Your Questions

Q: Dr. Eppley, Do you use stem cell therapy to fix atrophic rhinitis…to regenerate nasal bone, tissue and mucosa, particularly, nasal mucosa? I have a bad dry nose which is primarily atrophic rhinitis three years after the partial removal of nasal turbinate. All the medication from doctors does not help much. So I can’t wait to find out how stem cell therapy and tissue engineering are going on for help with atrophic rhinitis.  I read on other webpages that one plastic surgeon says you are the only doctor in the states doing this. Is that true? Thank you very much for your time. I’d really appreciate if when you kindly answer my question.

A: The treatment of atrophic rhinitis is a difficult problem for which there are no known therapies that are universally effective. The use of injectable autologous therapies offer promise for a lot of difficult clinical conditions in which some regeneration of function or regeneration of actual tissues would be therapeutic. Current autologous injection therapies include PRP (platelet-rich plasma) fat and stem cells. PRP is an extract of one’s own blood that contains platelet concentrates which have numerous potent growth factors in them. Fat concentrates are centrifuged or filtered aliquots of fat and stem cells. Stem cells can be isolated from fat but must be done concurrently as a direct isolate from the patient’s fat and immediately re-injected. The FDA currently bans the growth of stem cells from the patient as an isolated step in cell culture as a delayed reimplantation procedure.

The best approach currently for treating non-healing wounds and dysfunctional tissue elements, in my opinion, is the combination of PRP with a fat/stem cell concentrate. The entire nasal lining, septum and middle turbinates could be injected with up to 5ccs of this combined autologous therapy with the goal of reducing the degree of atrophic rhinitis. Understand that this is not exclusively stem cells but is a mixture of autologous elements that does partially include some stem cells. Whether this would be effective for atrophic rhinitis is not known as the primary problem is that the main producer of the moisturization of air (inferior turbinate) is missing. But whether the middle turbinate and other areas of nasal lining can compensate for it but being stimulated is the theoretical basis of the injections. Because it is an autologous therapy, there is no harm…it is just a question of how much benefit, if any, can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read a lot recently about stem cells and their potential rejuvenative properties. It seems logical that if our body is full of them that they can be used to treat a lot of problems including the negative effects of aging. I see some plastic surgeons offer a stem cell facelift. Does this really work and, if not, how come some doctors do it?

A: The use of adult stem cells for their potential cosmetic and anti-aging effects is very controversial at present. While our fat is a large reservoir of stem cells (300X to 500X more than bone marrow), that does not necessarily mean that they work as we would like or hope. The popularity of stem cells is largely because of the ability to harvest fat through liposuction as a source for stem cells,. It is fairly easy to ‘recycle’ the liposuctioned fat and put it back into the patient as an injection with the assumption that tissues of the face can be rejuvenated, Numerous anectodal claims are made about such injections as creating youthfulness, adding permanent volume and improving the appearance of the skin. This has led to a number of touted procedures carrying such names as the stem cell facelifts. Despite their appeal, there is no medical evidence by published clinical studies that proves that it actually works.

Most of the time, such stem cell injections are really nothing more than fat injections that unavoidably contain some stem cells. It is the fat that creates any volumetric or lifting effect and not the stem cells that it may contain. While such ‘stem cell’ injections are unlikely to be harmful, they have not been proven to have anti-aging effects. But the hope that they might, and the lack of any adverse effects, provides plenty of motivation for marketing hype.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a forehead issue that has been bothering me since I was like 14 years old. I know I need more than just one thing done to my forehead but my finances won’t allow me to do everything so I just try to do one step at a time. What do you suggest? I hate taking pics of myself but here are some for your review.

A: Thank you for sending your pictures. I am assuming that you are referring to/bothered by the deep horizontal crease that goes across your forehead. I doubt that forehead crease is caused by an underlying bone issue but rather is an indentation into the soft tissues over the bone. The one and only thing you can do is to have the crease released and injected with your fat. How well the fat  injections would survive and how much improvement would be obtained is uncertain but this is the safest and most natural approach to a facial skin indentation problem. You will never be able to eliminate it but fat injection will be able to reduced the depth of it. Given that a line is never going to be able to be completely eliminated, another possible approach is to excise (cut out) the groove and close it so that it is at least smoother and not indented.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a depressed cheek scar above my nasolabial fold from a previous skin cancer removal using a Moh’s technique. If you inject fat do you utilize the Coleman technique with micro droplets to ensure the tissue becomes a graft and not just a temporary filler? Anyhow, I do not like the dynamic feature when I move the facial muscle as well as when the sight catches  the groove of the scar. I have attached some pictures showing the scar. Thank you for your time.

