Your Questions
Your Questions
Q: Dr. Eppley, I came across one of your publications on the Internet regarding cutis verticis gyrata scalp condition.You recommend fat grafting to treat this condition.
A doctor I have consulted (where I am living) also recommend me to try this procedure. But I am not sure about the efficiency of this procedure. Would you mind to advise if fat grafting technique could be a good option to solve my case ? I have attached pictures of my scalp so you can have look. I am looking forward to hearing from you.
A: Cutis verticis gyrata of the scalp is a very unique, peculiar and fairly rare scalp condition. Why it is occurs is not known and how to really effectively treat it is similarly not known. The vertical grooves or grata are scalp indentations (not bone) that become fibrotic and adhered down to the bone. This adherence is quite dense and unbelievably stiff. There is almost nothing but scar tissue between the skin of the scalp and the bone. The only really viable treatment option is injectable fat grafting. Having done that procedure it is really hard to get into and raise the grata to place the fat grafts. It takes an initial release with ‘picklefork’ instruments to get the tissue separated to create the tissue plane to place the fat. And it will likely take more than one fat grafting session to get the best result. But you would have a good idea after the first treatment session of the value of doing further fat injection treatments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had injectable fillers in my cheeks with injections of several popular products over the course of three years now. It is costing a fortune since I metabolize it quickly. (so I’ve been told) I have used Radiesse, Juvederm, and most recently Voluma and love the results for correcting diagonal mid cheek lines and loss of fullness but they do not last more than 4 months. How do I find a surgeon who has sufficient experience in cheek implants ? What is cheek implant surgery downtime? Longevity? Any other cheek augmentation alternatives?
A: Your injectable filler story is not uncommon and many patients will be in your same situation in the years ahead. Injectable fillers are great at doing what they are intended to do most of the time. But despite the good results they provide, many patients have or will find out that the long-term costs of injectable filler ‘maintenance’ will become prohibitive for some patients. Thus seeking a permanent cheek augmentation solution has merits.
Cheek implants can provide a very satisfactory solution provided the proper implant style and size is chosen. Because the cheek area and the cheek implants chosen to augment it defy any exact method of measurement (unlike chin implants for example where the amount of horizontal augmentation needed can be measured) it takes a surgeon with a lot of cheek augmentation experience to get it right the first time. While the concept of cheek implants is simple, it can be difficult to get their placement anatomically correct with good symmetry. This difficulty is imposed on top of how to select the best cheek implant style and size for the patient.
Cheek implant recovery is largely about facial swelling and the time it takes for it to look acceptable. In reality expect that to be longer than one really wants. It takes about ten days to look socially acceptable, three weeks to ‘normal’ and really three months to judge the final result and how one feels about the facial change.
The intermediate step between injectable fillers and implants for cheek augmentation is fat injections. While far simpler and with a very quick recovery compared to cheek implants its issue is how well the fat will survive and how long it will persist. These are unpredictable and can be different for each patient.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have just learned of fat injections to help narrow small shoulders. Could you help me learn more about it? I have a lot of fat around my abdomen and obliques. Could that fat be used to make my shoulders bigger (broader and thicker)? If I were to diet, does that mean I would lose fat in the shoulders and they would shrink and I would have to repeat the fat transfer procedure? A lot of stomach fat has been something I always had. Even at 125 lbs. even when I do lose weight, I still have a big stomach. Would that fat be as difficult to lose in my shoulders as it is my stomach? How much broader could I make my shoulders with the fat transfer procedure (half inch, full inch)? Sorry to bombard you with questions.
A: Deltoid augmentation by fat injections can be a successful method for shoulder enhancement. The key is whether one really has enough fat to do the procedure or, more relevantly, to make it worthwhile. While you may think that you have enough fat, and you may very well do, that is somewhat hard to imagine at a 125lb weight. Whatever stomach fat you think you may have by appearance, that protrusion may be from an intraperitoneal basis (behind the abdominal muscles) rather than in front of it. (intraperitoneal fat is inaccessible from liposuction) This is obviously an issue that requires further assessment/examination even if only by pictures.
