Q: Dr. Eppley, My 19 year old daughter has some facial deformity and atrophy secondary to scleroderma. Although we are still in the early stages of diagnosis and treatment we are beginning to look for an experienced cosmetic surgeon that has dealt with this unfortunate condition. She has one side of her chin that is considerably smaller than the other. She also has some thinning of the upper lip unilaterally and a small amount of wasting to the same side cheek area. Again, we are still in the early stages but this appears to be a limited scleroderma with morphea traits. I would expect a chin implant would give her the best results but I would be very concerned to have any foreign substance placed in her at this time with the possibility of reactivating the condition. So I would expect “fat injections” to be the next best option?? Thanks for any insight you may be able to give.
A: Your daughter’s case sounds very classic in my experience and fortunately fairly ‘limited’. (I am certain she does not feel that way) You are correct in your assumption that fat injections are one good treatment option as that is the tissue that is largely missing/absorbed. Concentrated fat injections have one significant advantages, the introduction of stem cells with the fat that may help soft tissue rejuvenation. Often I will use PRP (platelet-rich plasma) with the fat injections to get optimal fat cell survival and perhaps stem cell stimulation. Although depending upon the degree of soft tissue indentation and its location I would not exclude the possibility of bone augmentation with an implant or even a dermal-fat graft. The best facial recontouring results come from using any of these available techniques based on the size and location of the defects. There is no evidence that treating this form of scleroderma reactivates or exacerbates the condition no matter what treatment is done. While it’s etiology is very poorly understood, it is believed to be of neural origin and of an automimmune nature.
Dr. Barry Eppley
Q: I have scleroderma and there are quite a few things that bother me about my face. Because of the scleroderma, it has caused a lot of damage to my appearance and the whole left side of my body is smaller than the right. If I could change how I look, I would want to look as close to normal as possible. I know I won’t look perfect but just looking like I’m not sick is good enough for me. My main issues are my cheeks which are sunken in, my chin which is uneven, my lips in which the top and bottom left sides are smaller and my nose which I think is too pointy. There is also an indentation on my forehead and the area under my eyes seems very hollow, all these affected more on the left side. I would really like to hear your opinions are on what I mentioned and your recommendations. I have attached a series of pictures for you to review.
A: I have taken a look at your pictures and your overall problem which is two fold; a short lower face and a lot of soft tissue thinning and atrophy. (more on the left than the right) In making an effort to get you looking better, you need a two-level approach. First, it is necessary to change the bony foundation by making the chin longer, more even and further forward by a chin osteotomy as well as a rhinoplasty to bring the nose/middle part of the face back into better balance. (this is what is imaged in the side views) Cheek implants are also needed to add some fullness to the cheek area. (this is what is imaged in the front views) The soft tissue deficiencies, which are difficult to image, are addressed by the placement of multiple dermal grafts and/or fat injections (if you have any fat elsewhere on your body to harvest) in the forehead, lower eyes, side of the face below the cheeks and in the left upper and lower lips. All of these could be done in one single surgery.
Dr. Barry Eppley