Q: Dr. Eppley, I am interested in fat augmentation around my facial implants. My biggest concern is how much fat will survive as the plastic surgeon I saw mentioned that the presence of the implants will make it less likely the injected fat cells will be able to develop their own blood supply and grow. This gives me pause as I’m not too keen on another procedure that might just be an expensive temporary natural filler. I would appreciate your thoughts on this and how to maximize the survival of any grafted fat. Are there any other options to reduce the noticeability of the implants and fill/round out the cheeks more?
A: Your plastic surgeon did reach out to me and I have discussed your case with him. Fat injections are the only treatment that can be used as the ‘missing’ piece of your face is now not what is on the bone but is where the bone/implants aren’t. It is true that the final take of injected fat is both variable and not completely predictable. But I know of no scientific evidence that supports the supposition that fat grafts take less well over or around facial implants. And where you need the fat is to fill in the areas around and between the implants which is only soft tissue anyway.
One technique that can be done to improve fat graft survival is the use of platelet-rich plasma. (PRP) By mixing PRP with the fat grafts, it optimally enhances fat cell survival through its growth factor effects. It may also have an inducing effect on the stem cells that naturally reside in fat. Given that it is an extract from your own blood, there is no reason not to use this natural fat ‘booster’.
Dr. Barry Eppley
Q: Dr. Eppley, I would like to get rid of my facial wasting due to HIV. I am interested in cheek implants and fat fillers for lipodystrophy. I have attached a picture of my face for your evaluation.
A: In looking at the one picture you sent, your greatest area of lipoatrophy is in the temples and secondarily in the submalar regions. Compared to many patients that I see, your degree of facial lipoatrophy is fortunately more moderate in severity. Given that you have existing lipoatrophy, and I assume you are on antiviral medication, this makes the use of injectable fat survival precarious at best. For this reason, I make an effort to use permanent synthetic implants when possible for its treatment. These would be applicable to the temporal, submalar and even the nasolabial fold areas. But facial implants do not cover all facial lipoatrophy areas and are at best thought of as building blocks from which to fill around with fat injections as needed. Even though fat injection survival is unpredictable, it is the best filler to use for broader facial areas. And since it is not the only method of treatment that is being done, any survival that is achieved is a bonus to the underlying implants.
Dr. Barry Eppley
Q: Dr. Eppley, I am 68 years old and had a mini-face lift when I was 55 and a Lifestyle neck lift four years ago. While these have provided improvement, the areas around my cheek and eyes have not been addressed by these previous procedures. I was thinking of some fat injections under eyes and into upper cheeks to “pull up” some of downward sag. I find I am more afraid of large incisions as I get older! Was thinking of correcting with long lasting fat injections first, and then see where that gets us?
A: Given that you have already had two versions of facelift surgery, you are correct in assuming that removing more skin even with longer incisions, probably does not have a great facial rejuvenation benefit. This would be particularly so in the cheek area and below. Fat injections for you are an interesting option. While they will provide more volume/fullness to the cheeks, I am not sure how much lifting effect they will have as they push out more than they push upward. There is also the additional issue of how long-lasting fat injections are in someone of your age. But if you adopt the attitude of ‘let’s see where that gets us’, that is a good mental attitude to have about a procedure in which it is not clear how well it will achieve your objectives. But there is little downside to doing since it is a natural material. I do overfill a bit with the fat injections but it would be important to not overdo it so there is not a prolonged period of being too puffy. More injected fat does not always equate to better long-term fat volume retention.
Dr. Barry Eppley
Q: Dr. Eppley, I had a facelift and upper and lower blepharoplasty a year ago. I always had a youthful round face. The facelift did give me a nice neckline and tighter skin, but changed the shape of my face which now looks thinner and older. Now I am considering fat transfer to restore my face to a more rounder look. Should I have the fat transfer in the malar area or submalar or both. Iam afraid I could get my jowls back. My face used to have the shape of Valerie Bertinelli’s if you know that actress. Thanks for your advice.