But for the sake of discussion let us assume you could have the procedure. Abdominal fat transfer to the shoulders (or anywhere else) is going to behave like the donor site and not the recipient site. Meaning if you lose weight the fat cells will get smaller as well as the reverse. These transferred abdominal fat cells have depot behavior with higher metabolic activity. Thus they are more sensitive to weight changes that normal shoulder subcutaneous fat would be. How much increased shoulder definition you could get would completely depend on how much fat is capable of being transferred…and how much survives the transfer process. Thus it could be anywhere from a very modest change to a more robust 1/2 inch or so.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I am looking for temporal implants due to significant thinning of my face with age and weight loss. I would also be interested in possible fat transfer or other procedures to fill my cheeks in some. Would like to consult on what my options are. Here is one old photo of me 30 years ago, I don’t ever expect to look that young again, but I would like my face to be plump or full looking again like it used to be. I’ve lost a lot of weight and my face now looks sunken and sickly. Please help me. I am embarrassed by my appearance.
A: Thank you for sending your pictures. You have very classic panfacial soft tissue volume loss which is very common in significant weight loss particularly in an older person. It affects some individuals more so than others. This is most manifest in your temporal region where it has turned into a complete concavity from the zygomatic arch all the way up to the anterior temporal line on the forehead. It is seen less severely in the cheek area only because your naturally high cheek bones have preserved some of the volume. (there is no bone protecting the temple areas) For your temporal areas there is no question that an extended temporal implant is the preferred procedure as it will create a permanent volume solution to that problem. It requires an extended temporal implant as opposed to the standard one given that it needs to reach all the way up to the forehead. For the cheeks your options are submalar cheek implants or fat injections. Each one has their own merits. (fat is better at total area volume addition but its survival may not do well given your age and lack of natural fat in the area…an implant has assured permanent volume but only provides volume to one specific area) In facial volume lose cases like yours I will often combine submalar cheek implants with fat injections to get the best of what each has to offer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen.. possibly with the combination of both procedures.
A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.
The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?
A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.
The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.
This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.
As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.
A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection. These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.
Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat injections to make my calfs and ankles bigger. My understanding is that fat injection is not a permanent solution. So if it is applicable in my case do I have to do it on regular basis?
A: While it is true that the lower legs (calf augmentation with fat) is not the best place for fat to take (due to the pressure of the overlying skin), the fat that does take can become permanent. So it is no true that fat is not a permanent procedure. It can be if enough fat is initially placed. The concept of lack of permanency in fat injections comes from the not rare scenario where a repeat fat injection treatment is done to finally get the desired result. This is not because it does not work, just that only a fraction of what was injected (maybe only 10% to 25% of the fat) survives and more fat injections are needed to get to a better end point. Think of it as adding layers to get to the desired result. In some patients, it is a one time procedure but in others a second procedure may be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a craniotomy from a car accident several years and it has left me a skull deformity. My skull deformity is around my left temple, a slight deviation/protrusion of the temple and temple area muscles especially when I move my mouth, such as when I am chewing. Along with a slightly more serious deviation (a dent) by my left ear skull area. They are both very minor, most people say they don’t notice it but it makes me very self conscious. All this being said…My next question is approximately how much will a plastic procedure to repair my damage cost? and will the repair be “undetectable” ? Just a “ballPark” figure/number?…I mean, does it sound like a $5,000 or $10,000 plastic repair? Or are we talking $50,000 or more to repair?
A: Based on your description of your concerns, I would lean towards fat injection as the corrective approach. You can’t shrink down the temple muscle protrusion and it is there simply because the temporal muscle has atrophied above it due to detachment from the craniotomy procedure. Your skull deformity is in the temporal area above the ear and again is likely due to a muscle issue. Since they both are ‘minor’ and are muscle based on their origin, fat injection grafting would be the simplest and most economical approach to their treatment.
I will have my assistant pass along the cost of the procedure to you. You will find it very affordable based on the numbers you have put forth.
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 a very narrow, dolichocephalic skull shape and I would like to increase the width of my head. According to the information on head widening provided on your website there are two options to achieve this:
1. Augmenting the posterior part of the temporalis muscle by injecting fat.
2. Placing an implant under the temporalis muscle above the ears.
I prefer option 1 since I would like to avoid implants. However, if the achievable results of fat injections are unsatisfactory I will gladly consider alternatives.
