Q: Dr. Eppley, can micro iposuction remove lumps from fat injections or it can only help removing the natural fat that is already there? The problem in that I have fat lumps (10 lumps n both cheeks varies which vary size between 5-10 mm) mainly found near the mouth, along the nasolobial folds and two lumps in the bottom of the cheeks. If these lumps can’t be removed by micro liposuction, what would be the way to remove them? Does radiofrequency help melting the fat? I already took 3 sessions and will take three more (machine is Endymed, temp used was 40C and 37 Watts) Would it be effective in melting the injected fat whether it’s lumpy or soft?
A: Certainly removing undesired fat collections (lumps) is more challenging than the original fat injection procedure. Any technique for facial fat removal (small cannula liposuction or any energy-based external therapies) are more effective for general fat removal rather than discrete fat lumps. Either surgical and non-surgical methods have their advantages and disadvantages. Small cannula liposuction (aka microliposuction) can access all your involved more central facial areas from small incisions inside the corners of the mouth. It would also be somewhat effective at breaking up the harder fatty lumps and likely removing some of their mass effect. (probably more effective at breaking them up than removing them) Conversely, topical energy-based devices are non-surgical and require no incisions but they will have a heat field effect, meaning they will create an overall fat reduction in the fat not necessarily just the lumpy area. I would be somewhat concerned with these energy-based devices that you might trade off one problem for another.
Another option would be injection therapy right into the fatty lumps if they can easily be felt from the outside. Very low dose steroids and old-style ‘lipodissolve’ (deoxycholic acid) solutions can be effective and I have used them successfully in the past for the exact problem that you have. The better ‘lipodissolve’ solutuion, ATX 101, has recently been FFA approved for facial fat reduction (technically submental/neck fat) and would be the best injectable solution as soon as it becomes commerically available later this year
Dr. Barry Eppley
Q: Dr. Eppley, I had facial fat grafting six months ago with 30 cc of on each side of the face into the bottom of the cheeks, smiles lines, nasolobial folds and near the mouth! This has unfortunately lead to a very bad new look! Fat lumps develop in the above mentioned areas as fat was injected too superficially. I read a recommendation from Dr Eppley on RealSelf that fat can be surgically excised! Would like to know more about this procedure! is it done from outside the cheeks or from inside the mouth?
A: There are numerous methods to try and reduce excessive fat contours after facial fat grafting. Surgical excision is rarely used unless the fat is located in an area that is easily accessible through a facelift or blepharoplasty incisions. Small cannula or microliposuction is the most effective method near the central face and mouth areas. This is usually done through a small incision inside the corners of the mouth.
Other non-surgical options to get rid of fat grafting lumps include steroid injections (low dose Kenalog) and the use of deoxycholic acid solutions. (originally known as Lipodissolve injections and now under clinical trial investigation as ATX101 by Kythera)
Dr. Barry Eppley
Q: Dr. Eppley, I reached out to you last year regarding a consult for reconstructive facial surgery following an ATV accident several years ago. Since I have had several reconstructions and am now looking to improve my overall appearance and have reached out to you because of your experience in both aesthetic and reconstructive plastic surgery. Your name was also mentioned in a report by Advance Medical as an expert in this area.
At the time, you had requested a CT scan of the face, which I did not have–but now have one. I have attached photos, 3D reconstructed CT scan, and a brief medical history for your review. The goals of surgery are:
– Improve symmetry of the face, especially involving the eye. This includes the buldging of the eye ball itself, and position of the lid. I fully realize that a full restoration of symmetry is not possible and that surgery on the opposite eye may be necessary to get the most aesthetically pleasing result.
– Reduce the appearance of the port wine stain on the left side of face, near the eye
– Reduce the appearance of the scar on left cheek
– Improve overall appearance, ie. what procedures could be done in combination to ENHANCE overall appearance. Would a strong chin/jaw divert attention from eyes? Would other facial implants help? Would removing the nose bump? (This is why I value your experience in aesthetic plastic surgery)
I know you are very busy and I appreciate you taking a preliminary look at this case for consult.
