patients initially seen at these franchise establishments and they were surprised to find out it was an actual surgical operation.

But limited facelifts are real surgery, even if it isn’t the same as an extended full facelift. It can become a more extensive procedure if combined with other facial aging treatments such as eyelid tucks (blepharoplasty)or browlifts, which is quite common. The concept of several smaller operations at a younger age is a sound maintenance approach that may make the need later for a full facelift unnecessary.

Limited facelifts, however, are not just for the young. For the older patient, who may really need a full facelift for the best result but does not want it, the limited facelift offers moderate improvement with less recovery and costs.

Contemporary plastic surgery is about adapting the operation to the magnitude of the problem. The limited facelift is a great illustration of that principle.

Dr. Barry Eppley

Just when you think you have heard it all, a new and bizarre tale of cosmetic surgery rears its head. If I didn’t know any better, this story may well have happened in China or the back streets of a remote Siberian city.

From the Garden state of New Jersey in Essex County, a group of female patients (six to be exact) ended up in hospitals after undergoing buttock enhancement. Apparently, they received buttocks enhancement injections containing caulking material. The same material that is used to caulk windows and bathtubs was injected to make their glutes larger. Different from medical-grade silicone, the substance used in these Mengele-like botched procedures was believed to be a diluted version of a nonmedical-grade silicone. Traditional buttock enlargement procedures are done with either a medical-grade solid silicone implant or with fat injections.

Apparently administered by unlicensed providers, the women were admitted to hospitals following  the injections after developing raging infections. They were treated with surgery and antibiotics and appear to be recovering (although, you can be certain their buttocks will never be the same).

While many may wonder why anyone would want their buttocks enlarged (since many women would actually want them reduced), this is a popular request amongst certain ethic groups where a fuller and rounder buttocks is more appealing. Some have called this the Jennifer Lopez effect.

While these cases are certainly a tragedy, the looming question is how could this happen? In a country with the finest and most advanced medical technology in the world, how does someone come to the fate of having their butt caulked?

While injectable aesthetic treatments, such as Botox, collagen and fat, have been a real advance in plastic surgery, there is a rare, dark side to the concept. Because injection therapy is not surgery, it is not regulated like traditional plastic surgery procedures. There is no oversight and many of these treatments take place in a wide variety of settings by ‘providers’ of all backgrounds.

Because of their apparent simplicity to administer, injectable treatments are often viewed as a commodity. As in, ‘what treatment can I get for the lowest price’? While searching for bargains is commendable in many retail situations, a faux watch or look-alike handbag does not carry the same risk as do faux injection materials.

While not common in this part of the U.S., black-market injectors do exist and their practitioners prey on the weakest and least educated consumer- those that often can least afford it. As crazy as the butt caulking incident sounds, there has been a recent history of dubious practitioners  providing cosmetic implants of nonmedical-grade materials. They function in a makeshift office for a short time, then get put out of business…only long enough for other shady providers to take their place.

Most of these incidents happen in large metropolitan cities with a high percentage of immigrant populations. In such an environment it is easy to hide, to be invisible to the authorities, and find plenty of victims before moving on. Smaller cities like Indianapolis are more difficult for unlicensed providers to remain anonymous as they are more quickly exposed, and appeal to a much smaller population.  

The conclusion is …Caveat emptor: Buyer beware.  If the costs of the procedure look too good to be true, there is probably a reason.

Dr. Barry Eppley

Q: I have been infected with HIV for nearly 15 years. While he medications have been invaluable and have saved my life I suffer from some of their cosmetic side effects including a very gaunt face and a  non-existant butt. For my face which is better, fillers or iimplants. Can anything be done to my butt bigger?

A: One of the well known side effects of the medications to treat HIV is lipoatrophy or fat loss. The fat loss is quite specific, however, and has a predilection for facial and buttock fat. Loss of the buccal fat pads and, in severe cases, much of the subcutaneous fat results in a sunken in or very gaunt look to the face. It is such a classic presentation that it can be socially stigmatizing has having the underlying medical problem. In the buttocks, fat is lost so they become very flat appearing. Other parts of the body, for unknown reasons, undergo fat hypertrophy (excessive growth) most commonly in the back of the neck (buffalo hump) and in the abdominal area.

Facial lipoatrophy can be successfully improved with a variety of approaches including synthetic cheek implants, fat injections, or synthetic fillers. (e.g., Sculptra) Which one is best must be determined on an individual basis considering the extent of the fat loss and whether one prefers to avoid actual surgery or not. Fat grafting is probably best avoided as its persistence in the face of the medications is unlikely.

Treatment of buttock lipoatrophy is a different matter with no good options. Fat injections are not adviseable due to likely complete resorption and a result which will be underwhelming. This leaves buttock implants as the only option which carries with it a significant recovery and risks of infection and seroma complications.