Thus I have the following questions:
1. By how many millimeters can the head be widened through fat injections to the posterior aspect of the temporalis muscle? Are 5mm per side achievable?
2. How much would the procedure cost if i) only the posterior part and ii) both the anterior and the posterior part of the temporalis were to be augmented?
3. How much does it cost to widen the head using semi-custom-made implants with a thickness of 5mm per implant?
4. Are there any other methods to increase the head without producing visible scars?
Thank you for your time.
A: The short answer to your question about head widening through posterior temporal augmentation is that only an implant is going to consistently work. The first issue with fat that you have to have enough to harvest, process and then inject. In a thin person, which it appears you are, that could be the rate limiting step right there. No matter what is injected only a fraction will survive and what survives most certainly is not likely to be symmetric.
The use of a semi-custom temporal widening implant is assured, can easily increase the side width by 5mms and is placed through an incision that is limited to the back of the ear. (thus being placed in a scarless fashion) Any consideration of fat injection use should be limited to the temporal hollowing located next to the eye area (anterior temporal augmentation) where a more posterior implant does not reach. There are very effective implants for that area as well but they require a more exposed vertical incision in the temporal scalp region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if you do Artefill or Radiesse injectable filler in the legs?Because I have skinny lower legs and I would like some volume. Also do you do butt injections for lift. Thanks!
A: Injectable fillers are never used to provide volume for such large body areas as the lower legs. Besides that fact that they are only temporary, the sheer volume of injectable fillers needed would cost $25,000 to $50,000 to create the desired effect. All of which would go away in less than six months. Injectable fillers are only used in the face where smaller volumes can have a more profound effect.
The correct injectable filler to be for augmenting any body area, including the legs and the buttocks, would be your own fat. Fat injections are the most common method used for buttock augmentation, known as the Brazilian Butt Lift. They could also be used for the legs such as in calf augmentation. Whether you have enough fat to harvest to have a successful buttock or leg augmentation procedure is the key question and is the rate limiting step in any patient considering a fat injection augmentation procedure. That could be determined by seeing some pictures of your body.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you and I spoke previously about temple implants. cheek implants, and forehead fat grafting. You did some imaging for me as well, and I realize you understand my goals in reshaping my face better than anyone. With this said, I would be interested to see how the overall look of what we discussed previously would first look by using injectable fillers to achieve the results in widening my face and adding more volume.
A: The issue with fillers for augmentation of various facial areas is one of pure volume and the associated costs. When it comes to small areas like the lips (1cc) or even the cheeks (2ccs), voluminization by hyaluronic acid-based fillers is reasonably cost-effective even though the effects will not be permanent. Beyond these volumes one has to look to the use of a filler like Sculptra to achieve a broader or wide-based facial volume effect. While these longer-lasting particulated fillers can achieve better volume enhancement of the cheeks and temples, the need for multiple treatments to achieve their effects and an increased risk of reactions to the implanted ‘seeds’, it is usually better to venture into the realm of injectable fat grafting where there are no volume restrictions or risks of any injectate reactions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw a post from last year in which you responded to a question regarding whether PRP/stem cells would be beneficial for Atrophic Rhinitis. I am wondering if you are interested in performing PRP on the turbinates. I have travelled to get PRP injections and have recieved some benefit but need further injections and would perfer to find a way closer to home. In my case, I have sufficient turbinate tissue but it has been damaged from cauterization so I am hoping to get further healing of the tissue.
A: Since you have received benefit from PRP injections to the turbinates previously, there would be no reason that you would not get further benefit by additional injection treatments of your atrophic rhinitis. The one caveat that I would add is that you consider the addition of a small amount fat with the PRP placed into the turbinates or go with fat injections alone. Fat has stem cells, (which PRP does not, and this should produce a more profound long-term rejuvenation of the turbinates than the short-stimulus that PRP provides. PRP can only stimulate the cells that are there while fat can create cellular rejuvenation and mucosal tissue regeneration, which ultimately is responsible for their function.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat injections (Lipodissolve) for my lower abdomen. I am done having children and have gained an excessive amount of weight during my pregnancies. I have lost the weight, but the aftermath is stretch marks, loose skin and a “pudge.” My upper abdomen has no stretch marks and is ok. I am trying to find an affordable procedure, that I can handle with minimal downtime, as I have 2 small children.
