Your Questions
Your Questions
Q: Dr. Eppley, I need advice for facial reconstruction. I had surgery consisting of a left partial maxillectomy to remove a muco-epidermoid carcinoma. (intermediate grade).
Since then, my face have partially distorted as per current picture. Could you please suggest what type of procedure is good for me , to have a better natural handsome look. Could you please recommend the best option and how the procedures are carry out.
A: Thank your for your inquiry regarding facial reconstruction and sending your pictures. The key question is whether you have undergone any radiation treatments to your face after your cancer resection??
Your face is collapsed inward on that side due to lack of underlying bone support from the maxillectomy. Replacing that bone and rebuilding that side of your face would require a complex form of reconstruction known as a free flap as there is inadequate soft tissue to cover any bony reconstruction. This would be particularly necessary if you have had radiation treatments.
A simpler and less complex form of reconstruction would be to focus on building up the soft tissues through fat injections. This can be done whether you have had radiation treatments or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a car accident over a year ago and had a portion of my scalp avulsed. I was missing a long swath of my scalp. I had to have surgery where my scalp was undermined and made into a flap and stapled back together. Everything has healed nicely and I have thick hair which covers the scar. However, there is a noticeable dent and asymmetry with my scalp which looks funny and requires me to grow my hair longer on that side to cover the area, kind of like a small comb over which I am not comfortable with. I am interested in having that area filled to improve the symmetry of my scalp and provide a normal look to the shape of my head. I buzzed my head and provided a picture that you will see attached.
A: Since your original injury was a soft tissue one (scalp) and not loss of bone, the indentation along the line of the original scalp avulsion closure is from a soft tissued defect not a bone defect. Building up the skull is not the solution to solving the scalp dent problem. This is a scalp reconstruction issue. The likely solution is either fat injections to release the scalp scar and build up the dent or open the scar and implant a dermal-fat graft or an alogeneic dermal graft. Either way the scalp tissue needs to be built up or thickened to create a smoother scalp contour.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’ve recently e-mailed you inquiring about deltoid implants/fat grafting and I was wondering what other areas of the body that fat grafting can be applied to?
I’m 24 years old and have a very thin and bony structure, thin wrists, narrow shoulders, and thin neck which has led to years of insecurity, yet at the same time I have a decent amount of fat on my stomach and chest.Due to severe tendonitis and several joint problems – accompanied with a muscular dystrophic disease in earlier life, I’m entirely unable to engage in hypertrophy training so the option to increase muscle mass through weight lifting isn’t possible, though I have tried for many years to work around it.
I was wondering if somewhat of a comprehensive fat grafting/contouring upper body transformation (increasing forearm, upper arm, deltoid, and neck thickness) is possible. Could it be done and look natural? or is there an alternative surgery that could be more suitable? I just want to feel/look like a normal person.
Thank you.
A: I think the key issue in you, who is very thin most everywhere, is that fat grafting is very unlikely to be successful. This is because most likely you do not have enough fat to harvest to be used and in very thin people the injected fat rarely stays or stays so little that it does not make much difference. The only option for arms, shoulders, chest and calfs are body implants which can look natural as long as they are not overdone. (too big) There is no procedure that can make your neck thicker.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old female with flat cheekbones that make my eyes look prominent. I have noticed that whenever I laugh the lower eyelid retraction vanishes and the eyes look quite normal. So I am thinking a fat transfer can considerably correct the problem. But I would like toknow if the maxillary hypoplasia is so severe as to make necessary the use of orbital/cheek implants. Or do you believe in using large volumes of fat transfer to treat such cases. And can fat grafts be used in the cheek eyelid junction too?
A: You have astutely discerned the two approaches to anterior midfacial/lower orbital hypoplasia. The bone can be built up with implants or fat can be added to the soft tissues that drape over the bones. Each has their own distinct advantages and disadvantages and the actual anatomy and severity of the tissue deficiency will play a major role in that treatment decision. It would be very helpful to see pictures of your face to provide a more specific answer to your exact facial concerns.
