Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

July 25th, 2014

Nasal Tip Rotation and Projection in Rhinoplasty


Rhinoplasty Tip Rotation and Projection in Rhinoplasty Dr Barry Eppley IndianapolisWhile there are many changes to the nose that can be done in rhinoplasty, one of the most significant and sought after is tip rotation. While tip position is very relevant to both genders, elevating and narrowing a low hanging tip is a particular focus for many female rhinoplasty patients. While it is well known that the nasolabial angle is more open and the tip is higher in women, there are no universally accepted methods to define the ideal nasal tip rotation and projection in women.

In the June issue of the JAMA Facial Plastic Surgery Journal, an article was published entitled ‘Population-Based Assessment of Currently Proposed Ideals of Nasal Tip Projection and Rotation in Young Women’. In this study, side view pictures were taken of young women between 18 and 25 years of age. Each picture was digitally assessed and modified with nasolabial angles of 96 degrees to 116 degrees at 5 degree increments. The pictures were then assessed for attractiveness by a variety of social groups. The most preferred nasolabial angle was found to be 106 degrees with a Crumley 1 tip projection. This angle was particularly preferred in faces that were considered to have above average attractiveness.

The nasolabial angle along with nasal tip projection are considered two of the most important side profile features of the nose. The nasolabial angle is straightforward to determine. When it is open too far, the nose can look short with too much nostril show. When it is too closed, the nose looks long and droops down

Nasal tip projection is somewhat less clear and has been traditionally defined as the distance along a perpendicular line from the vertical facial plane to the most anterior projecting point of the nasal tip. When there is too much tip projection, the nose looks long and out of balance with the rest of the face.

But there is an intimate relationship between nasal tip projection and rotation. A nose that is too long, even with a desirable nasolabial angle, will still not look good. Conversely, a short nose with too much or too little of a nasolabial angle will look even shorter.

While these nasal measurements along with many others can not always be replicated with certainty during rhinoplasty surgery, they serve as good guidelines to follow.

Dr. Barry Eppley

Indianapolis, Indiana

July 24th, 2014

Case Study: Liposuction of the Large Male Neck


Background: The shape of the neck is one of the most important aesthetic facial areas. Having a shapely neck allows the chin and the jawline to be more clearly seen which not only creates improved facial definition but creates a more youthful look. This is evidenced in patients who undergo weight loss and those who have facelift/necklift surgery.

The anatomy of the neck is fairly simple and has three distinct structures that are interdependent. There is the overlying skin, the underlying platysma muscle and the intervening skin.There are also structures underneath the platysma muscle (fat, submandibuar glands) but there are not as easily accessed or changed. How much loose skin and fat one has plays a major role in the shape of one’s neck.

Male Bull Frog Neck Dr Barry Eppley Indiana IndianapolisIn a large or ‘bull neck’ the contribution of the fat can be considerable. This is most frequently seen in men and women who often carry excess weight. This is no surprise given what percent of fat makes up the neck. The heavier in weight one is, the bigger the neck usually is. Weight loss can help reduce the size of the neck but that alone often is not completely successful.

Case Study: This 45 year-old male wanted to improve his neck. He was a large man but carried his weight well due to his height. But his large neck was disproportionate to how the rest of his body appeared. In reviewing the options for neck contouring (liposuction, liposuction with submentoplasty and a necklift/lower facelift), he opted for liposuction alone without any tissue excision. He did so with the understanding that the neck contour change would be the most limited and would only be about a 1/3 of that of a necklift.

Large Neck Liposuction result side viewUnder general anesthesia, the neck was infiltrated with a lidocaine and epinephrine solution. With small cannulas from puncture skin entrance sites under the chin and behind the earlobes, the entire neck was aspirated of fat from the supraplastysmal/subcutaneous layer. A total of 38cc of fat aspirated was obtained. A compressive neck dressing was applied.

Large Neck Liposuction result oblique viewIt usually takes at least six weeks after neck liposuction until most of the swelling, hardness and lumpiness resolves. It is common and to be expected due to gravity that prolonged fullness and stiffness of the tissues will be persistent in the lower half of the neck for awhile. The final result of any neck liposuction procedure should not be judged until three months after the procedure. The assurance of a final result is when the neck feels soft, the numbness of the skin is gone and it longer longer feels sore or hurts when squeezed.

