Centrofacial Rejuvenation

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
3 to 4 cm from the tip of the cannula. Placing the incision 5 cm from the donor
area will prevent vacuum loss every tim e the holes com e out of the skin when
the cannula is pulled back, if syringe aspiration is used. This also prevents dam -
age to the derm is around the incision by the sharp edges of the cannula holes,
which may result in a depressed scar.
If the desired volume of microfat is less than 10 cc, harvesting can be performed
with a cannula mounted on a Luer-Lok syringe.
For larger volumes vacuum aspiration is used, with a sterile canister interposed
between the cannula and the suction machine.
After harvesting, the fat is not centrifuged but is rinsed with either norm al sa-
line or Ringer lactate solution through a nylon tissue cloth w ith a pore size of
400 µm , which is m ounted on a sterile canister. When the oil and debris are
washed away, the fat is transferred to 10 cc Luer-Lok syringes with a spatula or

the help of a female-to-female Luer-Lok adapter. This entire preparation proce-
dure takes about 10 minutes. For larger volumes in particular, it is very easy and
quick in comparison with the centrifuge techniques.
This method of fat harvesting and preparation has been criticized because of the
extra trauma induced through the use of sharp-hole cannulas, full-vacuum aspi-
ration, and exposure to air. Nevertheless, we have been happy with our clinical
outcomes, including the “take” of the fat, with minimal to no overcorrection of
the deform ity. Perhaps in fat grafting, traum a is not the enemy but a friend. If
fat grafting has regenerative aspects, trauma can be considered the trigger to all
regeneration in the human body.


defense of each method are currently based more on personal experience than
on science. Proponents of both methods have presented outstanding results with

than centrifugation, because this produces a very liquid graft, which can easily
be injected through 0.7 m m cannulas w ith m inim al plunger pressure. Thus a
precise delivery of minute aliquots of fat graft per passage is possible, allowing
the surgeon maximal control over even distribution of the graft. This is especially
important when grafting delicate areas such as the tear trough or the eyelids.

is considered a transplantation procedure, a cold ischemia time exists between
harvesting and injection. The surgeon must minimize the cold ischemia time for

• Microfat Grafting

is to prevent the intraoperative swelling that starts after open surgery (for ex-
ample, a facelift and blepharoplasty) and masks the deformity that will be cor-
rected by the fat grafting.
Microfat Injection
The skin puncture hole is created with an 18-gauge intravenous needle. This is

do not need to be closed.

size and sm aller aliquots of fat injected per passage. The m ultistroke delivery
of the fat graft is key. On average 30 to 50 passes are made to inject a volume of
1 cc of fat. A m eticulous injection technique is very important. By m oving the
injection cannula swiftly backward and forward, only minute amounts of graft
are deposited with each pass. Thus the surgeon can evenly distribute the fat into
the receptor area. The fat is typically injected on withdrawal of the cannula.


-
cularis oculi muscle.

degree of resorption. Resorption is usually higher in areas with a high mobility,
such as the lips.
Table 2-1 Typical Volumes of Fat Grafted and Degree of Resorption Per Area
for Facial Rejuvenation
Facial Area




Upper eyelid sulcus
0.5-3
None to very low
Tear trough
1-2
None to very low
Malar
3-10
Low to moderate
Sunken midcheek
4-15
Moderate to high
Nasolabial fold
1-4
Moderate
Lip vermilion
2-4


Marionette groove
2-4
Moderate
Chin
6-20
Low
Temple
2-6
Moderate

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The puncture holes from the fat injection do not need closure or a dressing. No
bandage is applied onto the grafted area. Any compressive bandage will interrupt
already impaired lymphatic drainage.
We cool the grafted areas to 16° to 18° C for a m inim um of 1 hour w ith the

custom-made facial mask (Fig. 2-3). This low–room-temperature cooling is much
less aggressive than ice cooling, which elicits a rebound hyperemia after discon-
tinuation of the cooling.
Beginning on postoperative day 1, daily facial cleansing and hair washing are
allowed. Starting on postoperative day 4, lymphatic drainage with the Vodder
m ethod is allowed. This m ethod m assages the lymph nodes in the neck and
décolleté but not in the face. It w ill stim ulate the regional lymphatic nodes to
eliminate facial edema. Antibiotics (500 mg of amoxicillin, three times per day)
are prescribed for 3 days.
Fig. 2-3 After facial surgical procedures, including m icrofat grafting, the face is cooled to 16 to

