Centrofacial Rejuvenation

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Centrofacial
Rejuvenation

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EDITED BY

Director
Coupure Center for Plastic Surgery
Ghent, Belgium
Assistant Professor
Free University of Brussels
Brussels, Belgium

Director
Coupure Center for Plastic Surgery
Ghent, Belgium
Assistant Professor
Free University of Brussels
Brussels, Belgium

Executive Medical Director
The Bensim on Center
Portland, Oregon
Illustrations by
Cassio Lynm
Centrofacial
Rejuvenation

Managing Editor: J. Owen Zurhellen
Director, Editorial Services: Mary Jo Casey
Production Editor: Kelly Mabie
International Production Director: Andreas Schabert
Editorial Director: Sue Hodgson
International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Institutional Sales: Adam Bernacki
Senior Vice President and Chief Operating Officer:
Sarah Vanderbilt
President: Brian D. Scanlan

Names: Tonnard, Patrick L., author. | Verpaele, Alexis M., author.
| Bensimon, Richard H., author.
Title: Centrofacial rejuvenation / Patrick Tonnard, Alexis
Verpaele, Richard Bensimon.
Description: First edition. | New York : Thieme, [2018] | Includes
index.
Identifiers: LCCN 2017027938 (print) | LCCN 2017029334
(ebook) | ISBN 9781626238848 (E-book) | ISBN
9781626236868 (hardcover : alk. paper) | ISBN
9781626238848 (eISBN)
Subjects: | MESH: Face--surgery | Cosmetic Techniques | Reju-
venation | Dermal Fillers | Adipose Tissue--transplantation
Classification: LCC RD119.5.F33 (ebook) | LCC RD119.5.F33
(print) | NLM WE 705 | DDC 617.5/20592--dc23
LC record available at
Illustrators: Cassio Lynm, Andrea Hines, Amanda Tomasikiewicz
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Dedication
To my son Gilles and my life companion Veerle, who turned the second
part of my life journey into an unexpected paradise.
Patrick L. Tonnard, MD, PhD
To my ever supportive and loving w ife Helga, and to the pride of my life,
m y two sons Louis and Rémi.
Alexis Verpaele, MD, PhD
To Dr. Hector Bensimon, surgeon, anatomist, inspiration . . . w ho “doom ed”
me to a life in surgery by naming me after his beloved mentor
Dr. Ricardo Finochietto.
Richard H. Bensimon, MD

(Trang không có chữ)

Menu of Accompanying Videos ix
Foreword xi
Preface to Parts I and II xiii
Preface to Part III xix
Contributors xxiii
Part I
Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Chapter 1
The Role of Fat Grafting in Facial Rejuvenation 3
Patrick L. Tonnard • Alexis M. Verpaele
Chapter 2
Microfat Grafting 19
Patrick L. Tonnard • Alexis M. Verpaele
Chapter 3
Augmentation Blepharoplasty 33
Patrick L. Tonnard • Alexis M. Verpaele
Chapter 4
Perioral Rejuvenation 61
Patrick L. Tonnard • Alexis M. Verpaele
Chapter 5
SNIF: Sharp Needle Intradermal Fat Grafting 85
Patrick L. Tonnard • Alexis M. Verpaele
Chapter 6
Nanofat Grafting 109
Patrick L. Tonnard • Alexis M. Verpaele
Contents

Contents
Chapter 7
Centrofacial Rejuvenation: Putting It All Together 137
Patrick L. Tonnard • Alexis M. Verpaele
Part II
The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Chapter 8
Midface Volume Rejuvenation With Fillers 211
F. Javier Beut • Glenn W. Jelks • Christopher C. Surek • Jerom e Lamb
Chapter 9
Filling Temples With Highly Diluted Hyaluronic Acid Fillers 251
Val Lambros
Chapter 10
Aesthetic Contouring of the Upper and Central Third of the Face
With Soft Tissue Fillers 263

Chapter 11
The Microbotox Technique 289

Part III
The Art and Science of Croton Oil Peeling
Chapter 12
Background to Facial Aging and Facial Resurfacing 313
Richard H. Bensimon
Chapter 13
The Technical Use of Croton Oil Peels 323
Richard H. Bensimon
Index 379

1-1 Aging-Related Sagging
1-2
2-1 Microfat Harvest and Processing
2-2 Malar Microfat Grafting
3-1 Marking the Upper Augmentation Blepharoplasty
3-2
3-3 Marking the Malar Augmentation
3-4 Malar Augmentation Technique
4-1 Correction of the Nasolabial Fold by Deep Blunt-Cannula Microfat Grafting
and Subcision
4-2 Augmentation of Upper and Lower Lip With Deep Blunt-Cannula Microfat


and Philtrum Augmentation
4-3 Microlaser Resurfacing of the Upper Lip
5-1 Sharp Needle Intradermal Fat Injection (SNIF) of Cheek and Upper Lip
Rhytids (1)
5-2 Sharp Needle Intradermal Fat Injection (SNIF) of Cheek and Upper Lip
Rhytids (2)
5-3 Sharp Needle Intradermal Fat Injection (SNIF) After Blunt-Cannula
Microfat Grafting of the Nasolabial Fold
5-4 Sharp Needle Intradermal Fat Injection (SNIF) in the Neck
6-1 Vermilion Nanofat Injection (From Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting:
basic research and clinical applications. Plast Reconstr Surg 132:1017-1026, 2013.)
6-2 (From Tonnard P,
Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg
132:1017-1026, 2013.)
6-3 Nanofat Décolleté Injection Technique (From Tonnard P, Verpaele A, Peeters G, et al.
Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg 132:1017-1026, 2013.)
7-1 Introduction by Dr. Patrick Tonnard and Dr. Alexis Verpaele
7-2 Interview with Dr. Thomas Biggs and Dr. Patrick Tonnard: MACS-Lift
7-3 Interview with Dr. Thomas Biggs and Dr. Patrick Tonnard: Fat Grafting
Videos
ix