A: What you need, without even seeing a picture of you and based purely on your rather classic description, is not going to be achieved by an injectable fat reduction technique. Lipodissolve is intended for very small fat collections (like the neck) in which the overlying skin is of good quality. It is completely ineffective for the post pregnancy belly that you are describing. What you need is some form of a tummy tuck which can more effectively deal with the excess/loose skin and fat. With this type of abdominal problem, you either hold out for a tummy tuck one day or do nothing…as nothing will offer any acceptable level of improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I developed a depression/dent on the middle of my forehead that is circular after the birth of my second son. Whenever I bend over or pressure is applied to my abdominal area, the depression on my forehead fills up with fluid and a huge bump is visible. I have had a CT scan done and the results showed that it was not a dent on the skull surface, however it did not explain the cause. Why do I have it and will it ever go away?
A: The simple answer is I don’t know why you have it nor can I predict with any certainty if it will go away…but if I had to guess I would not think it is going to go away. Since the dent does to have a bone-basis for its presence, one can assume this is a soft tissue deficiency. That is predictable since if the dents as due to a bone issue, it would have been present essentially since birth. (short of some traumatic event) I have no doubt that the dent fill sour when you bend over but that is not because it fills with ‘fluid’ per se. That is probably due to blood vessel engorgement from the pressure which would be more obvious when the tissues are thinner.
What I would initially is to some temporary filler injections to make it more level and probably resistant to that bulging engorgement effect. If that us successful the you can eventually move on to a fat graft or fat injections for a more permanent result once you are assured that a soft tissue fill solves both problems.
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 need help in figuring out the best way to enhance facial volume. I have hollowing under my eyes and would like a stronger jawline. I had cheek implants placed two years which have done great so am looking for similar impact on my other facial areas. But I’m not sure what the best way to accomplish this is using either facial implants, fat injections or injectable fillers.
A: When it comes to facial volume enhancement the surgical debate is always whether it should be done by fat injections or facial mplants. This is no different that the debate would have been about your previous cheek augmentation. There are advantages and disadvantages for either approach but that debate must be assessed more specifically for the facial area that one wants to enhance and whether it is composed of underlying bone, soft tissue or both.
The jawline is primarily supported by bone so any effective augmentation is almost always done by some form of implant placement. You would have to further define what jawline area to which you want changed to better answer what type of implant may best address it. This is identical to your cheeks which are usually most effectively done by implant because they are a bony supported area.
The under eye area is different than the jawline because it is a combined bone and soft tissue area. The lower end of the under eye area is the inferior orbital rim while most of the lower eyelid is soft tissue supported. This usually means that fat injections are needed as an implant only covers the very lower end of the under eye area and placing it requires a lower eyelid incision to do so. So fat injections, even though they are unpredictable, usually win out over any implant augmentation. Their ‘softness’ is kore appropriate for the under eye area than the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.
The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.
What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?
A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking for a more permanent solution for a lip augmentation. I was looking into fat grafting, but I understand that that procedure may not turn out as well as I would like if not done by a surgeon who is very experienced in that procedure. I’ve also been looking into permalip, but I don’t know if that would be for me because my top lip is uneven (as you can see in the picture I’ve attached). In your opinion, which procedure would be better for me? Roughly, how many times have you done each procedure? And what are your prices for both procedures?
A: There are multiple options for lip augmentation from fat injections, implants and mucosal advancement procedures. (V-Y lip lengthening) There are advantages and disadvantages to all of these procedures and none of them are perfect. They all have flaws such an unpredictability of volume retention (fat injections), asymmetry and palpability (implants) and longer recovery. (mucosal advancements) While they all can be effective, it simply depends on which of their flaws you find most acceptable. I have performed many of all of these and I think the ‘safest’ (less risk of complications) is fat injections. Permalip implants are the easiest and can always be replaced by fat grafts should one not like their feel.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my buccal fat pad extracted a few years back when I was younger. I liked the look initially, but it has now made me look a little too gaunt.
Anyway, I’m looking to add more volume back to the buccal region. I’m not sure how to describe it, but imagine pressing a couple of fingers diagonally up below the cheek bones.