• Microfat Grafting
RESULTS AND OUTCOMES
The 50-year-old man in Fig. 2-4 presented for a lower blepharoplasty. As seen on
-
rior orbital rim is behind the eye globe, he had a negative vector situation. Thus
the surgical plan was to perform a soft tissue augmentation of the whole midface
with 25 cc of microfat per side. The actual lower blepharoplasty consisted only
of a skin-pinch excision with orbicularis m uscle suspension. No m anipulation
of orbital fat was performed. The nasolabial folds were also injected with 1.5 cc
of microfat. All surgery was performed with local anesthesia.
Fig. 2-4 Left to right, respectively: Preoperatively at age 50 years; at 6 days postoperatively; at
6 weeks postoperatively; at 9 months postoperatively; and at 4 years postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The postoperative results are shown at 6 days, 6 weeks, 9 months, and 4 years.
At 6 days the patient had moderate swelling, which allowed him to resume pro-
fessional and social activities in 10 days. At 6 weeks, after a period of slow ab-

years after surgery, the patient has a perfectly stable long-term result.
SAFETY CONSIDERATIONS
Intravascular injection is a risk that always needs to be considered when graft-
ing microfat around the orbit or the m outh. The following safety measures are
always taken when grafting in the periorbital and perioral regions:
• -
constriction
• The use of blunt cannulas to minimize the risk of cannulation of a vessel
• Injection on withdrawal
• Multistroke injection
• Injection of very small aliquots (less than 0.1 cc per stroke; ideally 30 to 50
passes per 1 cc syringe)
• Injection with low pressure
PROBLEMS AND COMPLICATIONS
The m ost com m on complications of fat grafting are overcorrection and lump-
iness. The latter is greatly prevented w ith the use of m icrofat grafting. Over-

procedure is m uch easier and better accepted by a patient than attempting to
remove overgrafted fat. Cyst formation has not been found, most likely because
of the microfat technique. To date no infections have occurred. Donor-site mor-
bidity mainly consists of overaspiration and is a technical error. The avoidance of

for a successful outcome.

• Microfat Grafting
Technical Pearls
• There is a relationship between graft particle diameter and the diameter of
the holes in the harvesting cannula. “Fine particle fat” can be obtained by
harvesting fat with small-hole cannulas.
• Sm all fat particles can be grafted w ith sm all-diam eter cannulas (that is,
0.7 to 0.9 m m ). This is indicated if grafting will be done underneath thin

and palpable fat grafts under the skin can be prevented w ith the use of
small fat particles.
• Sm all fat particle grafting w ill also reduce postoperative m orbidity and
downtime as a result of the reduced resorption of the fat particles. Indeed,
smaller fat particles have a larger contact surface in comparison with a sim-
ilar volume of larger fat particles.
• In particular when grafting the lips, less overcorrection is needed if small
fat particles are used because of dim inished resorption and thus better
take of the fat.
REFERENCES
1. Neuber GA. Fettransplantation. Bericht über die Verhandlungen der Deutschen Gesellschaft
für Chirurgie. Zentralbl Chir 22:66, 1893.
2. Colem an SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic
Plast Surg 19:421-425, 1995.
3.
repair/reconstruction. Regen Med 6(6 Suppl):33-41, 2011.

Boureaux E, Chaput B, Bannani S, et al. Eyelid fat grafting: indications, operative technique
and complications; a systematic review. J Craniomaxillofac Surg 44:374-380, 2016.

on the lumen size of injection needle and the injecting volume. IPRAS J 8:25-27, 2012.
-
tologous fat grafting: an updated, evidence-based review of the literature. Plast Reconstr
Surg 136:706-713, 2015.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004.

of early death and replacement of adipocytes. Plast Reconstr Surg 129:1081-1092, 2012.
Gause TM, Kling RE, Sivak WN, et al. Particle size in fat graft retention: a review on the im-

-
puted tomographic study. Plast Reconstr Surg 129:263-273, 2012.

aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Re-
constr Surg 115:1143-1152; discussion 1153-1155, 2005.
-

133:303e-313e, 2014.

viability. Ann Plast Surg 69:479-481, 2012.
Lin TM, Lin TY, Chou CK, et al. Application of microautologous fat transplantation in the cor-
rection of sunken upper eyelid. Plast Reconstr Surg Glob Open 2:e259, 2014.
Pontius AT, Williams EF. The evolution of midface rejuvenation: combining the midface-lift
and fat transfer. Arch Facial Plast Surg 8:300-305, 2006.
Pu LL. Towards more rationalized approach to autologous fat grafting. J Plast Reconstr Aesthet
Surg 65:413-419, 2012.
Pu LL, Yoshim ura K, Coleman SR. Fat grafting: current concept, clinical application, and re-
generative potential, part 2. Preface. Clin Plast Surg 42:xiii-xiv, 2015.
-
partments. Plast Reconstr Surg 133:756e-767e, 2014.