A:  Thank you for sending your pictures. I did not realize how young you were given that you have had Moh’s. It is actually a reasonable result in a difficult aesthetic area. The only modification I would make to my previous statement is that I would perform a geometric scar revision at the same time as microdroplet fat injections underneath. Even though the scar is well placed and has about as much narrowness as could be hoped for, there is always going to be a ‘groove effect’. That is just an unavoidable phenomenon in linear scar in that area. The scar line may need to changed from a pure straight line to get a better scar effect. Options include either fat injections with concurrent laser resurfacing (#1) or fat injections with a concurrent geometric broken line scar revision. (GBLSR) The conservative approach would be # 1 as GBLSR can always be done later based on the scar outcome. The more aggressive approach would be #2.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Moh’s surgery on my right cheek Dec. 27th 2012. I am unhappy about the indentation on the mid to lower half of the scar especially when I speak. I have photos I can send. Would like to know if you think I would need a revision, subcision, or laser, or this will subside in the months.  Also, if revised, do you agree with the theory of lasering 4 to 8wks after sutures are removed to reconfigure the modeling of the tissues resulting in superior results, rather than waiting the full year of the old theory. I am not interested in temporary fillers.

A: I am assuming that you had a primary closure of your original Moh’s defect. The reason you have an indentation is that there is tissue missing over a dynamic area. As such, no amount of release or scar revision is going to improve its appearance. This is a tissue loss problem and releasing underneath or cutting out the scar/indentation from above does not address the biology of why it is there. I would take a reverse approach to conventional wisdom by doing fat injections under the indented area. This will provide both a release and adds volume at the same time. While fat may be unpredictable in survival, this natural form of tissue volume expansion better addresses the cause of the problem. This would be more effective done early in the healing process (months) rather than later. (year or longer) The overlying scar in the face of underlying tissue expansion should wait for further healing.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a flat back of the head that I think makes me look odd and I want to build it out. I have attached pictures from the side of my back of the head profile. How can this head change be done?

A: Thank you for sending your pictures and illustrating your desired back of the head change. Based on your goals and drawings, the first thing I would point out is that the skull bone actually stops at just about the level of the top of the ear, an area much higher than most people realize. Therefore, no type of skull bone augmentation can go that low. The lower half of your desired expanded area are the soft tissue of the neck not bone. Secondly, as a man who shaves his head any incision to do skull augmentation  is a very treacherous aesthetic trade-off and I would not recommend it for most men. The only option I would consider would be fat injections to build up the back of the head. But the problem with fat injections is whether you nave enough fat to harvest to do the procedure and the unpredictability of how much would survive and how smooth it would be. But this is the safest aesthetic option with very little downside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 28 year old female.When I was12 whenever I opened my mouth very wide the left side of my face clicked under my ear. Therefter it became more painful to open and I had great difficulty in eating chewy foods. By the time I was 18 my face looked obviously asymmetric. My jaw is not properly aligned. I have been to an orthodontist and was told that I would need corrective jaw surgery which I can not afford and he also said it may not necessarily make my face look straight even if my jaws were better aligned. What can I do to straighten out my face?

A: Your face is significantly asymmetric due to an underdeveloped left side. That extends from the cheek bone down to the jawline with a significant left chin deviation.Your non-major orthognathic surgery options include a combined procedure by repositioning the chin bone (opening wedge genioplasty), a left cheek implant and fat injections to the left side of the face. These three procedures will help fill out the left side of the face and straighten it by aligning the chin with the midline of the face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you perform Love Band eyelid surgery. I have lost the fat padding directly underneath my eyes, which I would like back. In Korea, they call these fat pads “love bands” and promote surgery to enhance that area via fat transfer in order to make the eyes appear bigger. Do you offer “love band surgery” as welland not just fat grafting for lower eyelid hollows? Thanks so much.