A: Thank you for sending your pictures and 3D CT scans. What they show is that despite an excellent anatomic reduction of the fractured zygomatico-orbital bones (and an infraorbital-malar implant) your face is not normalied. The problem now, and is a quite common one after facial trauma and multiple reconstructive surgeries, is that the original injured tissues have become ‘skeletonized’. There has been loss of subcutaneous fat with scar tissue that has caused lower eyelid scar contraction as well as the lower facial scar prominence. I think that the left eye does not really bulge but that the lower eyelid is vertically short and contracted, exposing more sclera in that eye.
From a reconstructive standpoint focusing on the original injured tissues, I would recommend the following:
- Lower Eyelid Reconstruction with Dermal-fat Graft and Lateral Canthoplasty (your prior canthopexy was insufficient)
- Left Geometric Facial Scar Revision (your prior laser resurfacing probably made little difference)
- Injection Fat Grafting to Left Cheek and Infraorbital areas (the tissues don’t need suspending, they need more volume.
From an aesthetic standpoint, I would need more pictures for better assessment for both rhinoplasty and jawline enhancement.
Dr. Barry Eppley
Q: Dr. Eppley, I had jaw surgery just over a year ago and it left me with some irregularities. This led me to get chin and paranasal implants a month ago. While they have provided some improvement and there is still some swelling, they still have not completely solved the appearance of nasolabial folds and pre-jowls.
I now suspect that this may be a soft-tissue problem. However, because I am only 25 years old such soft tissue deficiencies seem unusual. Anyway, I’ve googled facial fat grafting and this image really pinpoints the areas I would like to build up and bring forward (the direction of the arrows). My biggest questions are as follows:
1) Could my soft tissue issues have been caused by my previous underbite (thereby affecting soft tissue development) or the jaw surgery itself?
2) Given my age, can fat grafting be done for these regions? If so, how much volume of fat is usually required?
3) Instead of fat grafting, are permanent fillers an option? Alternatively, are there any different implants that can be placed in these regions?
4) I have implants near these areas. Can fat grafting be done safely without infecting my implants?
Anyway, I also had some fat grafting done to my brow ridge and central forehead to make it look masculine. My surgeon did a decent job, but I’m noticing that insufficient fat was placed in the central forehead (the area between the two eyebrows and just above the nose), which means that my outer/lateral brow ridges are more augmented than the inner portion, causing it to look like I’m constantly frowning. I’m looking to add more fat to the central forehead, but I understand that a revision should only be done a few months later. Regarding this, I have a couple of questions:
5) It has only been 4 weeks since the fat grafting, can I use temporary fillers to augment the deficient areas in the meantime?
6) If so, will fillers affect how my fat graft survives at this stage?
A: I am going to assume that your jaw surgery was orthognathic surgery, possibly a mandibular advancement osteotomy. But that issue aside, let me address your specific facial fat grafting questions.
- The cause of your nasolabial folds and prejowls is impossible for me to comment on since I don’t know what you looked before your jaw surgery or your most recent facial implant surgery.
- While injectable fat grafting can be done for these areas, how retentive it will be is somewhat dependent on your body habitus. Thin young people usually have a poor rate of fat graft survival and retention. The fat graft volumes needed for the nasolabial folds are 3 to 5ccs per side. The prejowls usually require a similar amount of injectate.
- There are few permanent fillers available in the U.S. and, even if there were more, I would not use them. All of the so-called permanent fillers run the risk of lump and nodules. While more often these do not occur, but if they do they are problematic to treat. Other styles of facial implants may indeed be more effective than what you have such as a true maxillary implant. (combined medial and lateral maxillary coverage which is much ore comprehensive than a simple paranasal style which I find archaic and inadequate for many midfacial hypoplasia needs)
- Fat grafting is done above the level of the bone where the implants reside so they are not in danger of being accidentally injected.
