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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

I have heard many patients say “Can you fill up my lips with Botox’ or ‘I need a filler between my eyes to stop me from frowning’. This confusion comes from the fact that all these in-office anti-aging treatments come out of  a needle. But the reality is not all that comes out of a needle is the same. While such confusion is understandable due to the relative newness and apparent similarity of these injectable treatments, that is a little like saying that one scalpel can do all the same surgeries. Injectable agents are treatments which have different mechanisms of action, even if the end result is often times similar. (facial wrinkle or fold reduction)

To clear up the confusion, I often explain to patients the difference between static wrinkles and dynamic wrinkles that appear on one’s face. Dynamic wrinkles are those wrinkles and lines that appear when your face is moving or expressing yourself such as smiling or frowning. When we were younger, the only lines and wrinkles we had were dynamic. Our face was otherwise wrinkle-free when we weren’t expressing ourselves. Static wrinkles are those facial lines that are evident even when our face is not moving. All dynamic wrinkles, with time, will eventually lead to static wrinkles. When we are older, those static lines look even worse when they become dynamic. What looks cute on a child’s face when they laugh, decades later, will someday be viewed quite differently.

These two types of wrinkles are what separates Botox and any of the injectable fillers. (e.g., Restylane, Juvaderm and eight other brands) Botox is for dynamic wrinkling. It is a muscle-paralyzing or muscle weakening agent so it will soften the wrinkles and lines that occur from a dynamic facial movement, such as between the brows with frowning….or the crow’s feet around the eyes from smiling. Injectable fillers are for static wrinkling. They soften lines and larger wrinkles by plumping them out so they look less evident at rest. In some cases, the combination of Botox and fillers are used at the same when the line or wrinkle is very deep and weakening the muscle action will help preserve the longevity of the filler material but not being ‘beaten on’ by continuouosmuscle movement. This dual combination is almost exclusively in the furrows between the eyebrows from frowning. (also known as the ’11 sign’)

One other important difference between Botox and injectable fillers is where they are used. Botox is primarily a ‘northern’ facial procedure used on the forehead and around the eyes. Injectable fillers are a ‘southern’ facial procedure, used mainly around the mouth.

Feel free to contact me and get a free copy of my book on this subject entitled ‘INJECTING YOUTH’.

Dr. Barry Eppley

The plastic surgery treatment of the aging face often involves a facelifting surgery. A facelift is one of the top ten cosmetic procedures performed in the United States. Despite its frequent performance and its recognition by the public, it is a procedure that is usually misunderstood.

The most common misconception of a facelift is that it does very little for much of the face. It is a procedure that has its impact on the neck and jowl areas. The rest of the face is untouched by the operation. While other procedures are often done with it, such as eyes and brows, these procedures are not part of the a traditional facelift operation. A facelift should more properly be called a necklift or a neck-jowl lift.

Another misconception about facelifts is what is actually lifted. Everyone understands that face and neck skin is lifted and moved back, but what goes on underneath the skin layer is a frequent point of misinterpretation. Patients often ask me if I am going to lift and tighten the ‘muscles’. From an anatomic standpoint, lifting the facial muscles is an impossibility. Most facial muscles are attached tightly to the underlying bone and moving them would not only be very difficult but would not have any postive benefit. There is only one muscle that is often tightened in a facelift and that is the platysma muscle in the neck, which is often separated due to aging. It is never lifted per se but it is tightened in the middle, from the chin down to the adam’s apple, to help sharpen the neck angle.

The layer underneath the skin that patients misinterpret as muscle being moved is actually a different tissue altogether. Between the skin and the muscles is a layer of tissue known as the SMAS. This is an acronym for a more anatomic name but for simplicity of understanding think of the SMAS as another layer of skin underneath. This layer can be raised up off the muscles and resuspended up higher on the face. The combination of SMAS and skin tightening together generally makes for a better facelift result that may last somewhat longer. 

There is great controversy in plastic surgery about how to most effectively deal with the SMAS during the facelift operation. Many facelift surgeons tout their own techniques and may even have their own names for their ‘type’ of facelift based on their version of SMAS manipulation. While SMAS management in any form of a facelift is a plus, there is no proven superior method of what to do with it. If one single SMAS facelift technique was genuinely best, we all would be using it.