The success and limits of neck liposuction depends on what the skin will do. How much will it contract and shrink up? That will depend on how much extra skin exists and how much elasticity it has. Generally male neck skin has a better ability to contract than females due to thicker skin and more innate elastic fibers. But there is a limit to skin contraction and almost all full large neck liposuction results will not be a cut and sharp cervicomental neck angle. There will be improvement but more significant results require skin management as well.

Case Highlights:

1) Large full necks are an aesthetic challenge because of the amount of excess skin that exists.

2) In younger patients with thicker skin that may have some remaining elasticity, liposuction alone can have a positive effect without risk of loose residual skin.

3) The results of neck liposuction can always be followed by a secondary necklift for further improvement.

Dr. Barry Eppley

Indianapolis, Indiana

July 20th, 2014

Arnica in Recovery From Plastic Surgery – Is It Effective?


Arnica is a well known and recognized homeopathic supplement in plastic surgery. It is touted as an anti-bruise and anti-inflammatory treatment measure that is widely prescribed after many procedures from injectable fillers to facelifts. While it is widely used, the interesting question is whether it is really effective and what is the evidence that it works.

Arnica FlowerArnica is an orange-yellow flower that has its origin from Europe where it once grew over large areas. It is a genus with dozens of perennial herbaceous species belonging to the sunflower family Asteraceae. Several species within this genus contain helenalin (e.g., Arnica Montana) which is found in the leaves and stems of the flower. This is the agent that is believed to be responsible for any anti-inflammatory benefits.

Historically there are few studies that have shown that Arnica was more effective than a placebo for any of its touted benefits. More recent animal studies have shown increased levels of anti-inflammatory cytokine interleukin (IL-10) and decreased levels of pro-inflammatory protein tumor necrosis factor. (TNF) Both effects can have clinical effects of reduced swelling and inflammation. A clinical study of carpal tunnel surgery showed less pain at two weeks when oral and topical Arnica was used. In a clinical study of big toe surgery, Arnica was found to be equally effective at reducing wound irritation (less effective at pain reduction) but less costly and better tolerated than Diclofenac. A clinical study to evaluate bruising in facelift surgery did show a significant lessening of the amount of bruising with Arnica Montana.

The clinical evidence that Arnica has a significant anti-inflammatory effect is not strong. There is only one clinical study that shows it has an anti-bruising.  (despite the fact that it continues to be highly touted as such) There are a surprisingly limited number of studies in the plastic surgery literature that have been done let alone show it has beneficial recovery effects. But Arnica continues to be used in plastic surgery largely because there is no harm in doing so and it is very inexpensive. There is likely something to the homeopathic effect of a ‘natural remedy’ that also propagates its continued use.

Arnica Montana in Plastic Surgery Dr Barry Eppley IndianapolisOne of the problems with the use of Arnica is that its preparations have wide variability. Unlike a prescription drug, how Arnica tablets and creams are prepared is without significant manufacturing standards. Then there is the X and C potency or dose letter attached with a number. This adds to the confusion. An X preparation (decimal system) is, for example, where one part of the medicinal substance is mixed with nine parts of the vehicle. (1+ 9 = 10) In this system the X always follows the number. In a C preparation (Centesimal system), one part of the medicinal substance is mixed with ninety parts of the vehicle. Like the X system, the C always follows the number. It can be seen, therefore, that 10X and 10C Arnica preparations for example are not comparable in potency. The purpose of the letters X and C is to indicate how they are prepared and as no indication as to its potential effectiveness like typical milligram dosages of drugs are.

Because of the wide variability in how Arnica is prepared and the difficulty in studying the clinical effects of swelling, pain and bruising, demonstrating that Arnica actually has any positive benefits on surgical recovery is difficult.  Its continued use will be based on limited clinical information of its effectiveness and more on whatever placebo effects it may provide.

Dr. Barry Eppley

Indianapolis, Indiana

July 20th, 2014

Technical Strategies in Plastic Surgery – Fat Grafting in Migraine Surgery


Contemporary migraine surgery for the treatment of perpheral triggers involves decompression of the involved nerves. The most common involved nerves include the supraorbital, supratrochlear and the greater and lesser occipital nerves. (the zygomaticotemporal and auriculotemporal nerves are avulsed so they are excluded)  The success of nerve decompression depends on adequate release of the enveloping muscle and fascia so any pinching effect on the nerve is eliminated.

But decompressive migraine surgery does not always produce sustained relief and one of the reasons is recurrent compression due to scar formation. Despite being relieved of constructive muscle fibers, the surrounding tissues do have to heal and the space left behind can be replaced with scar tissue. Such scar tissue formation naturally contracts as it heals, thus potentially replicating the initial nerve compression problem.

