Q: Dr. Eppley, First of all, I want to thank you for the time that you took and will take to analyze my case, I’ll be eternally grateful for any help that you can provide to me in order to improve my condition.I have been really traumatized over the years for this mistake on a surgery that was made to me when I was 17 years old (I’m 39 years old now) Please see photos attached, I’ll be waiting anxiously your answer.
A: Thank you for sending your pictures. You have a very classic gynecomastia ‘crater’ deformity from over resection of the breast tissue. This has left no intervening tissue between the nipples and the pectoralis muscle fascia, thus allowing the nipple to contract inward and scar down. Its appearance may have gotten a little worse as you have aged because the chest tissue around it (fat) may have gotten bigger allowing the inward nipple retraction look worse.
The correction of nipple retraction after gynecomastia reduction depends on the degree of severity and requires tissue grafting for release and improvement. Your case is fairly severe and you would ideally need an open release and dermal-fat grafts to level out the nipple contours. Dermal-fat grafts do require a harvest site somewhere which is usually done in the lower abdomen. Injectable fat grafting could also be done but that would definitely require multiple treatments to get the best result. There may also be a role for liposuction of the chest around the nipples to help optimize the chest contour also.
Dr. Barry Eppley
Q: Dr. Eppley, I have very small earlobes since they were repaired from my gauging last year. After the repair the earlobes were too small and it bothered me greatly. A local ENT doctor that I saw talked me into using tissues from behind the ear to make an earlobe but it looked terrible. So I had him reverse the operation which now left me with scars behind my ears…but there is nothing I can do about that now. Is there anything I can do now to help make my earlobes bigger?
A: I am going to assume that these two sets of pics I have seen represent an initial attempt at local flap reconstruction of the earlobe which was subsequently taken down because you did not like how it looked. So the most recent pictures are the healed ear wounds now. I would first do some injectable fillers to stretch out the scar and surrounding skin of the earlobe. The purpose of the injectable fillers is to act like a temporary form of tissue expansion. It may take more than one injection to see how much they can stretch out over the course of a year. Once the earlobes have been stretched out (if they will), you may eventually place a small dermal-fat graft in them for permanent volume maintenance.
Dr. Barry Eppley
Q: Dr. Eppley, I have spent considerable amount of time in researching fat transfers believing it to be the most viable option when done correctly, especially for thin older women. The stem cell benefits of properly done fat grafting add tremendous benefits as well. I understand although fat grafting has been around for a number of years, the harvesting and injection procedures have changed, creating greater success in keeping the fat cells alive. What methods do you use to ensure the success rate of your fat transfers, and what is the success rate you are currently having? One of the greatest difficulty for a patient, are the major disagreements in the medical field regarding the procedures used. Please understand I believe fat transfers to be one of the greatest positive changes in how we address aging skin, I want to have it done, but I am still very undecided due to the conflicting medical opinions out there. There is a very heated debate regarding the “dropplet” vs larger blocks, and the placement location.
A: The concise answer to your basic question is that fat grafting is in a state of evolution and development. It is far from a perfected science from the harvest to the injection methods. No matter what you read or is touted by any one surgeon, no one knows the best method to do fat grafting and just about everyone does it using the same basic principles. No matter what any surgeon claims, they do not have a magical method that works all the time and claims about how much fat survives, in many cases, are perceptions about fat graft take not actual measurements. How well fat graft takes can not yet be measured in any quantifiable way and is based largely on photographs and what the surgeons perceives has survived. Quite frankly as a surgeon I can tell that such perceptions are often skewed by what one wants to see and most claims of survival are likely overstated, some with good intent and others for pure marketing purposes. What may work well in one patient and one face or body area may not work well in the next patient. Fat grafting by injection remains an imprecise art with the science lagging far behind as of yet.
The most straightforward and honest answer that I tell prospective patients about fat grafting take is…no one can predict it and it will likely end up somewhere between 10% to 90%. While the goal is to have have maximal take on one procedure, every fat grafting patient needs to be prepared that more than one procedure may be needed.
Most fat grafting is done by injection because it is the only practical way to either treat a large area or get the material without undue scarring. En bloc fat grafts, also known as dermal-fat grafts, actually work and take very well. But their uses are very limited because a donor site is required and the size of the recipient site must also be relatively small.