In a facelift, the underlying tissues that are manipulated is the SMAS layer not muscles. SMAS tightening does usually make for a better facelift result that is more durable. However, time and aging will eventually outlast any facelift result no matter how it is done. And the overall goal for most patients is to ultimately outlive their facelift result….or at least I would think so.

Dr. Barry Eppley

Breast reduction is one of the most common plastic surgery procedures in the United States. Reduction of large breasts provides immediate and long-term improvement in back, shoulder, and neck pains that come from a woman having to carry around the equivalent of a rope around their neck with several pound bags hanging from them.  Despite the common performance of the breast reduction  operation, there are numerous misconceptions and misinformation that surround the procedure. Here are the top five breast reduction myths.

Breast reduction causes a lot of pain after surgery. Despite what many paients fear, breast reduction is not associated with much pain after surgery. There certainly is some soreness  and discomfort, but acute and unbearable pain just does not occur. Since breast reduction is about the removal of skin and breast tissue, not muscle or bone, pain is far less than what many women fear.

 My breasts will still sag after surgery even though they will weigh less. Breast reduction is a combination of a reduction AND a breast lift procedure. The surgical technique o f breast reduction involves an entire reshaping of the breast, upward nipple repositioning along with breast tissue removal. Beast lift procedures are essentially the same operation but without any breast tissue removal.

 My nipples are removed during the operation and are put back in place at the end. In general, this is rarely done.  In the most commonly performed method of breast reduction, known as the inferior pedicle technique, the nipples are left attached to a central mound of breast tissue. Breast tissue and skin is removed around it. Keeping the nipples attached keeps them alive and preserves feeling in them. In a less common breast reduction method, known as free nipple grafting, the nipples are in fact removed and put back later. But this method is only done in very large breasts in which the nipples are in danger of survival with the traditional inferior pedicle method of breast reduction.

 I won’t be able to breast feed or feel my nipples after a breast reduction.  In the inferior pedicle technique, the nipples (and their underlying glands and nerves) remain attached. Thus, the nerve supply to the nipple is maintained allowing for sensation, the ability of the nipple to get erect, and to be able to breast feed. There is always the risk that even with the nipples remaining attached, the nerve supply to the nipple will be injured from removing breast tissue from other areas, but this is not common. (although a possible risk)

 My insurance won’t cover my breast reduction. No one, patient or plastic surgeon, can predict with any accuracy what any insurance company may do. This is why the submission of a pre-determination letter from the plastic surgeon in absolutely necessary in all cases. Your insurance company has very specific criteria for what qualifies someone for breast reduction (they all do) and the pre-determination letter must have all your information (breast size, symptoms, amount of breast tissue to be removed) to see if you qualify. My experience has been that over 80% of patients get approved on the first submission.

Dr. Barry Eppley

The greatest misconception about facelift surgery is that it does very little for what most people think of as their face. A facelift is really a neck and jowl lift, changing only the lower third of the face or the neck. Facelift surgery is also not a ‘one size fits all’ operation. Facelifts come in a variety of variances that are customized to the each patient’s specific problems. Subtle differences in each facelift do make each one a little unique.

Despite many nuances in each patient’s facelift surgery, they are done in fundamentally two ways or types, limited and full. The differences lie in how much work is done in the neck area.

Limited facelifts affect mainly the loose skin in the jowls with some minor effect on the neck. Often neck liposuction is done as part of the procedure. This type of facelift has become popularized by different surgeons and companies that implies its simplicity and ease of recovery. Despite these name differences, they are are essentially the same operation. It is a good procedure for those who have early to moderate signs of face (neck and jowl) aging. The recovery is quick, one week or so, and in my Indianapolis plastic surgery practice the limited facelift makes up about one-half of all facelifts that I do.

A full or traditional facelift is an extension of the full facelift. More skin is undermined in the neck and the platysmal muscle is often sewn together as well. It is reasonable to think of a full facelift as about twice that of a limited facelift. The surgery is twice as long, the amount of work done is about double. This is a better procedure when one is older and the facial (neck and jowl) aging process is more advanced. If you have significant loose skin in the neck, then a full facelift is probably needed.