x
Videos
7-4 Chapter I: Analysis of the Aging Face
7-5 Chapter II: Markings
7-6
(MACS)-Lift Solution
7-7 Chapter IV: Submental Liposuction
7-8 Chapter V: Microfat Harvesting
7-9 Chapter VI: Microfat Preparation
7-10 Chapter VII: Nanofat Preparation
7-11 Chapter VIII: Nanofat Injection Technique
7-12 Chapter IX: Microfat Injection Technique
7-13 Chapter X: Sharp Needle Intradermal Fat Injection (SNIF) Technique
7-14 Chapter XI: Simple Minimal-Access Cranial Suspension (MACS)-Lift
7-15 Chapter XII: Temporal Lift
7-16 Chapter XIII: Skin Redraping, Resection, and Suturing
7-17 Chapter XIV: Lip Lift
7-18 Chapter XV: Summary on Contralateral Side
7-19 Chapter XVI: Results
8-1 Layered Midface Anatomy (From Surek CC, Beut J, Stephens R, et al. Pertinent anatomy and
analysis for m idface volum izing procedures. Plast Reconstr Surg 135(5):818e-829e, 2015.)
8-2 Midface Injection Analysis (From Surek CC, Beut J, Stephens R, et al. Pertinent anatom y and
analysis for m idface volum izing procedures. Plast Reconstr Surg 135(5):818e-829e, 2015.)
8-3 Beut Type 1 (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the midface. Aesthet
Surg J 35:121-134, 2015.)
8-4 Beut Type 2 (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the m idface. Aesthet
Surg J 35:121-134, 2015.)
8-5 Beut Type 3 (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the m idface. Aesthet
Surg J 35:121-134, 2015.)
8-6 Beut Type 4 (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the m idface. Aesthet
Surg J 35:121-134, 2015.)
8-7 Dynamic Midface Rejuvenation Summary (From Surek CC, Beut J, Stephens R,
et al. Pertinent anatomy and analysis for midface volum izing procedures. Plast Reconstr Surg
135(5):818e-829e, 2015.)
9-1 Temple Filling
9-2 Immediate Result
13-1 Croton Oil Peel Without Anesthesia
13-2 Croton Oil Peel With Anesthesia
13-3 Removing the Zinc-Oxide Tape Mask and Applying Bismuth Paste
13-4 Lower Lid Peel Without Anesthesia

Foreword
I have known Drs. Patrick Tonnard and Alexis Verpaele since they had m ete-
oric rise to stardom in plastic surgery with their minimally invasive facelift sur-
gery book, The MACS-Lift: Short-Scar Rhytidectom y, in 2004 by introducing a full
facelift procedure that could be performed under local anesthesia on an outpa-
-
nique was m inim al in every way from a shorter scar to reduced recovery and
less morbidity postoperatively. This was a hallmark of the tantalizing, exciting,
and innovative career of these two co-authors. I had the pleasure to get to know
them in the ensuing decade as cutting-edge leaders and compassionate, caring
physicians as well as superb plastic surgeons. Drs. Tonnard and Verpaele have
been very introspective in not only looking at their results, but by truly herald-
ing the beginning of a new era in facial rejuvenation from that of “less is more”
to “more can be done with less.”
It is not surprising that this new text, Centrofacial Rejuvenation, represents the
next step in the evolution of rejuvenation, getting more and better outcomes by
doing less. This certainly is parallel with the philosophies that have led to more
natural results in facial rejuvenation. An enhanced understanding of the science
of aging has evolved from the understanding of fat compartments and that cen-
trofacial aging is the hallmark of early facial aging. It followed that the resulting
loss of facial shape and structure requires both centrofacial fat rejuvenation in
the fat compartments and outer facelift procedures done with traditional super-

This book puts all of this entirely in perspective as they describe the role of mi-
crofat and nanofat grafting in perioral, centrofacial, and augmentation blepha-
roplasty. These authors really have been the clinical leaders in shining the light
on centrofacial augm entation as the way to restore beauty and natural facial
youthfulness, which is the hallm ark of an excellent facial rejuvenation today.

incorporated into modern facial rejuvenation practice.
These chapters bring to life both the science and art of plastic surgery with the

-
modulators. Dr. Richard Bensimon describes the etiology of aging from the skin
viewpoint and how the role of m odern croton oil peeling truly helps augm ent
long-term results for patients who have undergone centrofacial fat augmentation

Foreword
and facial rejuvenation concomitant with skin resurfacing. He also explores the

This book will become another landm ark bestseller, illuminating modern con-
cepts in both centrofacial and facial rejuvenation. I congratulate Drs. Patrick Ton-
nard, Alexis Verpaele, and Richard Bensimon for bringing this tremendous col-
lection of experience and expertise into focus with this excellent book.
Rod Rohrich, MD, FACS
Dallas, Texas

Preface to Parts I and II
Facial rejuvenation surgery is a young speciality. It has been around for barely
100 years, and it has known some periods of exponential development followed
by m ore or less prolonged tim es of status quo. Every generation is tempted to
-
cally we know that to achieve the ultim ate goal of m aking patients really look

present day “state of the art” techniques will probably be outdated in another
30 years or less.
The latest revolution in facial aesthetic surgery was the discovery of the super-
-
niques to m ake the best use possible of this key facial structure. Results were
satisfying, but only to the extent of the understanding of facial aesthetics at that
tim e. Indeed, facial aging was then m ainly contributed to a relaxation or elon-
gation of the facial integument, and thus treatment focused on restoring tension
and “lifting” structures back into their original elevated position.
We believe that now again we are at the threshold of an era of an enormous bur-
geoning of innovative approaches. We are in the age of volum etric restoration
and at the start of the new era of regenerative surgery and medicine. Both these

of contemplating and treating facial aging.

the ingenuity of plastic surgeons. Our contribution to facelift surgery was to
m ake the procedure safer and simpler and the result m ore natural looking.
The m inim al access cranial suspension (MACS) lift concept was gradually de-
veloped and published in Plastic and Reconstructive Surgery in 2002. Initially
we believed that short-scar facelifting would perhaps be som ething of a tem -
porary hype, but gradually it becam e well accepted worldw ide, and we pub-
lished two m onographs on the subject in 2004 and 2007. Except for the ad-
dition of the temporal lift, there were no great changes in surgical technique.
-
larized by Sydney Colem an from New York, we incorporated the procedure in
our MACS-lift technique, occasionally since 2002 and routinely since 2004. We



great potential of this procedure and becam e aware that in som e patients this

Preface to Parts I and II
“ancillary” procedure becam e m ore important than the facelift surgery itself.
The concept of “centrofacial rejuvenation” was introduced.
The center of the face involves three zones: the periorbital area, the m idface,
and the perioral area. In essence this concept covers all the ancillary procedures
used for restoring the youthful appearance within the “facial oval.” The actual


Centrofacial Rejuvenation consists of three parts:
Part I, “Fat Grafting: From Volume Restoration to Regenerative Cell Therapy,” con-

techniques “from volume restoration to regenerative cell therapy.”

role of fat grafting in facial rejuvenation: its growing position in the armamen-


the indications for revolumizing, and the correct positioning of the fat grafts. The

major causal factor of facial aging.
Chapter 2, “Microfat Grafting,” describes the details of harvesting, processing,
and injection of small-particle fat grafts with adapted harvesting and injection
cannulas. It focuses on the importance of the small size of the fat grafts for the
survival of the graft and the predictability of the technique. All details concern-
ing anesthesia, patient safety, recovery, and outcomes are addressed.
Chapter 3, “Augmentation Blepharoplasty,” is based on the hypothesis that peri-

of adding volume to the periorbital area instead of excision and removal. Much
attention is given to the exact positioning of the fat particles with detailed ana-

Chapter 4, “Perioral Rejuvenation,” changes the paradigm of enhancing the

the lip. This involves m ore than volum etric enhancem ent, and often a surgical
shortening of the lip height with a liplift is required. A short mention is made of
resurfacing techniques, which are explained in more detail in Part III.
Chapter 5, “SNIF: Sharp Needle Intradermal Fat Grafting,” describes how microfat

w ith several clinical cases, and the injection technique is illustrated in detail
with video clips.