235, 2016.
Sinno S, Mehta K, Simmons C, et al. Current trends in facial rejuvenation: an assessment of
ASPS members use of fat grafting during facelifting. Plast Reconstr Surg 136(4 Suppl):141,
2015.
Strong AL, Cederna PS, Rubin JP, et al. The current state of fat grafting: a review of harvesting,
processing, and injection techniques. Plast Reconstr Surg 136:897-912, 2015.
Tambasco D, Arena V, Finocchi V, et al. The impact of liposuction cannula size on adipocyte
viability. Ann Plast Surg 73:249-251, 2014.
Xie Y, Zheng DN, Li QF, et al. An integrated fat grafting technique for cosmetic facial contour-
ing. J Plast Reconstr Aesthet Surg 63:270-276, 2010.

avoid, and treat them. Clin Plast Surg 42:383-388, 2015.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
3
Augmentation
Blepharoplasty
Patrick L. Tonnard • Alexis M. Verpaele
W hen the w ind of change blow s,
some seek shelter while others
build w indmills.
HERACLITUS

Chapter Videos
3-1 Marking the Upper Augmentation Blepharoplasty
3-2
3-3 Marking the Malar Augmentation
3-4 Malar Augmentation Technique
Additional procedural video and author discussion of technique can be
found on Media Center.

• Augmentation Blepharoplasty
Loss of fat tissue is an important cause of physical aging of the face. Clinical

m ovem ent from m uscle activity occurs, nam ely the temporal areas and in the
central part of the face.
THE CONCEPT OF AUGMENTATION BLEPHAROPLASTY
The concept of augm entation blepharoplasty is based on the hypothesis that
-

is a collection of generally accepted principles, methods, assumptions, and tech-
-
erations. Working within a paradigm produces a certain comfort level, because
everyone agrees on the method and philosophy being applied. Nevertheless, the
accum ulation of unsolved problem s can change the value of an existing para-
digm. New solutions from outside the accepted framework (“out of the box”) can
then lead to a migration from the old paradigm to a new one. This is exactly what
has taken place regarding the need for extra volume in periorbital rejuvenation.
Traditionally blepharoplasty is a resection operation in both the upper and the
lower eyelid. Eyelid skin can be resected, either with or without orbicularis mus-
cle and fat from one or more compartments. As a consequence, classic resection
blepharoplasty can lead to hollow, excavated and empty eyelids, whereas youth-
ful eyelids are mostly full and crisp and rarely hollow (Fig. 3-1).

develops. Because skin grow th likely is not occurring in that region, the skin ex-
-
Fig. 3-1 Traditional resection blepharoplasty often leads to a hollow, excavated appearance,
whereas youthful eyelids alm ost invariably are full and crisp, rarely hollow. (Right, Courtesy Syda
Productions/Shutterstock.)

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

gradual and continuous process. Analysis of photographs of very old people (80
to 100 years) reveals almost all of them have hollow eyelids (Fig. 3-2). Even in the
presence of a bulging medial fat pad, a hollowing in the apex of the eyelid can be
observed, often referred to as the A-frame deformity. Failure to correct this will
result in an incomplete rejuvenation of the eyelid.
The descent of the tail of the eyebrow is known as temporal hooding and is ex-
plained by the lack of muscular suspension from the frontal muscle in its lateral
part. The logical way to rejuvenate the upper periorbital region is thus to suspend
Fig. 3-2 Much older adults alm ost invariably have hollow eyelids. (A, Courtesy Photobac/
Shutterstock; B, Courtesy Catalin Petolea/Shutterstock; C, Courtesy Ilya Andriyanov/Shutterstock;
D, Courtesy Laurin Rinder/Shutterstock.)
B
A
D
C

• Augmentation Blepharoplasty

below the supraorbital rim. Skin resection can be limited to a small strip of skin
without resecting any orbicularis muscle to preserve as much volume as possible.
The classic lower eyelid blepharoplasty is even more problematic because of the
risk of changing the shape of the eye opening, causing scleral show or even ec-
tropion. This can originate from cicatricial retraction of the midlamellar struc-
tures or from excess skin removal. The fat bulging in the lower eyelid compart-
ment is classically resected by a transcutaneous or transconjunctival approach.

eyelid-cheek junction. Fat-conserving techniques have been described that in-
volve transposing the herniating orbital fat over the orbital rim in an attempt to
blend the eyelid-cheek junction. Generally, the aging eyelid deformity is accen-



takes place in a region overlying the m im ic m uscles (see Chapter 1). A logical

malar area, especially in its anterior part medial to the lateral canthus. This can
be combined with a resection or transposition of the bulging fat from the lower
eyelid compartments over the inferior orbital rim.
In 2003, on the basis of studies by Trepsat,1 Lam bros,2,3 Little,4 Roberts,5 and
Benslim ane,6 we began using fat grafts to address periorbital aging, gradually
incorporating the correction of volum e loss into standard orbital rejuvenation
procedures. Since 2008 we have been using this revised approach, which now