- I would probably wait another month before placing synthetic fillers into the fat grafted areas. The fat grafts are still healing and there is an increased risk of causing an infection by introducing another material into these areas.
- At 8 weeks after fat grafting, injectable fillers will not have any adverse effects on the outcome of the fat grafting.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in your facial fat grafting procedure. I am a fairly young guy, 38 years old and in good physical shape. I have always had a very tired look under my eyes. I had cheek implants and orbital rim implants placed. They helped, but the problem is still there. I could also use more volume in the upper cheeks, and help with rounding out the edges of the implants. My questions are as follows:
1) How many facial fat transfers do you do per year?
2) Can fat grafting be done on someone with orbital rim and cheek implants?
3) Have you personally operated on many people with cheek/orbital rim implants?
4) Is there a chance of your needle touching the implant and causing an infection?
5) Is the procedure done under general anesthesia or would I be awake?
A: Fat grafting to the face today has become very popular and is commonly performed despite the reality that the survival of the injected fat is far from assured. It has reached the current state of widespread use because of its easy introduction to nearly any facial area, its natural composition and the potential benefits of some cellular survival particularly its stem cell component. In answer to your questions:
- I perform fat grafting as part of many facial procedures, either done alone or in combination with more invasive procedures. I would estimate that it exceeds over fifty facial fat grafts per year.
- Fat grafting can be done on someone with any indwelling form of facial implants and may be placed in the soft tissue overlying them.
- I have placed fat grafts in patients with indwelling cheek and infraorbital rim implants and at the same time as the placement of the same implants
- Fat grafts are placed by blunt cannulas, not needles, so there is little chance of injecting into the actual implant pocket. I suspect that even in the rare instance where fat may have been injected directly into the implant pocket no adverse sequelae would result.
- I have performed facial fat grafts under local, IV sedation and general anesthesia. The choice between the anesthetic type depends on the patient’s preference, the amount of fat to be injected and the location and size of the donor site.
Dr. Barry Eppley
Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years). I also unfortunately had a small amount of buccal fat removed when I was younger. That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt). What do you feel is the best way of treating this fat loss? I’m not really interested in an implant due to cost and I really am interested in restoring volume. I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view. I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV). I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.
A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.
Dr. Barry Eppley
Q: Dr. Eppley, I am 22 years old and had 12 IPL treatments. My entire face has gone flat with no underlying support as the laser had a laserlipo affect where all the fat was melted, turned into liquid and digested by my body. However I read your article on fat returning after liposuction, so in a couple of years will the fat cells and all fat regrow back in my face, especially if I gain weight?
A: IPL is not a laser but high intensity pulsed light, hence the acronym IPL. Regardless of the semantics, it creates a subcutaneous heating effect which can affect fat. While not a typical effect, reports do exist like yours where facial fat has been resorbed. Whether the effect you are seeing is temporary or a long-term result is unknown. You will know your answer by one year after your last IPL treatment or if you attempt to gain weight. If not you may need to consider injectable fat grafting for restoration of certain facial areas if they are aesthetically problematic.
Dr. Barry Eppley
Q: Dr. Eppley, Hello, I am 25 years old and have had twelve IPL treatments. It has disfigured my face, somewhat like a thermage side effect. I have lost all collagen, subcutaneous tissue, and tissue and facial padding. My skin just sags, there is no elasticity or tightness or shape in my face any more, just very thin skin. Would cheek, chin, forehead, and temporal implants help bring my face back? Or can that all regenerate and grow back after time?
