Your Questions
Your Questions
Q: Dr. Eppley, Can you please tell me if you perform buccal lipectomy and if so, how many he has performed? Thank you.
A: I have performed well over a 100 cases of buccal lipectomy procedures in the past twenty years. A buccal lipectomy surgery is very straightforward and uncomplicated to perform. There is no real risk to performing the procedure and I have only seen one infection in my 100 plus cases. (1% infection risk) I have not seen any cases of buccal nerve injury.
The key to a successful buccal lipectomy is one of patient selection. Determining who will and who will not benefit from the external facial change that the procedure can create has both short and long-term implications. The concern today with a buccal lipectomy is that it may result in facial gauntness as one ages. Since facial fat is lost as one ages, removal of the buccal fat pads in youth can result in a sunken face look decades later. This is why it should be only considered with caution in younger leaner people. It is ideally best done for patients that have fuller rounder faces who appear to be genetically predisposed to a natural rounder face
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very wide face and protruding cheek bones and it’s always been an insecurity of mine. I’ve also always has chubby lower cheeks.when I smile my cheeks tend to protrude a lot which makes my profile look very awkward. I really want to have a slimmer more masculine face/jawline. I’ve also been considering a lip lift to shorten the gap between my upper lip and nose, and a nose job for a slimmer less bulbous nose. What surgeries are right for me? And what combination of surgeries are safe to perform simultaneously?
A: When it comes to fullness of the lower cheeks, which are below the cheekbones and down closer to the side of the mouth, a defatting approach is needed. Given your pictures and the fullness that runs from just below the cheekbone almost down to the jawline, I would recommend the combination of a buccal lipectomy and perioral mound liposuction. These two together are the most you can do for helping change a round face to a more V-shape based on soft tissue changes only. It is also important to remember that the thickness and quantity of skin also plays a role so there are limits as to what facial defatting can do.
When it comes to a rhinoplasty and a subnasal lip lift, I do not recommend that these two procedures be done together. This has to do with ensuring good blood flow into the intervening columellar segment. They will need to be staged or done separately.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a year ago I made a big mistake, I had a buccal fat removal operation (buccal lipectomy) and now I’m really sad about the results. My cheeks are too sunken and this makes me look older. I was reading an article you had written where you said that there two solutions for the buccal lipectomy defect. To add volume where my buccal fat was is it better a dermal-fat graft or fat injections? Will this leave scars on my face?
A: To restore lost volume from an over aggressive buccal lipectomy you can either do fat injections into the buccal space or place an actual dermal-fat graft into the original buccal space. One harvests the fat by liposuction (injection) while the other by an excision. (dermal-fat graft) A dermal-fat graft creates more assured volume but does leave a scar somewhere in your body to harvest it. For this reason many patients may initially opt for the fat injections. Either approach will leave no scars on the face as they are done from inside the mouth….just like your buccal lipectomy was done. In short, restoration of a buccal space defect must replace like with like…or fat lost with fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to remove fat from both sides of chin and redefine my jawline and make my face symmetric again. I had a procedure 3 months ago to remove fat from my cheeks (bichat fat) in order to make it look thinner. I did not attain the expected results as my face doesn’t look thinner but is now asymmetric and it looks like I have a lot of fat on both sides of my chin (makes me look older!). Can you please help?
A: Often surgeons think that taking out the buccal fat pads will make a face thinner when the fullness problem is actually much lower. There are two separate fat compartments between the cheek and the jawline, the well encapsulated globular buccal fat pads located just under the cheek bone and the more superficial and less volume perioral mounds located just under the skin besides the corner of the mouth and extending down to the jawline. Since I have no idea what you looked like before their removal, I can not say whether removing the buccal fat pads was truly the main cause of your facial fullness concerns. But the subcutaneous fat around the mouth and chin (perioral mounds) now looks fuller because it remains unchanged as the area above it where the buccal fat pads are is now thinner. It may be that microliposuction of this fat area would complete the ‘project’ and should help. Whether any fat should be replaced due to the asymmetry above caused by the buccal fat pad removal may be a solution to also consider. It is either that or do further removal on the fuller side. That choice is a matter of your aesthetic judgment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had perioral mound liposuction and buccal lipectomies a fews days ago to thin out my face. I have some questions about the facial swelling that I now see.
1) I’ve read there can be persistent fluid accumulation that could need to be aspirated…how do I know if I have this problem or just normal swelling?
2) Would wearing a compression garment facilitate faster resolution of swelling?