was published in the Aesthetic Surgery Journal as augmentation blepharoplasty.7
Similar to the term augmentation mastopexy in breast surgery, the term augmen-
tation blepharoplasty refers to the two components of the surgical procedure: the
addition of volume and the resection of skin. Unlike classic resection blepharo-
plasty techniques, our approach is based on maximal preservation of all existing
volume, along with correction of volume loss in the eyelids and the periorbital
region by means of microfat grafting and conservative trimming of excess skin.
PATIENT EVALUATION AND SELECTION
Rejuvenation involves restoring a youthful, fresh, or untarnished appearance. In
aesthetic surgical terms this means making patients look younger. We routinely
ask all blepharoplasty and facial rejuvenation patients to bring pictures taken
at a younger age (20 to 30 years), and these are analyzed during the preopera-
-

and because facial aging is not the sam e in every patient, accurately im agining

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
a patient’s younger face without these pictures of the patient at a younger age
is impossible.

Critical analysis of the pictures of patients at a younger age reveals that there is
nearly always a certain degree of volum e loss in the upper eyelid, especially in
the medial part. This was earlier described as the A-frame deformity.8
Classic resection blepharoplasty rem oves the apparent excess of upper eyelid
skin and orbicularis muscle with or without emptying of the medial and lateral
fat compartm ents.9,10 This approach will rarely restore the features of youth if
volume loss is not addressed. A browlift traditionally completes the classical re-
section blepharoplasty.11 In most cases, however, a hollowing of the upper eyelid
occurs with ongoing aging. Therefore the postoperative result does not always
resemble the full upper eyelids most patients have in their 20s and 30s.

Analysis of a patient’s pictures at a youthful age also reveals that most patients
experience a loss of volume in the malar area, especially in the anterior part, even
those who have gained some weight in recent decades. The malar area typically
supports the lower eyelid; therefore volume loss in this area will accentuate the
appearance of the “bags” in the lower eyelid. In traditional lower eyelid bleph-
aroplasty, fat is rem oved from the m edial, m edian, and lateral compartm ents,
with or without suspension of the orbicularis muscle and trimming of the lower
eyelid skin.12 Although the bulging of the lower eyelid is temporarily corrected,
the blending of the eyelid-cheek junction is seldom improved, especially as fur-

These shortcomings thus decrease the rejuvenative value of standard resection
blepharoplasty techniques.
INDICATIONS AND CONTRAINDICATIONS
-
ration is necessary in almost every aged eyelid situation. This is the true expres-
sion of a paradigm shift. Once one learns to analyze the aging eyelid properly,

responsibility to recognize this condition, to point it out to the patient, and to
take the necessary measures to treat it. Volume restoration by microfat grafting
is imperative in periorbital rejuvenation.

• Augmentation Blepharoplasty
An isolated skin redundancy can be found in a sm all subpopulation of young
people who have a familial eyelid laxity. In those cases a pure skin resection may

of the aging process, such as in very young patients (younger than 35 years), a


-
cally ask to remove skin and to make the eyelids “tighter.” It is very tempting to
lim it the correction to excision of the apparent skin excess, and like m any sur-
geons we have been doing this for many years, with often disappointing results,

-
traindications such as bleeding disorders, smoking, and severe systemic disease
apply.
Fig. 3-3
still full. In this case a conservative excision of skin only has been perform ed. No m uscle or fat
was resected.
Fig. 3-4 -
juvenate the eyelids. It results in increased tarsal show, but does not correct the hollowing of the
infrabrow region, which is typical for an aged orbit. Ultim ately the patient does not look younger
or healthier.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
PREOPERATIVE PLANNING AND PREPARATION
Middle-aged patients m ay require an ophthalm ologic workup for lacrim al in-
-
continued 10 days before surgery. Sm oking is detrim ental for fat graft survival
and should be stopped 3 weeks before surgery. The patient is given the option of
a local anesthetic or a general anesthesia for the surgery. Contact lenses cannot

SURGICAL TECHNIQUE

Markings
The skin excess is marked preoperatively in red with the patient standing or sit-
ting (Video 3-1). The supratarsal crease in the upper eyelid is m arked with the
eyes closed. The patient is then asked to open the eye and gaze straight ahead.
The upper limit of the skin excess is marked at the level of the supratarsal crease.
With the eyes again closed the skin excess to be excised can be seen between
the two markings.
The area to be augmented is marked in green preoperatively with the patient in
the upright position (Fig. 3-5). This area typically comprises the medial one half
to two thirds of the infrabrow region and often incorporates the lower third of
the m edial part of the eyebrow. Eyelid fat grafting is a confusing and anatom i-
cally incorrect term; the fat is not injected into the eyelid proper, but rather into
the infrabrow region extending under the upper orbital rim . The extent of this
Fig. 3-5
in red, the areas of m icrofat grafting of the infrabrow area and the tear trough and m alar area are
marked in green.