One of the fears that many patients have is that a facelift involves a lot of pain, swelling, and an extended recovery. In reality, this is simply not true. One of the main reasons people think this goes back to a basic misunderstanding of what a facelift really is. (it does not involve any operations above the mouth…..while many other facial procedures can be done with a facelift, they do not count as a facelift) Isolated facelifts are much easier to go through than most imagine. Even a full facelift takes only slightly longer than a limited one.

Unfortunately, the fear of what a facelift may entail after surgery prevents some people from even considering this very effective procedure. Once I explain in detail the type of facelift a patient may need and what is really involved to go through it, these fears subside and the process to get what one wants is no longer so daunting.

Dr. Barry Eppley

With spring now in the foreseeable future, many people will be thinking about getting ready for the summer. As part of some get ready lists, removing unwanted body and facial hair works its way up that list. With the method of laser hair removal widely available, many will seek out these treatments. While laser hair removal is a good treatment method for many, the marketing and advertising claims frequently do not give an accurate reflection of the facts and the science behind it. 

Laser hair removal should be best thought of as a hair reduction method. While some patients do get a high percentage of permanent hair reduction, the concept of permanent and complete elimination of hair is not accurate. The biology of hair growth and the way the laser light works makes this very difficult to achieve. When laser hair removal first came onto the scene in the early 2000s, this was naively widely touted. We now know better. If you can live with 50% to 90% reduction in hair, then laser hair removal may be for you.

Not all hair responds well to the laser. Like a black colored car that attracts sunlight and gets very hot, it is all about driving heat down to the growing hair bulb. For this reason, dark colored hair with fair colored skin always works the best. Blonde, gray, white, and red colored hair is not reduced as much because it is a ‘poor’ target. Expect less hair reduction if this is your hair color. Conversely, dark colored skin picks off some of the laser light before it can get to the hair bulb. (which actually is below the skin) Because higher energies of laser light is needed to get past the pigment in the skin, there is a slightly higher risk of skin burns and irritation.

Laser hair reduction requires a series of treatments to be effective. Because the laser will only knock out hairs in an area that are actually growing (less than 10% of your hair in any area is actually active at any one time), a series of treatments over time is needed. A general rule is that it will take 5 or 6 treatments over a 6 month period to get the best result. So while spring may bring hair removal to mind, you ideally should have started last fall! 

Long-term maintenance treatments may be needed in many cases. Hair that was initially suppressed by laser treatments can get activated later in life with hormonal changes or medications that one may be taking. While this seems to be contradictary to the way most people think lasers on hair works (frying the hair bulb so that it is ‘killed’), the reality is that the laser changes the hair growth cycle and teaches it to grow differently. Often times, it changes a thick dark hair to a fine and clear baby hair. But certain changes in life can reactivate its original growth cycle making you see hair ‘coming back’.

Laser hair treatment is commonly done for both women and men. (men and back hair make up about half of the patients that we see) While it can be very effective for the right person, proper knowledge and education will determine if laser hair treatments are a good or better value over traditional waxing methods.

Dr. Barry Eppley

Due to the marketing and appeal of a facial rejuvenation procedure called the Lifestyle Lift, many people have at least heard of it. A scaled-down version of a facelift, the Lifestyle Lift is not unique or new but is actually a common procedure performed by many plastic surgeons. Todays trend toward less invasive plastic surgery and beginning facial rejuvenation earlier has led to the marketing of an otherwise routinue facial procedure.

Unknown to most, the Lifestyle Lift is a branded name and is a blended marketing and service approach to delivering minimally invasive facelift surgery. In essence, it is a franchise approach to selling surgery with office locations in 22 states. (the closest office to Indy is in Cincinnati)

While there is nothing wrong with that concept, the Lifestyle Lift company was recently fined $500,000 in New York where its corporate headquarters is located.. The attorney general there has settled complaints against the company as it has admitted that it used its employees to pose as satisfied customers in online ads. Apparently the company ordered employees to write positive reviews of the Lifestyle Lift on message boards and other internet forums to appear as unsolicited testimonials and endorsements, thus violating consumer protection laws. (proving once again that www. really means the wild wild west…believe at your own risk!)

While the company and the way it operates may have some deceptive marketing practices, the actual operation however is still a sound one. The limited facelift or short scar facelift (a.k.a Lifestyle Lift) is very popular and highly successful. It is a scaled down version of a more extended facelift into which many other smaller facial procedures can be added as well.