No type of plastic surgery should be performed in an HIV patient unless their cell counts have been normalized and medical clearance is obtained from their treating physician. According to recent studies, the infection rate for plastic surgery procedures is not different in HIV vs non-HIV patient populations if good cell counts exist.

Dr. Barry Eppley

When spring just around the corner, this is the time of year when many people start thinking about their body again. Warm weather and less clothing cause some women to think about their ‘curves’.  Perhaps to the surprise of some, spring is the peak season when the greatest number of breast augmentation surgeries are done. This is a seasonal trend that is very unique to this type of cosmetic surgery.

When considering breast augmentation, most women today opt for silicone gel breast implants. Since they have become available again for human use in late 2006, they rapidly have become the preferred implant for many breast augmentations. Yet, despite FDA-approval, many patients understandably ask about their safety. Even if one was not old enough to even be aware of what transpired in the early 1990s with the previous generation of silicone breast implants, there remains some lingering concerns that are easy to find on the internet.

Since silicone gel breast implants are FDA-approved, and they would not be available if they were not, that speaks to their safety. But most do not know the extent of information that goes into that type of approval process. And because of their history, silicone gel breast implants have become the single most studied implantable device in the world. As a result, the most common questions that women may have about this type of breast implant has well known answers.

Can breast implants make me sick? In 1997, the Federal government (Department of Health and Human Services) appointed the National Academy of Science to study the likelihood of medical complications after breast implant surgery. After reviewing years of evidence and research concerning silicone gel-filled breast implants, they found that health problems such as connective tissue illnesses, cancer, and other diseases were no more common in women with breast implants than in women who had never had the surgery.

 In the 1990s, thousands of women claimed that they had become ill from their implants. Some studies around that time suggested that these health symptoms of women with implants may improve when their implants are removed. We now know conclusively that this is not true. The relationship between autoimmune diseases and breast implants is coincidental…both largely occur in women between the ages of 20 to 50…but one does not lead to the other. The FDA has even gone so far as to conclude that there is link between fibromyalgia and breast implants either.

Will breast implants cause cancer? Reviews of research and medical studies on silicone breast implants show that breast cancer is no more common in women with silicone breast implants than in those without. In fact, for reasons different than one may think, women with breast implants actually have earlier breast cancer detection. This has nothing to do with the implant per se, it is a function of breast awareness. Women with breast implants are more likely to be ‘attuned’ to their breasts and how they feel.

 Can I breast feed with breast implants? For the younger women, this is a frequent question. The issue is not whether one can physically do it, but will any harm come to the baby by doing so. The American Academy of Pediatrics concluded in 2001 that having silicone breast implants is not a contraindication to breastfeeding nor does it pose any health risks to the infant. Similarly, epidemiological investigations have not found any increased risk of health problems in children born to women with silicone breast implants.

Dr. Barry Eppley

The mere mention of the word ‘facelift’ is to many people a frightening concept that is best avoided.  Beyond implying surgery, images of ‘perpetual surprise’, ‘wind-tunnel’ and ‘unnatural’ come to mind. It is these very misconceptions and fears that have led to a surge of procedures that have become broadly known as non-surgical facelifts.

Cleverly marketed as appealing improvements known as ‘lunchtime facelifts’ and ‘liquid facelifts’ , these facial procedures are hopefully performed in a doctor’s office with a combination of Botox, injectable fillers (such as Juvaderm and Radiesse), and light and laser treatments. They are tremendously appealing precisely because they are not surgery, and involve no scarring or downtime. And they are based on a recently appreciated anatomic understanding of facial aging which is that of volume deflation (loss of fat) and not just sagging tissues alone. ‘Re-inflation’ of the face is the result of these treatments, even if it is only temporary (there are no permanent injectable fillers).

Under the guise and enthusiasm of anything that is pain and recovery-free being better than a real facelift, a patient inquired about the ‘new’ Y-facelift published this past weekend in New York Times Sunday Magazine.  Buried in the center pages of this magazine was a story entitled ‘Houston, We Have Facelift’. Reading this story got me thinking about everything that is both good and bad about the non-surgical facelift ‘revolution’.

The concept:  Developed by a dentist who claims to have taken four years to develop this approach, the Y-facelift involves filling the face with large volumes of injectable fillers, molding it around with one’s fingers, and then treating the skin with radiofrequency treatments to tighten it. I am not sure what the Y means but some filling out of the face is most certainly achieved, without surgery, for a subtle improvement.

The bad:. It may be shocking for some that everything in New York isn’t always better (although always twice as expensive) and the New York Times Style magazine does not carry the same scientific clout, for example, as the New England Journal of Medicine. Cosmetic procedures are fraught with a common problem- marketing that frequently gets way ahead of proven science. This practice is so prevalent that doctors and companies alike have learned that appearing in Allure, Cosmopolitan and other beauty magazines with exaggerated and unfounded claims drives business better than a scientific discourse in any medical peer-reviewed magazine. (and much easier to get published) Even the pharmaceutical industry has this figured out which is why almost one-third of television ads today are for some prescription drug.   The bottom line is the ‘Y-Lift’, while based on a few known plastic surgery procedures, is an unproven amalgamation which most likely benefits the treatment provider more than the recipient.