• Augmentation Blepharoplasty
area depends on the hollowness of the upper eyelid in comparison with how it
appeared when the patient was younger.
Anesthesia

muscle with a lidocaine and adrenaline solution (minimal access cranial suspen-
sion [MACS] lift solution, containing 0.3% lidocaine and 1:600,000 adrenalin)

Technique
An 18-gauge needle is used to m ake a puncture hole in the lateral part of the
eyebrow. The 0.7 mm microcannula is inserted, and the fat is deposited with the
typical multistroke Coleman technique in a layer deep to the orbicularis muscle
in contact with the superior orbital rim (Video 3-2).
An important factor is that the fat is deposited not into the eyelid, but directly
onto the periosteum of the inferior and anterior surface of the supraorbital rim
(Fig. 3-6). This is actually m ore under the eyebrow skin than under the eyelid
skin. Grafting the upper eyelid skin could lead to undesirable fullness and even
ptosis of the upper eyelid.
Fat graft
Periosteum of
supraorbital rim
Orbicularis oculi
Supraorbital
septum
Superior tarsus
Supraorbital rim
BEFORE GRAFT
AFTER GRAFT
Fig. 3-6
that is augmented comprises the medial one half to two thirds of the upper eyelid and the lower
third of the m edial part of the eyebrow. Fat is deposited w ith a m ultistroke Colem an technique
in a layer deep to the orbicularis muscle directly onto the periosteum of the anterior and inferior
surface of the supraorbital rim. The fat graft will wrap around the supraorbital rim, lowering and

that is deposited too far laterally w ill create a “prim atelike” appearance.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
An am ount of 0.5 to 2.5 cc is injected depending on the patient’s needs. Most
frequently the fat injection is accompanied by a resection of apparent skin excess
in the upper eyelid. This can be done before or after eyelid fat grafting. Skin ex-
cision is performed after incising the marked area with the cold blade and then
with microneedle electrocautery at a subdermal level. Orbicularis muscle is not
resected to preserve as m uch volum e as possible. Occasionally the orbicularis
muscle is opened in the medial part if resection of herniated fat from the nasal
pocket is mandatory (seldom) or when a transpalpebral resection of corrugator
muscle is to be perform ed. The orbicularis muscle can be opened in the lateral
part if an associated canthoplasty or internal browpexy procedures are indicated.
Skin closure is performed according to the surgeon’s preference. Often the bleph-
aroplasty is completed with a temporal lift with a separate temporal incision to
correct lateral hooding of the eyebrow.

The decision to com bine fat grafting of the m alar area w ith fat m anipulation
through lower eyelid surgery is based on the extent of fat herniation in the lower
eyelids. In patients who do not have fat herniation and whose eyelid-cheek junc-
tion is slightly marked (mostly in the medial part, the nasojugal groove or tear
trough), isolated fat grafting of the tear trough together with the malar area is pro-
posed. When obvious fat herniation exists, transconjunctival trimming of excess
orbital fat is performed. Fat transposition over the inferior orbital rim through a
subciliary lower eyelid incision combined with fat grafting of the malar area can

for temporary scleral show by denervating the orbicularis oculi muscle and lower
eyelid retraction by midlamellar cicatrization. Incision in the muscle is avoided
whenever possible.
Markings
The malar recipient area is marked preoperatively with the patient standing or
-
tioned solutions in the deep layer on top of the zygom atic bone. For patients

Technique
Malar area fat grafting is performed through two 18-gauge needle puncture holes
(lateral and inferior) (Video 3-4). A perpendicular approach is made to the tear
trough and malar area from the inferior puncture to crisscross the grafted area

surgeon’s nondominant hand is used for tactile control over the position of the
cannula tip. This is especially important when grafting from the inferior punc-
ture over the inferior orbital rim. If necessary the malar augmentation can blend

• Augmentation Blepharoplasty
out into the lower eyelid up to the level of the inferior border of the lower tar-
always beneath the orbicularis muscle. The

in the anterior part of the malar area, medial to the level of the lateral canthus,
where most volume loss has taken place (Figs. 3-7 and 3-8).
Fig. 3-7 Marking and guideline for volum e distribution of m alar augm entation. Because m ost

go to the area m edial to the lateral canthus. The area lateral to the lateral canthus w ill take ap-
proximately one third of the volume, preventing overcorrection and widening of the bimaxillary
width of the face.
1 3
2 3
Fig. 3-8 Placem ent of m icrofat grafts in the m alar area of the lower eyelid, extending over the
infraorbital rim . Most of the grafted volume is in the malar area, blending into the lower eyelid.
Fat graft
Inferior
tarsus
Orbicularis oculi
Infraorbital
septum
Periosteum of
infraorbital
rim
Infraorbital rim
BEFORE GRAFT
AFTER GRAFT

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The amount of fat injected varies depending on the volume loss in the midface
and the desired amount of anterior projection. This amount is determined during
the preoperative assessm ent and m arked in the patient notes. On average 4 to
10 cc of fat per side is injected, but some cases may require as much as 25 cc per

little or no fat resorption occurs in this immobile area. When skin excess exists,
a conservative skin excision is performed (pinch blepharoplasty). After transcon-
junctival fat resection, good alternatives to skin trimming are croton oil peeling
or Erbium-YAG laser to improve the eyelid skin quality and tighten the skin.

