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Dr. Barry Eppley

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Posts Tagged ‘facial wasting’

A Facial Implant Approach To Volume Restoration in Facial Wasting (Severe Lipoatrophy)

Sunday, June 29th, 2014


Fat loss in the face is referred to as facial lipoatrophy. While some people have it occur naturally with aging or weight loss, for others it is a medication side effect. While retroviral drugs have extended the lives of patients with human immunodeficiency virus (HIV), one of its well know side effects is the loss of the facial fat compartments. This has become known as facial wasting since it is an abnormal and active process. In facial lipoatrophy terms, there are various degrees of it classified as I through V. Many HIV positive patients have advanced type IV and V facial lipoatrophy appearances.

While facial wasting affects all fat layers in the face, its biggest impact is on the buccal fat pad. With its numerous fingers of fat that extend throughout the face and up into the temple region, loss of the buccal fat pad creates a skeletonized and hollow facial appearance. In its fullest extent, it makes one look ill and unhealthy and carries the social stigmata of someone who has the disease.

It has been shown that thymidine analogue drugs are the cause of this facial lipoatrophy effect. Recovery of some of the lost fat can be achieved with a switch to nucleoside reverse transcriptase inhibitor-sparing therapies but it is slow and never complete.Various forms of plastic surgery are needed to create a more dramatic and immediate facial change.

Facial rejuvenation procedures for facial wasting is focused on volume restoration around  the periorbital region (eyes), specifically that of the cheeks and temple regions. The temple hollowing is a pure soft tissue deficit while that of the cheek area is a combined bone and soft tissue deficit. This is not to say that the cheek has lost bone but that it has become very skeletonized adn looks withered, thus cheek (malar = bone) and the area below the cheek (submalar = soft tissue) needs building back up.

While there are injectable treatments available to treat facial wasting, synthetic (Sculptra) and natural (fat), they have favorable degrees of effectiveness. Sculptra injections are for those patients who are definitely opposed to surgery and have the patience to wait until their fill effect is seen…and then have it repeated 18 to 24 months later. Fat injections are problematic both in harvest and persistence. Many facial wasting have little fat to harvest and its ability to survive in tissue beds with very little subcutaneous fat is precarious at best.

Temple Implants in Facial Wasting result front view Dr Barry Eppley Indianapolis_edited-1A facial implant approach can be very successful and create an immediate volume restoration with long-term stability. The temple hollowing is treated with new soft silicone elastomer temple implants that are placed below the fascia but on top of the muscle. This camouflages the implant edges and is a remarkably simple procedure to insert them with no postoperative pain, little swelling and a very quick recovery. They are far superior to any injectable filler because they are so effective. They key in using them is to not pout in a size that is too big which is very easy to do in a very skeletonized temporal region.

Cheek Implants for Facial Wasting Dr Barry Eppley IndianapolisThe cheek area requires a very broad-based implant, part of which is placed below the cheek bone on the masseter muscle. Proper implant placement actually puts at least half if not more of the implant below the bone. While once submalar cheek implants were exclusively used, I have found that larger combined malar-submalar shell implants do a better job of midface volume restoration. Because these type of cheek implants are substantative in size, screw fixation is useful to keep them in the desired location as they heal.

One area that is left out with temple and malar-submalar shell implants is the intervening area over the zygomatic arch and immediately beneath it into the lower face. A complete facial wasting surgery includes implantation of this area as well but has to be done with either fat injections or preferably a dermal-fat graft placed through a limited facelift approach. Without filling in this area there can be a step-off in the face behind where the malar-submalar shell implant ends.

Facial wasting treatment is one specialized form of facial reshaping surgery. These procedures allowing for volume restoration of the face hopefully to a level that is close to what they looked like before starting their anti-viral drugs. With a more ‘plump’ face, one self-confidence is improved, they look healthier and they will be encouraged to stick with their long-term drug therapy.

Dr. Barry Eppley

Indianapolis, Indiana

Implants and Fat Grafting for the Treatment of HIV Facial Wasting

Sunday, February 22nd, 2009

Facial wasting is a very specific condition of the face in which specific areas of fat are resorbed and, in its severest form, is unique to the HIV patient taking retorviral medication. Nobody knows exactly why fat from the faces specifically goes away on people taking anti-HIV drugs, but a significant percentage of such patients will  experience it depending on their particular retroviral medication regimens. It seems to occur particularly in men of low body weight who are over the age of forty.


Facial wasting can present in a variety of appearances from subtle to very dramatic, based on the amount of fat under the skin that has been lost. Patients typically present with sunken-in cheeks, very prominent cheek bones not covered by the usual fat layer, and hollow temples. This also creates loose facial skin due to the lack of underlying fullness.


Facial wasting can be treated by a variety of plastic surgery methods. The most popularized is the injectable approach using Sculptra or other long-lasting fillers such as Radiesse. While injectable fillers definitely provide a benefit, I don’t find them to be the best value, given what they cost and the repeated treatment sessions necessary. In my experience, several surgical options are more effective with injectable fillers or fat grafts used to supplement them.


I find that cheek implants, specifically submalar implants, are a good foundation to  build out the sunken face. These implants come in a wide variety of shapes and sizes so some customization of them can be done for each patient. These implants provide a good fill of the lost volume of the buccal fat pad and are easy to place through an incision inside the mouth. Once in the proper position, I prefer to place a screw through them to hold them permanently to the underlying cheek bone. There is some mild swelling after surgery but one can go back to work and resume all normal activities within just a few days. The advantage of an implant is that its volume will remain stable over time unlike injectable fillers. I have yet to experience any infections with cheek implants in the HIV patient nor do I think that such patients are at an increased infection rate from such procedures.


But augmentation of the bony cheek and submalar area can treat the full extent of the facial wasting. This requires soft tissue augmentation using an injectable approach to fill in around the edges of the implants and beyond. Often there can be a step-off or obvious demarcation from the implant to the surrounding skin in cases where the facial wasting is quite severe. In more mild cases, this may not be necessary. Fat injections are very versatile but they require having some subcutaneous fat tissue into which to be placed. In severe facial wasting I have used dermal-fat grafts, harvested from the abdomen, to be placed below the cheek through a nasolabial incisional approach.


When the facial wasting is associated with loose skin, a modified facelift can also be very helpful. Changing the facelift to more of a jowl-neck tuck-up helps stretch out the loose cheek and facial skin. When done in combination with submalar cheek implants and fat grafts, some really nice facial improvements can be achieved.

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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