3) I’ve read massaging the liposuctioned areas can help resolve swelling…would you advise this or is it a better idea to just leave it alone and let it heal on its own?
4) The perioral region is much more swollen, stiff and numb than my cheeks. Is this normal? When I touch the area it feels hard under my skin. What is this? Swelling? Scar tissue? If scar tissue, how long will it take to shrink down?
A: What you are experiencing after facial buccal lipectomies and perioral mound liposuction is normal early after the procedures. But to answer your specific questions:
1) There is no fluid accumulation that will develop under the skin in facial liposuction. That is a phenomenon that is unique to body liposuction where large volumes are fluid are initially instilled (tumescent infiltration) to facilitate the procedure. Facial liposuction does not use this technique.
2) A compression garment will not facilitate the resolution of the swelling nor is it really practical to wear.
3) Digital massage (aka lymphatic therapy) can be beneficial for swelling resolution since it stimulates the lymphatic channels to open up by the pumping effect on the vessels.
4) The perioral region is stiffer and even more swollen than the cheeks because it is in a lower dependent position (gravity) and even the cheek swelling drifts down to that area. That is why the perioral tissues are so stiff.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I can not figure out what my face needs to look better. I’d really appreciate you taking your time for this. I have been given different surgery options from doctors here in Australia. However my opinion is that the best doctors are located in America, especially for facial surgery. It has been recommended to me that I have cheek implants, buccal lipectomy and a chin implant. But I want to know your opinion since you are regarded as one of the best surgeons in the world for facial reshaping surgery.
A: In looking at your pictures, your facial reshaping/restructuring goal would be to shorten your longer face and provide some more central projection. You have a more flat paranasal/midface and thus you have to be careful with how you change things to not look worse. I would recommend the following:
1) Chin augmentation but by sliding genioplasty as your chin needs to come forward but should become vertically shorter not longer. (implants tend to make the chin longer or at least neutral in vertical length)
2) Malar/Submalar implant augmentation with emphasis on providing with anterior projection not so much width
3) Avoid a buccal lipectomy. That would be one of the worst things you can do to a face that already lacks projection and could easily end up looking gaunt.
4) Paranasal augmentation to build out the base of the nose and the maxilla. This complements what the dimensional changes of the cheeks and chin and avoids ‘leaving the area between the two behind’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, After doing some more research, I’ve also wondered about the possibility of facial liposuction or a buccal lipectomy with my vertical chin lengthening procedure.. I know that buccal lipectomy has to be done selectively, because it can cause a gaunt look. Do you think that buccal lipectomy or some cheek liposuction would help me? The fullness of my cheeks bothers me a lot and so I thought the genioplasty would help elongate my face to reduce the roundness or fullness. Basically my question is if some sort of facial liposuction may be a better option, or if it should be done in addition to the genioplasty? (I’ve had one other doctor mention that my chin height isn’t really lacking and that not much vertical height would need to be added). I’m interested in getting your opinion on this.
A: It would not be rare to do further facial derounding by a subtotal buccal lipectomy as a complement to other procedures. A buccal lipectomy produces a subtle effect so it alone would rarely create significant facial slimming. As long as it is not done overaggressively, it will not ultimately produce the gaunt look and will reduce some fullness right under the cheekbones.
By aesthetic measurements, you vertical chin height may be fine. But in the spirit of what you are trying to achieve, vertical chin lengthening is needed. Rather than rely on numbers or what looks right to someone else, use computer imaging to see what facial look is created with and without vertical chin lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had buccal fat pad removal (buccal lipectomy) recently and am already seeing positive results. I can see my strong cheekbones a lot more. However, there are parts of my face that still display bits of fullness. Based on your responses to other questions, it appears I still have some perioral mounds. I am considering liposuction in this area. However, my concerns are a return of fat after treatment. I’ve read different online opinions that indicate fat can return after liposuction. As such, my questions are:
1. If I get liposuction on my perioral mounds will the fat go back to my buccal fat pads to compensate for the fat loss in my perioral mounds?
2. If I choose not to get liposuction on my perioral mounds, but either gain some weight, or stay the same weight, will my buccal fat pads eventually return? From what I recall, I had my surgeon take out as much buccal fat as possible, but the temporal part was of course left alone. Can buccal fat regenerate?
3. Lastly, I am also considering some type of laser resurfacing procedure for acne scarring but I am worried the regeneration of new skin cells promoted by these laser procedures will bring my buccal fat pads back. Is this possible?