A: Love Band surgery is fat injection grafting done just under the lashline of the lower eyelids to create an elevated skin roll. This is done by placing small fat droplets in a linear fashion with a microcannula technique. It usually takes less than 1cc per eyelid to create the roll. This is viewed in some countries, particularly Korea, as enhancing the eye area and making it more attractive. It is a variation of contemporary fat injection grafting that is done just to one specific area of the lower eyelid in a very precise manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Where do you do surgery? What are the facility fees? What would the price be to narrow or burr the chin just at the bottom edges to make it look less square? Also, I have a flat forehead in the center with prominent eyebrow muscle, which makes the flat forehead area look flatter. How wold you fill in the flat forehead or the center of the forehead in a female? Fat injections? What would the price be?
And can you shorten the forehead skull if the hairline is a little high?

A: In answer to your questions:

1) My cosmetic surgeries are done in a private outpatient cosmetic surgery center. The operating room and anesthesia fees are based on the time that it takes to perform the procedure(s). That must be determined on an individual patient and the specific procedures they are having.

2) Narrowing the chin is done by intraoral ostectomies or removing the sides of the chin through a reciprocating saw technique.

3) A flat glabellar area can be built up by a variety of techniques with fat injections being the simplest to perform.

4) If one’s frontal hairline is too high, its length is not going to be lowered by reducing the height of the skull as that amount of skull height reduction can not be done. Shortening the long forehead is done by a procedure known as scalp or frontal hairline advancement.

I will need to first review some pictures of your face to see exactly what needs to be done before the costs of the procedures can be provided.

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 have very little earlobes. Can I increase their size and shape using dermal fillers??

A: The size of your earlobe can be increased (expanded) by the use of either injectable fillers, fat injections or even a small dermal-fat graft placed from an incision on the backside of the earlobe. Which technique is better for you depends on the current size of your earlobes and the amount of earlobe skin that you have. You may feel free to send me pictures of your earlobes for a more definitive recommendation. But as a general rule, the first step to do is to use temporary injectable fillers to see of you like the change they make. If so then you may consider a more permanent solution with one of the fat grafting options.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.

A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

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

Indianapolis, Indiana

Q: Dr. Eppley, I have been searching the Internet for resources on augmenting the brow ridge and have come across your very informative website. I would like to have deeper and a more masculine brow ridge. I understand that it can be done with bone cement. However, would fat transfer to the area work if only a moderate correction is needed as I would prefer to avoid the scalp scar.

A: I would certainly agree that fat injections would be a very reasonable alternative to the formal placement of bone cement for modest/moderate changes in brow bone projection. There is always great uncertainty as to how much fat would survive and its potential for asymmetry/unevenness. But those risks seem as very tolerable when one wants to avoid a scalp scar in brow bone augmentation. In other words, there are not other non-incisional options and this is a very safe and low risk approach using one’s own natural tissues. I have used an injection approach numerous times with synthetic injectable fillers and good results have been seen even if they are only temporary. The thickness of fat allows it to give a better tissue ‘push’ than the softer synthetic fillers.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to look younger and more attractive. I used to get comments that I looked so much like Angelina Jolie. I don't get those compliments anymore. One of the attached photos is me when I was younger. The other one is me now. I need some cheek sculpting to bring my now fat cheeks in more.

A: Thank you for sending your pictures. The difference between you now and when you were younger appears to be wide or 'fatter' cheeks with loss of a high cheek definition look. This could be caused by aging (falling cheek tissue) or increased fat collections in the lower cheeks with age and some potential weight gain. Careful analysis of your pictures shows that the main difference is inversion of the soft tissue cheek triangle. When younger the cheek was an upside triangle with most of the fullness up top and the apex of the triangle down below inverted inward. With time the triangle has inverted with the base of the triangle now at the bottom of the cheek (most fullness) and the top of the triangle up high over the cheek bone. (Ileast fullness) To attempt to rearrange this soft tissue triangle the following needs to be done…buccal fat pad extraction and relocation to the cheek bone (like placing an implant) or cheek fat injections and perioral (lower cheek) liposuction. In essence, add fullness over the cheek bones and remove fat below the cheek bones. Since fat changes are the crux of the facial problem it makes most sense to undergo a fat redistrbution surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have attached a number of pictures of my wife. She has a prominent forehead dent that is very bothersome to her. It even makes her appear more serious or even angry at time even though she is not. What could have caused this dent in the first place? What can be done for smoothing this out for my wife? I didn't really think that something can be done for this type of forehead issue until I came across your website. Thank you very much for your help.

