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
Q: Dr. Eppley, over a decade ago I approached a surgeon as my upper lip did not raise well when smiling and my appearance was edentulous and a little tight when I smiled. Rather than the more typical bull horn type sub nasal lip lift procedure, the surgeon performed an operation that he designed to raise the complete base of my nose and debulk the premaxillary area. He did this by taking a full thickness crescent of skin from the floor inside the nasal vestibule of each nostril as well as segment of the nasal spine lifting the nasal base and sill into the deficit on closure which also closed the naso labial angle. By lifting the nasal base the columella was slightly rotated inward. This left me with a flatter lip which gives the impression of being overly long rather than shortened. I understand that the current wisdom is that this is not surprising. For some reason it also left me with difficulties in balancing the facial expressions involving the central elevator muscles which seem unrestrained or supported seemingly due to the missing bulk of the premaxillary soft tissue. The result has been a hyperactivity of the depressor alae or alae nasalis pulling my nasal base and lip downwards (see attached pic) and my impression is that this is in compensatory opposing the levator labii muscle or alaequa nasi. I had Restylane injected into the premaxillary area some time ago which very temporarily helped moved the central lip forward rather than downwards looking noticeably odd. I believe that the original incision needs releasing to allow the nasal labial angle to fall back into place for the best function and cosmetically (ie a de-rotation). I am unsure how to proceed or better describe the subjective problems I have and any advice or help would be welcome. If I were to describe this in more approachable terms I am trying to lower the base of my nose to its previous position by nasal spine augmentation and soft tissue repositioning / release.
I have attached some pictures pre- and post- op which demonstrate the difficulty I have in expression and smiling. I am hoping that you might be able to offer operative help or advice.
A: Certainly the operation you had done was unusual and predictably problematic. The question now, however, is how to reverse its effects. The fundamental problem appears to be a scar contracture/tissue loss at the nasal base/spine area. I would agree that the original incision and underneath it need releasing but that alone would not be adequate as it would just scar back done. It would need to be filled/augmented (premaxillary augmentation) and that is probably best done by a dermal-fat graft not an implant. You need biologic tissue that can fill the released space and not just turn into hard scar. You could do the same thing with injectable fat grafting but it would take several injection sessions to achieve a good release and tissue fill. This is better done by an open approach and en bloc tissue grafting
Dr. Barry Eppley
Q: Dr. Eppley, I have an indented scar on my cheek that needs some type of scar revision. It started out getting an injectable filler treatment (Restylane) that got infected. After antibiotics cleared the infection a few months later the area appeared indented and became a samll atrophic scar. It then had V-beam treatment for the indentation several months later but only became more indented. It lost whatever fat it had. It is an area under the eye where the cheek fat pad starts where there is a circle that is indented. One surgeon said there is no fat there and that is why it is sunken. I want to know if there a full thickness fat graft or some type of soft tissue implant that can be used to fill it?
A: The scar revision to which you refer is really the need for fat volume restoration. It sounds like you have a distinct area of fat atrophy with scar contracture on your cheek. While this is water over the dam so to speak, the use of a V-beam treatments was ill-advised for that type of depressed scar and did exactly what could have been predicted. That issue aside, options include fat injection or the placement of a small dermal-fat graft that treats exactly what the problem is…lost fat volume. Fat injections involve no incision or harvest site but are somewhat unpredictable in terms of volume retention and do not do a good job of releasing and scar contracture. A small dermal-fat graft would be more effective but it has to be placed somehow through a small incision and requires a harvest site which could be behind your ear.
Dr. Barry Eppley