Greater Occipital Nerve Decompression Dr Barry Eppley IndianapolisGreater Occipital Nerve Decompression with Fat Graft Dr Barry EppleyOne simple strategy to prevent recurrent nerve compression in migraine surgery is the use of fat grafts. Placing a fat graft over or around the released nerve can have several beneficial effects. Its obvious benefit is that it fills the open space around the nerve from the release and provides a quickly revascularized soft tissue buffer from the surrounding tissues. The other potential benefit is less obvious and unproven but theoretically possible.

Fat tissue is seen today as an active and secreting organ that produces a variety of special proteins. One of these are neurotrophic factors such as nerve growth factor and brain-derived neurotrophic factor. Such factors are known to have a role in stimulating repair of peripheral nerves as well as a regulator of immune and inflammatory responses. Placing a fat graft against a nerve that has been compressed and inflamed may have a healing and reparative effect.

The harvest of a small fat graft is quick and easy and its placement onto the released nerve is similarly so. There is no morbidity in doing so and fat graft placement around the nerve can be done either in an open wound or in an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

July 19th, 2014

Case Study: Temporal Implants in Severe Facial Lipoatrophy


Background: Facial lipoatrophy is the loss of facial fat which has various causes. Genetics, aging, weight loss and side effects of medications can all create variable degrees of facial fat loss. While fat exists throughout the face in the subcutaneous plane and around the eyes, the largest concentrated fat depot is in the buccal space. It is this fat area that is mosts severely affected in all degrees of facial lipoatrophy.

Buccal fat Pad Anatomy Dr Barry Eppley IndianapolisKnown as the buccal or Buchat’s fat pad, it is located deep in the face between various facial and masticatory muscles underneath the cheek bone. While it is called the buccal pad because of its primary location, it has numerous extensions or fingers into the pterygoid and temporal regions. Thus when loss of part or even all of the buccal fat pad occurs, temporal hollowing ensues along with submalar indentation.

The treatment of temporal hollowing is most commonly done by a variety of injectable filler materials. Hyaluronic acid-based and particulated fillers are office treatment methods while fat injections is more of a surgical approach. While these injection treatments for temporal hollowing can be effective, they are rarely permanent, may require multiple treatments, and are prone to irregularities and asymmetry.

Case Study: This 45 year-old male requested treatment for generalized facial lipoatrophy. One of his areas of concern was his very deep temporal hollows which were very concave and whose depth was well below the level of the zygomatic arch. This gave him a very skeletonized appearance across the bitemporal region.

Temple Implants in Facial Lipoatrophy result front view Dr Barry Eppley IndianapolisUnder general anesthesia (as he was undergoing various other facial procedures), small vertical incisions were made in the temporal hairline above the ears. After locating and incising the deep temporal fascial plane, blunt disection developed a pocket to the laterial orbital rim and along the superior edge of the zygomatic arch. Small soft silicone temporal shell implants were easily slide into the subfascial pocket, creating an instant temporal augmentation effect. The incisions were closed with dissolveable sutures.

Temples Implants in Facial Lipoatrophy result oblique view Dr Barry Eppley IndianapolisAugmenting temporal hollows with a preformed implant creates a muscular augmentation effect unlike most facial implants whose aim is to create a bone augmentation effect. It is the soft tissue volume of the temporal region that is lost in facial lipoatrophy below the level of the subcutaneous fat beneath the skin. Thus it seems most logical to treatment the exact location of the tissue loss which is the temporal fat pocket beneath the temporalis fascia.

Placement of an implant in the subfascial temporal plane is a very easy dissection and pocket to create. This pocket location for the temporal implant requite no form of fixation as it can not migrate below the level of the zygomatic arch due to the narrow space behind the arch and the blocking effect of the coronoid process of the mandible below it.

Temporal implant augmentation offers a simple surgical solution that is both permanent, has yet to reveal any significant medical risks, and involves minimal discomfort and swelling. It has the fastest recovery of any of the facial implant procedures.

Case Highlights:

1) Temporal hollowing is a major manifestation of significant forms of facial lipoatrophy.

2) A soft silicone temporal implant is a new method to permanently correct temporal hollowing by muscle augmentation.

3) Temple implant augmentation is a simple surgery that has virtually no significant recovery or swelling associated with it.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2014

Case Study: Transgender Brow Bone Reduction/Reshaping


Background: The shape of the forehead is very gender specific and these differences are well known. The male forehead has prominent brow ridges, a brow bone break and a forehead that has a slight backward slope. The female forehead has no visible brow ridging or break and a more convex shape as it extends upward into the frontal hairline. These forehead shape differences are driven largely by the influence of testosterone on the development of the frontal sinuses and the frontal bone.