The question is, I’m not sure what route to go for volume restoration to the region. Personally, it seems the more logical choice would be to replace like with like and to use fat injections to the region. However, I’ve read some doctors advocate the use of submalar implants.
In your opinion, which would present with the better result?
A: By far and away, the best approach is the submalar implant combined with a little fat injection around it. The submalar implant covers the upper half of the buccal space but not the lower half. So depending upon the extent of the buccal deficiency, fat injections may or may not be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to achieve more definition and masculine features. I want a more defined jawline, neck and cheekbones. I actually am even more dissatisfied with how my face looks from the side or profile view. Do you think that liposuction of any area of the neck or cheeks would be beneficial? Or just all implants? I’m slightly hesitant to do implants other than the chin and wondering if you yourself would be able to use fillers instead of something permanent. I have attached some front and side pictures for your assessment.
A: Your side picture clearly shows a more recessed chin that would benefit from a chin augmentation. I think this combined with small jaw angle and cheek implants would provide much better facial definition. But it is clear that you are only comfortable with a chin implant at this time.
When it comes to fat removal, many chin/jawline enhancement patients will benefit from sub mental/neck/liposuction as a complementary procedure. For the cheeks, fat removal is done by a buccal lipectomy procedure which help define or skeletonize the cheek bones better. There is certainly nothing wrong with using injected fat for cheek augmentation. It does not create a sharper or mored defined cheek augmentation effect because it is a soft material and its survival is anything but assured. But for those patients who are a bit skiddish about cheek implants and want to do an initial trial with something more natural (albeit with its own drawbacks), injected fat for cheek augmentation is a good treatment approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for some insight as to what to do with my undereye hollows. I am 50 years old and starting to show a little hollowing under eyes. I think the fat has shifted and there is less volume. I’m looking for ideas as to the best and least invasive way to improve it. I had a lower blepharoplasty about six years ago. I have heard conflicting views on using temporary synthetic fillers (Radiesse, Juvaderm, etc) vs. fat injections. If I did something, I would prefer permanent, rather than a touch up every 6 months or so. Perhaps you could comment on fat injections and whether its a reliable way to correct this. I do have some creepy skin underneath and would like to know about skin resurfacing, laser, etc… No knives and cutting for me.
A: When it comes to under eye hollowing, it is an issue of volume addition. But there is no under eye filler approach that can guarantee smoothness or permanency. Fat is the only injectable option that may achieve some permanency but it has the risk of unevenness or small lumps. While they would likely not be seen, they may be felt. It is just the nature of a filler that does not have linear flow coming out of the end of the injection cannula. If you particulate the fat into a liquid that will have linear flow, then there will likely be 100% absorption of the injectate.
The best approach to undereye skin tightening is fractional laser resurfacing which can be done in the office under topical anesthesia. Because of the very thin skin of the lower eyelid, one has to be careful to be too aggressive to avoid a burn injury. Thus it may require more than one fractional laser treatment to get the best result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know for sure I want a Brazilian butt lift I don’t know how the procedure works. Do you take the fat from the stomach as I sure have plenty to give?
A: In a Brazilian Butt Lift (BBL), the goal is to get the maximum amount of fat possible to do the transfer injection procedure. In most people, the important question is whether they have enough fat to justify undergoing the procedure and to meet their aesthetic buttock size goals. The greatest donor site for fat is the abdomen, waistline and flanks. This is where about 80% of available subcutaneous fat depot sites exist in just about anyone. This harvest site is also the side benefit of the BBL, a natural body contouring effect from the necessary harvest site. This body site reduction is also why many BBL results look as good as they do…not because the buttock size increase is that great but but because what lies around the buttocks has gotten smaller and more shapely.