Younger patients today want to treat jowl and neck sagging early rather than wait until it looks worse. Therefore, their facial concerns are less severe and they do not need a full facelift operation. The limited facelift is often combined with other smaller procedures (e.g., Botox, injectable fillers, laser resurfacing, neck liposuction, eyelid tucks) to create an even better overall result without extending one’s recovery.  Older patients (who really do need a bigger operation but do not want it) can still get a simpler and less invasive operation that will provide some real improvement. (although less than that from a full facelift) This usually fits their financial situation and allows them to have surgery that they can afford with a recovery that fits into their work or leisure schedule.

Dr. Barry Eppley

In researching a plastic surgery topic this week, I came across an entertainment article in which the writer presented an opinion on the top ten plastic surgery disasters in men. Using photographs, they compared the ‘before’ and ‘after’s of several well known male celebrities- of which there is no doubt that these men have had facial work done. And I am not referring to in-office procedures such as Botox and injectable fillers. All had obvious surgical manipulation of aging facial features.

Those listed are well chronicled and include often cited celebrities such as Kenny Rogers, Gary Shandling, Carrot Top, Sylvester Stallone, Bruce Jenner, Burt Reynolds and Gary Busey to name a few. While I am certain that they don’t feel unusual looking, most women would disagree. This begs the question of what is it that makes them look unnatural? Is there a common problem that they now all share?

In reviewing these pictures it appears the problem lies for many of them in the work around the eyes and cheeks. On the whole, the appearance of these men has changed to more of a feminine look. This is the result of a variety of changes that include over-elevation of the brows, a ‘pulled too tight’ appearance around the eyes, and unnatural cheek bone augmentation giving an ‘apple-cheeked’ effect.  The neck and jowl lines, while no longer sagging, have changed them. In an effort to rejuvenate the aging and sagging face, they have been overlifted and plumped up too much.

This may make the skin much smoother and eliminate a lot of skin wrinkles and folds, but the end result is anything but ‘natural’ in appearance, and is a red flag that screams ‘facelift!’ to even the least discerning eye. Certainly, men care about their appearance as they age, and want to look as young as they feel.  With regard to celebrities, it’s a usually a foregone conclusion that plastic surgery is a necessity in order to keep pace with the up and coming younger entertainers.  However, great work – and natural looking results are never a guarantee in Hollywood surgical circles, and paying top dollar to a well-known or famous surgeon really has nothing to do with the final outcome.

To get a natural looking result in men, facial rejuvenation really has to be ‘underdone’ in comparison to that of a woman. Women can aesthetically tolerate more significant facial changes.. The goal of very smooth skin and sleek facial features simply looks better on women. Even when women have gone too far, they rarely look as bad as what can happen in men. Nips and tucks are very helpful to slow the aging process down in men, but dramatic sweeping changes simply trade-off one problem for another. Facial rejuvenation in men illustrates the age-old concept that less is often more.

Dr. Barry Eppley

Breast cancer remains a threat to every women and the emphasis on early detection can not be overemphasized. As October and Breast Cancer Awareness Month has now passed, the upcoming holiday season may temporarily displace some of these concerns. Plastic surgery throughout the year, however, plays an inadvertent but beneficial role in the detection and management of this disease.

Breast reduction remains as a very popular and commonly performed plastic surgery procedure. It provides a dual reconstructive and cosmetic benefit by making the large breast better shaped and more uplifted and improving back, shoulder and neck pain by size reduction. As part of the reduction procedure, breast tissue removed is almost always sent to the Pathologist for examination. While I have yet to have positive cancer findings from submitted breast reduction tissues, reports exist that it is occasionally found.

The finding of breast cancer during a reduction procedure can occur in two circumstances. The first is during the course of the operation some suspicious tissue is found and sent to pathology for an immediate evaluation, known as a frozen section. The second is when the submitted tissues are examined by the pathologist and cancerous tissue is found. A recent study report has shown that the finding of breast cancer or precancerous tissue in pathology specimens existed in 12% of the patients studied in one treatment center.

This is a rather surprising finding given that prior published reports have not shown such high caner rates of cancer detection in breast reduction patients. However, given the relatively high incidence of breast cancer in women, it does seem logical that a significant number of yet symptomatic women have the disease.