Preface to Parts I and II
Chapter 6, “Nanofat Grafting,” narrates how we discovered a m ethod for con-
centrating the stromal vascular area of the fat tissue through elimination of the

contains m uch sm aller cellular elem ents than the native fat graft, hence the

-
tions such as aging, traum a, and pigm entation. Again m uch attention is given
to the technical details of nanofat preparation and a safe injection technique by
means of text and videos.
Chapter 7, “Centrofacial Rejuvenation: Putting It All Together,” presents a great
num ber of case studies in w hich all the techniques described previously are
com bined. These cases dem onstrate the power of the synergy of using several
techniques together and illustrate the importance of centrofacial rejuvenation,
because the eyes and the mouth are the key to restoring the emotional expres-
sion of the face.
Part II, “The Place of Toxins and Fillers in the Modern Plastic Surgery Practice,”
consists of three chapters, each w ritten by world-renowned plastic surgeons

Chapter 8, “Midface Volum e Rejuvenation With Fillers” is written by the inter-
national group of Javier Beut (Mallorca, Spain), Glenn Jelks (New York, United
States) Christopher C. Surek (Kansas, United States), and Jerome Lamb (Missouri,
United States), who are respected anatom ists and clinicians. The chapter con-
tains several spectacular videos with unique anatom ic details of the injection
technique.
Chapter 9, “Filling Temples With Highly Diluted Hyaluronic Acid Fillers,” by Val
Lam bros (Newport Beach, United States) describes a very elegant technique of
-
vantage of the dilution is the avoidance of the risk of irregularities and lumpi-
ness, and it is very comfortable for the patient. Several cases are described and
illustrated with detailed video clips.
Chapter 10, “Aesthetic Contouring of the Upper Third of the Face With Soft Tis-

the nose, periorbital region, and brow. It features a detailed description of the
relevant anatomy regarding injection sites and danger zones for intravascular
injection.

Preface to Parts I and II
-

secretion.
Part III, “The Art and Science of Croton Oil Peeling,” by Richard Bensimon (Port-
land, United States) consists of two chapters on the science and art of skin peel-
ing techniques w ith croton oil dissolved in phenol. Dr. Richard Bensim on is a


with The MACS-Lift Short-Scar Rhytidectomy, followed by Short-Scar Face Lift: Op-
erative Strategies and Techniques in 2007. The concept has rem ained the sam e
throughout the whole work, with a focus on practical use for the reader; many
technical details, tips, and tricks; and thorough illustration with photos, artistic
drawings, and video clips.
The MACS-Lift Short-Scar Rhytidectomy, was conceived as a clin-
ical atlas, guiding the reader through the basics of the technique and trying to
provide a comprehensive understanding of the MACS-lift concept. The second
volum e, Short-Scar Face Lift: Operative Strategies and Techniques, is the natural

concept to the next level of understanding. The contribution of the collaborat-
ing authors Daniel Baker, Alain Fogli, Joseph Hunstad, Mark Jewell, Daniel Labbé,
Foad Nahai, and Tom Roberts gives a good overview of the possibilities and lim -
itations of short-scar facelift techniques. Short-scar temporal lifting is explained

In this third volum e we focus on what we perceived as the “m issing links” in
comprehensive facial rejuvenation surgery: volume restoration and skin resur-
facing. Interestingly, both these aspects m ainly apply to the central oval of the
face. This led us to the concept of “centrofacial rejuvenation,” which goes hand
in hand with the facelift and browlift techniques, which were described in Vol-
umes One and Two.
-
ward better and more natural results, and each addition that contributed to this
goal was shared in our publications and books. We feel that this third volume is
the keystone that has brought our results to an unprecedented level of comple-
tion and natural appearance, while maintaining good safety, predictability, and
reproducibility.

the practitioner of facial aesthetic surgery with a very solid technical basis, each
of these volumes can stand alone as a teaching guide on its subject and contrib-
ute to the reader’s understanding of facial rejuvenation.

Preface to Parts I and II
In the history of m ankind, the search for knowledge and beauty has been ever
present. The search for eternal youth and the battle against aging have been
fought since the beginning of civilization. Modern facial rejuvenation techniques
-
enced our approach to combatting the physical signs of facial aging, but we must
realize that we are just at the beginning of this interesting journey. Writing this
book was a rewarding but humbling experience, and although it occupied most
of our limited free time after busy days spent in the operating room, it is our pro-
found hope and desire that this work will continue to stimulate thinking about
facial aging and its treatment in an open-minded way, and that our patients will

ACKNOWLEDGMENTS
Centrofacial Rejuvenation is the result of a creative and intellectual process that
started after the publication of our second volume, Short-Scar Face Lift: Operative
Strategies and Techniques. At that time in 2007, we never thought there would be
a third volume, but through daily interactions and constructive discussions with
many colleagues met at international meetings all over the world, we started to
feel the need for writing another volume. We consider this work to be the result
of a long series of chances and opportunities in which m any people played an
important role. First, we cannot thank enough the people who professionally
trained us. From our late professor, Guido Matton, we learned that only the best is
good enough and that perfectionism isn’t as much a quality as it is a requirement.
Late professor Fernando Ortiz Monasterio inspired Patrick with his creative imag-

We should never underestimate the importance of our teachers in reconstructive
plastic surgery and microsurgery, professors Stan Monstrey and Phillip Blondeel,
-
struction, not to forget professor Moustapha Ham di, who was the prom oter of
both our doctoral theses.