Having done a lot of both infraorbital and tear trough implants and fat grafting in this area, I am facile with both techniques and my treatment decision rests with what is best to anatomically correct the problem. Anatomic needs should dictate the treatment, not what ay surgeon is most familiar with doing. What I can tell about treating this area in general is that I often use a combination of both implants and fat grafting to get the best result. Implants can only go where the bone is, fat injection grafting can volumize soft tissues where implants can not. (e.g., lower eyelid above the infraorbital rim)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I had cheek, infraorbital rim and paranasal implants placed last year. While they have helped the look of my flat midface significantly, the implants look a bit ‘skeletonized’ and need some additional volume around them to create an overall fuller facial look. I know that injectable fat grafting is the only long-term option available but I am concerned that I will spend a lot of money and it will not work. What are some insights to improving the success of fat grafting to the face?
A The take of injected fat is a multifactorial issue and includes where and how it is harvested, the technique of concentration, the method of injection and what facial area is being injected. (cheek and the midface have the highest average percent of take) Because of all of these variables, most of which are not understood how they influence the process, it is no surprise that fat grafting remains as much an art as a science. It is also fair to say that all surgeons who inject fat are not created equal.
The most important key in properly injecting your facial areas of concerns is to have enough fat volume to do it. The surgeon must harvest at least 60cc and concentrate it down to 15cc to 20cc. (it takes far more fat than one would think to really create the overall volumetric increase that it is needed) I personally prefer to add to facial fat injections a PRP solution to have a ‘booster’ effect. PRP (platelet-rich plasma) is an extract of your own blood that adds numerous growth factors and cytokines which theoretically improves fat cell survival and stem cell conversion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tracheostomy scar revision. I have already consulted some local plastic surgeons, but they are not expert with this kind of procedure. One of them told me I would have to go there twice or three times to have a reasonable repair conclusion. Actually, I am kind of afraid of it. I would like to receive an advice from you. Please, show me if it is possible to be removed! Would you perform a lipofilling procedure? Thank you!
A: Thank you for your inquiry and sending your pictures. You have a very deep tracheostomy scar deformity that goes well into the sternal notch area. This represents a severe loss of fat between the skin and trachea. I imagine that there is also a skin retraction deformity which occurs when you swallow. In my hands, I believe you can get a very good result in a single procedure using a dermal fat graft to fill the defect and excising and closing the horizontal skin scar over it. Dermal-fat grafts survive very well in small defects like a depressed tracheostomy scar.This is a very straightforward and uncomplicated procedure that has a very minimal recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat graft 4 years ago that I am unhappy with. I have too much fat particularly along the jowl line and near my masseter/jaw area. It feels as if some of the fat near the sides of my jaw/masseter has calcified. Do you think that either 5FU or diluted Kenalog could help in either of these locations? I realize that Kenalog could cause a dent, but perhaps a dent near the jowl would look good versus an area where there is soft tissue only?
A: While injected fat grafts have the potential to undergo located areas of calcification, that is more common in the breasts and buttocks where large volumes of fat are placed. Calcified areas in facial fat grafting are much more unlikely due too smaller graft sizes and better blood supply of the facial tissues. If a fat graft is calcified, I doubt at this point that this fat can be ‘dissolved’. However if the fat is soft even though it is an ‘old graft’, it still may be susceptible to the effects of triamcinolone. (Kenalog) I would start off with a very low concentration (like 5mg/ml) and give it 4 to 6 weeks before repeating or increasing the concentration. If steroids are injected in low concentrations over time you should have success of thinning it out without creating the reverse problem of indentations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been doing some research and I found some info on Refine Suture lift and mesh lift with fat grafting. I was wondering about these procedures and if you would suggest this over the traditional lift with implant. I have read that these help with the lifts lasting longer and upper pole fullness, but wanted a professional opinion.
A: Your research and questions into these developing methods of breast reshaping are timely and insightful and merit a full explanation to put them into perspective and how they may or may not apply to you and your breast reshaping goals.