A: Thank you for sending your wife's pictures. I believe what your wife has is known as linear scleroderma. This is a rare craniofacial condition in which the fat under the skin largely disappears and the overlying skin gets thinner. What is unique and easily identifiable about this condition is that it often occurs along a very distinct line. (hence the name Linear) While it can occur anywhere on the face, when it occurs in the forehead it appears as a straight line running right down the middle of the forehead vertically from the frontal hairline to the eyebrows. It always appears, as in your wife's case, as an indented vertical groove in the forehead. This is not a bone problem as the underlying forehead bone is usually normal. The groove is due to a soft tissue deficiency. (hence the name Scleroderma although this is not associated with the more generalized autoimmune disorder of scleroderma) It is not known why this unique soft tissue deformity actually occurs although it has a fairly classic presentation. It is not present at birth and only begins to appear in late childhood or teenage years. Its progression usually stops by early adult hood and progresses no further. (the indent does not get any deeper)

Treatment of a forehead linear sclerodermal defect is about soft tissue augmentation, building up the forehead indent from underneath the skin. I have treated them by a variety of soft tissue methods including fat injections and the placement of allogeneic dermal grafts or dermal-fat grafts. Any of these procedures can be completed in one hour of surgery. It may takes months to see the final result, in terms of volume retention and smoothness, as the fat or dermal graft survival integrates into the surrounding soft tissues.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I think I may have screws up my chuin surgery. I was washing my face and was pushing really hard on my chin but didn't know because it is numb and then something felt different…on the right the implant was in a different location. Then I protruded my mandible forward and it only felt tight on the left of my chin, not on both sides of it anymore. And then I palpated my implant and on the right the implant is completely on the outside of my mandible and on the left it is under it. It is bad. Now it is in a lot of pain. I tried putting it back in place but it is of no use. I will just injure myself. Now the incident is giving me a lot of pain: my whole chin and the new location of the implant. Before this happened I called about having you call in more pain medication to my pharmacy and I mentioned a painful tumor-like lump on the left side of my mandible. It is hard like bone, and round, and inferior to the bone as well as lateral to it. My pain includes pain in this area. However, the area felt different to the touch than other areas. Now, after what I have caused to happen with the implant, I cannot assess it. It is still painful to the touch, although the lump seems smaller and less obvious. It was causing my chin to look shifted to the left, because the right of my chin was flat and the left protruded where the lump was/is. Where the implant was feels like a dent in the bone of my mandible and somewhat looks like one. Now that the implant, out of place, adds width to the right side, my chin looks more centered than before, where it looked shifted to the left. I am also sending a picture of the area where the fat was inserted, just checking if everything looks normal. Both of the areas containing the transplanted fat feel to the touch like I am touching like hard rubbery rubber implants. Just want to know if everything's normal. Thanks.

A: Thank you for the follow-up and sending your pictures. Let me share with some basic concepts about the recovery process from your chin osteotomy/implant and fat injection surgery. It takes a minimum of at least 6 weeks and closer to 3 months to see the final result. It is very normal to have everything that you are feeling and showing at this point, which is very early at just 9 days after your procedure. Besides the swelling, numbness and bruising, every chin osteotomy patient at this point will have hard lumps at the end of the osteotomy cuts on the side of the jawline. That is what you are seeing on your left side and I would not consider that abnormal at this point. While it is possible that could be a malpositioned end of the implant overlying the osteotomy site on that side, it is just as likely that is swelling and a collection of blood from the surgery. I would be a lot more concerned about that issue if this was 4 or 6 weeks but not yet at 9 days out from surgery. I also doubt that you could have malpositioned the implant by rubbing on the outside. The bone and the implant are secured in placed by plates and screws so it would be very hard to displace it. The fat injections into the nasolabial folds will feel and look exactly how they do at this point and that is perfectly normal. It will take 4 to 6 weeks for them to smooth out, blend in and feel normal.