to produce the work you are about to read, it is because we are standing on the
shoulders of these giants. But even today we continue to learn from other plastic
surgeons. First of all, we (Patrick and Alex) learn from each other in our associ-
ation as plastic surgeons. We are convinced that without the daily discussions
and critical feedback, we would never have been able to develop and advance our
-

and our partnership is an ongoing source of creativity, inspiration, and working
joy for both of us.
We want to thank several young colleagues, including Assaf Zeltzer, Geert
Peeters, and Nicole Lindenblatt, who helped us trem endously with articles on

Preface to Parts I and II
augm entation blepharoplasty, sharp needle intraderm al fat grafting, nanofat

to express our gratitude to so many plastic surgeons, including Dan Baker, Fritz
Barton, Fahd Benslimane, Tom Biggs, Giovanni Botti, Gary Burget, Syd Coleman,
Bruce Connell, Claudio Cardoso De Castro, Joel Feldman, Alain Fogli, Raoul Gon-
zalez, Joe Hunstad, Mark Jewell, Michael Kane, Roger Khouri, Daniel Labbé, Bill
Little, Tim othy Marten, Bryan Mendelsohn, Foad Nahai, Mario Pelle-Ceravolo,
Gino Rigotti, Tom Roberts, Rod Rohrich, James Stuzin, Frank Trepsat, and so many
others, who by their pertinent sharp questions and critical remarks stimulated

to the next level. Their support has given us the courage to persist in presenting
and publishing our results, and we greatly appreciate the genuine friendship of
all these experts. Special thanks go to the co-editor of this book, Richard Ben-
simon, with whom we have developed a special friendship and have organized

the last couple of years. We also thank the other contributors of the book, Glenn

because of their original and sometimes unconventional views on certain prob-
lem s, their contributions are invaluable to this text. This is also true of the nu-
merous colleagues we have met at international meetings all over the world who
shared their com m ents and critiques on our work. Their input has stim ulated
us to further elaborate on surgical techniques and the best way to teach them.
Thanks also to the team of Thiem e Publishers. Sue Hodgson, Kelly Mabie, and
-
lines.
We would also like to take the opportunity to express our great appreciation to

assistants, Elisa Bultynck and Carmen Van Eeckhoute; our nurses, Christelle Wul-

Lieve D’hoore and Nancy De Meyere. They are all irreplaceable in their jobs, and
we still mourn the loss of our head nurse Katrien Depoortere, who passed away
at the age of 38 in 2014. They all take work out of our hands and support us in
every new project, despite increased workloads and pressing deadlines. We feel
fortunate to work with such an enthusiastic team.
Finally we want to thank all our patients who consented to the publication of
their photographs. This work would not have been possible without their co-
operation.
Patrick L. Tonnard, MD, PhD
Alexis M. Verpaele, MD, PhD

Preface to Part III
Throughout my career as a plastic surgeon, the term “comprehensive facial re-
juvenation” has been thrown about rather glibly as a potential ideal, as the con-
tent of m eeting panels, even as the title of entire m eetings. Despite the best of
intentions, this goal has been illusory, because an entire category of rejuvena-
tion, namely the improvement of deep wrinkles and damaged skin texture, has
been largely ignored. We plastic surgeons are well versed in cutting skin and
manipulating soft tissue, but ironically, either by history or education, we seem
ill-prepared to deal with the skin itself.

-
provement of wrinkles. I was aware this was inadequate treatment, but I did not
feel there were viable options available to me.

sm oker’s lines. I knew that surgery would not serve her well; therefore I reluc-
tantly prepared to perform a classic Baker peel despite my apprehensions and
with resigned acceptance of the hypopigmentation I expected. Before performing
the peel, I serendipitously came across Gregory Hetter’s groundbreaking articles
on croton oil peels and everything changed.
I studied Dr. Hetter’s articles carefully, and arm ed with this new information, I

patient was rewarded with healthy-appearing, smooth, supple skin—indeed ra-
diating the very essence of youth.
Enthused by this experience, I continued to peel, and in preparation for a re-
gional society meeting, I telephoned Dr. Hetter requesting a photograph for the
presentation. Intrigued by my interest, he encouraged me and shared his expe-
rience. This blossom ed into an ongoing m entorship and a friendship that lasts
to this day.
As I became more involved with the peels, I came to realize that there were very
few of us performing them, even worldwide. A common impediment was a his-

recovery, and cardiac toxicity. Adding to this, even today there are textbooks
repeating decades-old m isconceptions and errors without proof. Hetter’s ex-
periments and my own experience debunked these old assumptions, and I felt a
responsibility to empower other practitioners to embrace this technique.

Preface to Part III
One fortuitous invitation was to address and perform a live peel at Controver-
sies, Art & Technology in Facial Aesthetic Surgery (CATFAS) IV in Ghent, Belgium,
in 2013. While there, I became acquainted with the novel process of sharp nee-
dle intraderm al fat (SNIF) grafting and nanofat espoused by Drs. Verpaele and
Tonnard. I noted w ith interest that these approaches improved the texture of

When Drs. Verpaele and Tonnard saw my presentations and peel, they came to
the same conclusion and approached me to organize a workshop to teach both

workshops that have been the inspiration for this book.
My role with croton oil peels has been to digest and implement Hetter’s teach-
ings, build upon them, and expand the utility of facial resurfacing. An unexpected


from early peeling that can change the course of aging. An important personal
focus has been to simplify the process, attempt to make it less intimidating, and
help the student through the early learning curve. In this manner, this remark-


-

of the modern croton oil peel is explained.
The second chapter is a very detailed tutorial on how to evaluate patients, pre-
pare the solutions, and safely execute a peel. The details m ay at tim es seem
extreme, but my purpose was to supply as much practical information and ex-
perience in one tom e as possible, to serve both as a guide and a reference. The
suggestions for the novice are meant to ensure safety so that students can build
on early experience and quickly advance into seasoned peelers. Finally, I have
endeavored to simplify the entire procedure by providing an alternative method

Any plastic surgeon who is serious about providing true comprehensive facial re-
juvenation must accept the vital importance of dealing with the quality and tex-
ture of the skin. It is my belief that at last we have an excellent option to provide
this, and it is my earnest hope that this work will inspire and guide the reader
through the process. The science and application of croton oil peels, now free
from old misconceptions, is in its infancy and ripe for development. The great-
est compliment to me as an educator would be that these words will be read by
a future innovator.