While implants for volume increase and lifts for repositioning the breast mound and nipple upward are the traditional and time-proven methods of reshaping the deflated and sagging breast, they rely on a synthetic implant and scars to create their effects. So understandably alternatives have long been sought for either a more natural result (non-implant) and breast lifting methods that create less scars and more resistance to any lower pole breast relaxation.
Historically these searches for improved breast reshaping methods have been met with disappointment. But the three techniques you have mentioned (fat grafting, Refine anchors and internal mesh supports) have recently come into play and are promising…although they are still in various stages of development. Thus their use does not have a long track record so the initial enthusiasm must be viewed with guarded optimism.
Fat grafting can work in restoring volume to the deflated breast but what it can only achieve moderate volume increases. Fat grafting can not create large increases in breast size. This translates into an implant volume of about 200cc or less. If one has enough fat to harvest, then fat grafting can be a good substitute for this low volume increase which is usually perceived as ‘just adding a little extra upper pole breast fullness’. The only caveat about fat grafting is that its volume retention is not assured. As a genera statement, the volume of injected fat into a breast that survives and is maintained is around 50%…but some may have more or less volume retention.
Refine suture anchors for internal breast tissue suspension (internal breast lift) is based on placing a matrix of sutures with small plastic anchors that pull up the breast tissue upward and help anchor it to the upper pectoralis muscle fascia. As one of the few Refine-trained plastic surgeons in Indiana, I am very familiar with this device and its use. For small amounts of breast lifting, particularly in conjunction with fat grafting, it can have a useful role in breast lift surgery. But it will not provide a major lift when the transposition of the nipple-areolar complex must be moved significantly upward. In addition, its long-term effects are not well known as the device remains in clinical trials with long-term follow-up data yet to be reported.
The long-term stability of a breast lift is largely based on the skin tightening of the lower pole of the breast. This naturally relaxes to some degree in many breast lift patients, particularly when the breast mound is not supported by an underlying implant. The concept of adding a sling of support across the lower pole of the breast during a breast lift is both logical and has been tried in the past. But the use of non-resorbable synthetic meshes (hernia repair mesh) in the past has been met with wound healing and infectious complications. The concept has enjoyed re-emergence today because of a wide variety of cadaveric dermal slings and resorbable synthetic meshes. The two resorbable synthetic meshes currently available (GalaFlex and SIRI scaffold) offer a very adaptable thin mesh-like scaffold that be easily sutured across the bottom pole of the open breast lift patient. They are resorbable and are eventually replaced by new collagen tissue. Their use is gaining in popularity with good results and few complications and probably better long-term breast shape results. But they will not attain use in every breast lift patient as the cost of the mesh is around $2000 per breast. This adds substantially to the overall cost of the surgery which currently limits their use to the high-risk or revisional breast lift/implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In elementary school I was diagnosed with Linear Morfia but I have also heard the doctors call it scleroderma as well. I am now in college and it effects the right side of my face. I notice it on my forehead, under my eye continuing down to my cheek and a little on my nose, on the corner of my lip, and also some places under my chin and on my neck. The places on my neck are barely noticable so I’m not sure if they are even fixable but all other places I think would be able to be improved. I’m not sure what procedures would be needed but I’ve heard a lot about fat grafting. I would love to hear from you on what you could possibly do for me to make me feel better about it. I am attaching a picture of the left side of my face to compare to the picture of the right side of my face. Thank you for your time.
A: Fat grafting is the best treatment that we currently know for the soft tissue atrophy that linear scleroderma causes. Since fat loss is a big part of the tissue thinning effect it creates, it is logical that fat replacement would be a key part of its treatment. Harvesting fat by liposuction and then processing it for concentration is how injectable fat grafting is done. Injectable fat grafting is very versatile so it can be placed almost anywhere on the face.I have done this many times for linear scleroderma and it is certainly the one treatment that can help. While historically any treatment for linear scleroderma was recommended to be done once the disease processhad burnt itself out, my feeling is that fat grafting should be done even if the atrophic process is ongoing. It may help abort further tissue atrophy. Sinjce fat grafting is harmless since one’s own tissues are used, there are no adverse effects with its use and it can be repeated as many times as is necessary for optimal soft tissue volume restoration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had injectable fat grafting done to my brow ridges several months ago. I like the results of my fat grafting but my only issue is that it leaves the area between the eyebrows (and above my nose) looking hollow. I’m not sure why my surgeon did not inject fat in that region. But could fat be injected there to provide a smooth transition between the brow ridges? I have circled the region between the eyes that is my concern from a stock photo for your reference. Are there any risks associated with fat grafting to the circled area?