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 a Brazilian Butt Lift (fat injections to the buttocks) but I have a few questions. I want at least 900ccs of fat injection done. Are you able to meet this request or do you have a fat injection limit? I want my upper and lower abdomen, flanks and lower back for the taking of the fat to accentuate my buttock. Please let me know if this is possible. Thanks
A: When it comes to the Brazilian Butt Lift (BBL) and the amount of fat that is injected, the first important question is how much fat does a patient have to give. Liposuction is used to harvest fat from as many body sites as is needed. In thin patients with little fat, a BBL procedure may not be possible. In patients a moderate amount of fat will have to accept a modest BBL result. In patients with more fat then a large amount of donor material can be obtained and a bigger result will occur. The second issue in a BBL is to understand that concentrated fat is injected not just the liposuction aspirate only. Just because 2 liters of fat aspirate is obtained, for example, does not mean that 1liter can be injected per buttock. Rather the liposuction aspirate must be filtered and concentrated so that only pure fat is injected. As a general rule, about 1/3 of the liposuction aspirate turns into concentrated fat. Thus 2 liters of aspirate becomes roughly 700ccs of fat and that means 350cc can then be injected into each buttock.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about paranasal implants. May I ask what do you think about fat graft to the sunken paranasal area ( and a malar implant on top)? Will fat grafts ( say inclusive of a few touch ups ) have the same effect as a paranasal implant?
A: Fat grafts by themselves will not have the same effect as paranasal implants. A solid implant on the bone can very effectively push outward on the overlying mid face tissues. (it has a more rigid structure that the tissue that it is designed to displace) Conversely, a fat graft is soft and does not have the same degree of push (augmentation) as a solid implant. The overlying soft tissue has the same structural rigidity as the fat graft so there is some rebound effect and less defined augmentation than one would think. In addition, the retention of a fat graft is unpredictable.
Thus fat injections are not a comparative ‘implant’ to that to a true paranasal implant. For those opposed to the placement of an actual facial implant, fat injections are the only other option and are not unreasonable…it just does not create the same effect as a paranasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue. Can you help me decide between fillers and cheek implants?
A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.
Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be a good test or trial if one is uncertain about whether cheek augmentation is for them.
The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.
Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.
When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ribcage narrowing. I came to your website as I was researching a couple procedures. I am 33 year old male to female transsexual. My waistline and hip area have always bothered me. I have pretty good shape but I have always wanted curvy hips and waistline. I have spoken with many physician’s everywhere and located a couple of options for rib resection. I thoroughly enjoyed your article on ribcage narrowing. I have been studying the process and anatomy for a long time and this was a very nice description and summation. It seems as though you’ve had some hands-on experience in this procedure. I am having my breast implants replaced in a couple months. My surgeon mentioned tummy tuck at sometime in the future. I know I have a little pooch and would like that. But I really would like it by aiding access for Thoracoplasty at the same time. The other procedure is an enhancement to my nipples. I have large breast 36D but sadly I have short, flaccid & small diameter nipples and would like them to be fuller length & diameter and also perkier. Thank you once again for your time.
A: Rib resection can be done at the same time and through the same access as a tummy tuck…depending upon what type of tummy tuck is being done. In a full tummy tuck, the elevation of the upper abdominal skin flap is done right up to the subcostal margin which provides direct access to the lower rib cage. However, during a mini-tummy tuck, there is little to no elevation of the upper abdominal skin flap and the access is better done by direct incisions over the lower rib cage.
From a nipple enlargement/enhancement standpoint, the only really effective approach would be fat injections. Injecting fat can both thicken, lengthen and stiffen the nipples with a minimal risk of any loss of feeling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I benefit from cheek implants? I have a long thin face that has always bothered me. I don’t know what if anything can be done to add fullness or reduce length? I always look like I am scowling and as I age…it gets worse. The first picture attached us awful I know but it at least gives you an idea of my situation. The second pic is simply one I have played with to widen my features and wish were possible. Thanks for your time.
A: There are improvements that can be made to a long thin face in terms of both length and width. Facial height reduction options are more limited than those of width and are often relegated to the considerations of vertical chin reduction, upper lip lift (shortening) and in some cases rhinoplasty. Numerous facial width increase options include jawline and jaw angle widening, cheek implants and fat injections between these two skeletal area. (the trampoline facial zone) Which one(s) of these might be most beneficial to your face depends on a computer imaging analysis. Unfortunately your one picture is not adequate to much of anything with due to the poor picture quality. If you could send me a front, quarter and profile views of your face (non-smiling) I would be happy to do that assessment for you. Based on this one picture it does seem that cheek implants may be helpful for more facial width and that could be combined with fat injections for a more blended transition from the implants into the thinner and non-bony supported areas outside of the cheek zone.
Dr. Barry Eppley
Indianapolis, Indiana