Preface to Part III
ACKNOWLEDGMENTS
At the outset, all due credit must be given to Dr. Gregory P. Hetter, whose ground-
breaking work is the cornerstone and foundation of my writings on the peels. His
pioneering publications and eventually his mentorship have been invaluable in
my involvement in chemical peeling. It has been the singular honor and privilege
of my career to disseminate and build upon his work.
I consider myself extremely fortunate to have been drawn into association with

book. I am equally grateful for the lasting friendship that has been forged; only
time will tell what further fruit this collaboration will yield.
Earlier in my peeling history, I was bolstered by the encouragement of Dr. Foad
Nahai. He has become a vocal supporter of croton oil peels and has paid me the
best complim ent by co-authoring a chapter with m e in his great work, The Art
of Aesthetic Surgery.
Throughout my “journey” in chem ical peeling, I have been joined by my assis-

I read Dr. Hetter’s articles to the preparation and planning of this book. She has
been present during m any peels, and her keen clinical eye has helped m e to
better understand and standardize the process. Her insistence on approaching
each case analytically and formulating an individual treatment plan has resulted
in greater clarity that I hope is evident in this writing. Any claim I have to be a
teacher, I owe to her.
Last, I give thanks to my editor, Sue Hodgson, whose polite yet insistent encour-
agement has kept me (mostly) on task and has made the entire process a pleas-
ant one.
Richard H. Bensim on, MD

(Trang không có chữ)

Contributors
Richard H. Bensim on, MD
Executive Medical Director
The Bensim on Center
Portland, Oregon
F. Javier Beut, MD, FACS
Instituto Dr Beut
Palma de Mallorca, Spain
Glenn W. Jelks, MD
Private Practice
JelksMedical
New York, New York
Jerom e Lam b, MD, FACS
Private Practice
Centerpoint Medical Center
Independence, Missouri
Val Lam bros, MD
Clinical Professor of Plastic Surgery
University of California, Irvine
Irvine, California
Christopher C. Surek, DO
Chief Resident
Department of Plastic Surgery
University of Kansas Medical Center
Kansas City, Kansas

Patrick L. Tonnard, MD, PhD
Director
Coupure Center for Plastic Surgery
Ghent, Belgium
Assistant Professor
Free University of Brussels
Brussels, Belgium
Alexis M. Verpaele, MD, PhD
Director
Coupure Center for Plastic Surgery
Ghent, Belgium
Assistant Professor
Free University of Brussels
Brussels, Belgium
Woffles T.L. Wu, MBBS(S’pore),
FRCS(Edin), FAMS(Plastic Surgery)
Private Practice
Singapore
Senior Lecturer
Anglia Ruskin University
Cambridge, England, United Kingdom
Honorary Head of Plastic Surgery
Department
Zhejiang Peoples Hospital
Hangzhou, China

(Trang không có chữ)

Part I
Fat Grafting: From
Volume Restoration
to Regenerative
Cell Therapy

(Trang không có chữ)

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell

Chapter
1
The Role of Fat
Grafting in Facial
Rejuvenation
Patrick L. Tonnard • Alexis M. Verpaele
Many things that exist only
in the imagination later becom e real.
GIACOMO CASANOVA

Chapter Videos
1-1 Aging-Related Sagging
1-2
Additional procedural video and author discussion of technique can be
found on Media Center.

• The Role of Fat Grafting in Facial Rejuvenation


Surgical correction of aging-related sagging of facial structures has existed for
more than 100 years. Nevertheless, during the aging process much more occurs
than just sagging of the skin (Fig. 1-1). There are changes in skin texture and
pigmentation and loss of volume in certain areas of the face (Video 1-1). Certain
facial m uscles contract, producing folds and rhytids, especially in the frontal
area and the neck. All these factors m ust be considered when educating a pa-
tient about facial rejuvenation. If the treatment goal is a total and natural facial

individually adapted to each patient’s needs.
Sagging of facial skin can be corrected w ith a surgical facelift procedure. The
options range from m inim ally invasive to deep plane or subperiosteal proce-
dures. Surgeons can treat the eyelids, the eyebrows, the lips, and the neck; per-
form subm andibular gland resection; or rem ove the adipose corpus of Bichat.

combination of procedures and to understand the correct indications for the dif-
ferent techniques. The texture and quality of the skin can be altered by skin care
products with alpha-hydroxy acids or retinoic acid, light therapy such as intense
pulsed light, or more drastically with resurfacing techniques such as dermabra-
sion, a chemical peel, or CO2 or Erbium laser resurfacing. Muscle hypertrophy or
hypertony can be treated with surgical myotomies, selective neurotomies, or less
invasive temporary chemical denervation with botulinum toxin. Volume deple-
tion can be corrected with volumetric surgical techniques or by adding volume
Loss of
animation
Sagging
Wrinkling
Contraction
Volume
loss
How do we age?
short-scar facelift
laser resurfacing temporal lift
blepharoplasty microfat
grafting submandibular gland
deep plane facelift canthopexy
resection
IPL
botulinum toxin
liplift myectomies
rhinoplasty
browlift SMASectomy fillers
genioplasty
earlobe reduction
chemical peel
Fig. 1-1
loss, and loss of anim ation. The surgeon m ust determ ine to what extent each factor contributes.
The patient can fall anywhere in this diagram. Understanding the importance of each of these fac-
IPL, Intense pulsed light; SMASectomy, resection of the

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
-
alyzed, and a personal treatm ent plan m ust be developed in consultation with
the patient. The surgeon is personally responsible for choosing and com bining

personal experience, and technical training. For the past 20 years, we have al-
ways tried to use a combination of minimally invasive surgical techniques. The
magic word in this context is “synergy” (Fig. 1-2).
COMBINING FACIAL FAT GRAFTING WITH FACELIFT
PROCEDURES
The com bination of fat grafting and surgical facelift is an example of synergy.
Performing facial fat grafting alone can produce certain results, whereas surgi-

these two can achieve results that cannot be obtained by either option alone.
The addition of volum e in the routine treatm ent plan of patients undergoing
surgical facial rejuvenation deserves special attention and is the subject of the


tightening procedure into a subcutaneous sculpturing and skin redraping pro-
cedure. In the late 1980s and early 1990s, some surgeons such as Ramirez et al1
and Little2 focused on “volumetric” facelift techniques; the intent was to preserve
3 popularized the tech-
nique of surgical fat grafting in the early 1990s. The idea of fat transfer was not
really new, because this was already proposed 100 years earlier by the German
surgeon Neuber.4 Nevertheless fat transfer did not become popular and was in-

SYNERGY

Fig. 1-2 Synergy can be expressed as “a result that is more than the sum of the components.”