This raises an interesting and  obvious question. Does breast reduction surgery decrease the incidence of breast cancer? Will it decrease the risk of some women from eventually getting this disease? The answer to that is an emphatic yes….for some but not all women.

This question has been looked at and reported on in 2004. A study published in the pretigous journal of Plastic and Reconstructive Surgery reported a difference in risk of breast cancer after breast reduction surgery. This appears to be especially true in women who are over 40 years old at the time of surgery. Risk of cancer reduction in this age group was 28 to 50 percent. No reduction was seen in women having the surgery before the age of 40. Although the complete removal of a woman’s breasts (prophylactic mastectomy) can virtually eliminate the risk of breast cancer, most women find it extremely difficult to elect to remove all of their breast tissue. Women now have an additional preventative option to have their breasts partially reduced rather than removed. This represents a real alternative for someone who is a candidate for breast reduction, even though the amount of tissue removed may be small.

Given the occult incidence of breast cancer found in the pathology of asymptomatic women during routinue breast reduction surgery, this can be viewed as an additional benefit of the operation. However, I would emphasize that breast reduction is a risk reducer, not a preventative guarantee.

Dr. Barry Eppley

Since its commercial availability since 2002, Botox has revolutionized wrinkle treatment of the face with emphasis on improvement in the forehead and eye areas. There are few people who would not recognize the name, even if they may not understand what it exactly does.

Botox is so effective (although only temporary) and simple to do, it has given rise to an entire industry of treatments, cosmetic practitioners, and business models based out of strip malls to doctors offices. Billions of dollars of annual revenues have been created out of what is essentially a chemical poison. But the doses used are so small to treat wrinkles that it is harmless to humans. But calculated out per pound, Botox would roughly cost a trillion dollars… making it the most expensive material on the planet.

With such a proven and desireable commodity, it is no surprise that other manufacturers have been feverishly working on coming up with a competitive product. The recently available Dysport can now stake its claim as second in line. Whether it will make a significant dent in Botox’s business remains to be seen.

Dysport is not new and has been used around the world for years. In those countries where Dysport and Botox co-exist, the market shares of each are not that different. But Botox in the United States has tremendous brand awareness and a huge headstart. As a result,  it will likely be the ‘Coke’ for a long time in facial wrinkle treatment and Dysport can best hope to become ‘Pepsi’ in time.

Like any new product, Dysport must seek a marketing edge. Claims have been made that it lasts longer and costs less…the holy grail doctrines of the cosmetic industry. But a close look at the scientific studies and available evidence on Dysport does not support those marketing theories. The company does not actually claim them as the FDA would not allow such unsupported statements based on the studies that were submitted. Such claims appear to be the propagation of rumors and hope… and zealous physician marketing. In my experience, Dysport appears to be a good but equivalent treatment to Botox. In time, it may show a few select advantages (or disadvantages) but they are not obvious yet.

While competition usually drives down price, that does not appear to be the case in this battle of wrinkle reducers. Because they are given in different doses, it is not even possible to compare Botox and Dysport prices on  a unit basis…which is how they are given by injection. Because Dysport is new to the public, it is natural to assume that it may be better. Its value at this point, however, appears to be as a treatment alternative for those few patients who are either resistant to or becoming less responsive to their current Botox injections.

For those patients clamoring for a cheaper and better Botox, Dysport will not be the new fountain of youth.

Dr. Barry Eppley

An important concept in cosmetic plastic surgery is that of value. In short, what are you getting for your money?  The importance of a good return on one’s investment is one factor of how you will interpret the result and the experience.

While talking frankly about a patient’s expectations before surgery remains the cornerstone of good ‘doctor-patient’ communication and goes a long way toward a patient’s satisfaction afterwards, the ‘value’ concept in plastic surgery is often overlooked. What is the inherent value or lifespan of the operation or procedure? In other words, how long will the results last? Interestingly, this will vary greatly amongst the many surgical options available.