A: When it comes to liposuction, you have to separate face and body liposuction as the long-term results can be quite different. This is especially true for the unusual buccal lipectomy procedure. To answer your specific questions:
- Once the buccal fat pads are removed, they will never come back. A buccal lipectomy is the most unusual of all fat removal procedures in the body as it is a total glandular excision not subtotal fat extraction. Fat only returns in the body by cell hypertrophy not new fat cell growth.
- Buccal fat cells, like almost all fat cells in the body, do not regenerate or make new cells. Only the residual or existing cells can get bigger.
- A skin laser treatment will have no effect on the deeper underlying fat in terms of ever promoting fat cell hypertrophy or fat cell replication.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like I have a good bone structure but my jawline and lower face shape is hidden by excess fat. Will a buccal lipectomy get rid of the fat above my jawline and chin or would it get rid of the fat below the hollows of my cheek bones? I ask this because I know this procedure can create a hollowed skeletal/meth-head look and having very high cheekbones, I know I may be prone to this effect. I am 20 years old.. Though this procedure is generally for older people, do you think it would benefit me by outlining the contours of my lower face? I would like an estimate and maybe an opinion on the procedure if you can spare one. Thank you for your time 🙂
A: When it comes to a buccal lipectomy, it is important that one distinguish what it can and can not do. It can reduce some fullness right below the cheekbone which you can locate by placing your thumb on the underside of the cheekbone. As you can see by doing this, that will not affect any fullness below it near the mouth or the jawline. This is an area that I commonly treat with small cannula liposuction to reduce the fullness in this area. This procedure has no risk of ‘overskeletonizing’ the face as it is subcutaneous fat removal and not one large lump or ball of fat like that of the buccal fat. (actually if done properly and in a subtotal fashion a buccal lipectomy will not make the face too hollow)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial liposuction. I am slim but hate my chubby cheeks. Whatever I do they don’t go away. I tried buccal fat removal with little luck. Problem is the round bit of fat in malar pads which always goes very high on my apples of my cheeks when I smile. Can the cheek malar pads be removed completely? I want like male models so it looks like no fat at all on cheeks and so When smile it is just skin that raises up instead of the fat malar pad. I dont need malar lift, I just want it to be gotten rid of for good. Can it be completely removed and sucked out even if this may leave some sagginess of the skin. After that maybe I can have midfacelift if needed but I really want this malar pad gone. It is not buccal fat that I want gone, it is malar pad which rests on top of cheekbone. I don’t want a malar lift to redistribute fat on to higher position, just complete removal. Is it possible?
A: I understand perfectly as to what you are referring to and it is no surprise that a buccal lipectomy would have no effect. The buccal fat pad is in a lower anatomic location. The tissues that you are referring to are over the malar region but to describe them as the malar ‘fat pad’ is not anatomically accurate for what you are trying to achieve. The malar ‘fat pad’ is not like the buccal fat pad, it is not an isolated and thus easily extractable type of fat. Rather it is fat mixed in with other tissues giving it a more fibrofatty quality to it. Thus it is not amenable to excision (like the buccal fat pad) and is more resistant to small cannula or microliposuction. This does not mean it can not be treated, it is just a question of how effective it would be and that disrupting these tissues will cause it to sag as the suspensory ligaments would be traumatized. But when it comes to complete removal of the malar fat pad fullness, I do not believe that is surgically possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping/liposuction for my son. For several years my 16 year old son has expressed concerns with excess fat in the cheek/chin/neck area. He has a genetic double chin that upon weight loss did not help and did not go away. In tears, my son asked if he could do what I did (lower face lift/liposuction) While I do not feel it would be necessary for him to go as extreme, I told him I would research his options. In my own experience, I know it’s not something that diet and exercise alone can help with. As a parent though I am conflicted regarding the risks/ psychology etc. of a surgery for cosmetic purposes at his age. Thank you in advance for your help and information!
A: When it comes to facial reshaping via fat removal, there are several specific areas in the face where fat extraction can be very helpful. This includes the neck (liposuction), buccal fat pad (buccal lipectomy) and the perioral mounds. (liposuction) All three areas would be of benefit to your son based on his pictures. That may not necessarily completely deround is face or give him a thin face but would make a substantative improvement.