A: The area to which you refer between the eyes is known as the glabellar area. It lies between the inside of the eyebrows and, in a male, is a more normally indented area than the brow ridges which overlie the eyes. If the brow ridges have been augmented and the glabellar area has not, then it may well look now by comparison that it is more indented than before. You would have to ask your surgeon why that area was not grafted alone with the brow ridges. I have not specific problem with grafting all the way across the brow ridges, from one side to the other, as long as it is done with a blunt-tipped injection cannula.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my clavicles on both sides stick up. Have you dealt with this surgery before – do you recommend anything (would deltoid implants resolve this)? I don’t want huge shoulders, just bones not so prevalent and I don’t want scars. Appreciate any feedback.
A: I have seen and treated prominent clavicles before and they are not rare. From an anatomical standpoint, the clavicle or collarbone is the only long bone in the body that lies horizontally as it connects the medial sternum to the lateral scapula. The knob at the acromial end of the bone can be felt in anyone but in some people this bony bump is very prominent as a bulge underneath the skin on top of the shoulder. This occurs due to either more bone in some people or less surrounding fat in others.
Cosmetic camouflage can be done by bony reduction by burring but this creates a scar which you have eliminated as an option. Deltoid implants are not appropriate for camouflage as this type of implant fits over the larger muscle belly of the deltoid which is more to the side of the shoulder. The only scarless treatment option would be injectable fat grafting. Since a thin fat layer is one reason why a prominent clavicular knob is seen, fat grafting around the knob and out into the deltoid muscle belly provides the best treatment option. While fat graft survival is unpredictable and survives least in areas of thin fat with tight overlying skin, it is the one true scarless camouflage method. What may be helpful is deltoid augmentation by fat grafting not implants.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I consulted with a local doctor and he said that because of the height and projection of the nasal implant it made my nostril more visible. I think I’m leaning more towards rib cartilage as use for the implant. What I want to accomplish is a nose that’s less deviated, less nostril visibility and appears less short. Also, being that I have thin skin, what can we do to prevent the rib graft from being visible when someone is looking at me? At the moment, my nose looks thin and skeletal like and I want to remedy that.
For my chin, I want the implant removed and fat grafting done to the area. I just want a chin with an appropriate projection in relation to my face and nose. Also, I would like to see if we can use fat grafting to restore a natural jawline to my face before resorting to implants. I would like fat grafting to my nasal labial folds as well as the cheek/hollows of my eyes.
A: There us nothing wrong with using injectable fat and that is clearly a treatment approach that you find most comfortable. However, you need to be aware that fat grafting never works the same as an implant regardless of how it is presented in surgeon’s websites. Fat grafts are soft and don’t have the same push on the overlying soft tissues. As a result, the amount of augmentation and the definition it creates is far inferior to a firm implant. But with that being said, I think fat grafting is reasonable since you have other fat grafting needs so ti is worth the effort. There is certainly nothing to lose by so doing.
It is difficult in any rib graft to a nose with thin skin to not have it look skeletal. Ways to lessen that aesthetic risk are carving the edges of the graft so that they are round and not sharp and to cover the rib graft with a thin layer of allogeneic dermis. Together these two approaches can be effective at softening the look of a rib graft to the nose.
In replacing a chin implant with fat, it is again important to know that it will not create the same effect and many not even survive inside the relatively avascular lining surface of the chin implant pocket. But again it is a reasonable approach with little risk other than complete graft absorption.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, thank you for the great fat grafting done to my cheeks a few weeks ago. It has helped a lot and I know that it is too early to tell how much fat will survve. But should a significant or at least enough fat go way that I want more at the three month time after the surgery, would you be able to go in and get more fat to put into that cheek? I was looking at some publications by Coleman and it appears that it is OK to inject more into the face after a three month waiting period. Also, is it true that you can extract a lot of fat and then freeze it for use in future treatments? What does the literature say about this type of procedure?