• The Role of Fat Grafting in Facial Rejuvenation


Coleman standardized the technique of fat harvesting by using liposuction with
-

-

plastic surgeon can be seen as a real landmark in plastic surgery, similar to the
way breast implants were in the 1970s, endoscopy in the 1980s, and microsur-
gery in the 1990s. We started to occasionally incorporate fat grafting in facial
rejuvenation procedures in 2002 and since 2008 have routinely used fat grafting
as an ancillary procedure at the same time as facelift in about 95% of our cases.
We routinely use fat to augment the periorbital, malar, and perioral region with


Understanding the importance of facial fat grafting in facial rejuvenation depends
-
cial sagging occurs at the periphery of the face, for example, lateral to the lateral
canthus and oral commissure, and continuing in the neck (Fig. 1-3, A). Facial de-

including the glabella and the eyelids, the m alar area, and the perioral region
(Fig. 1-3, B, and Video 1-2). This is exactly the region where most mimic muscu-


take place on the whole facial skin (Fig. 1-3, C).
Fig. 1-3 A, This patient has a problem with sagging, especially in
the lower third of the face and neck. B, C, This patient
shows marked structural changes in skin quality.
B
A

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy


Based on our observations we hypothesized that facial fat atrophy could be
caused by a pure mechanical factor; for example, a piece of paper will show at-
rophy in the region where it is folded over and over again for a certain time in-
terval. In this context we introduced the hinge hypothesis of facial fat atrophy5
(Figs. 1-4 and 1-5). This hypothesis postulates that fat cells atrophy under high
pressure. This can be observed clinically in skin overlying tissue expanders, in
6 This also occurs
in the subcutaneous tissue of the skin under an abdominal belt. The only periph-
Fig. 1-4 Deep facial grooves are mainly present in areas of repeated facial animation, such as oc-
curs with crow’s-feet, orbitomalar grooves, nasolabial folds, and a marionette groove. With time
these folds become permanent as a consequence of atrophy of the underlying fat tissue. These re-
peated m ovem ents mim ic the action of a hinge and thus the hinge hypothesis of fat atrophy.

• The Role of Fat Grafting in Facial Rejuvenation



area, overlying the temporal muscle.

Generally speaking, we use facial fat grafting in combination with surgical facelift
techniques for two reasons: (1) longer stability of the surgical facelift result and
(2) a m ore natural result. Our analysis of the long-term results of facelift cases
in our early series (1998 to 2003) that used our classic m inim al access cranial
suspension (MACS) lift technique showed a typical relapse of the nasolabial fold

fat injection was not performed.
Fig. 1-5 Facial animation occurs by the action of the mimic musculature, which is concentrated
in the centrofacial area. Fat atrophy is m ost important in the sam e centrofacial area. This can be
explained by a pure mechanical action of the mimic musculature on the facial fat.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

For example, the 49-year-old m an in Fig. 1-6 underwent an extended MACS
lift, lower skin-pinch blepharoplasty with transconjunctival fat resection, and
short-scar temporal lifting to correct facial sagging.7 Ten m onths after surgery
he had good correction of the sagging of the neck, jowls, and temporal hooding.

had a stable correction of the sagging facial features (neck, jowls, and temporal
hooding) but a degree of relapse of the nasolabial fold and an undercorrection


to the midface and nasolabial fold.
Fig. 1-6 Left, Preoperatively at age 49 years. Center, At 10 m onths postoperatively. Right, At
4 years postoperatively.

• The Role of Fat Grafting in Facial Rejuvenation


We now use a m ultim odal approach, which incorporates fat grafting into the
rejuvenation strategy. Thus we can obtain better longevity by sim ultaneously

Figs. 1-7 through 1-9.
B
A
Fig. 1-7 A, Preoperative appearance of a 52-year-old woman who had an extended minimal access
cranial suspension (MACS) lift, upper blepharoplasty, temporal lift, and m icrofat grafting of the
nasolabial folds, corner of the mouth, and marionette groove. B, The very deep nasolabial creases
were corrected by m ultilayer m icrofat grafting and subcision, which delivered a m uch better and
longer lasting result after 3 years.
Fig. 1-8 A, This 46-year-old woman requested correction of facial aging. Except for minor jowling the
major problem was the absolute absence of soft tissue padding between the skin and malar bone. The
postoperative result at 2 (B) and 7 (C)
B
A

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

Volume-enhancing microfat grafting is even more important in secondary facelift
procedures.
-
cial myoaponeurotic system (SMAS) facelift that was performed elsewhere (Fig.
1-10). Except for some relapse of facial sagging, his main issue was centrofacial

cervical laxity and jowling, a short-scar temporal lift for correcting the tempo-
ral hooding, rhinoplasty, and microfat grafting of the upper eyelid sulcus, malar
-
trofacial volume correction is by far more important than the surgical lifting of
relapsed laxity.

areas at the time of surgical MACS lifting (Fig. 1-11). Thus we have longer-lasting
results, as seen in our long-term postoperative results.
Fig. 1-9 A, This 48-year-old woman had marked nasolabial folds. B and C, Postoperative results
are shown 2 and 6 years after an extended m inim al access cranial suspension (MACS) lift and
transconjunctival blepharoplasty with nasolabial microfat grafting and subcision. Long-term sta-
bility of the nasolabial fold correction is evident.
B
A

C

• The Role of Fat Grafting in Facial Rejuvenation


Fig. 1-10 A, This 62-year-old m an presented for a secondary facelift 10 years after a prim ary su-
B, One year after an extended m inim al access
cranial suspension lift, temporal lifting, and fat grafting of the upper eyelid sulcus, malar area, na-
solabial folds, and marionette groove, the main rejuvenating factor in the correction is centrofacial
volum e restoration by m icrofat grafting, which has turned the triangle of age into the inversed
triangle of youth.
B
A
Fig. 1-11 A, This 69-year-old patient had a lifting procedure combined with microfat augmenta-
tion of the periorbital and m idface region. In older patients the importance of correcting m idfa-
cial volum e depletion cannot be underestim ated. B, The patient at approximately 35 years of age.
C, The result at 4 years postoperatively, with a stable replenishment of the midface area.
B
A

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy


We also perform simultaneous fat grafting at the time of surgical facelift, because
we can produce more natural results. The goal of a facial rejuvenation procedure

-
tion. For the past 10 years of our practice, we have asked all our facial rejuvena-
tion patients, including those undergoing blepharoplasty, to bring photographs
of when they were in their 20s and 30s to the consultation; our goal is to analyze
their appearance when they were younger so we can adjust the treatment plan
accordingly. Am azingly, alm ost all patient have lost volum e in the centrofacial
area during the aging process, even if they have gained som e weight over the
years, which is often the case. Both surgeons and patients m ust recognize that
a good facial rejuvenation procedure will reconstruct the facial architecture to
a younger state (Fig. 1-12).
Fig. 1-12 A, This 70-year-old patient had a minimal access cranial suspension lift procedure com-
bined with m icrofat grafting of the periorbital and m alar areas. B, At 1 year postoperatively, the
importance of the volum etric rejuvenation is evident in the outcom e.
B
A