What matters:  The debate between non-surgical or surgical facelifts can be debated ad nausem. Both may be appropriate for any patient under the right circumstances. The practitioners of both will hotly contest each one’s merits. But the non-surgical boom of cosmetic procedures speaks to an important issue that is rarely discussed…value. What does one get for what one pays? The non-surgical Y-facelift retails between $4,000 and $8,000 for results that will last one year, maybe slightly more. The price of non-surgery, when looked at long-term, is frequently more than that of actual surgery…with results that are not nearly as long-lasting.

There are many factors that go into deciding what is the best facial rejuvenation procedure. Never forget that the concept of value in plastic surgery, like any other retail purchase, is extremely important. But the medical merits of such procedures should not be determined by what is written in a trendy magazine whose sole intent is newsstand and ad sales, not satisfied and happy patients.  

Dr. Barry Eppley

With the winter Olympic games ongoing in Vancouver, it gives one pause to ponder about more than the traditional meaning of this event. Every two years, the Olympics and the media exposure that surrounds it provides athletes, known and unknown, with the rare opportunity to showcase their skills and personality on an international stage. As an audience we are glued at night (and sometimes during the day thanks to Tivo) to watch athletes perform in ways that we only fantasized about in our youth. For some of these athletes, their accomplishments will be a springbroad to fame and riches thereafter.

The ancient Olympics were held in Olympic Greece over a span of nearly 1300 years beginning in the 8^th century BC. Revived 1400 years later in 1894, Baron Pierre de Coubertin resumed the games in Athens. To adapt the games to the ‘new’ world, a variety of modern inventions since their rebirth have included the Winter Games for ice and snow sports, the Paralympic Games for physically disabled athletes, and the Youth Olympic Games for teenage athletes. To support all these activities, the games have long shifted away from pure amateurism to complete corporate commercialization. Over half of the Olympic coverage seen in Vancouver on NBC were commercials.

The vast majority of Olympic competitors are under the age of 35. As a result, most athletes  have much, if not all, of their youthful appearance. Some have had some form of plastic surgery, however, to look better under all this media exposure. Few have owned up to it however. In this young age group, Botox, injectable fillers, rhinoplasty and ear surgery would be the likely plastic surgery procedures. For obvious reasons, liposuction and other body contouring procedures would be unlikely given their state of physical conditioning.

Olympic gold medalist and four-time Word tennis champion  Lindsay Davenport has freely spoken about her experience with Juvederm injectable filler. The years of sun damage from playing tennis led her to seek non-surgical facial rejuvenation. Concerned about her ‘parentheses’ (laugh lines), she had those injected to restore volume and had Botox in her forehead and around her eyes to decrease wrinkles as well. Her experience was so positive that she has been a spokesperson for Juvederm’s educational campaign.

Olympic hurdler Jana Rawlinson from Australia has opted to have her breast implants removed in preparation for the 2012 Olympics in London. Such a cosmetic move may be the first in the world of competitive athletics. She felt they were slowing her hurdling down. Having breast implants, adding just 1% to one’s total weight and causing some minor adjustment in balance, may make the fraction of a second difference between winning and losing. Interestingly, she cited  a patriotic duty to do the best that she could  for her country over her own vanity for the removal decision.

While most recognize the Olympic symbol of the five interlocking  rings, fewer know that there is an accompanying motto as well. The Olympic motto is “Citius, Altius, and Fortius” which in Latin means “Faster, Higher and Stronger”.  Given the evolution of the Olympics today, perhaps the motto should include Richer and Better Looking as well.
Dr. Barry Eppley

Facelift surgery is one of the top five requested procedures in plastic surgery. Despite its popularity, it remains as the most misunderstood of the known plastic surgery operations. Almost everyone thinks that a facelift is a total makeover of the face, from the scalp down to the neck. In reality, it only treats the lower third of the face, the jowls and the neck. Therefore, it is a much less extensive operation to go through than one thinks, with a smaller than anticipated recovery as well. Facelifts are often combined with other facial procedures as well such as blepharoplasty and browlift.

In this edition of the Doc Chat radio show, Dr. Barry Eppley discusses many aspects of facelift surgery, demystifying the operation and providing insight into what it can and cannot do. In discussion of facelift surgery, Dr. Eppley interviews a husband and wife, both of whom had different facelift operations. The wife underwent a traditional full facelift, the husband underwent a direct necklift. Hear what they have to say about their experiences and the learn from actual patient experiences what facelift surgery is all about!