A: Secondary fat grafting can be done anytime after the initial procedure. The reason that the three month time period is given is so that one has enough time to fully appreciate how much fat has taken. Three months is the generally accepted time period to see the balance between what fat has died and been absorbed and how much has survived…thus making the final achieved contour change visible. Harvested fat can be stored in a frozen state for future use. Despite its appeal, however, the medical literature indicates that the thawed and re-injected fat quickly undergoes complete resorption. While not completely understood, the freezing and thawing process apparently is very detrimental to fat cells. (adipocytes)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in calf augmentation with fat grafting/lipo filling. I am a 33 year old man with over a decade of weight lifting and exercise experience. I have trouble building muscle particularly in my calfs. I am hoping fat grafting can give me the desired look I’ve been working so long for.
A: While I appreciate one’s desire to build body contours using one’s own tissues, there are several key issues about injectable fat grafting. First, one has to have enough fat to harvest that, after filtering and purification, has enough volume to augment the calfs as well as any other areas. Whether a young man who is most likely fit has enough fat to accomplish that remains to be seen. Secondly, fat grafts are not like implants. The predictability of their survival to maintain volume is far from assured. Injectable fat grafting is associated with a wide variability in fat volume retention and young lean people usually have a lower retention rate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i am interested in nano fat grafting. I have heard that fat is beneficial to scar contracture but also I am aware that fat won’t survive in a scar bed and I could wind up with lumps. That is why I thought that the nanofat probably won’t do any harm and may even help. The side of my nose that has a depression or drop off angle is the area with the scar tissue build up. The tissue is parchment thin there. I would like to fill this area with an autologous material. I had surgery 3 years ago to revise a rib graft done nearly 6 years ago which left me with unatural harsh drop offs on either side of my bridge. I already had restylane done last year and it lumped up on me and caused too much pressure in my nose. I have also been considering trying belotero filler, Would you have any suggestions?
A: While I think nano fat grafting would not hurt, I don’t think it will produce any positive benefits in terms of filling in skin depressions or rib graft step off areas. This all would be better served to be filled with alloderm (allogeneic) dermal grafts.
There is a difference between scar tissue build-up (contracture) and trying to make the skin thicker or fill in contour depression areas. If the rib graft not has sharp edges or visible stepoffs,, adding a layer of alloderm or been temporalis fascia would be the more assured way of improving the soft tissue cover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, the left side of my face is different from the right side. It seems to be missing jaw bone. Is it possible to even up my face with the jaw implants? I have attached a picture.
A: Thank you for sending your picture. It is not the best picture (from an angle standpoint) but it does show that you do have significant facial asymmetry which appears to affect the jawline the most. It would be optimal if I had some different picture angles of your face that had your chin more upward and not pointing down. But to provide some basic answers, some form of a jawline implant is needed. Whether this could be a done with a stock preformed implant or would be best done with a custom implant would require a little more in-depth information with some x-rays. At the minimum a panorex x-ray is needed, more ideally a 3D CT scan is best. That information will answer what type of implant is needed and how it would be done. Also, fat injections to fill out the overlying soft tissues is always needed as well as the facial asymmetry is caused by more than just a bone deficiency. Think of improving your facial asymmetry from the bony foundation underneath outward to the skin.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis,Indiana
Q: Dr. Eppley, I would love to smooth out the under eye area- fill in the depressions created when I smile, and add an over-all fullness that I have lost, most recently in the last year as I have gone through menopause. I experienced a rapid and major estrogen deficiency that truly took a toll, especially in my face to appearing almost gaunt. (being a woman is quite a life-time adventure in of itself!) Looking at pictures just one year ago show a noticeable loss of facial volume even though I have experienced no overall weight loss or gain. Again, thank you for sharing your time and expert skill with me.