Forehead feminization Surgery Dr Barry Eppley IndianapolisIn facial feminization surgery (FFS), forehead recontouring is an important one-third of the facial changes needed. This is usually perceived as ‘burring of the brow bone’ but this is an overly simplistic understanding of how to reshape the entire superior orbital rim. Because of the thinness of the outer cortex of the brow bone with a large underlying frontal sinus air space, simple burring of the frontal bone can only make a limited change. Most brow bone reductions of any significance require an osteoplastic bone flap technique in which the entire outer cortex is removed, reshaped and replaced.

But the brow bone reduction is often not enough to get a definitive gender change in the FFS patient. As part of the brow recontouring, the lateral or tail of the brow bone must be reduced to allow a more upward sweep to the tail of the eyebrow. In some cases, the orbital rim reduction may need to be carried around to the side to help with greater orbital exposure. (opening of the eye) Also, the frontal hairline may benefit from being advanced or lowered. If access to the brow bone reduction is done through a hairline or pretrichial approach, then vertical forehead reduction/hairline repositioning can be done at the same time as the brow bone reduction.

Case Study: This 35 year-old patient was undergoing a variety of facial feminization surgeries from the forehead down to the adam’s apple. The concerns on the forehead was that the brow bones were too strong but the upper forehead was adequately shaped/projected. The hairline was also in good place (not too high) with reasonable hair density.

Osteoplastic Brow Bone Reduction Technique front view Dr Barry Eppley IndianapolisOsteoplastic Brow Bone Reduction Technique side view Dr Barry Eppley IndianapolisUnder general anesthesia, a pretrichial or frontal hairline incision was made in an irregular fashion paralleling the direction of the hair shafts. The forehead flap was turned down and the brow bones exposed, protecting the supraorbital nerves. A reciprocating saw was used to take off the outer brow bones at the levels of the surrounding forehead. The two pieces were reshaped and put back with resorbable sutures. The tail of the brow bones were the frontal sinus cavities did not exist was burred done to reduce its prominence. The forehead flap was put back in a two layer closure with small sutures for the skin.

Transgender Brow Bone Reduction result side view Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction result oblique view Dr Barry Eppley IndianapolisBrow bone reduction is usually more than just simple burring, particularly with the goal of changing a prominent masculine brow shape to a flatter more feminine one.  The osteoplastic bone flap technique is needed with the potential for additional procedures of lateral orbital rim contouring, forehead augmentation and hairline advancement done at the same time.

Case Highlights:

1) Brow reduction is an important part of many facial feminization surgeries.

2) Brow reduction can be done by burring but usually needs a more aggressive approach with an osteoplastic bone flap to create a more feminine brow shape.

3) Many FFS brow bone reductions can be done through a hairline or pretrichial incision which allows for a simultaneous hairline advancement if desired.

Dr. Barry Eppley

Indianapolis, Indiana

July 13th, 2014

Breast Lifts Cause A Drop In Bra Cup Size


Breast Sagging and Involution Dr Barry Eppley IndianapolisSagging of the breasts is a common development for most women due to aging, pregnancy or weight loss. It is most severe with multiple pregnancies or significant amounts of weight loss. While corrective breast lifting is most frequently performed with  implants to restore and even increase original breast volume, it can also be done alone when the woman requests to just ‘put them back where they once were’.

Many women assume that a breast lift will also make their breasts more perky as well as fuller in the deficient upper pole. While this may be true for some women who have more sagging than breast tissue loss or a lot of volume that has fallen over the inframammary fold, this is not necessarily so for most women with breast sagging.

Breast Lifts Make Breast Appear Smaller Dr Barry Eppley IndianapolisIn the July 2014 issue of the Plastic and Reconstructive Surgery journal, an article was published entitled ‘The Impact of Mastopexy On Brassiere Cup Size’. This article was a clinical study that evaluated the change in bra cup size in women who had undergone breast lifts. Over a nine year period from the perspective of a single surgeon, twenty women who had underwent mastopexy alone (breast removed less than 150 grams per side) were surveyed regarding before and after surgery cup size, changes in bra manufacturer and weight gain/loss. The majority (80%) had grade II ptosis while the remainder had Grade III. Average breast tissue removed was almost 60 grams. (minimal) Average change in bra cup size was a decrease of 1.05 cup sizes.

