Q: Dr. Eppley, I am interested in the procedures of jaw enhancement, facial fillers, and nosejob. I would like to achieve a more defined and symmetrical jaw line. I want a more filled out face. Perhaps cheek fillers or cheekbone reduction also? I am not sure which approach would be best to give me a fuller face. I want facial features more similar to Brad Pitt.
A: I can see your concerns in regards to a fuller face. You have a very skeletonized face with virtually no fat between the prominent cheek bones and your jaw line. I have done some imaging based on the procedures of jaw angle implants to widen the lower posterior face, a rhinoplasty and fat injections to the sides of the face below the cheekbones down to the jawline. This combination appears to give you better facial proportions and also demonstrate that the cheekbones are not really so prominent. It is the lack of soft tissue fullness (fat) that is why you have your current facial appearance. While cheek bone reduction is an option, I used fillers just to see how the face would look without changing the width of the cheekbones. This confirms their benefit over cheekbone reduction.
The pictures are not of good enough quality to reveal what a rhinoplasty can really do but I made my best effort.
Dr. Barry Eppley
Q: Dr. Eppley, I have had deformity to my face due to scleroderma. I am now in remission, but the damage is done. Tightening around the mouth and jowls make me appear to be so much older than I am. I see you have replied to several people who have the same disease. Have you helped people with scleroderma and what type of procedures do feel would help me? Thank you.
A: I have seen many variations of the effects of scleroderma on the face from a small area to an entire hemifacial region. In the facial areas of scleroderma involvement, the subcutaneous fat is lost, the overlying skin is thinner, and in severe cases even the underlying bone can be notched or atrophic. In the treatment of scleroderma, the fundamental principle is to add volume which almost always is fat. Because it is injectable and can be placed anywhere, liposuction-aspirated fat is a mainstay of treatment today. While it’s success (survival) is not always assured, and scleroderma defects are more challenging than normal tissues due to less vascularity, the versatility of fat injections makes it a preferred method in most cases. There are indications for other augmentation methods, such as dermal-fat grafts, allogeneic grafts, and onlay bone implants, but there use is more limited.
For involvement around the mouth and jowl area, the use of fat injections would be the best treatment choice. It may require more than one injection session to get the ideal result but adding volume will relieve that tight feeling and make it look rejuvenated as well.
Dr. Barry Eppley
Q: I want a fuller face with full cheeks. I have a very thin face that looks gaunt and sunken. It seems to be getting worse as I age. I think I need either cheek implants or fat injections but am not sure which is best. I have attached some pictures of my face for you to see and do some computer imaging to see what the possible changes would be. Thank you for your time.
A: Thank you for sending your photos. To do accurate imaging, however, a front and side view photo is needed in which one is not smiling. Your photos can not be used for any imaging as the smile obscures the whole process.
Otherwise, you have a type IV facial lipoatrophy condition with near complete loss of the buccal fat pads and most of the subcutaneous fat tissue. This gives you that sunken facial appearance. You would ideally benefit from a combination of submalar cheek implants combined with concentrated fat injections to the upper and lower submalar area as well as back along the side of the face. Given your thin face, it may well be that your body is equally thin so whether you have enough donor fat remains to be determined. With fat concentration techniques, one needs to harvest as least twice as much fat as the face requires. I would estimate that you need about 20cc of fat for each side of the face so it would take about 100cc of liposuctioned fat to do the job.
Dr. Barry Eppley
Q: Hello Dr. Eppley I am a 26 years old girl. Actually I have an oval face. I like all my features in my face except the shape of my face. This feeling destroyed my confidence, so I must do something about it. I like to make it more round and fuller. I would like to know which options do I have for that goal, fillers, fat injections, or what else? Do you think what is the best option for me, which has a reasonable price, is long lasting, with the least side effects and also look very natural. All your advices would be so valuable for me. I am looking forward to hearing from you. Thanks so much.
A: Increasing the fullness of your face involves expanding the ‘middle third’. This is the soft tissue area between the bony cheeks and the jawline on the sides of the face. The only practical approach would be the use of fat injections. While their survival and volume retention is always variable, they offer the best economic approach, virtually no complications, and the most natural looking result. For my facial fat injections, I now add Matristem collagen particles and platelet-rich plasma (PRP) to the fat for a ‘supercharging’ effect to try and get the best volume retention. That being said, it is still adviseable to overfill the injected facial areas to some degree. The fat needed to inject usually comes from the abdominal or waistline areas by liposuction.
Dr. Barry Eppley
Q: Hi I was wondering what you think of Bioplasty or have you ever heard of it. Doctors in Brazil does the whole face with pmma called Newplastique, injecting it into the jaw, cheeks, chin, eyes, brow anywhere. I saw a doctor in Mexico who uses this new plastic pmma and he quoted me $2400 for jaw jawline cheeks chin and said second touch up treatment would be half the price. What do you think?
A: What you are referring to are ‘permanent’ injectable fillers for facial fillers and volume enhancement. They are permanent based on that they contain a percent of non-resorbable particles (usually about 30% or less in volume) mixed in with fluids which allow them to be injectable. (flow through a relatively small needle) The percent of particles in any given size syringe is always less than the amount of fluid otherwise they would clog up the needle and not be injectable. There are a variety of these type injectable fillers that exist in the world using different plastic particles and different fluids. The concept, however, is the same and the potential complications are similarly the same.
Quite frankly, I am not a proponent of these type of injectable fillers for widespread facial use. I would be concerned about the potential for long-term problems from the particles such as granulomas and lumpiness. They would be difficult to remove and may have to be cut out should these types of problems arise. Advocates of their use feel that these problems can be minimized by good injection technique, which I am sure is true, but how do you know who does it well and who does it poorly? Around the world, where the medico-legal implications are not as severe, these fillers are more widely used. In the United States, however, their use and many of these type of fillers are not widely done and are not even FDA-approved for use. Nonetheless, It is not an injectable procedure that I feel comfortable doing to patients. That doesn’t make it wrong, just that I have a different practice philosophy.
I feel more comfortable doing enhanced fat injections for facial volume and reshaping. While their permanency is variable, they also are not associated with any long-term complications since it is the patients own tissues. While it is more effort and expense, and may have to be repeated sometimes as well, safety is more important than a lower cost.
Dr. Barry Eppley
Q: I feel like I am ready for a facelift and want to get the best result that I can. In doing my research on the internet, I have come across several recent articles on a procedure called the Stem Cell Facelift. In reading them, they make it seem like it is the best way to go with the best results. But I don’t understand what stem cells have to do with a facelift. Do they help lift the droopy skin or do they make what is already there better. I would like to go to a doctor that does them but I am also worried about whether this is so new that maybe it doesn’t really work that well or it is just some sort of a scam. What is your opinion?
A: The concept of the Stem Cell Facelift is based on two simultaneous techniques, a traditional facelift to lift and tighten loose neck and jowl skin and fat/stem cell injections to add facial volume. The injections are not responsible for any type of skin lifting. They add volume to areas of fat absorption that have happened with age and are purported to help make the skin look better. (which remains far from proven) They may be done together but the fat and the stem cells they contain can not make for any tightening effect on the skin
Is this facelift concept hype or hope. At this point, a little of both in my opinion. The concept is very appealing and the technique uses all natural products from each patient, thus there are no risks involved in doing it. Conversely, whether this facelift approach is better than the traditional proven methods has yet to be adequately studied over the long-term. It may well prove to be an improved method with better results but at this point the promotion of it is ahead of the actual science.
Dr. Barry Eppley