When it comes to plastic surgery in teens, the major consideration is their level of expectations. Being less mature and often being guided by information that they find on the internet, their sense of realistic expectations and the necessary recovery process until they truly see the final results is often not accurate. But from a physical standpoint, there is no greater risk of these facial procedures in a teen ager than in an older adult.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking into buccal fat pad removal (buccal lipectomy) and possibly perioral mound liposuction. My face holds a lot of weight compared to my low body fat percentage. I workout consistently and follow a very precise diet but no matter how hard I try I can never seem to lose the fat on my face. I am self conscious and try not to smile in public as smiling makes the fat on my face more apparent. My father and my grandfather both have the same issue. I would like to know your opinion on what could be done to improve my appearance. I would really like to have a thinner face, similar to that of a male model.
A: I think your face would benefit by a buccal lipectomy and perioral mound liposuction to provide some improved contouring. Whether that would be enough of a change to give your face the ‘male model’ look is a more indeterminate question. It would definitely be beneficial in that regard, and you have the right face for these procedures that will best show their effects, but the male model look per se may be asking more than is possible. That, of course, depends on how one expects that type of face to look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, will a buccal lipectomy make a noticeable difference in the shape of my face? I am trying to get a shadowing effect below my cheek bones so I will have more of a male model look.
A: While the buccal lipectomy procedure has a controversial side as to its long-term facial aging effects (creation of the gaunt face), it is also importanbt to look at their upfront effectiveness as well. In most cases, a buccal lipectomy is a complementary facial reshaping procedure whose magnitude of effects differ based on one’s facial make-up. In a thinner and more skeletonized face, its effects are more visible but this is also the patient who is most predisposed to have sunken in cheeks later in life. In a heavier rounder face, buccal lipectomies often have a more minor effect and other procedures must be done around it to create a more visible facial reshaping effect. These are also the same patients that will not have a sunken in cheek look later in life. Opting for buccal lipectomies in facial reshaping must take into consideration the balance of early facial shape improvement versus potential detrimental long-term facial shape changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 19 year old considering a buccal lipectomy and wondering if I am a good candidate for it. I feel that there is some roundness to my cheeks that make the lower half of my face disproportionate to the upper half. I was wondering if the procedure would benefit me or if it wouldn’t make much of a difference. And if it does, whether I might not look too gaunt. I’ve seen a lot of regrets online but I wonder if it’s just a vocal minority. Thanks for the opportunity to gain some nice insight! Truly appreciated.
A: In looking at your your pictures and your young age, you would not be a good candidate for a buccal lipectomy procedure. While the initial result would meet your objectives, the long-term of it in your case would leave you looking gaunt and end up along with those that you have read that has regrets online. It is not that a buccal lipectomy is a bad procedure, as it can be very effective and successful in the right patient, but your face is not one of them. You do not have a ‘fat face’ or even a round face. Your level of fat lipodystrophy is very modest and the buccal lipectomy is too aggressive for your facial fat concerns.
In addition, where your facial fat concerns are is actually below of where the buccal fat pad actually is. It is situated just under the cheekbone and not down by the side of the mouth.
If you were to consider any facial thinning procedure, perioral mound liposuction is a better choice as it helps reduce the fat thickness at the lower end of the cheek and is a procedure that cannot really be overdone and has no long-term ‘gaunt face’ consequences.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in perioral mound liposuction. I have a problem with fat pockets around the corners of the mouth. I’ve had buccal fat pad removal before, but it did not help at the right area. I also have some fat along my jaw line that I do not like. Do you think it is possible to perform microliposuction at those areas? And how drastic will the result be? Are there any complications with this surgery? Have you done this surgery many times?
A: I am not surprised that a buccal lumpectomy do not affect your area of concern as the large buccal fat pad or any of its arms does not extend downward toward the corner of the mouth and jawline. This area, as you have correctly pointed out, is known as the perioral mound area which is a subcutaneous layer of fat. (not like a well defined fat capsule like the buccal fat pad) I have done perioral mound liposuction numerous times. It is done with a very small cannula from a small incision inside the corners of the mouth. As there are no facial nerve branches in this area, one can aggressively liposuction it. It never produces a large amount of fat and often only a few ccd is obtained, but in the right patient, that can make for a noticeable thinning effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face makes me look like I am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. Thank you for your help!
A: To treat the soft tissue facial triangle area (lines drawn between the cheek, chin and jaw angles), the procedures of buccal lipectomies and perioral mound liposuction may be useful for ‘facial derounding’. It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. A buccal lipectomy removes a very distinct large ball of fat that sits right below the cheek bone. It is done from a small incision inside the mouth. It is important to not totally remove it so one does not get a gaunt look later in life. But for someone with a really round ‘fat’ face this potential issue may be irrelevant. The perioral liposuction procedure removes fat from below the buccal fat pad that sits right under the skin opposite the mouth. It is done from a small incision inside the mouth. Done together these two distinctly different facial fat removal procedures can help create a facial thinning effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.