No obvious increase of bruising or swelling is seen compared w ith a classic
blepharoplasty. Oral antibiotics are prescribed for 3 days (am oxicillin 500 mg
three tim es daily). Sm oking is strictly prohibited from 3 weeks before until 3

4 months after microfat grafting, because any catabolic state will counteract the
take of the fat graft.
Patients are seen for follow-up after 6 days for suture removal, and after 6 weeks,
3 m onths, 6 m onths, and 1 year. At the 3-m onth follow-up the take of the fat
graft is assessed. Approximately 15% of patients need a touchup microfat graft-

All touchup procedures are done on an outpatient basis with a local anesthetic.

• Augmentation Blepharoplasty
Fig. 3-9 A, Preoperatively at age 51 years. B, At age 20 years. C, At 1 year postoperatively.
B
A
C
RESULTS AND OUTCOMES
The 51-year-old woman in Fig. 3-9 presented with aged, hollow upper eyelids.
Photographs of her at a younger age reveal she had full eyelids. An upper aug-
mentation blepharoplasty was performed that included 2.5 cc of microfat graft-
ing in the infrabrow sulcus and a conservative skin resection.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 47-year-old woman in Fig. 3-10 presented with hollowing of the medial up-
per eyelid. The lower eyelid showed dem arcation of the eyelid-cheek junction
and atrophy of the m alar region, especially in the anterior part. A photograph
taken at the age of 25 years dem onstrates full and crisp upper eyelids and full
malar regions without eyelid-cheek demarcation. An upper and lower augmen-
tation blepharoplasty was performed with 2.5 cc of microfat grafting in the in-
frabrow sulcus and 10 cc in the lower orbitomalar area with a skin-pinch bleph-
aroplasty. No skin was resected from the upper eyelid. At 3 years postoperatively
the procedure retained stability.
Fig. 3-10 A, Preoperatively at age 47 years. B, At age 25 years. C, At 1 year postoperatively. D, At
3 years postoperatively.
B
A
D
C

• Augmentation Blepharoplasty
-
bitomalar area, as compared with her picture at age 22 years, when a highlight
was evident at the apex of the malar volume. An augmentation blepharoplasty
with temporal lifting was perform ed in conjunction with a MACS lift. The up-
per eyelid had a skin-only resection and 1.7 cc microfat grafting bilaterally. The
lower eyelid was treated with orbitom alar augm entation with 9 cc of m icrofat
grafting and a skin-pinch excision.
Fig. 3-11 A, Preoperatively at 55 years. B, At age 22 years. C, At 3 years postoperatively.
B
A
C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 55-year-old wom an in Fig. 3-12 presented for upper and lower blepharo-

m edial portion), and a descent of the tail of the eyebrow resulting in temporal

in a very marked eyelid-cheek junction and atrophy of the anterior malar area.
An augmentation blepharoplasty was performed under local anesthesia. Simple
skin excision (no m uscle or fat resection) was perform ed in the upper eyelid,
with 1.5 cc of m icrofat grafted in the m edial part of the upper eyelid. Internal
browpexy was performed to lift the tail of the eyebrow. In the lower eyelid a fat
redraping procedure was performed without resection of fat, and 4 cc of microfat
was grafted into the anterior m alar area. Skin was excised conservatively after
orbicularis muscle suspension.
An elevated position of the eyebrow tail and a sm ooth eyelid-cheek junction
were obvious after 2 months preoperatively. Nine months after the augm enta-
tion blepharoplasty, the stability of the result was evident.
Fig. 3-12 Left, Preoperatively at the age of 55 years. Center, At 2 months postoperatively. Right, At
9 months postoperatively.