• The Role of Fat Grafting in Facial Rejuvenation


VOLUME DISTRIBUTION IN FACIAL REJUVENATION
Volume distribution in the face plays a very important role in this process. For
example, a surgeon can estimate a person’s age from a distance of 20 meters not
because one can discern small details such as perioral rhytids or crow’s-feet but
based on the information that we receive from the face as a “gestalt.” The distribu-

to determine a person’s age. The typical changes in the transition from a younger
to an older face is the evolution from an inverted triangle with high cheekbones, a

2,8 made
this analysis previously in his description of “the inverted cone of youth.”
A 62-year-old-woman requested facial rejuvenation and correction of a second-
ary nasal deform ity (Fig. 1-13, A). Compared with the photograph taken of her
at age 26 years (Fig. 1-13, B -
ment plan consisted of an extended MACS lift, short-scar temporal lift, second-
ary rhinoplasty, and microfat grafting of the upper eyelids, malar area, and lips.
The result is seen 18 m onths after surgery (Fig. 1-13, C). Except for correcting
the sagging of the neck, jowls, and tail of the eyebrow, the reconstruction of the
facial architecture can be compared with the photograph showing the patient at
26 years of age; the facial ogee curve and periorbital and perioral volume have
been restored. This natural rejuvenation result could not have been obtained
without restoration of centrofacial volume.
Fig. 1-13 A, This 62-year-old woman was seeking facial rejuvenation for a combination of lifting
and volume repletion. The facial architecture of youth (B) was restored by microfat grafting of the
periorbital area, the m idface, and the lips (C).
B
A

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

CENTROFACIAL REJUVENATION
Every m eeting on facial rejuvenation surgery includes a panel discussion on
whether surgeons should open the neck. An open approach to the neck involves
making a subm ental incision, complete undermining of the anterior neck skin,
and median platysmarrhaphy, sometimes combined with digastric muscle and/
or subm andibulary gland resection. A closed approach to the neck involves a
3 mm incision with submental liposuction and a vertical suspension of the lat-

the surgeon, the degree of neck deformity of the patient, and the surgical risks
and morbidity involved in both options.
Although a youthful neck is extrem ely important in global facial rejuvenation,
we need to ask how m uch cervicoplasty contributes to the rejuvenation of the
facial gestalt, especially when considering the power of volumetric centrofacial
rejuvenation.

In facelift publications from the 1980s, most of the preoperative and postopera-



and oblique views to reveal the changes in the m idface and perioral and peri-
orbital areas. Facial expression originates from the eyes and the mouth and not
from the neck. Moreover, communication occurs mostly in the frontal or oblique

may be slightly obsessed with a perfect cervicomental angle, whereas much in-
formation regarding the age of a face is derived from the central part of the face.

than sagging. Lam bros9 showed in his tridim ensional, long-term facial aging
study that centrofacial landmarks such as nevi and folds are not displaced down-
ward during aging. This means that lifting the soft tissues in the central part of




better results without the risks of disastrous complications and with less mor-
bidity and a shorter recovery. In our MACS lift experience, placement of the third

of the malar area. The logic behind this is that an empty space does not need to

• The Role of Fat Grafting in Facial Rejuvenation


A
B
C
D
C
B
A
A
B
C
D
C
B
A
1
2
3
4
5
6
7
A
B
C
D
C
B
A
A
B C
D
C
B
A
1
2
3
4
5
6
7
Fig. 1-14 Visual illusion of sagging in an aging face while all the anatomic landmarks (eyebrows,
orbitom alar groove, nasal tip, and m ental crease) rem ain in the sam e position. The only feature
that truly lengthens is the upper lip (see Chapter 4).

position. This is particularly true for the m idface. The only facial feature that
lengthens (descends) is the vertical height of the upper lip (Fig. 1-14). The con-

causal factor. The center of the face involves three zones: the periorbital area, the
midface, and the perioral area.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

Traditionally periorbital aging was treated with a combination of resection and
lifting procedures. Current concepts reveal that periorbital aging is m ore the
10 described volum e-preserving bleph-
Several
surgeons (Benslimane,11 Little,12 Marten,13 Roberts,14 and Trepsat 15) have taken
a further step by adding volume around the orbit. This had led to the concept of
augm entation blepharoplasty, which is discussed in the next chapter.

of the upper lip, and textural changes in the skin. The logical treatment involves

comprehensive rejuvenation.
REFERENCES

soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg 88:227-236; discus-
sion 237-238, 1991.
2. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvena-
tion. Plast Reconstr Surg 105:252-266; discussion 286-289, 2000.

1994.
4. Neuber GA. Fettransplantation. Bericht über die Verhandlungen der Deutschen Ge-
sellschaft für Chirurgie. Zentralbl Chir 22:66, 1893.
5. Tonnard PL, Verpaele AM, Zeltzer AA. Augm entation blepharoplasty: a review of
500 consecutive patients. Aesthet Surg J 33:341-352, 2013.

skin and soft tissue after controlled tissue expansion. Plast Reconstr Surg 70:704-710,
1982.
7. Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques.
St Louis: Quality Medical Publishing, 2007.
8. Little JW. Three-dim ensional rejuvenation of the m idface: volum etric resculpture by
malar imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000.
9. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367-
1376; discussion 1377, 2007.
10. Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper
periorbita. Plast Reconstr Surg 110:278-291; discussion 292, 2002.
11. Benslimane F. Periorbital fat grafting. The frame concept. Presented at Controversies, Art
and Technology in Facial Aesthetic Surgery (CATFAS) III, Ghent, Belgium, June 2010.


13. Marten T. Sim ultaneous face lift and fat grafting. Presented at Controversies, Art and
Technology in Facial Aesthetic Surgery (CATFAS) III, Ghent, Belgium, June 2010.
14. Roberts T. The synergy of multimodal facial rejuvenation. In Tonnard PL, Verpaele AM,
eds. Short-Scar Face Lift: Operative Strategies and Techniques. St Louis: Quality Medical
Publishing, 2007.
15. Trepsat F. Volumetric face lifting. Plast Reconstr Surg 108:1358-1370; discussion 1371-
1379, 2001.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
2
Microfat Grafting
Patrick L. Tonnard • Alexis M. Verpaele
I keep on making w hat I can’t do yet
in order to learn to be able to do it.
VINCENT VAN GOGH

Chapter Videos
2-1
2-2 Malar Microfat Grafting
Additional procedural video and author discussion of technique can be
found on Media Center.