Certain plastic surgery procedures have tremendous value because they will essentially last a lifetime, almost regardless of the patient’s lifestyle postoperatively. In this category would be procedures such as rhinoplasty (nose job), otoplasty (ear pinning), and facial implants (e.g., chin implant) for example. Once these changes are made, barring complications, they are permanent and will never change no matter what the patient’s lifestyle. The same can almost be said for breast augmentation and abdominoplasty (tummy tucks), although how permanent these results are is influenced by the patients’ age at the time of surgery.  If a woman is done having children, these two operations can have a long lifespan with little change. If you amortize these more ‘permanent’ procedures over one’s remaining lifetime, they can become well less than a dollar a day. It is hard to find anything you could buy that would last so long at such a low lifetime cost.

More moderate lifetime value plastic surgery procedures are those which can be influenced by one’s lifestyle…the potential for weight gain and a lack of care for one’s self. Liposuction is the leader in this category. While immediate postoperative changes can be quite gratifying, the short and long-term benefits of the procedure are only going to be as good as long as the patient continues to support their original investment ( proper nutrition and exercise).  Any anti-aging facial procedure, such as a facelift, browlift, or blepharoplasty (eyelid tucks), falls into this category because it treats the symptoms of the problem and not the actual problem itself – aging.  Therefore, time will always outlast the surgical benefits (and I would argue you want to outlive how long these operations will last!).  The value of these procedures must be judged more in the intermediate term (5 to10 years) and the cost must be averaged over this time period, which makes it a few dollars per day.

Ironically, those procedures that have the shortest value period (Botox, injectable fillers) have become tremendously popular during this decade. While Botox lasts just four months, its cosmetic uses account for nearly a billion dollars in sales nationally. These very short value procedures overcome the economics due to how easy they are to administer, immediate results, and lack of any recovery from them. In other words, an instantaneous fix at a relatively low cost (compared to actual surgery) increases their relative value.

While elective cosmetic plastic surgery decisions are really emotionally driven, it is interesting to look at their economic value in terms of the lifespan of their results. Such considerations are not a major determining factor in the decision for surgery but may help in deciding if a certain procedure is ‘worth it’. 

Dr. Barry Eppley

There is sure to be much discussion about a provision in the U.S. Senate’s version of Health Care Reform which would impose a tax on elective cosmetic procedures. With a tax rate of 5%, the measure presumably will raise close to $6 billion of the projected $850 billion price tag of the healthcare bill (most analysts agree that this projected cost is fancifully low).

Given the name of “Botax” by many, the intent of it is to clearly tax those who can ‘afford’ to pay it…some call it a tax on the wealthy. But those who do so clearly have no idea who really makes up the cosmetic population. The Botax name is a clever variation of Botox® facial injections which have become the beacon procedure for non-surgical office procedures used for wrinkle reduction. In theory, the Botax could impact about 12 million cosmetic procedures and surgeries performed each year in the U.S..

As one would expect, all sides of the cosmetic surgery industry from physicians to patients are voicing opposition. Their argument is that such a tax unfairly targets the middle class and working women in particular. Statistics from the American Society of Plastic Surgeons (ASPS) show that only a minority of people who undergo any form of cosmetic surgery has a household income greater than $90,000 per year and the vast majority (greater than 80%) are women between the working ages of 18 to 65. Clearly this is not a tax on the wealthy and is a discriminatory tax that falls largely on women.

While the idea that it is a tax on the wealthy is fallacious, it is a tax on the healthy. Contrary to what many would guess, the vast majority of cosmetic procedures are done are health-conscious individuals. Most are already reasonable fit and are ‘appearance focused’.  The obese, smokers, diabetics and other ‘unhealthy’ patients make up just a fraction of those people ever undergoing cosmetic procedures or surgery. This proposed discriminatory tax is targeting those who do take care of themselves to help some who have made poor health choices along the way. It would make more sense to tax unhealthy food items, for example, that have incredibly high fat content…and it would bring a hundred fold increases in revenue to support health care reform.

This type of tax proposal is also troubling because it treads on choppy waters that health insurance companies have trouble deciphering.  What is the official or tax definition of a cosmetic procedure? IRS rules for tax deductions state that any procedure necessary to treat a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease is a medical procedure. Anything else is a cosmetic procedure. Some delineation is quite clear- Botox® used for wrinkles or for migraines for example. But what about a tummy tuck to treat the effects of pregnancy?   Are the effects of childbirth on a woman’s abdomen a cosmetic or reconstructive procedure? 