Hang in there as it is still very early in your recovery process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a step-down of about 3-4mm from the rim of the orbital bone under my eyes straight down to the eyeball. There is no fat. Post after blepharoplasty about 6 years ago. I don’t like the look. Any help available? I am 56 years old and healthy with good skin. Thank you.

A: With the loss of fat, either through surgical removal, aging or a combination the edge of the lower orbital rim is now skeletonized. There are three approaches to consider for obliteration of this orbital rim step-off with the underlying theme that they all add volume but do it in different ways. I will first mention synthetic injectable fillers but this is not really on my list of sustainable long-term approaches.

Replacing what has been lost, fat, constitutes two of the orbital rim augmentation approaches. Fat injections are a well known option which is principally marred by the unpredictability of such fat grafts. It is however the simplest and least invasive approach. The other way to add fat is through dermal fat grafts, like a natural implant, placed along the inside of the orbital rims done through your existing blepharoplasty scars. These fat grafts take remarkably well but do require an open approach and a harvest site which is usually from the abdomen or from any existing scar that you may have on your body.

The other implant options are synthetic orbital rim implants that are made for exactly this area. Like a dermal-fat graft, they are placed through a lower eyelid incision and are secured to the bone with 1mm small screws.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, am very unhappy with the right side of my face. My face is assymetrical; the right side looks smaller, there is less volume in the cheek, and my right eye and eyebrow are lower than the left. Also, the right side of my lower lip is smaller than the left. I feel that the left side of my face is the “good” side. I am very self-conscious of my appearance and avoid having my picture taken. I also feel that my nose is fairly wide from the front, although my profile is not that bad. Most surgeons in my area seem to focus on anti-aging procedures. I am too young (31 years old) that the right facial volume loss is due just to aging. The fact that I have always slept on my right side probably did not help. Please let me know what procedures you would suggest. I’ve attached a picture of my face straight on and also one of my right profile.

A: I would agree with you that you do have some degree of facial asymmetry. All features you have pointed out I can see and agree that it exists. The question is given the asymmetry what is reasonable to consider to do for improvement. I would also agree with youir three procedures of interest. A small right cheek implant with fat injections to the submalar (buccal space compartment) and the perioral mound area are very straightforward low risk procedures that can occur from visible improvement. While asymmetry issues exist in the eyebrow area, I would live with those for now. From a nose standpoint, a tip rhinoplasty to narrow the tip would work nicely. I would leave your profile and the upper portions of the nose alone.

The only point in which I disagree with you is that sleeping more on the right side of your face would not have caused the problem. This is a congenital ‘deformity’  and is a result of in utero development not from postnatal molding influences.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift about six weeks ago. This was a very traumatic experience for me. While my jowls and neck got better, my nasal folds and turned down corners of the mouth did not. They initially looked good while I was still swollen but that has now all gone away. This is very disappointing since this was one of the main reasons I had the operation. I feel like a wasted my money as my jowls and neck were not that bad.

A: This is a common misconception and occurs either as a result of inadequate education during the consultation or a failure to understand what a facelift does best on your part. Because the tissue pull of a facelift occurs from around the ears, it has the least effect on anything far away. The mouth area is the furtherest point from the ears on the face, thus deep nasolabial folds or a downturned corner of the mouth will ultimately remain unchanged. It is just biomechanically impossible to substantially change the center of the face from back in the hairline. This is an issue that has frustrated facelift surgeons for years and many techniques have been tried, few with much success. This is why adjunctive techniques are often done with facelift that address the mouth area directly, like fat injections and a corner of the mouth lift. These can be at the time of a facelift or afterwards as may be desired in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have deep nasolabial folds and a mouth whose corners turn down. I have read about a way to improve them by using your own tissue through grafting. I had a facelift already which got rid of my jowls and helped my neck but didn’t do a thing for the area around my mouth. I don’t want to treat them with injectable fillers because that will only be temporary. Are you familiar with this tissue grafting technique?

A: What you are talking about is an old plastic surgery technique, dermal-fat grafts, that has been applied to a cosmetic problem. A dermal-fat graft is a piece or strip of skin that has a thin layer of fat on its underside. The overlying epithelium or skin layer is removed, leaving just the dermal skin layer with the attached fat. Provided that the graft size is not too big, it survives quite well as the blood vessels of the recipient site attach quickly to the vessel ends in the dermis. This allows a quick return of blood flow to the fat thus enabling it to survive.