A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My face is slightly asymmetrical; the right side of my face is less wide than the left side. Consequently, my jaw line is more square and substantial on the left, and less so (its a little more rounded) on the right. There is also a greater fat buildup in my right cheek, since it has less area to distribute itself over than the left. Finally, my nose has a fatty round tip (I am not sure of the proper medical term for it, but I can feel that the problem isn’t the cartilage, so it must be a fat buildup), and it obscures the definition of my nostrils.
So, the surgeries I would like to have done are 1) rhinoplasty (reducing and defining the tip of my nose; the cartilage and bone are fine), 2) buccal fat removal from my right cheek, and 3) a jaw implant on my right jaw to balance with the left side. Each of these features affects the others, so I assume that it is best done by the same doctor, and at the same time under general anesthesia. The reason I am writing to you about this is because of all the plastic surgeons I have researched, you are one of the only ones who explicitly does jaw implants, not just chin implants or facial injections. I understand my face will not be totally symmetrical after this procedure (my whole left skeleton is slightly wider than the right side), but I do want to balance out the corner of my jaw, the fat in my cheek, and the nose with the rest of the face.
I have attached an informal frontal shot of my face, so you have some sort of visual to accompany my description.
A: Thank you for your inquiry. I believe your description of your facial asymmetry and your approach to improve it is spot on. I would just make a few modifications/clarifications on your proposed procedures. First, the round tip of the nose is not primarily caused by the subcutaneous fat under the skin. It is a component to it and minimally modifiable due the risk of skin necrosis of the overlying skin. The major component to making one’s nasal tip less ‘fat’ is to modify the underlying lower alar cartilages, particularly that of the dome area. Thus a tip rhinoplasty changes the size and width of these cartilages to make the tip more refined. Second, a buccal lipectomy affects the fullness right under the cheekbone and not further out on the face. Lastly, the type of jaw angle implanted needed would be a lateral augmentation style that only adds width and not length to the jaw angle area.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I want to look younger and more attractive. I used to get comments that I looked so much like Angelina Jolie. I don't get those compliments anymore. One of the attached photos is me when I was younger. The other one is me now. I need some cheek sculpting to bring my now fat cheeks in more.
A: Thank you for sending your pictures. The difference between you now and when you were younger appears to be wide or 'fatter' cheeks with loss of a high cheek definition look. This could be caused by aging (falling cheek tissue) or increased fat collections in the lower cheeks with age and some potential weight gain. Careful analysis of your pictures shows that the main difference is inversion of the soft tissue cheek triangle. When younger the cheek was an upside triangle with most of the fullness up top and the apex of the triangle down below inverted inward. With time the triangle has inverted with the base of the triangle now at the bottom of the cheek (most fullness) and the top of the triangle up high over the cheek bone. (Ileast fullness) To attempt to rearrange this soft tissue triangle the following needs to be done…buccal fat pad extraction and relocation to the cheek bone (like placing an implant) or cheek fat injections and perioral (lower cheek) liposuction. In essence, add fullness over the cheek bones and remove fat below the cheek bones. Since fat changes are the crux of the facial problem it makes most sense to undergo a fat redistrbution surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in a more structured feminized face. I am 40 years old and have wanted to balance my face my entire life. The fat never dissipated with age so I now find it agonizing. I also think chin augmentation would help but I am not sure about that.
A: In looking at your face, I believe your fat concerns go beyond the buccal fat pad area. Most people have a misconception about where the buccal fat pad lies. Even though it is a fairly large fat collection, it only occupies a small area immediately below the cheek bone. It does not extend down near the mouth area which is a different area of fat in the subcutaneous layer know as the perioral mounds. When looking for facial thinning in the cheek area, it is usually necessary to combine partial buccal fat pad reduction with perioral mound liposuction.
I can not tell about the potential benefits of chin augmentation based on just a frontal picture only. I would need to see a side picture. Chin augmentation is usually only beneficial to facial thinning if it helps elongate the face and helps makes the chin more narrow in the frontal view.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had buccal fat removal upon the misleading instruction of a doctor . Now my cheeks look sunken and dented. After reading your article “Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations”, I have the following questions which are consistently suffering me.:
1. Will the removal of buccal fat pad lead to great fat loss (lipoatrophy)? e.g. due to loss of the supporting fat. I just found myself look like dying.