• Microfat Grafting
Fat grafting is not new. In 1893 Neuber1
autologous fat transplantation.

and complete demonization. It was only with the pioneering work of Coleman 2
in 1995 that “lipostructure” became predictable and reproducible.
-
ing the lower eyelids sometimes resulted in palpable or even visible irregulari-
ties or lumpiness. Downtime was also excessive, with pronounced and lengthy
swelling of the face.
From discussions with colleagues such as Thomas Roberts III, Frank Trepsat, and
J. William Little, we realized that a reduction in grafted particle size may resolve
many of these problems.
Geom etry teaches that the surface area of a spherical particle is inversely pro-
portional to its radius (Fig. 2-1). Thus given a certain volume of fat particles, re-
ducing the particles to half their size will double the total contact surface area.

embedding phase before revascularization, the likelihood of particle survival is
n spheres r
m spheres R
Number of spheres
n = 64
m = 8
Radius of each sphere
r = .25
R = .5
Volume of all spheres
Vn = n ( 4—
3 3)
=
Vm = m ( 4—
3 3)
Surface area of all spheres
An = n (4 2)
Is 2× greater than
Am = m (4 2)

An × r = 3Vn
=
Am × R = 3Vm
Radius is inversely
proportionate to surface
r. Surfn
=
R. Surfm
Fig. 2-1 The principle on which m icrofat grafting relies: Reducing the diam eter of a sphere pro-
portionally increases its contact surface.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
increased. Moreover, as Yoshimura et al3 showed in their 2011 research, grafted
fat particles larger than 2 mm in diameter will develop central fat necrosis.
According to Yoshim ura, a fat particle exceeding 2 m m in diam eter will show
three zones of behavior after transplantation: (1) the external “surviving zone” of
100 to 300 µm, (2) a “regenerating zone” of 600 to 1200 µm, and (3) a central “ne-
crosis zone” of all the fat tissue deeper than 1 mm in the particle. This means that
any fat particle exceeding 2 mm in diameter will have a central necrosis zone.
Because fat graft survival becomes more predictable with the use of smaller fat
particles, overcorrection is less necessary. Better fat survival also results in less

in turn reduces downtime and the risks of visible and palpable lumps, especially
under the thin lower eyelid skin (Box 2-1).
Presently we harvest all fat with small 2 to 3 mm diameter cannulas with multi-
ple sharpened 1 mm diameter holes. A direct relationship exists between the size
of the holes in the cannula and the size of the harvested fat particles. For exam-
ple, 1 mm holes will produce fat particles with a maximum diameter of 1 mm.
The sharp edges of the holes enhance the harvesting yield by cutting any small
particle, which is suctioned into the cannula. Without these sharpened holes,
the aspirated m aterial contains m ore liquid than fat. With the sharp holes the
fat is literally grated out of the subcutaneous tissue. These cannulas are known
as grater-type cannulas (Fig. 2-2).
Box 2-1
Better survival
Less need for overcorrection
Reduced downtim e
Less risk of visible and palpable lumps
Fig. 2-2 Sharp “grater” or “Tonnard” cannula. The harvesting cannula consists of a sharp, m ul-
tiport cannula that is 2.4 m m in diam eter, with holes 1 m m in diam eter. Note the sharp edges of
the holes, which transform the cannula into a rasp, augmenting the harvesting yield of this small-
holed cannula. (Courtesy Tulip Medical Products, San Diego, CA.)

• Microfat Grafting


that can be mounted on a Luer-Lok syringe (smaller-diameter cannulas) or a li-
posuction machine (larger-diameter cannulas).
These cannulas have sharpened edges on the small holes, so they act like a grater,


larger-volume harvesting, a larger-diameter (3 mm) cannula can be chosen with
the same multiple sharpened 1 mm holes at the tip.


injection into the facial areas should be obtained. With this method of harvest-
ing, which resulted in sm aller fat particles, we began to use sm aller-diam eter
injection cannulas. Today we exclusively inject m icrofat through 0.7 to 0.9 mm
diameter blunt-tipped cannulas.
-

to pass through. Exerting too much force on the plunger of the syringe will pro-
duce accidental large blebs that will be delivered under the skin.
PATIENT EVALUATION AND SELECTION

is analyzed by comparing the present appearance with photos taken between
20 and 35 years of age. The areas m ost com m only involved are the periorbital
area (upper and lower eyelids, temples, and m alar area) and the perioral area
(nasolabial fold, upper and lower lips, and m arionette groove). These subjects
are covered in detail in Chapters 3 and 4.
INDICATIONS AND CONTRAINDICATIONS
Microfat grafting is now used in 95% of all facial rejuvenation treatm ents. We
routinely use microfat grafting separately or in combination with surgical lifting
procedures. Contraindications are the use of anticoagulant medication, smokers,
cachectic patients, and all catabolic states.
PREOPERATIVE PLANNING AND PATIENT PREPARATION
Microfat grafting does not substantially prolong the m orbidity and downtim e
of associated facial aesthetic procedures. Downtim e after fat grafting is largely
caused by an unnatural appearance resulting from overcorrection. The microfat
system, however, results in very little graft resorption because of the better take

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
of small particles. Therefore overcorrection is rarely indicated. This considerably

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is performed using local anesthesia. In our practice this occurs in about 10% of
facial fat grafting cases.
For 2 to 3 weeks after surgery, the face will look and feel unnatural. The patient
may experience a tense feeling, especially in the malar areas and the lips, which
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porary and that patience is essential. Before surgery patients can be reassured


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tient. We usually select the infraumbilical region, the inner thighs, or the knee
areas as donor sites, because these areas are easily accessible with the patient in

sites, the anterior thigh is a useful option. Considering that the surface of the
palm of the hand is about 200 cm 2, aspiration of a 1 m m layer of fat from this
surface yields 20 cc of fat. From an average anterior thigh, a surgeon can easily
harvest at least 60 to 100 cc per side.
MICROFAT TECHNIQUE


lidocaine and 1:1,000,000 epinephrine.
In the acceptor areas the anesthetic solution (Box 2-2) is the sam e as that used
for m inim al access cranial suspension (MACS) lift procedures; a diluted 0.3%
lidocaine solution is used along w ith 1:650,000 epinephrine and 0.15% ropiva-
caine, which is a long-acting local anesthetic with very low cardiotoxicity. The
Box 2-2 Local Anesthetic Solution
100 ml of 0.9% NaCl
20 ml of 2% lidocaine
10 ml of ropivacaine, 10 mg/m l
2 ml of 8.4% sodium bicarbonate
0.2 ml of epinephrine, 1 mg/m l

~0.3% lidocaine
0.15% ropivacaine
+ epinephrine 1:650,000