Dr. Barry Eppley
Q: Dr. Eppley, I have attached a number of pictures of my wife. She has a prominent forehead dent that is very bothersome to her. It even makes her appear more serious or even angry at time even though she is not. What could have caused this dent in the first place? What can be done for smoothing this out for my wife? I didn't really think that something can be done for this type of forehead issue until I came across your website. Thank you very much for your help.
A: Thank you for sending your wife's pictures. I believe what your wife has is known as linear scleroderma. This is a rare craniofacial condition in which the fat under the skin largely disappears and the overlying skin gets thinner. What is unique and easily identifiable about this condition is that it often occurs along a very distinct line. (hence the name Linear) While it can occur anywhere on the face, when it occurs in the forehead it appears as a straight line running right down the middle of the forehead vertically from the frontal hairline to the eyebrows. It always appears, as in your wife's case, as an indented vertical groove in the forehead. This is not a bone problem as the underlying forehead bone is usually normal. The groove is due to a soft tissue deficiency. (hence the name Scleroderma although this is not associated with the more generalized autoimmune disorder of scleroderma) It is not known why this unique soft tissue deformity actually occurs although it has a fairly classic presentation. It is not present at birth and only begins to appear in late childhood or teenage years. Its progression usually stops by early adult hood and progresses no further. (the indent does not get any deeper)
Treatment of a forehead linear sclerodermal defect is about soft tissue augmentation, building up the forehead indent from underneath the skin. I have treated them by a variety of soft tissue methods including fat injections and the placement of allogeneic dermal grafts or dermal-fat grafts. Any of these procedures can be completed in one hour of surgery. It may takes months to see the final result, in terms of volume retention and smoothness, as the fat or dermal graft survival integrates into the surrounding soft tissues.
Dr. Barry Eppley
Q: Dr. Eppley, I have a step-down of about 3-4mm from the rim of the orbital bone under my eyes straight down to the eyeball. There is no fat. Post after blepharoplasty about 6 years ago. I don’t like the look. Any help available? I am 56 years old and healthy with good skin. Thank you.
A: With the loss of fat, either through surgical removal, aging or a combination the edge of the lower orbital rim is now skeletonized. There are three approaches to consider for obliteration of this orbital rim step-off with the underlying theme that they all add volume but do it in different ways. I will first mention synthetic injectable fillers but this is not really on my list of sustainable long-term approaches.
Replacing what has been lost, fat, constitutes two of the orbital rim augmentation approaches. Fat injections are a well known option which is principally marred by the unpredictability of such fat grafts. It is however the simplest and least invasive approach. The other way to add fat is through dermal fat grafts, like a natural implant, placed along the inside of the orbital rims done through your existing blepharoplasty scars. These fat grafts take remarkably well but do require an open approach and a harvest site which is usually from the abdomen or from any existing scar that you may have on your body.
The other implant options are synthetic orbital rim implants that are made for exactly this area. Like a dermal-fat graft, they are placed through a lower eyelid incision and are secured to the bone with 1mm small screws.
Dr. Barry Eppley
Q: Dr. Eppley, I have deep nasolabial folds and a mouth whose corners turn down. I have read about a way to improve them by using your own tissue through grafting. I had a facelift already which got rid of my jowls and helped my neck but didn’t do a thing for the area around my mouth. I don’t want to treat them with injectable fillers because that will only be temporary. Are you familiar with this tissue grafting technique?
A: What you are talking about is an old plastic surgery technique, dermal-fat grafts, that has been applied to a cosmetic problem. A dermal-fat graft is a piece or strip of skin that has a thin layer of fat on its underside. The overlying epithelium or skin layer is removed, leaving just the dermal skin layer with the attached fat. Provided that the graft size is not too big, it survives quite well as the blood vessels of the recipient site attach quickly to the vessel ends in the dermis. This allows a quick return of blood flow to the fat thus enabling it to survive.