The recent surprise decision by Senator Evan Bayh to not seek re-election is likely a strong reflection of his desire to flee an unpopular ship as it is with his frustration with the ways of Washington. The recent questionable efforts to ramrod through a monster of major health care reform is certainly one factor that drove him closer to the edge of this decision. Perhaps Bayh knew that as the details of the health care bill began to see the light of day, great public disdain for all those that voted for it was sure to occur.

As a plastic surgeon, I was happy to see that the unsavory ‘Botax’(a 5% tax on all cosmetic procedures, surgery or otherwise) was cut from the final version of the Senate health care reform bill. The ‘Botax’ was eventually eliminated when it was quite rightly pointed out that it was not only a discriminatory tax on women but it was punishing those who sought self-improvement…the equivalent of taxing healthy behavior given the efforts of most patients to take good care of their investment in themselves.

As a replacement for taxing cosmetic surgery, the Senate desperately searched for ways to redistribute more of your money.  They turned their focus to… indoor tanning of all things. Known as the ‘Tan Plan’, a 10% federal tax on indoor tanning was quietly included in the revised bill. Optimistically, it is expected to generate close to 3 billion dollars to help pay for the uninsured. Tanning is a more palatable target because it is a debatedly unhealthy behavior that in the very least, doesn’t improve your skin’s condition from the experience.

While I don’t want to be an endorser of any behavior that exposes people to more ultraviolet radiation and thereby increases their risk of developing skin cancer, this new federal tax is just as reprehensible as the Botax and may even be more discriminatory.  Though the tanning industry and tanning advocates have put forth their concerns, I have yet to hear anyone mention the very biased nature of this tax. I am most definitely not a tanning expert,  but I am certain that the vast majority of the population that patronizes tanning salons are light skinned individuals seeking to darken their natural skin tone.  The number of non-Caucasian users of tanning salons must surely be very low, at best just a few percent of the total client base.  The Tan Plan is really a racially-biased tax, likely unintentionally but true nonetheless.

What the Botax and the Tax Plan demonstrate is that it is virtually impossible to pick and chose what type of human behavior you want to tax (penalize), and not raise a lot of concerns. If you really want to generate a lot of tax revenue and maybe even change societal health behaviors in the process, there should be a Fat Food Tax. Taxing food purchases with a certain percentage of fat content and the industry that makes them would make these other tax proposals as insignificant as the antioxidants in a soda.

Must we really be deluged with food choices that have such high fat or sugar contents? They taste great and we all love them, but most are a nutritional desert and have led us to be one of the most overweight countries per capita in the world. Obesity and all of the problems that it causes is a far greater health problem that cancer, AIDS and many other medical diseases combined. Such a food tax would, however, cause such a societal clamor that the mere mention of it makes one reach for that bag of Doritos. Taxing personal lifestyle behaviors is risky and will never be a politically popular way to try and fund some levels of health care reform.   

Dr. Barry Eppley

As if  Michael Jackson’s stunning death this past summer was not tragic enough, last week  his personal physician was formally charged with manslaughter . Dr. Conrad Murray, a cardiologist who was with Jackson at the time of his death, is accused of medical behavior that led to his demise. Murray is claimed to have  administered  the sedative propofol to help Jackson sleep.  Shortly thereafter Jackson was found unresponsive, and was declared dead after arriving at the hospital. These charges against Dr.Murray are sure to be the prelude to another sensational celebrity courtroom drama set to play out later this year.

Until this event occurred, most people had never heard of the drug propofol. Known as the ‘milk of amnesia’ amongst anesthesiologists, this white-colored liquid sedative has undoubtedly performed perfectly during millions of surgical procedures – certainly for many surgical patients who are reading this very column. Propofol is intended  to be administered only by an anesthesia professional in a medical setting, because it depresses breathing and heart rate while lowering blood pressure.  Propofol is absolutely not an insomnia medication .  How then did the ‘milk of amnesia’ come to be in use at a private residence?

It’s my belief that the thing that killed Michael Jackson is the very same thing that led to his facial disfigurement from  multiple plastic surgeries.  The ‘fame’ monter and the opportunity to rub shoulders with a pop star is capable of  making anyone, let alone a physician, cross the  line between appropriate behavior and  irresponsibility. Dr. Murray will ultimately pay a steep price for his short time as a celebrity’s physician but the deceased is not a guilt-free victim. A lifetime of privilege and asking for the ‘extraordinary’ created a pattern of behavior that ultimately proved fatal. It is one thing to demand the best room in the hotel or to make special accommodations for your private plane at the airport…but pushing the envelope in medical treatments can have different consequences.

Ultimately, the doctor should have used better judgment. The use of propofol at home can not be defended at any level. We are certain to hear in court testimony, however, a fantastic story that will justify his actions. It probably will be as equally convincing as the glove that did not fit O.J.’s hand.