For use in the face for nasolabial folds,  it must be taken from the lower buttock crease or any other large scar site and must be at least 6 to 7 cms in length for each nasolabial fold. From inside the nose, a tunnel is made under the nasolabial fold curving down to the corner of the mouth. The dermal-fat graft (dermis side up) is then placed through tunnel and fixed to the corner of the mouth through a small incision from inside the corner. It is then lifted and tightened from inside the nose and the excess graft trimmed and closed. The graft simultaneously augments the nasolabial fold and lifts the corner of the mouth. I have done this procedure numerous times and it does have its merits. But the issue is that it requires a harvest site and the buttock crease is almost always the best choice because of the thicker dermis. The discarded skin from a pretrichial browlift can be used as well. There are also other simpler ways to achieve both of these facial objectives. Fat graft injections combined with a corner of the mouth lift is another approach. But for the right patient who does not mind a buttock scar, the dermal-fat graft approach can be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is about face fillers. I had some permanent filler injections done on my cheeks 4 years ago. I am now developing hypersensitivity, not at the site of the filler, but over the sinus and neck muscles and headaches. Plus my eyebrows are thinning .The surgeon told me the filler used is BIOALCAMID .What is your opinion on can the filler be removed?

A:  Bio-AlCamid is a gel polymer filler that is composed of a 3% to  4% concentration of alky-amide polymer and 96% water. It is used around the world but is not approved in the U.S.  It maintains it volume through the attraction of water to the non-resorbable polymer which is then surrounded by a scar capsule. The manufacturer says that it can be removed relatively easily and this may be true if it is well encapsulated and can be palpated. Once the capsule is entered, the material will likely be expressible. The other key question is what to do after the material is removed as there may likely be a deflation effect seen on the outside of the face. While one could use any of the available temporary hyaluronic injectable fillers, I would strongly think about fat injection replacement. Otherwise, I see no direct correlation between it and your hypersensitivity symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a condition known as facial lipoatrophy. From what I have read it is type III or IV based on how my face looks. I am 24  years old and have had this look since I was a teenager. It makes me look older than I really am and I am concerned if I look this way now what I will look like in 10 or 20 years. I have high cheekbones but they are very skeletal-looking with indentations beneath them with loose skin sitting atop them. What type of surgery will make my face look more normal?

A:  The look of facial lipoatrophy is easily identifiable with loss of some or nearly all subcutaneous and buccal fat over the central portion of the face. Surgery must incorporate both hard and soft tissue augmentation since the problem extends over both bone-supported and non-bone supported facial areas. One successful treatment strategy is a combination of submalar implants to fill out the upper submalar triangle and fat injections for the lower submalar triangle and the sides of the face. Temporal implants can also be used for the always present temporal hollowing which is often overlooked in the treatment of facial lipoatrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, on your website you mentioned orbital implants. I have deep set eyes. Can these orbital implants be placed in the upper eye area to fill in the hollowness. Thank you.

A: No they can not. There is no easily accessible superior bone space above the eye to access without significant risk. Actual implants can only be placed on the floor of the eye socket in which that space is more easily accessible without risk of eye muscle injury. Hollowness of the eyes, however, is rarely treated by implants anyway. It is better treated by fat injections/grafting which is placed between the skin and the underlying muscle. This is far easier to do and more effective. Its risks are largely cosmetic, how well does the fat survive and how smooth is its outward appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed nearly fifteen years  ago at age 31 for some facial sculpting. Now that I am older, I look completely different. My face is very flat and not as attractive. What can I do to look like before? What are my choices for making my face now a little fuller?

A: As you have aged, your face likely has lost overall fat and the prior removal of the buccal fat pads has only accentuated this natural fat involution process. There are several options available to consider for facial volume restoration. The first approach is fat injections which focuses on replacing like with like. The only question is how much fat will survive after transplantation. This is an overall facial volume approach. The next approach is focal or spot treatment, just adding volume to the buccal or submalar area. This could dbe done with either submalar cheek implants or injectable fillers. The real value of injectable fillers in your case, in my opinion, is to be an initial test to determine if augmentation of this area is what you are looking for. It serves as a test to determine if more formal augmentation (implant) is worthwhile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been getting injectable fillers into my smile lines and lips for several years now. While I really like the effects that it creates, I do tire of having to be stuck by needles and the recurring expense of doing it once or twice a year. Is there any injectable treatment that would be permanent or at least last a lot longer?