• Augmentation Blepharoplasty
The 54-year-old wom an in Fig. 3-13 requested facial rejuvenation. A MACS lift
and temporal lifting were performed in conjunction with centrofacial microfat
grafting that included 1.5 cc in the upper eyelids, 5 cc in the malar area, 2 cc in
the marionette groove, and 4 cc in the sharp needle intradermal fat perioral area
(see Chapter 5). No skin or fat was resected from the upper or lower eyelids. At
1 year postoperatively she had perfect blending of the eyelid-cheek junction and
augm entation of the m alar em inence. The infrabrow area was lightened com -
pared with the dark hollow shadow she had preoperatively. Similar results were
obtained on other patients with this technique (see Figs. 3-14 through 3-17).
Fig. 3-13 A, At age 22 years. B and D, Preoperatively at age 54 years. C and E, At 1 year postop-
eratively.
B
A

C
D

E

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 40-year-old woman in Fig. 3-14 presented with bulging of the lower eyelid
orbital fat and a marked tear trough and orbitomalar groove. Treatment consisted
of a transconjunctival fat resection in three compartments and microfat grafting
with 2.5 cc in the tear trough and 3 cc in the malar area. The result is shown at
7 months postoperatively. The eyelid-cheek junction is blended, the malar con-
tour is improved, and correction of the negative vector is evident in the lateral
view.
Fig. 3-14 Left, Preoperatively at age 40 years. Right, At 7 months postoperatively.

• Augmentation Blepharoplasty
The 41-year-old wom an in Fig. 3-15 presented w ith upper eyelid skin laxity
and a m oderate m idfacial retrusion (negative vector). Treatm ent consisted of
an upper and lower augm entation blepharoplasty and internal brow pexy. She
was treated w ith 8 cc of m icrofat grafted into the m alar region bilaterally. In
the lower eyelid a lim ited skin excision and orbicularis m uscle suspension
were perform ed. Microfat lip augm entation was also perform ed. Results after
3 m onths and after 3 years show a good blending of the eyelid-cheek junction,
a well-supported lower eyelid, and a correction of the negative vector and m a-
lar retrusion.
Fig. 3-15 Left, Preoperatively at age 41 years. Center, At 3 m onths postoperatively. Right, At
3 years postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 41-year-old woman in Fig. 3-16 presented with orbital fat bulging, a marked
tear trough deformity, and moderate skin laxity. Treatment consisted of micro-
fat grafting of 1.5 cc into the tear trough, 3 cc into the m alar area, a transcon-
junctival fat resection, and croton oil peeling of the lower eyelid. The result after
6 m onths shows a good blending of the eyelid-cheek junction and satisfactory
skin tightening.
Fig. 3-16 Left, Preoperatively at age 41 years. Right, At 6 months postoperatively.

• Augmentation Blepharoplasty
The 47-year-old m an in Fig. 3-17 presented with a m arked eyelid-cheek junc-
tion and a m alar hypoplasia with negative vector, described as the “polar bear

methods because of the negative vector and consequent poor lower eyelid sup-
port. Treatment consisted of 9 cc of microfat grafting in both orbitomalar areas
and a skin-pinch blepharoplasty with orbicularis muscle suspension. The result
after 1 year shows an adequate blending of the eyelid-cheek junction with pre-
served lower eyelid support. Thanks to this very conservative approach without
invasive procedures on the canthal mechanism , the risk of lower eyelid retrac-
tion has been prevented.
Fig. 3-17 Left, Preoperatively at age 47 years. Right, At 1 year postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
PROBLEMS AND COMPLICATIONS
Fat grafting in the upper and lower orbital region has not been without compli-
cations, especially in the earlier phase when the procedure was introduced. Be-
tween 2003 and 2008 we gradually started introducing fat grafting in our bleph-
aroplasty practice. After 2008 we applied microfat grafting as a routine addition
to virtually all blepharoplasties. Most complications were seen in the early phase
and can be attributed to technical errors or misconceptions.
The typical beginner mistakes are grafting too much volume, grafting too close

with too large fat particles producing visible or palpable lumps under the skin
(Fig. 3-18).
Fig. 3-18 Beginners’ mistakes include overgrafting and malpositioning. A and B, This patient is
shown 6 months after an attempt was made to correct her hollow lower eyelids with microfat. As-
suming an important resorption would take place, 3 cc of fat was administered. This resulted in a
permanent overcorrection, for which revision surgery was needed. C and D, To obtain a satisfactory
result, 2 cc of fat graft was excised. She is shown 2 months later. E, The living adipose tissue under

the fat should be placed in the malar area, blending into the lower eyelid as described in the text.
E
B
A
D
C

• Augmentation Blepharoplasty
The classic 2 m m Colem an injection cannulas are too big to be used under


fat, we started using the typical “grater” m ultihole sharpened cannulas w ith
1 mm diameter holes on the tip.
Another m istake is failure to blend the fat into the shape of the surrounding
structures. Depositing the fat as a lump into the infrabrow sulcus without fading
it out into the lateral eyebrow region can lead to unsatisfactory show of the fat
graft (Fig. 3-19). Secondary blending can be performed in touchup procedures.
Fig. 3-19 Microfat grafting of the infrabrow sulcus failed to blend into the lateral brow. Although
this is m ost visible in a forced eyebrow elevation it can be prevented by blending the fat graft lat-
erally into the eyebrow region.
We had no major complications. Complications in the early “premicrofat” phase
(before 2008, n = -
ity and lumps (8%), asymmetry (4%), scleral show (2%), and hematoma (1%). In
the late “m icrofat” series (after 2008, n = 362) we did not have any expanding
hematomas, but bruising was seen in varying degrees in all patients. Prolonged
edema (more than 1 month postoperatively) of the malar area occurred in 7% of
patients. Postoperative scleral show occurred in 1%, associated with orbital fat