With so many differences between the House and Senate Health Reform bills, it is difficult to say what will eventually shake out. But this hidden tax will largely penalize health conscious women. It is a troubling signal of how far reaching your legislators will go to get more of your hard earned money. And once again the beneficiaries of your ‘generosity’ will likely be those that have sacrificed less.

 Dr. Barry Eppley

Some may have read the recent story of a 38 year-old ex-Miss Argentina who died from complications after undergoing plastic surgery on her buttocks. Solange Magnano, who won the crown in 1994, died of a pulmonary embolism three days after having buttock augmentation in Buenos Aires.

For many, this tragic story points to the inherent dangers of cosmetic surgery and that someone risked everything she had in life for a more firmer behind. On the one hand, there is some truth to that perception.  Surgery of any kind always involves some risk. The potential for deep vein thrombosis and pulmonary embolus has become a big prevention emphasis in any kind of surgery these days.

But the ex-Miss Argentina did not die from a vein-clot related pulmonary embolism.

Closer inspection of this story shows that she died from a lung embolus that resulted directly from what was injected into her. When I first read this story I thought this woman died from a fat embolus from having had buttock enlargement by  fat injections. It is rare but fat emboli have been reported to occur from liposuction and fat injections. But when pictures showed how thin she was, it became obvious that she had not enough fat to use. What was not printed was that a liquid filling material that contained tiny beads was used. Such a material is used here in the United States for facial injection purposes, but never anywhere else in the body. With many thousands of beads and clumps of beads injected, it would be very easy for some of them to get into the larger veins in the buttock…and be transported right upward through the heart into the lungs. Such a risk does not exist in the face where such materials were developed and intended for use.

What does this story tells us about the risks of cosmetic surgery? Does it indicate that cosmetic surgery is inherently dangerous? The answer is no…when done under the proper circumstances with good medical judgment. Almost everyone of these tragic stories that I have seen in my years of practice ends up showing some breach of the known standards of care. Whether it be how the surgery was performed, by whom, or in what type of setting and circumstance, violating established methods and standards of care can have catastrophic results.

Cosmetic surgery is real surgery…and there are no shortcuts. Sacrificing safety for what appears to be easy and quick has not usually proven to be a good trade-off.   

Was the death of the ex-Miss Argentina preventable? By not doing the surgery… for sure. But if the surgery had been done with proper methods and materials (or not done at all if there was not enough fat to be used), the risk of such an outcome would have been no higher than a similar fate occurring from an accident while driving to work everyday. Outside of the United States, there are few rules governing what ‘cosmetic doctors’ do.  In the United States the plethora of regulations and training requirements for plastic surgeons, while certainly contributing to costs, go a long way towards a much safer experience.

Dr. Barry Eppley

Liposuction continues to be one of the most popular plastic surgery procedures. Without question, significant changes in one’s body contours can be achieved. The marketing and promotion of liposuction across all types of media strongly suggest that it is a precise surgical procedure. Inferences are not subtle that surgical fat removal is equivalent to sculpting or the chiseling out of body parts.

While some body areas can be sculpted, most liposuction results are not like art work. The body is not a bar of soap nor a block of marble. And most patients will not end up like the model that appears in an advertisement. The outcome of a liposuction procedure is certainly influenced by the surgeon performing it and the tools that are used. But there are numerous logistical factors that will always limit the exactness of the results that can be achieved.

The topography of the treated area is one important factor. Most of the body is not flat but rather a curved surface that has different thicknesses of fat as it curves around from area to another.  This certainly makes it difficult to always ensure evenness of fat removal, particularly when the removal is done with a straight cannula.

Liposuction surgery is almost always done with the patient in the horizontal position.  While this does not affect some body areas such as the stomach, such positioning allows most fat collections to shift backward and become distorted as they lie pressed up against the operating table. The concept of ‘standing up’ liposuction is theoretically appealing but currently impractical.

Skin quality remains a very important determinant of liposuction outcomes. Looseness of skin, stretch marks, and cellulite over a treated area does not bode well for the needed skin contraction of deflated areas. One must appreciate that it is highly likely that the smoothness of overlying skin will never be better after liposuction and, in some cases, can be made worse. Liposuction, by any method, is not a treatment method for cellulite as some patients mistakenly believe.