For use in the face for nasolabial folds, it must be taken from the lower buttock crease or any other large scar site and must be at least 6 to 7 cms in length for each nasolabial fold. From inside the nose, a tunnel is made under the nasolabial fold curving down to the corner of the mouth. The dermal-fat graft (dermis side up) is then placed through tunnel and fixed to the corner of the mouth through a small incision from inside the corner. It is then lifted and tightened from inside the nose and the excess graft trimmed and closed. The graft simultaneously augments the nasolabial fold and lifts the corner of the mouth. I have done this procedure numerous times and it does have its merits. But the issue is that it requires a harvest site and the buttock crease is almost always the best choice because of the thicker dermis. The discarded skin from a pretrichial browlift can be used as well. There are also other simpler ways to achieve both of these facial objectives. Fat graft injections combined with a corner of the mouth lift is another approach. But for the right patient who does not mind a buttock scar, the dermal-fat graft approach can be used.
Dr. Barry Eppley
Q: Dr. Eppley, after enduring over twenty years of having an indented tracheostomy scar, I am finally getting it revised. I understand that up to 50% of the fat tissue that is used as a filler gets dissolved by the body while it is healing. Is it possible that one would need multiple visits over the years to keep adding filler injections or something of that nature? Also, if one were to avoid that route in favor of something “off the counter” which product would you recommend? Thanks in advance.
A:Most tracheostomy scars can be revised and the neck skin leveled by simply closing the deeper layers of the excised scar as it is closed. This brings in tissue from the side and fills the defect or area of missing tissue underneath the skin. Larger or more indented tracheostomy scars, however, do have a real subcutaneous tissue deficiency as a result of fat loss due to pressure atrophy caused by the indwelling tratcheostomy tube. When these are merely excised and closed, they will revert to some degree of inversion as the skin is essentially closed over an ‘open space’. This is why the placement of fat grafts can be so helpful in tracheostomy scar revisions. However, the choice of fat grafts is critical and should be a dermal-fat graft and not fat injections. These are small composite grafts that can be taken from many locations with a small resultant scar. There are no ‘off the shelf’ products, such as allogeneic dermal grafts, that are a good substitute for a supple dermal-fat graft.
Dr. Barry Eppley
Q: I am HIV positive as well as a diabetic with deflated cheeks. Do you think transferring fat from my own body to my face will work?
A: Facial lipoatrophy is a common sequelae from the antiviral medications used in the treatment of HIV. Often this loss of fat is quite severe with the skin literally be right down on the bone with loss not only of the buccal fat but loss of the subcutaneous fat as well. When the condition is this severe, the concept of injectable fillers must be looked at very carefully. While fat injection transfer can clearly be done, the question is will it work long-term. How much of the injected fat will survive? The HIV patient on antivirals poses an additional variable to the biology of injected fat which is already challenged in the variability of its survival. Will the same medications that caused the fat atrophy to begin with do the same to the injected fat? No one knows with absolute certainity.
For these reasons, I prefer an additional approach to just injected fat for this cheek lipoatrophy. I like to place a submalar implant on the lower edge of the cheekbone and then cover this with an internally placed dermal-fat graft. Then injected fat can be placed subcutaneously throughout the cheek and lateral facial areas as an additional outer layer. This is a good way to hedge your bet so to speak by at least having some type of cheek augmentation that you can be assured will have stable volume preservation.
Dr. Barry Eppley
Q: I was just wondering if I am a good candidate for a tracheostomy scar revision. I had a tracheostomy back in 2005 and never knew that a revision surgery was possible until recently. I am really self-conscious of this hole in my neck. Plus it constantly reminds of why it is there in the first place. (a car accident)
A: Tracheostomies that remain in for any extended period of time (weeks to months) will often leave a depressed scar once they are removed and heal. This is the result of a phenomenon known as pressure atrophy of the subcutaneous fat. The pressure of the tube and the subsequent scar that it creates results in fat loss and tethered or scarring down of the skin edges. Tracheostomies wounds are now closed after tube removal and are allowed to heal in on their own.
Some initial tracheostomy scars may look depressed or indented but may ‘fill out’ as healing progresses to an acceptable level. This is why I don’t do tracheosotomy scar revision in the first six months after tube removal unless the wound has real trouble healing. Conversely, it is never too late to revise the depressed neck scar.
Many tracheostomy scars can be improved by simple scar revision. Others may require some fat volume restoration with scar revision. I prefer a small dermal-fat graft to replace the lost tissues between the scar overlying the trachea and the underside of the skin. Even a small graft, 2.5 cm x 1 cm, can be really helpful. There is no substitute for your own natural fat for small areas of tissue filling. The graft can be easily harvested from old scars almost anywhere on the body.
Dr. Barry Eppley