2. I guess the doctor just removed the whole fat pad, which was not told to me. May I know if there are any suggestions for repair with the least potential risks? I consider fat grafting, but it seems so unpredictable. Do fillers like Juvederm or Artefill work in my case?
I will move US next year and I think surgeons of US are better. Wish you can save me out of this. Thanks a million for your great help!
A: Buccal fat removal can be beneficial for facial reshaping in the properly selected patient, such as someone with a very thick and round face with full tissues. But in the wrong type of patient or if too aggressively done it can result in a gaunt overresected look. I suspect by your description you fit into the latter category. In answer to your questions:
1) I do not know how far out from surgery you are. But if you are six months or more after surgery, the result you see is likely stable. The degree of surgically-induced ‘lipoatrophy’ that you see could be worsened with additional weight loss or further facial fat loss with progressive aging. Whether this occurs or not depends on your facial type.
2) Synthetic injectable fillers is certainly a simple albeit a short-term fix. I would not rule out injectable fat grafting. Its volume retention results may be unpredictable but the cheek is one of the best areas on the face for fat transplant survival. Other options include submalar implants placed intraorally and even dermal-fat grafts placed through a limited facelift incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 old year guy and I am really not satisfied with my looks. I am looking to improve upon my face for a more youthful look .I know it’s not wise to compare yourself to others as everyone’s face is unique but I think the most distracting feature of my face is a very big and wide lower face (mandible) that makes my face chubby and more old looking. The last time I inquired you about an outer cortex osteotomy for as such the same problem and you requested my pictures so I did attach them. Now I would be really grateful if you clarify me my following doubts:
1. Is it possible to reduce my lower jaw width and angle to make my face more slimmer and proportionate?
2. If yes, how much is it possible to reduce the bigonial distance and achieve a more ovoid looking face (Front view) in my case?
3. Would chin augmentation be helpful to achieve the same?
4. I also want to have a tip rhinoplasty that would give my nose tip more definition and sharpness. Again, how much is it possible to achieve a nose like the one in the model pictures I have attached?
5. Please suggest any additional improvements in case you notice that would be required for a more youthful appeareance such as brows,cheeks or any other.
A: In answer to your questions:
1) There is not a really good procedure to make your entire lower face more narrow. Even if one could do a lateral corticotomy (remove the outer layer of the lower jaw bone) that would just not make enough of a difference in your face.
2) Certainly the jaw angles can be removed but whether that would make a very visible difference is uncertain. Some of your facial width is soft tissue and can not be reduced. The best way to answer whether this procedyure would be worth it is frontal cephalometric x-ray or facial film to look at how much flare the angles have. If it is significant then it may be worthwhile.
3) Vertical chin lengthening is, by far, a more practical approach to facial lengthening (and narrowing) for you given the more square facial shape that you have.
4) A tip rhinoplasty will definitely help narrow your nose but trying to achieve the very slim noses in the pictures you have sent is unrealistic. You will likely end up halfway between where you are now and those type of results.
5) Some soft tissue (fat reduction) would also be helpful, removing part of the buccal fart pad and thinning out the fat outside of the corners of the mouth.
I would think that a vertical lengthening chin osteotomy, tip rhinoplasty and buccal lipectomy with perioral liposuction would be the three procedures that I would recommend that could make the greatest difference in your facial shape/appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a slimmer less round lower face, so a slight ogee curve is visible. How is that best done? Or can it even be done?
A: When it comes to contouring the area between the cheek and the jawline, it is important to remember that this is an area not supported by bone. So any fullness is due to the thickness of the soft tissues. (skin, fat and muscle) To get any change in this area (a midfacial slimming effect), a combined buccal lipectomy with perioral liposuction (affects lower cheek area, buccal lipectomy does not) is needed to achieve the best facial contouring. The question for this procedure combination is how much of a change can it make. In my experience, most patients will experience a visible contouring effect but it may take up to six weeks after surgery to see the full result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would be very grateful if you could answer some questions about the removal of the buccal fat pad. What is the level of risks of sustaining damage to the buccal nerve branch of the facial nerve? Approximately how long does it take to recovery and when to expect the end result?