Even in a small, Midwestern practice, our best judgment as physicians is tested. When a friend or family member asks for a Vicodin prescription for a ‘bad back’, or a patient expects us to write off her co-payment, or when a local celebrity asks for pain medication that is waaaaaay more than what is necessary for a simple elective surgery, we’re expected to uphold our professional standards and do the right thing.  We’re supposed to say no.    Because when you don’t refuse, and when you do write that ‘questionable’ prescription because you feel obligated, you’ve opened the door to further indescretions.  And before you know it, you’re saying ‘yes’ more often than not, and over time you allow the patient to dictate the course of treatment.  And sooner or later you wind up like Dr. Murray.

Dr. Barry Eppley

One of the first signs of aging is what happens around one’s eyes. We are so expressive with our eyes and forehead that they bear the brunt of much of the early and visible signs of the aging process. How many times has someone said to you…are you tired?…have you been working late?…when in fact you just had eight hours of sleep. The development of extra eyelid skin, lower eye bags, and wrinkles around the eyes can be telling.

This makes the blepharoplasty (eyelid tucks) a vital plastic surgery procedure in making one look more refreshed. Many patients fear, however, that such an eyelid procedure will change their appearance rather than just making it more youthful or rejuvenated. This fear is promoted by just looking at today’s over-operated celebrities who have had too much surgery, or overly aggressive surgery, and look very unnatural. Such changes do make one look different, but not better.

Modern blepharoplasty surgery avoid these problems using a more conservative approach based on a better understanding of how the eyelid and face changes with age. Greater emphasis is placed on not disturbing the eyelid’s complex system of support and removing just the right amount of extra skin. This leads to a  more natural looking result that does not alter one’s appearance.Baggy upper and puffy lower lids can now be treated with less tissue disruption and scarring for a safer and more natural long-term result. The goal is to look like yourself…just better!

When considering an upper eyelid procedure, the position of the eyebrow must be considered. A low hanging eyebrow can make it look like there is more skin in the upper eyelid than really exists. A browlift procedure is occasionally done with a blepharoplasty when it is determined that a higher brow is aesthetically beneficial. How do you know if your eyebrow is too low? That would depend on where one’s brow was when they were young.  I would submit that most people do not remember where it was in their younger days. You simply have to play with it in the mirror to decide if higher is better.

Browlifts are primarily a procedure for women, they are rarely done in men. When browlifts are done, emphasis should be on more lateral brow elevation and less inner brow elevation. A woman’s eyebrow usually has an upward and outward sweep to it towards one’s temple area. Bringing up the inner part of the eye brow is what creates an unnatural overelevated look.

Today’s in-office ‘needle’ treatments can also provide some around the eye area improvement. Botox (and Dysport), not injectable fillers, is what is used. It is a great treatment for reducing the frowning look between the eyebrows, horizontal forehead lines, and crow’s feet wrinkles at the side of the eyes which can be particularly evident when one smiles. As an early treatment before significant eye aging changes occur or as a complement after blepharoplasty surgery, Botox is a simple and cost-effective non-surgical treatment.

One no longer has to be told that they look tired or are seeing their eyeball slowly disappear in a sea of loose and hanging eyelid skin. Between the three Bs (blepharoplasty, browlift and Botox), a more rested and refreshed you awaits!

Dr. Barry Eppley

The trail of plastic surgery devotees in Hollywood is growing faster than sequels to the movie Saw. From aging musicians and film makers to young actresses on the rise, Tinseltown is awash with everyone getting nips and tucks.  While an occasional tweak or two may be the norm, some ‘ stars’ are becoming more mannequin than human in their quest to turn back the hands of time.

Most recently, Heidi Montag of ‘The Hills’ fame,  underwent a second round of extensive plastic surgery procedures. The 23-year-old reality TV star, who had a rhinoplasty and breast augmentation in 2007, confessed to having ten plastic surgery procedures in one day according to People magazine. By her own admission, she admits to being addicted to plastic surgery. In her quest to be “the best of me”, she had  liposuction on her neck, waist, hips, and thighs, a buttocks augmentation, revision of a prior breast augmentation, an ear pinning, a “mini” brow lift, chin reduction, Botox in her forehead as well as fat injections in her cheeks and around her mouth.

Ms. Montag represents the ‘extreme’ plastic surgery patient.  Low self-esteem, combined with easy access and large amounts of disposable income and an insatiable need for attention, can create this perfect storm with the end result what we now see on the cover of People magazine.  

Heidi Montag’s situation is definitely the exception.  But real addiction can and does occur outside of reality TV  and mainly affects those that suffer from Body Dysmorphic Disorder. (BDD) In this condition, there is a never-ending unhappiness with changes that keeps the person affected with it coming back for more. Most repeat plastic surgery patients, however, are not ill and are motivated by what I call ‘accomplishment feedback’, a normal psychological response that creates a desire for further benefits after a previous positive experience. Every retail business thrives to create that outcome. That is a far cry from a BDD illness or a ‘plastic surgery addiction’. The sheer reality of economics prevents most  people from ever crossing the line into either of these behaviors.