A: In interpreting your facial concerns they are two-fold: lower eyelid hollowness and a general mid-/lateral facial involution below the zygomatic body and arch bone levels. While both of these are caused by loss of fat, they may or may not be treated similarly. For the generalized facial wasting, the only effective treatment is fat injections. This is the only way to help restore larger facial surface areas that have no underlying bony support. (what I call the facial trampoline area) The lower eyelids are a bit different because the thin skin exposes the use of fat injections to risks of asymmetry and irregularities with so little interface of tissue between the lower eyelid skin and the underlying orbital bone. Other options include the use of orbital rim implants and dermal-fat grafts but those are not without their own issues. (more invasive, palpability, donor site harvest) Given these issues I would favor fat, whether it is of the injected or en bloc variety.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am at wits end. 🙁 I had goretex implants in nasal-labial folds about 12 yrs ago. They capsulated shortly after and I looked hideous. So I've been filling around them for years even had a face lift. Finally, about 6 months ago I had them removed and replaced with Alloderm.. It looks worse!!! One side is hard and they both show thru the skin. The company will not give me info. Can they be successfully removed??? Today, I am having Ultherapy in hopes of tightening to minimize the awful protrusions.:((I used to be a model and now I can't even look in a mirror)
A: I see no problem with easily removing Alloderm. It does not usually incorporate much into the surrounding tissues. It gets encapsulated, almost like your original Gore-tex implants, which is why it contracted and became distorted. In hindsight, that probably was not the best choice for a replacement for the Gore-tex as it did exactly what could have been predicted in that situation. I would not expect Ultherapy to make any difference. That approach is a hopeful but flawed concept. A much better replacement once they are removed would be dermal-fat grafts or fat injections, a natural tissue that will heal into the surrounding tissues adding volume and will not develop contractures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know what kind of result to expect by injecting 1cc of fat grafting in the upper lip. Thanks for your answer.
A: Your question in regards to fat injection grafting of the upper lip has a two-fold answer. First, fat injections to the lips are associated with a very high rate of reabsorption often being completely gone within 6 weeks of the procedure. This is the most difficult area of the face in which to get fat to be persistent. Lip tissue is different than the rest of the face and their near constant motion all contribute to the low rate of sustained augmentation. When fat injections into the lips are done, overfilling is a common technique in the hope that even if most of it is reabsorbed some will remain. Based on this premise, usually 2 to 3ccs of fat is injected into a lip. Second, while 1cc of a synthetic injectate would be considered more than adequate for any lip (because the objective is to have an immediate but not overfilled result) that would not be a good approach with fat for the reasons just described.
Thus 1cc of fat injected into the upper lip will produce an immediate and satisfying result (just like that of a synthetic filler), I suspect most of it will be gone before a month has passed after the injection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting some volume back in my face. I lost a fair amount of weight over the past two years and my face has become quite gaunt. After doing a lot of reading, I know that there are the options of either some type of injectable filler or using your own fat. There doesn’t seem to be any consensus as to which is best. What is your opinion?
A: The development of synthetic fillers has created a whole new field of aesthetic medicine, mainly for facial rejuvenation. They are understandably hugely popular because of their instantaneous effects. While some last longer than others, in the end they are all temporary fillers. This issue only becomes truly relevant with major facial volumization is desired. The issue is simply one of cost. Given the volume of synthetic filler needed and the time that they last is the cost worth it? That, of course, is an individual question but the cost:benefit ratio does come into play for most patients.
Fat injections do not suffer from volume concerns and are more cost effective when considering the volume that is capable of being injected. Fat also has the added benefit of providing some stem cells as well although what their role is and how much they contribute to fat graft survival and overall tissue rejuvenation is still a matter of some debate. While fat grafts have the potential for long-term survival, their retention is not completely assured. Fat grafting procedures are a surgical procedure, however, and need to be performed under either local anesthesia or IV sedation depending upon the volume needed.
In the end, both synthetic fillers and fat grafts have their advantages and disadvantages. When it comes to substantial facial filling as in the gaunt face, fat grafting has more advantages as long one is willing to commit to more than an office procedure with some downtime.
Dr. Barry Eppley
Indianapolis, Indiana