A: The buccal fat pad is an encapsulated fat mass in the cheek which is located between the buccinator muscle and the masseter and zygomatic muscles and largely lies underneath the zygomatic arch. It is deep to the malar fat pad which lies directly under the skin and the jowl fat pad which is situated much lower near the jawline and should not be confused with these two regionally close fat collections. The buccal fat has one large body and usually four processes like fingers which extend outward from it. The part that is removed in a cosmetic buccal lipectomy is part of the main body. The biggest risk in buccal lipectomy is transection of its blood supply, the buccal artery or vein during its removal. This can result in bleeding and a hematoma afterwards. The key to avoiding this complication is gentle dissection of the main body outward and cauterizing attached blood vessels under direct vision. The buccal branches of the facial nerve are in close proximity to the main body but usually cross over top of it. Staying inside the buccal fat pad capsule and not being too aggressive with removal are the keys to avoiding a traction nerve injury. It is not a complication that I have ever seen. Trying to pull too much fat out runs the risks of pulling the nerve branches into the field of removal/cautery.
Buccal lipectomies will cause some swelling but most of that is gone after about three weeks from the procedure. The final result can be judged six weeks from surgery although some continuing fat atrophy may be ongoing based on how the fat pad was removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to have a well defined face shape, so I am thinking of doing buccal fat removal but at the same time I want high cheek bones. Is it possible for me to do buccal fat removal and at the same time still put Juvederm fillers in right under my eyes? Does that make sense?
A: That does make sense with the exception of it is unclear how that will give you high cheek bones. Buccal fat reduction provides some submalar ccontouring which helps in some small amount of facial thinning in that area but will not, by itself, give you high cheek bones. The Juvederm filler will help with tear trough filling but also will give not give you any cheek bone augmentation effect. Those two procedures make sense for what they are intended to improve but neither one will create the illusion of high cheek bones. For that result, you should consider a small cheek implant which can be placed through the same incision as tha of buccal fat removal. That combination will create a more shapely cheek look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very weak jawline and some fullness to my cheeks and face. My face is sort of round and not very distinct. I went to one plastic surgeon and he said that a chin implant would change my facial shape. But I have read that many chin implants also have liposuction under the chin as well. This seems to make sense to me but I still don’t see how that will improve my chubby cheeks. What would be your recommendations? I have attached some pictures of me from the side.
A: I think there is no question that you have a short chin and a rounder fuller face. A chin implant will definitely over good improvement of your profile. But to really ‘deround’ a fuller face it is going to take other adjustments. These would include some fat removal as well. Liposuction under the chin would also be a definite plus and, with the chin implant, can dramatically change the jawline. But the cheek area needs thinning by a partial buccal lipectomy with perioral liposuction. Buccal fat removal only affects the upper cheek area below the cheek bone. Perioral liposuction is needed to remove fat from the lower cheek area at the level of the corners of the mouth. The combination of chin augmentation and fat removal from the neck and cheeks can very effectively make a round face have a much more defined shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buccal fat removal to make my cheek area less full but I have a few questions. If complete removal of the buccal fat pads is what is decided to be the best result after seeing my photos, is there a high risk for nerve damage? I’ve read that partial, more superficial removal is fairly safe but complete removal poses a risk of possible facial paralysis and/or nerve damage. From what I’ve heard and read it seems as if plastic surgeons are either for or against buccal fat pad extraction, in regards to the risks and how the patient will look when aging. I don’t seem to find any middle ground.
A: Having done many buccal fat manipulations over the years, I have no concern with facial nerve damage with buccal fat removal. It is not something that I have ever seen. Whether it is subtotal or closer to a more complete buccal fat removal, that problem is completely avoidable if you know how to do the procedure properly. How aggressive one should be with buccal fat removal is based on what type of face they have and how much the buccal fat pads are contributing to the submalar fullness. The amount removed varies depending upon the patient, their immediate thinning needs, and in consideration of what the future may be as they age with their kind of face shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a former patient of Dr. Eppley. I had buccal fat removal and love my results… however, I am still interested in having facial liposuction to sculpt my cheeks out a bit. I am wondering if he can do this and this is possible.
A: The removal of the buccal fat pads is the largest fat depot that can be surgically removed on the face aside from the neck. Its removal creates a slimming change in but one region of the face, the submalar region or the area right below the cheek bones. There are no other distinct or encapsulated fat areas to remove on the face. The rest and majority of facial fat is located in the subcutaneous level or right under the skin. This is much more difficult to remove and can only be addressed by small cannula liposuction. Many such facial fat areas are not even treatable by liposuction.