This study demonstrates what plastic surgeons know based on a lot of observational experience…a breast lift will make one’s breasts look smaller. They will be more uplifted and have variable degrees of perkiness but they will be smaller both by appearance and in actual bra cup size. This occurs because in most cases of breast sagging the actual breast volume is less than the actual cup size a woman is wearing. This phenomenon is often called the ‘rock in the sock’ effect as the skin sleeve is bigger than what is inside of it. But when the breast is lifted and tightened, the bra cup size usually decreases despite teh fact that little to no breast volume has been removed.

As this study shows, breast lift surgery alone results in an average drop of one bra cup size. This is important to preoperatively appreciate as maintaining the same breast volume (or to even end up slightly bigger) may require an implant to be combined with the lift.

Dr. Barry Eppley

Indianapolis, Indiana

July 12th, 2014

Artefill Injections for Acne Scars


acne scarsAcne scarring remains a very difficult facial problem that defies any single method of improvement. Fundamentally, acne scars are treated by either outer skin resurfacing, complete excision, or injectable filling for pushing out the depressed scar. Each approach has its own utility based on the type of acne scar size and shape.

The simplest and easiest treatment to apply for acne scars are injectable fillers. And for the right type of acne scar (broader based saucer shape scars or atrophic acne scars), the push of a filler can be very effective. But not all fillers push out scars equally and all have variable time periods of persistence.

artefill injections Dr Barry Eppley IndianapolisIn the July 2014 issue of the American Academy of Dermatology, a study was published entitled ‘A Double-Blind, Randomized, Multicenter, Controlled Trial Of Suspended Polymethylmethacrylate Microspheres For The Correction Of Atrophic Facial Acne Scars’. In this study, nearly 150 patients that had multiple rolling, atrophic acne scars randomly received PMMA-collagen (Artefill) or saline injections.. They usually received two injections session and were followed for up to six months after treatment. Success was obtained in two-thirds (64%) of the Artefill injected patients compared to one-third of those that had received saline injections.. Adverse reactions to Artefill were mild and reversible. No differences were seen between ages, race or skin types.

It is not surprising that a particulated filler would produce better results in depressed scars than water (saline) or even a non-particulated filler. (not studied) The viscosity and push of an injectable filler like Artefill is simply more robust which is exactly what scarred and atrophic skin needs to be sufficiently elevated. The observation that almost all acne scars were not improved by Artefill is somewhat surprising but that is probably reflective of the  tough adherence of many acne scars and injector technique. What is not shown in the study is how long the Artefill effect lasts but this was really a pilot study to evaluate safety and effectiveness.

One very interesting aspect of this study was that saline injections produced any effectiveness at all, not that Artefill was more effective. This effect is hard to explain particularly at the six month follow-up period. Does saline alone by lifting the scar produce some degree of collagen formation?

Dr. Barry Eppley

Indianapolis, Indiana

July 10th, 2014

Five Things You May Not Know About Custom Facial Implants


The use of facial implants dates back to over fifty years ago when the first chin augmentation was done. With the expansion of facial implant styles and sizes over the years, there are many options today for nose, cheek, chin and jaw angle implants as the standard facial areas treated. In addition to these areas, there are expanding options available for other facial regions that are less commonly done. But despite a large number of available facial implants, some patients require or request a custom approach for their facial augmentation needs.

As custom facial implants are becoming more popular due to improved technology, there are numerous misconceptions about them. Here are some things you may not know about custom designed and fabricated facial implants.

Custom Facial Implants Are Not Really New. While the technology has dramatically improved and the internet has made their existence easily found, the use of custom implants for the face has historic precedence. Surgeons for years have used blocks of various materials to fashion implants during surgery. (although I would call this a semi-custom approach with a lot of guesswork in doing so) But the use of a patient’s model to create an exact fitting implant to the bone before surgery dates back to when higher resolution CT scanning and computer-generated models became available. I did my first such custom facial implant case back in 1997 where modeling clay was used to create a mockup of the implant from a resin-spun hand-held model.

A 3D CT Scan Is Needed To Make Custom Implants. Whether it is done by an actual model or on the computer screen, only a high resolution CT scan of the face with 3D reconstruction can be used. The scan has to be done using .1mm slices and not the standard 3mm or 1mm slices normally taken. An old or regular facial CT scan will not do nor will an MRI. These type of facial CT studies are quick and easy to do today at a very low cost at any CT scanning facility. The software to do them is now standard.

