Your Questions

Q: Hello, I have severe facial wasting. I am not an HIV patient, I had a normal plump face as a young child and by about the third grade my cheeks had completely sunken in and has given me a much older and skull-like appearance. I am only eighteen years old. I would like to have a procedure to correct this done this summer before I begin college in the fall. I would like to know if you handle this sort of procedure and what you would suggest to be done. I have attached some pictures with this e-mail inquiry.

A: Thank you for your inquiry and sending your pictures. You have a classic case of facial lipatrophy, type IV (type V is more consistent with HIV related facial lipoatrophy) Your history is classic for it as most patients convert from the plump face of childhood to a thinner more gaunt facial look during grade or intermediate school. Of the augmentation methods for treatment (implants and fat injections), I think you need a combination approach. I would place submalar cheek implants that specifically builds up the area right under the cheekbone known as the buccal area. This implant is placed through the mouth under the upper lip. Then I would do fat injections with Acell collagen particles to the area below the implants out into the side of the face and down to opposite the corners of the mouth. The goal is to add some fullness to the sides of your face and help reduce your more skeletonized appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr Eppley, I was wondering if fillers can be used on a sagging elbow area instead of the surgical procedure?

A: Sagging of skin around the elbow area can be the result of age, body type, and weight loss. Most commonly I have seen it to be an issue in the extreme weight loss patient (greater than 75 to 100 lb weight loss) and it is one of the areas dealt with using bariatric plastic surgery techniques. While the usual approach to loose skin is to cut it out, the creation of a scar around a joint area can be problematic. The skin around joints, such as the elbows and knees, is not meant to be fixed. Rather it needs to have some flexibility and movement so the joint can go through its range of motion. Scarring around the joint may cause joint motion restriction in the long run and wound healing problems in the short run. (motion across a suture line) Known as elbow or knee lifts, the excision of loose skin must be carefully done to avoid these problems.

I suspect in this question that it is not a weight loss issue. Rather it likely  is aging and the development of some loose skin around the elbow in an otherwise non-overweight person. (can particularly happen in an aging thin person) Therefore, excision and the scar that it creates is not an acceptable solution. This changes the approach to maybe an opposite solution…filling or reinflating the tissues. While injectable fillers can be placed anywhere, their temporary effects and the large volumes needed for a body area make them impractical. The only soft tissue filling option to be considered would be fat grafts. Harvested by liposuction, fat can be purified and then reinjected into soft tissue spaces. This is the only option I would consider when it comes to injecting any body area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’ve read your article on calf augmentation using fat transfer. Since 2008, have you performed this procedure? I have finding very mixed feedback on this. Some surgeons are saying this is high risk and will be unsuccessful because the fat will all be absorbed. Another doctor in NY I’ve been in contact with says he has had great success and with little side-effects. Appreciate your feedback.

A: Calf augmentation is most reliably done with implants. There are specific silicone rubber implants made for the calf and they are placed through a small incision on the back of the knee. (popliteal fossa) Because an implant is used, the result is stable and consistent in the amount of size increase obtained. Conversely, because it is an implant there are the associated issues of the risk of infection, malposition and asymmetry as well as a significant recovery and discomfort.

Fat injections, no matter where they are considered and what they me be used for, always have the same appeal. Using a natural tissue that has virtually none of the risks of an implant-associated procedure. Despite those benefits, fat injections have one significant downside…their volume retention is unreliable. At this time, there are no standard techniques for fat preparation and injection and the science behind its survival once transplanted remains to be discovered and utilized for more stable outcomes.

Because of the differing techniques and injection methods, fat injections for larger volume areas (breast, buttocks, calfs) have widely variable results. With these inconsistent results come quite discrepant surgical opinions about their effectiveness. There is now to reconcile one plastic surgeon’s experience vs another at this time.

Calf augmentation with fat injections is relatively ‘new’ and the worldwide experience is still evolving. The issues with the calfs are no different than the buttocks or breasts. It is a very safe procedure with minimal downtime. But one has to accept the reality that how much fat survives is the risk of the procedure. And more than one session may be needed to get the best results. (more likely than not) My experience has been with just a few cases and the early results have been acceptable. But the key is patient selection…don’t ask the fat to do what an implant can do better. (mild enlargement, not big enlargement)  

Dr. Barry Eppley

Q: Hello, I have a few questions.I’m interested in getting my leftover fat from my entire body put into my boobs. I’d like to get my bmi to be just at 18, although it is at a 20 right now. I was just wondering if anyone would be willing to even work with me since I weigh around 115 and am 5’3″.

A: Breast augmentation using injectable fat rather than a synthetic implant remains in an ‘experimental’ or an investigative phase currently. Since it does not involve an implant and uses your own natural tissue, it is understandable to think that it is  a safer and perhaps better procedure.

While fat may be natural, it is not a predictable implant material particularly in the volumes needed for breast augmentation. No standard techniques exist for fat preparation or injection methods and very different results can occur in various hands. At the least, much if not all of the fat can be absorbed rendering it a waste of time. At the worst, the fat may make the breast lumpy with cyst formations or develop sterile pools of liquid fat. What impact fat injections have on mammogram imaging and breast cancer detection remains unknown and not studied.

While much of this discussion sounds negative, the concept of using fat for breast augmentation has appeal and work is ongoing in this area. The only FDA-approved clinical trial that I know of is with the BRAVA system in which injectable fat is stimulated after surgery with an external low-level suction device.  Otherwise, any clinical work that is being done is occurring in an independent fashion as an individual-precribed surgery amongst a handful of practitioners.

With the low BMI and body fat that this patient has, she would not be a good candidate for the procedure even if it was proven and widely used. A simple breast implant is so much easier and more predictable that fat injections, which for now, remain as a more complicated and morbid approach for breast augmentation.

Dr. Barry Eppley