A: While facelift do a nice job of redefining the jawline and neck, tightening facial skin in some patients can make their face more gaunt in appearance. This can counteract the favorable anti-aging effects of the skin tightening. This is particularly prone to occur in Caucasian females who have a thinner face to begin with. This is why many plastic surgeons today, myself included, advocate a combination of fat injections for volume and less skin tightening for this type of facelift patient. The injections will usually be in the submalar and lateral facial area. Whether the fat injections should extend up onto and across the malar area would depend on what your facial skeletal structure is like. Flatter cheeks would benefit by some volume but strong cheekbones will not. The real benefit of fat injections in facial rejuvenation/facelifts is in the submalar or buccal area and extending outward and down from that area. I would have no concern about recurrent jowling from the fat injections as they do not fall because of their linear placement.
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: Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer. I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.
A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift. Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done. I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.
Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.
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: Hi Dr. Eppley, I am interested in filling in my lower cheeks. They are sunken in and I have had multiple fillers from Radiesse, Juvederm etc for years. I am tired of it looking really good for 2 weeks due to swelling and then having it all disappear and look the same within the month. Do you ever do a tissue fill on the lower cheeks? I had one doctor do filler one time on the upper cheeks and I hated it. I looked like cat woman and I don’t like that look. I just want to fill in the bottom cheeks. I’m afraid to put in an implant because of the risk of crooked smiling. What do you suggest?
A: The area below the cheeks is known as the submalar triangle which extends from below the cheekbone down (in an upside down triangle) to below the side of the mouth. It is important to appreciate that this area is not supported by underlying bone. This is why anyone with a thin face or fat loss will show an indentation in this area and create a ‘gaunt’ look. This also means that there is no type of a bone-based facial implant providing any fullness to this area.
While synthetic injectable fillers will produce some temporary fullness, they are not a long-term solution to this area of soft tissue facial deficiency. The next logical approach is that of fat injections. While they offer at least the potential for some long-term retention, they are also plagued by potential resorption. I have mixed these fat injections with PRP (platelet-rich plasma) for facial injections and feel that this combination does offer better results. But the risk of near to complete resorption still exists. No one can predict how well fat injections will persist in any particular patient.
The remaining good alternative is that of dermal grafts. Using allogeneic dermal grafts, they can be put it in sheets and layers. They can nicely built up an area and are very soft. They are human collagen which will eventually be replaced by your own tissue. They can be put in through a limited facelift incision. Their long-term volume retention is much more assured than fat injections.
Dr. Barry Eppley
Q: I had my face injected with fat and it was initially overfilled. The doctor that did it said it would go down and look more normal but it has not. Can anything be done to make the fat go away or at least become less full?
A: Fat injections to the face is a good and safe technique for adding soft tissue volume to specific areas. Its almost sole problem is that its volume retention (aka how much survives) is not completely predictable. Studies have shown that certain areas of the face do retain transplanted fat better than others. For example, the cheek and side of the face do much better than that of the lips. Thus, it is standard practice to overfill or add more volume than one thinks is really necessary. How much one should overfill has never been precisely defined. Some plastic surgeons may do it just a little, others may significantly overfill.
Despite overfilling, the most persistent fat injection problem is that not enough ultimately remains. It is rare, but I have seen it, that too much fat remains. One should wait at least 3 months after facial fat injections to judge the outcome. By then, one is most likely looking at how much fat volume will be maintained.
There are two basic methods for reducing overfilled fat facial areas. If the location permits, ‘micro-liposuction’ can be done if a small incision can be cosmetically tolerated. The other approach is using injection therapy. I have seen successful use of either a steroid (Kenalog or triamcinolone) or very dilute Lipodissolve solutions. (phosphatidylcholine) The two can be combined together to create a mild fat dissolving solution that does not cause a lot of facial swelling afterwards. Injection therapy as the advantage of a non-surgical approach in which the treatment can be done in very discrete spots. It is also a more gradual process that lowers the risk of removing too much fat and causing the reverse contour problem.
Dr. Barry Eppley