A: You did not say why you had the IPL treatments, for what condition, and why so many. But that issue aside, IPL does create a subcutaneous heating effect. When done enough times it is possible to cause to cause subcutaneous fat loss. You are not the first person that I have heard that has had this effect. I would wait up to a full year after the last IPL treatment to see if any regeneration of tissue substance will occur. While I would not be optimistic that it will happen, time will answer that question. If not, then the first thing to consider is injectable fat grafting, perhaps even using a stem cell-enhanced method. You should try and replace what is lost as the first approach. While facial implants are bone-based methods of facial contour augmentation, and they may be appropriate for some facial areas, I would think fat replacement first by facial fat injection. Some combination of the two may also be considered. But I would need to see some pictures of your face for further assessment to provide more detailed recommendations.
Dr. Barry Eppley
The recent tragic events that are ongoing in Libya actually have some plastic surgery implications. It was recently reported that a Brazilian plastic surgeon says he performed cosmetic surgery on Libyan leader Moammar Gadhafi in 1995. This included harvesting fat from Gadhafi’s belly and injecting it into his face to smooth wrinkles as well as giving him hair plugs.
The plastic surgeon stated that while he really needed a facelift, he refused and wanted something that would have a less noticeable change. Gadhafi reportedly told him that he had been in power for 25 years at that time and that he did not want the young people of his nation to see him as an old man. (even dictators can be vain) Interestingly, the Libyan dictator insisted on using local anesthesia and interrupted surgery at one point to eat a hamburger.
While this story may be mildly amusing and seemingly ancient occurring over 15 years ago, it was an early use of a plastic surgery concept that has become very much in vogue today…that of facial fat grafting.
All faces age by loss of fat and the stretching of skin, gravity just compounds the problem by making it look worse in certain positions. By losing fat, the skin gets closer to the underlying bones of the face and sags as well. To ideally restore a more natural and youthful appearance, the skin must be expanded outward by lifting it away from the underlying bone. This is where the role of fat grafting has come into play. By harvesting fat from another part of your body, it can then be artistically injected back into the face to restore some youthful contours. From the method by which liposuctioned fat is processed prior to injection, it contains a good number of stem cells. (fat has been shown to have 300X to 500X more stem cells than bone marrow) This may partly explain why patients tend to notice improvement in their skin as well as more youthful contours with facial fat grafting.
When facial fat grafting alone is not enough to fill out the deflated face (too much sagging skin), lifting procedures can be done as well. Many types of facelift procedures are done today, which can be lumped into the concept of short incision face lifts. These incisions do not disturb the hairline and results in a very fine line scar around the natural curves of the ear, extending slightly behind the ear. These limited types of facelifts result in some small amount of neck and jowl tuck-up. By adding fat grafting to them, a real 3D (three dimensional) face lift can be achieved.
The Libyan leader was way ahead of his time by getting facial fat grafting before the technique was as developed and understood as it is today. You may say that such fat grafting to the face is the ultimate form of recycling or ‘green surgery’.
Dr. Barry Eppley
Q: I’m interested in a facial fat graft. You’ve mentioned in one your Explore Plastic Surgery blogs about the use of growth factors with fat grafting. My understanding is that these can be derived from the patient’s blood . How is that done and how does it work?
A: Fat grafting to the face through injection techniques become popular because it is both natural (organic you might say) can be placed fairly precisely. Its one drawback is that the survival of the fat is not predictable. There are numerous steps with fat grafting that will influence survival from the way it is harvested to how and where it is injected. One historic variable in this pathway has been the addition of agents to the fat graft that may help it survive. Insulin is the best example of this approach. A contemporary agent to add to fat grafts is growth factors. This is done by adding the patient’s own concentrated platelets. Known as platelit-rixh plasma (PRP), this is an extract from the patient’s own blood that is drawn during surgery. The blood is processed in such a way so that several ccs. of platelet concentrate is obtained. This is then mixed in with the fat graft.
While the use of platelets with fat graft injection is a natural agent, it has yet to be proven to be conclusively beneficial to an improved survival volume. Its concomitant use is currently based on more of an alchemy approach with the hope that the potent growth factors which the platelets contain will help the stem cells in the fat graft survive, differentiate into fat cells, and help main graft volume.