Ms. Montag’s plastic surgeon has also been the target of criticism.  When should plastic surgeons tell patients no? How much is ‘enough’? While many people are appalled by what Heidi Montag did and felt she did more than she should have been ‘allowed’, the answer is not so straightforward. Should McDonald’s be selling those 80 grams of fat in a burger and fries meal to anyone overweight or should home mortgages or debt consolidation services be tendered to people whose finances knowingly don’t support them?

Elective plastic surgery is medicine mixed with a good dose of business and marketing. While the safety of the patient is the number one limiting factor to the number of procedures that should be performed at a given time, it’s impossible to remove the component of ‘personal responsibility’ from the equation.  Defining what is reasonable for someone to want is akin to you telling me what I should like. While beauty may be in the eye of the beholder…what is needed to get there is most certainly in the mind of the beholden.

Dr. Barry Eppley

Liposuction remains one of the most popular and successful of all cosmetic plastic surgery procedures. Patients considering the procedure have many typical question about it and here are the most common.

How much weight should I lose before having liposuction?

Ideally, liposuction is best used as a ‘spot’ treatment for resistant areas of fat. This would imply that one should be near to what they consider to be their ideal body weight. On a more practical basis, one’s weight should be down to what can be achieved with a reasonable effort.

The ‘weight loss before liposuction’ approach is best for two reasons. First, the amount of liposuction needed will be less…and less surgery of any kind is always better than more. Secondly and most importantly, the losing weight process allows one to have made lifestyle changes before surgery. The effort to do so and the induced lifestyle changes provide for a better chance that the liposuction results will be longer lasting.

What type of liposuction is the best?

There are numerous liposuction devices currently available such as ultrasonic, laser (hot), and water jet (cool)devices. With these methods comes the associated marketing and hype that is associated with the manufacturers as well as endorsements by surgeons. In addition, because some of these devices are new, they are promoted as the latest and the greatest.

What all these liposuction technologies share is that they are used for the first phase of the surgical process…loosening up the fat…which is then suctioned out as the second phase. Whether anyone of these methods is better than another can be debated but no one can conclusively prove that one is better than another. The reason is that the technology is only as effective as the surgeon who is using it.

The current use of Snartlipo (laser-assisted liposuction) has a three or four year history of widespread clinical use. While just a promising tool a few years ago, today’s units have higher powers, temperature monitoring, and multiple wavelengths. The very sensitive nature of fat cells to heat makes this technology very appealing and effective.

 Are liposuction results permanent?

One of the common myths is that once fat is removed, it can not come back. As patients often say, ‘I have heard that once fat cells are removed, they can not return.’

This perception is false for two reasons. First, not all fat cells are removed from any area that is suctioned. That is not only impossible but unaesthetically undesireable. There needs to be a certain layer of fat between the skin and the muscles so the skin is not stuck down and tethered. Secondly, stem cells exist in fat which always have the potential to turn into fat cells if properly stimulated. Excess food intake and the need for fat storage is just the stimulus for fat re-accumulation.

The best answer is that the long-term results from liposuction are stable if your weight remains fairly stable. If you gain weight of any significance (greater than five pounds), it has to go somewhere and that will likely be from whence it was originally removed.

How much time should I allow for recovery before going on vacation or a trip?

It is quite common that I see patients who have a trip or vacation planned and want to do some body shaping before they go. The biggest mistake is to not give enough time for a ‘full recovery’. You don’t want to go on a well planned and long thought out trip only to still be sore or limited in what you can do and enjoy. Depending on the number of body areas and amount of liposuction, I would allow for at least six to eight weeks (as a minimum) before leaving. Three months is most ideal.

There are also some patients who want to use a trip to recover and their intent is to go and lay around somewhere. In this case, I would recommend one week before you leave.

Dr. Barry Eppley

In running across a copy of Nora Ephram’s best selling book by the same title, I could not help but think how many times I have heard this very phrase from patients. While we are long past Thanksgiving,  some may still be thinking of turkey in a different light…that of their ‘turkey neck’.

Many people want to improve the appearance of their neck without having to resort to a facelift. Getting rid of a neck wattle would return them to a younger look and be able to wear ties, turtlenecks or jewelry more comfortably. The fear of a facelift is a near universal one. Whether one feels that they are too young or too old for surgery, do not have time for any significant recovery or cannot afford it, many potential patients are drawn to any procedure or method that offers an alternative.

Some fuller necks or neck wattles may benefit from targeted treatment just to the neck. Such neck rejuvenation, known as submentoplasty, only works on the neck removing fat and tightening muscles. No incisions are around the ears are needed unlike traditional facelift surgery.

As we age, definition and smoothness under the chin and along the jaw line is lost. This occurs due to fatty deposits, weakening muscles and the appearance of loose skin. This results in the obliteration of a sharp neck angle, where the neck and chin meet. Often this just becomes a straight line angling obliquely down from the chin to the lower neck.