A: While current off-the-shelf injectable fillers produce some wonderful facial changes, they are synthetic and will be eventually resorbed and the effect will be lost. While no truly permanent injectable filler can be definitely claimed, there are several promising options that are now being used. Most people have probably heard of using liposuction-derived fat for injection, and it has been used for some time, but its known problem is that its survival is unpredictable. While it does work well is many areas of the face, the smiles lines and lips are not amongst the most favored. Encouraging injectable cell treatments include fibroblasts and stem cells, both harvested and grown from the patient. Taking a skin biopsy from behind your ear allows fibroblasts which make collagen to be grown for later injection. Known as laViv, this is an FDA-approved treatment that allows the injection of millions of fibroblasts into any desired facial site. Comparatively, Cryo-lip (an Indianapolis biotech company) creates large numbers of stem cells for injection into any desired area. Whether any of these cell-based injectable fillers can create a long-term permanent effect is not yet known.      

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in using PRP for lip augmentation. I am looking for something more natural and longer-lasting other than the typical injectable fillers. Can PRP be put into the lips and how well does it work?

A: PRP can be injected into the lips just like anywhere else. It is not a question as to whether it can be done but whether it should be done. Will it create a lasting augmentative effect beyond that of a short-term fluid distention is the question. There is no medical evidence that it would nor would I biologically understand why it would. PRP is not a filler material per se but rather an adjunctive healing agent. It has no primary effect on its own such as creating more collagen than would normally exist in an otherwise healthy tissue site. The PRP I have put into the lips has been combined with fat to offer a higher probability of a sustained effect. It is the fat that is the filler and the PRP is added for its theoretical benefit on helping fat cells to survive or in helping stem cells to convert to fat cells. This is the most natural lip augmentation injection treatment but it is unproven as to how sustained or permanent the lip enhancement effect is.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  I have lost a lot of the fat in my face particularly in the cheeks which has left them very hollow and sunken in. The area below my cheeks looks too full because it is indented above it. I havhe been told that fat injections would be the way to go even though fat transfer may not always stay. I know that cheek implants are permanent becuase they can not be absorbed. But I didn’t know of they come big enough to fill out the entire depressed cheek area. What sizes do they come in and do you think they are big enough to fill out the whole cheek area?

A:Your concept of considering cheek implants for helping restore facial volume loss is only partially correct. Cheek implants are not a substitute for fat injections when it comes to facial fat volume loss. The submalar style of cheek implant can help fill out the buccal area of the cheek (right below the cheekbone) but this represents only part of a larger surface area of the cheek and surrounding tissues which makeup the gaunt or skeletal facial look. Therefore, the use of this type of cheek implant may be a companion strategy with fat injections but is not a stand alone treatment for refilling out the deflated or fat-depleted face. Fat injections are more versatile because they can be placed anywhere. Cheek implants, even the submalar style, can not go very far from the edges of the bone and are more limited as to the facial area that they can cover.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I was wanting to know if you do fat transfers to the arms? I had liposuction done to my arms over a year ago that left me with a lot of dents and irregularities. It has improved a lot over the past year and now there is just some loose skin that bothers me. I think these arm areas could could benefit from some filler. I wanted to get some fat removed from my stomach which has always been a problem area for me. Thank you for your time.

A: Arm liposuction is very prone to irregularities given its thinner skin and that the liposuction technique can not really use a cross-tunneling method, which is really useful to prevent large irregularities in fat removal. It is good that you have waited until the arm sites have matured and all the tissues have settled. Many arm liposuction irregularities will improve with time although they rarely go completely away. For small remaining areas, injected fat would be the only good treatment option. Only a small amount of fat would be needed so your stomach sounds like it would provide more than an adequate donor area. The fat that is harvested is washed and concentrated so that the highest percentage of viable fat  and stem cells gets transplanted. This should help fill in some irregularities and expand out some loose upper arm skin.

Dr. Barry Eppley

Indianapolis Indiana