When patients seek a slimming effect of the face, they often are referring to the side of the face from the cheeks down to the jaw line. This leaves a lot of facial areas beyond the submalar or buccal fat region. Most of these areas can be treated by liposuction if done carefully and not done too deep. The buccal branches of the facial nerve lie on top of the muscle layer just underneath and injury to them should obviously be avodied. The question is not whether it can be done, but whether any significant change can be achieved. In general you can not make a wholesale facial slimming change by facial liposuction but small discrete areas may be able to be improved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have been researching how to make my cheek area look better as it seems to be kind of flat and has no cheek highlights, plus my face is a little round. It seems I have two choices, cheek implants, buccal fat removal or some combination. In my research I have reading that cheek augmentation would be better than the buccal fat removal as far as years down the road as I may not like it and it may look like I am older than I really am. Just doing some research on this subject. What is your opinion? Thanks for your help.
A: Both cheek implants and biccal lipectomies do impact on the appearance of the midface. While they are in close proximity, they create different midface effects. Buccal fat removal decreases the fullness below the cheekbone area. If the complete buccal fat pad is removed then a gaunt look may eventually appear is some patients. The key is subtotal reduction, particularly in someone who does not have a ‘fat’ or round face. Cheek implants create a different effect as it brings out the prominence of the bone above the buccal fat area. These can be not so subtle differences and you have to look and play with your own face to see whether more cheek or less fullness below it is better. They are not necessarily interchangeable procedures. Whether one is better than the other, or whether a combination of both is best, is determined by one’s facial shape and must be decided on an individual basis
Dr. Barry Eppley
Indianapolis Indiana
Q: I`m considering having some plastic surgery and that`s the reason I`m writing to you. I am 28 years old and I`ve got a very rounded face with lot of babyfat and I want to make it more sharp/angled and more masculine looking. I have had a rhinoplasty done on my nose when I was 18 and it looks great from the profile, the only thing is that from up front one of the sides is indented and I was thinking that either an injectable filler to build up that side up or a silicone implant to make that side more fuller and match the other side. I don`t need a major or new nose job, just to fill up one side of my nose. I`ve got a double chin and even when I was thinner I still didn`t have a 90 degree angel between my neck and chin. So I want a liposuction and tightening of the neck muscles. I think this will also help to make my jawline stand up a bit more. I have a very round and big chin. It`s not too big but it`s very round so I was thinking that the liposuction of the double chin and platysmaplasty will also help to give my chin more angles but I`d also like to have a small dimple there. This will give me that masculine clefted chin look. I`d also like to have liposuction of my lower face (removal of buccal fat) to give it more angles and make it less rounded and more masculine. I think some cheek implants will give my face more bone structure. I want to remove the bags under my eyes. I`d like the procedure where the incision is from the inside of my eyelid. My upper lip is a bit uneven. One side is more rounded than the other, so I`d like to correct and get more symmetry to my lips. It`ll be nice to get them a bit bigger too. I have attached some photographs for you to review and await your comments/recommendations.
A: In reviewing your photographs and your concerns, I can make the following suggestions/recommendations:
1) Nose. Your nose is asymmetric because you have left upper cartilage/middle vault collapse. That is why it appears deviated due to the inward turning of the dorsal line. This is the result of your prior rhinoplasty. That is best corrected not by an implant or an injectable filler, but by cartilage grafting. The use of a left spreader graft and a crushed cartilage onlay graft over the indented area is the treatment of choice.
2) Lips. Fat injection grafting would be best. Although a vermilion advancement would perfectly correct the left upper lip asymmetry (lack of vertical height), that fine line scar in a male would be unacceptable.
3) Lower Eyelids. The lower eyelid bags could be removed by a transconjunctival lower blepharoplasty with fat removal only.
4) Cheeks. Cheek implants would be a good choice for your malar-infraorbital hypoplasia. I would also add fat injections above the cheek implants along the infraorbital rims.
5) Cheeks. Buccal lipectomies are needed to get rid of the fullness below the cheek bones which are going to be highlighted with the implants.
6) Chin. A square-shaped chin implant is needed with the placement of a central dimple or cleft, whichever is your preference. The chin implant would have minimal forward projection but is more to create fullness on each side.
7) Neck. it could be improved by some liposuction and a corset muscle plication (platysmaplasty ) to maximize the cervicofacial angle.
Lastly the Jaw Angle. A would do some liposuction around the jaw angle area to try and make it a little more distinct although the result would be fairly subtle.
Most of these procedures you had already surmised but here is what can be realistically done in an effort to achieve more of a sculpted masculine facial appearance.
Dr. Barry Eppley
Indianapolis, Indiana