Neck skin is different from the rest of facial skin. It generally has much more elasticity and can actually contract or shrink upward after being released from the underlying muscle and fat. Given that the neck skin lies on the underside of the chin, many would think that it would fall downward and hang more after being released. But this does not generally occur unless one’s neck skin is paper thin.

The submentoplasty procedure is done through an incision under the chin. First, fat removal in the neck is done with liposuction. This is followed by midline platysmal tightening and wide freeing of the neck skin from the muscle. Whether liposuction alone or the complete submentoplasty procedure is needed will depending on the age of the patient and the quality and amount of loose neck skin that is present.

Younger patients (less than age 35), who generally have more skin elasticity and have a skin wattle because of too much fat underneath the skin, usually just need liposuction only. Middle-aged patients (ages 35 to 55) have fat deposits also but in addition have a loose or split plastysmal neck muscle and skin. This requires the full submentoplasty method of treatment. Older patients (age 55 and over) almost always need extensive neck recontouring and a facelift is needed where loose skin is actually removed.

In my Indianapolis plastic surgery experience, I have found that adequate neck rejuvenation for many patients requires some version of a facelift. But age is a key factor in determining the suitability of a submentoplasty. In patients under age forty-five, about half of them can get good results with a submentoplasty and avoid a facelift. Over the age of forty-five, however, that number drops to less than one in ten. And over the age of fifty-five that numbers drops to essentially zero.

While submentoplasties are a primary treatment for certain neck issues, it can also be used as a secondary tuck-up after a facelift. Some facelifts, particularly with really saggy necks, will often get some rebound relaxation in the submental region which is furtherest from the point of skin pull way back at the ears. A submentoplasty allows further neck refinement when the results of the facelift begin to relax.

Dr. Barry Eppley

China has long been credited for the term ‘saving face’. In Eastern cultures, in particular, preserving one’s dignity is paramount and an extremely important part of everyday life and business conduct.  Chinese politicians are, however, putting a new spin on this age-old phrase.

There is a reported surge of government officials having various forms of plastic surgery of the face. It is credited to the fact that such officials have to appear more regularly in public, including television, and they want to make sure their face appears strong and attractive. An appearance which indicates confidence and leadership.  The most common procedures being done are blepharoplasty, injectable treatments like Botox, and facial reshaping.

Despite being a communist country, the Chinese people have turned plastic surgery into a multibillion dollar-a-year industry which is growing briskly. While this may be interesting to you, you may be asking what does any of this have to do with the price of tea in China?

The similarity between the United States and China, like most every other country in the world, is that one’s appearance counts albeit for selecting a mate or getting a job…and getting ahead in that job. The importance of one’s physical appearance for career promotion and advancement is certainly influenced by the type of job  one has. Fashion models are expected to be lean attractive and weight appropriate.. Professional athletes  are expected to be muscular and fit. Business executives should be well groomed and coiffed.

But even in jobs where one’s appearance doesn’t seem to be essential, it still is. Attractive and well groomed will usually make more money and be promoted more often than those who are not. It is well known that taller businessmen have a better chance to get a job and be promoted than those who are more height challenged. The same applies to weight.  Is this fair? Of course not. But as the contemporary saying goes…it is what it is.

In Gordon Patzer’s very insightful book,  Looks: Why They Matter More Than You Ever Imagined (2008),  this bias in favor of attractiveness is called ‘lookism’. In the book, he discusses and reviews the evidence between physical attractiveness and body type and vocational success. Patzer claims that the influence of looks go way beyond the workplace, including school and home. While looks aren’t exclusively the key to success and status, they are far more important than most people suspect or want to believe.

The recent and ongoing recession of the past few years has seen a dearth of new patient interested in improving their appearance for work purposes (or so they say) and they are often quite upfront about it. They openly admit they fear job competition and displacement from younger, less experienced candidates.   Professionals today want to project an image of good health and success, and good looks are one important part of that package.

Wanting to be attractive, or even more so (just ask any model) is universal. Most people, however, want to look and feel better…not morph into another person. Today’s extreme plastic surgery examples are outside of the bell curve and do not represent the norm. Contemporary plastic surgery offers a lot of smaller and more ‘lifestyle-oriented’ procedures that really can help one ‘save face’.  From Botox to little ‘nips and tucks’ here and there, much can be done to keep one looking fresh and vibrant…and maybe just a tad more attractive too.

Dr. Barry Eppley

With the summer season nearly here, spending time outdoors and ditching those layers of cold-weather clothes has many of us worrying about how our bodies fared over the winter!. For some people, the ‘getting in shape’ process seems to never end, and for others there seem to be problematic areas that just won’t improve no matter how much they diet and exercise. Whether it be a small stomach pooch, love handles, or a little fullness on the thighs, improving these areas would not simply offer a better look, but would provide more self-confidence in shorts and at the pool.