To work around these limitations, there are some presurgical and intraoperative  techniques that are used to get the best results possible. Marking the surgical sites immediately prior to surgery is critical. One must look at the planned treatment areas like a topographic map. The marks will indicate how far one has to go as the body areas shift and distort when one lies down. Marking the high and low spots also indicates how much time should be spent or tissue removed from one encircled area to another. Positioning the patient on the table can help see the marked areas more ‘three-dimensionally’. For example, it is better to treat the lateral thighs or the flanks with the patient turned on one side. While this is more difficult for the surgical team, it is the best way to avoid seeing irregularities and missed areas of fat when the patient is seen standing weeks later in the office.

While new liposuction technologies appear fully capable of improving how well and even fat is removed, they are not magical devices. The use of laser liposuction (a.k.a. Smartlipo) is one example of how using a thermal approach (melting and liquefaction) may produce more consistent and even fat removal. The heat that it creates is promising for helping skin contraction, but it will not transform skin that is already damaged.

Liposuction is an improving plastic surgery technique but it is not yet an absolutely precise art. Patients should appreciate that perfect symmetry and evenness throughout a treated area can not be guaranteed and the desire for secondary improvement through touch-up procedures is not rare.

Dr. Barry Eppley

We are exposed everyday to incredulous claims about health and cosmetic products and services. Advertisements from radio to infomercials bombard us on the weakest aspect of our inner selves…how we look and feel. We all want to look better and feel healthier and to do it with the least effort possible. It is this cross between desire and effort that results in many retail sales that usually benefit the manufacturer or seller the most.

I saw an infomercial just yesterday on an abdominal stimulator device. Being able to read a book, watch TV, or even eat dinner while the device delivers perfect abs certainly seems appealing. With testimonials by six-pack endorsees and seeing their abdominal muscles twitch through their nearly transparent skin made even me as a physician a near believer. After all, their muscles were actually moving and surely that is more muscle activity than I can produce with a series of half-hearted sit-ups. But the price was the clincher…$14.95! Six-packs at the price of less than a week of Starbucks…how could one go wrong?

Or the radio commercial from earlier in the week where another topical potion espouses how it can make cellulite and stretch marks disappear…and it starts working with just the first application! After all, it is so effective that it was given away in bags at a recent film festival. If that isn’t scientific evidence then I don’t know what is. The demon of many a women’s belly and thigh skin, the search for an effective treatment for cellulite and stretch marks has been more elusive than real evidence on Ghost Hunters.

But grandiose claims about cosmetic surgery are not so apparent. Because these services are provided by physicians and always cost more than $19.95, the public’s acceptance of treatment claims is far less discriminating. The use of needles, sophisticated lasers, and actual surgery strongly suggest that the desired outcome will surely happen.

The last decade has seen the merging of two highly compatible themes- busy lifestyles and non-invasive to minimally-invasive cosmetic procedures. The potential for big improvement in appearance with little to no recovery time is the cosmetic holy grail. The concept of a little effort (time, money, and pain) with a big result is what most patients want. But short of Botox and injectable fillers, most other hyped ‘quickie’ cosmetic treatments fail to deliver so successfully.

Lunchtime surgery and weekend recovery procedures, while providing some benefits, do not produce results that are as dramatic and long-lasting as many of the established and well known cosmetic surgery procedures. One really cannot get inches off one’s waistline in a few weeks without real liposuction or a tummy tuck, breasts will not grow larger or become uplifted with pills and injections, and that neck wattle won’t disappear with a laser treatment, suspension sutures or an exercising device. The allure of some of these procedures preys on exactly what that infomercial does…the greatest selling tool of all time…hope.

Marketing is an essential part of elective plastic surgery and all cosmetic procedures. But when the promotional content gets ahead of proven medical science, it is almost always too good to be true.

Dr. Barry Eppley

Breast Augmentation continues to be one of the most sought after of all cosmetic procedures. While the idea of making a breast larger is conceptually simple, there are several choices that women have to make. What type of implant (saline vs. silicone), what size implant, what amount of implant projection, and whether to have it placed above or below the muscle are the major decisions. Women are also interested in knowing what the experience was like afterwards. Dr. Eppley discusses breast augmentation in this Doc Chat radio show and interviews several women about their experiences and feelings about having been through the procedure. Listen to this show to hear what actual patients have to say about their breast implants and what the process was like for them!