The Design May Be Done On The Computer But The Surgeon Creates It. While computers and their software can do incredible things, they do not yet know how to create a specific look for any patient. In designing facial implants, the computer has no innate knowledge or software algorithms to know what size or shape the implant(s) needs to be….unless they have a desired and exact target to mirror. This works for facial asymmetry (making an implant to match an opposite  normal side) but not for purely aesthetic facial augmentations. It is the doctor that must tell the computer (specifically the design engineer) the shape, thickness and orientation that they want the implants to be. The computer design process will make sure the implants fit the bone perfectly and compensate for any bony asymmetries.

Custom Implants Can Be Made For Any Craniofacial Area.  Implants can be designed from the end of the jaw to the back of the skull on any bone area. While most implants are made for bone augmentation, soft tissue implants can be similarly made. The outline and bulk of the muscles on the bone can be imaged and implants designed to fit under or on top of them. This is most useful for the temporal region where aesthetic width issues may exist.

The Cost of Custom Facial Implants Can Be Affordable. While the cost of custom implants does cost more than using preformed implants, the difference today is not as dramatic as it once was. If one has significant facial asymmetry or has extreme facial augmentation needs, the use of preformed implants may lead to disappointing results and revisional surgery. This can end up costing much more than using custom implants initially.

Dr. Barry Eppley

Indianapolis, Indiana

July 10th, 2014

The Biology of Injectable Fat Grafting – When Will I See The Final Result?


Fat Injection Location Dr Barry Eppley IndianapolisThe principal objective for fat grafting today is to serve as a soft tissue filler. Patients understandably expect that the fat that is injected will largely survive and they will retain much of the initial result for a successful outcome. A properly educated patient, however, will have been informed that fat graft survival is unpredictable and varies with each patient, anatomic location and volume of injection. In some cases, it may be necessary to have multiple injection treatments to achieve the volume needed. Rarely, but possible, some problems treated by fat injection will retain none of the fat at all.

But variability of survival aside, when can a patient expect to see the final result from their fat grafting procedure? To understand the answer to this question, it is important to look at recent experimental studies and the dynamic nature of the zones of fat graft behavior after injection.

Fat Graft Survival Theory Dr Barry Eppley IndianapolisImmediately after fat grafting, almost all fat cells die unless they are located within a few hundred microns of the host tissues. This occurs in just days after the procedure. In this more central necrotic zone, fat and stem cells do not survive and become replaced by a scant amount of scar tissue. In an intermediate zone, fat cells still die but stem cells survive. Over the ensuing three months, adipose-derived stem cells are activated and convert to fat cells and/or replace dead fat cells. In the outer or more superficial zone right up against the recipient tissues, many cells do live including the donor site fat cells. Thus by three months after injection, the volume retention of the graft is usually apparent and stable.

The wild card in fat graft volume retention is what happens to the free lipid material after fat cells die. Some of the dead fat cells and their released pools of lipid do eventually get absorbed by macrophage cells. But this is dependent on the size of the lipid ‘pools’ or droplets. Generally they are completely absorbed by three month afterwards. In larger  lipid droplets, this is a much slower process that can take up to a year to be absorbed.  But if the pools of lipid are large enough, they may remain forever and become quietly encapsulated. (oil cysts) This is not the type of volume retention one wants as these cysts could become calcified or even serve as a nidus for a delayed inflammatory reaction. This speaks as to why it is important to filter, strain or otherwise remove as much of the free lipid as possible prior to injection.

In most patients, the expected final fat grafting result should be reserved to what is seen at three months after the procedure. At this point in time, the cellular component of the graft is stabilized and most of the free lipid has been absorbed/removed. Armed with this time period, patients should not get too anxious if the fat grafted area looks too big or distorted within the first month after surgery. Conversely they should not get too excited about the size of the fat graft if it looks like what they wanted in the first month either. Like all tissue transplantations, fat grafting is a dynamic process that takes months to play out.

As a final point about fat grafting retention, there is an urban legend that fat grafting is like planting seeds that take time to grow. This internet myth is propagated in that the transplanted fat will take off and get bigger months later as it grows. Much of this is seen in online buttock augmentation (Brazilian Butt Lift) discussions. There is no scientific basis for this phenomenon and thus it remains as an unsubstantiated theory. This does not mean that those fat cells that have survived or been replaced by stem cell activation can not acquire more intracellular lipids with weight gain years later. But this is a different type of growth which should not be confused with creating an initial fat grafting result.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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