Enter the consideration of liposuction. While most people know what liposuction is, today’s Smart liposuction is a huge step forward from the traditional standard of the last twenty years. Liposuction  is no longer a brutal beating that  you may have seen on TV or the internet. The latest advance in liposuction is known as Smartlipo or laser liposuction. SmartLipo is a cutting-edge, highly effective method to significantly improve the safety and effectiveness of traditional liposuction.  Routinely used in dental procedures, lasik eye surgery, and other fields of surgical reconstruction, laser technology is what sets SmartLipo apart from all other methods of liposuction.

Traditional liposuction uses a vacuum with a metal tube attached, which the plastic surgeon moves back and forth manually. Because the human hand is not that precise, patients can sometimes get a lot of bleeding, swelling and trauma to the tissues. SmartLipo is different in that it uses a carefully calibrated laser to liquefy fat deposits in the top layers of the skin. The laser actually ruptures  the fat cells, like a hot knife going through butter, and the resulting oily, liquid substance is then suctioned out through a tiny incision in the skin. The small laser can also seal blood vessels as it zaps fat, so there is less swelling, bleeding and bruising than with traditional liposuction….and less pain! Research has shown that little, if any, fat is reabsorbed back into the body. The more gentle technique of the SmartLipo procedure allows patients to recover faster and see the results they are looking for more quickly.

The heat from the laser also has another very valuable contribution to the final result – it helps tighten loose skin. The historical problem in traditional liposuction is that it relies on the patient having good,  taut skin to begin with. Otherwise, removing fat will simply make skin looser and to sometimes  ‘sag’ after the procedure . By heating the underside of the skin to temperatures of 45 degrees C (approximately 112 degrees F), the skin is made to shrink to some degree. This makes it possible for some people to successfully undergo liposuction today who may not have gotten good results in the past.

SmartLipo also makes it possible for many patients with smaller problem areas to require only a local anesthetic for the procedure. Traditional liposuction often requires general anesthesia. This makes it more practical for some people,  as they can drive to and from the procedure, eliminating the transportation and care needs of a typical surgical operation.

Liposuction has a long history in plastic surgery of being a very good body contouring method for the right patient who is willing to undergo the recovery. Like most everything in life, liposuction has now gotten better….smarter if you will. SmartLipo is a technological advance for certain – but it is not a miracle. One still needs to have realistic expectations about what the procedure can and cannot do. But for smaller fatty deposits, or for someone who is fairly fit to being with,  Smartlipo may be the simplest solution to regaining confidence with their body.

Dr. Barry Eppley

Enhancing one’s bust size through breast implants today is easier than ever before!….That is certainly the marketing hype and there is a lot of truth to it. But to call the recovery after breast augmentation as….no recovery….or  painless… as some advertisements suggest does not quite convey an accurate picture. All surgery induces some pain, swelling, and bruising. Breast augmentation is no different.

 Breast augmentation is most commonly done today by placing the implant under your big chest muscle known as the pectoralis. (although there is a recent trend back to above the muscle for some plastic surgeons as silicone gel implants have become available again) By putting the breast implant under the muscle, it is stretched, bruised, and even some fibers are cut. This makes the muscle sore, swollen and difficult to stretch. This also makes the upper arm hard to lift up very far. In essence, breast augmentation makes the muscle stiff and sore. It is not the incision that causes any discomfort, it is the muscle.

While breast augmentation can not be completely pain and recovery free, rebounding from the surgery and getting back to normal activities definitely can be accelerated. This is made possible by doing something to the muscle after surgery…early and aggressive physical therapy. Breast augmentation physical therapy starts the night of surgery and consists of range of motion exercises of the arm. By early stretching of the arm in circles and by raising the arm from one’s side to the level of the shoulder and above, the pectoralis muscle is mobilized. Stretching helps loosen up the injured muscle fibers and prevent restrictive scar formation. The more you move, the quicker you will recover. Just like pulling a leg muscle, the earlier you begin to stretch and use it the quicker you will get over it.

This form of pectoralis physical therapy, combined with anti-inflammatory drugs such as Alleve and Ibuprofen, allows one to get moving very early. While swelling, a little bruising, and some pain can be expected, early physical therapy can lessen its effects to just a few days. Even in the worst-case scenario, one should have a significant recovery by one week after surgery.

One other helpful recovery aid I use in my Indianapolis plastic surgery practice is the ActiPatch anti-inflammtory device. This is a small battery-operated battery device that emits pulsed electromagnetic fields  that penetrate the breast tissue and help reduce swelling and inflammation. I have started my patients wearing it for the first 36 hours after surgery. It is easy to wear it inside one’s bra as the loop fits over much of the breast  mound.

Rapid recovery breast augmentation is a reality through a combination of early physical therapy, anyi-inflammatory medications, and the ActiPatch device. Significant recovery should now be a matter of days not weeks.

Dr. Barry Eppley