gained 12 kg of weight over the course of a year after smoking cessation for her
facelift surgery ended up with an overprojection of both m alar areas. This was
solved by performing a microliposuction under local anesthesia.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
ARTISTIC AND MORPHOLOGIC CONSIDERATIONS
When counseling a patient for augmentation blepharoplasty, the issue of fat re-
sorption m ust be addressed. With reference to our conviction that m obility of
the grafted area is proportionate with the degree of fat resorption, we expect a
decrease of grafted volum e of about 15% in the relatively im m obile periorbital
area. We discuss with the patient the option of 15% overcorrection, with the log-
ical consequence of an increased downtime during the resorption period, which
takes several extra weeks to months. Most patients prefer a minimal downtime
and choose not to overcorrect the grafted area. An overcorrection is considered
a complication, which sometimes requires open surgical removal. The option for

15% of patients request such a touchup procedure. In sum m ary, our policy in
periorbital fat grafting is not
needed (Fig. 3-20).
BEFORE GRAFT
AFTER GRAFT
1 3 of fat
volume
Supraoribtal
rim
Infraorbital
rim
Fat grafts
2 3 of fat
volume
Lateral
canthus
Fig. 3-20
eyelid: The graft wraps around the supraorbital rim in its m edial two thirds. Lower eyelid: The
m alar area is augm ented, blending into the lower eyelid. Most of the volum e in the lower eyelid
goes medial to the lateral canthus.

• Augmentation Blepharoplasty
-

-
velope is a conceptual error, because this will not lead to aesthetically satisfac-
tory results. This has also been observed by Lambros (personal communication,
2010), who states that “fat looks good under tight skin.”
The surgeon should avoid grafting too much into the lateral part of the eyebrow
region, which will cause a primatelike appearance that is aesthetically very dis-
pleasing.
The lower eyelid is also very easy to overcorrect. In the early period w hen
large-particle fat grafts were used, several patients had palpable and even visible
lumps. This was also partially due to a poor injection technique, done in just one
direction parallel to the infraorbital rim. This very easily led to the creation of a
sausagelike fat deposit across the nasojugal and orbitomalar groove (Fig. 3-21).
Correcting the tear trough and orbitomalar groove as an isolated deformity, as is
-
Fig. 3-21 A beginner’s m istake is m alposition and parallel delivery of fat, resulting in a sausage-
like deformity in the tear trough. Early postoperatively, the deformity isn’t apparent, but after the
edema resolves, the malposition is evident. Fat grafts should not be treated like a hyaluronic acid

blending into the tear trough, is advised.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
tion of this deform ity should be incorporated into the correction of the whole

actual groove is then corrected by fading the m alar volume into the lower part
of the lower eyelid.
Like with upper eyelid microfat grafting, it is not the actual lower eyelid that is
augmented but the inferior orbital rim that is covered with an extra layer of soft
tissue. Also like the upper eyelid, the lower eyelid is never overcorrected.
Grafting the m alar area should focus on m ainly augm enting the anterior part,
where most of the fat atrophy takes place because of the greater degree of mimic
activity that occurs in this region. Overcorrection of the lateral part of the malar
area widens the bizygomatic distance of the face and often changes its original
characteristics, which m eans that rejuvenation m ay not be achieved. A rule of
thum b is to inject two thirds of the volum e in the anterior m alar area and one
third in the lateral part (that is, lateral to the lateral canthus).
Technical Pearls
• Unsatisfactory results may be a result of technical errors or conceptual er-
rors:
Technical errors

–

– Injection with inappropriate cannulas

– Wrong level of graft placement
Conceptual errors

–

–

– Grafting in the wrong area
• Augmentation blepharoplasty is a periorbital rejuvenation technique that
combines the restoration of lost periorbital volume with judicious and con-
servative excision of lax skin, w ith or w ithout a lifting of the tail of the
eyebrow.
• In both upper and lower eyelids, undercorrection is better than overcor-
rection.
• It is not the eyelid that is augmented, but actually the bony orbital rim that
is lowered for the upper eyelid, and raised for the lower eyelid.
• Periorbital m icrofat grafting is a valuable and safe alternative to compli-

techniques.

• Augmentation Blepharoplasty
REFERENCES
1. Trepsat F. Periorbital rejuvenation combining fat grafting and blepharoplasties. Ann Plast
Surg Aesthet Plast Surg 27:243-253, 2003.
2. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367-
1376, 2007.
3. Lambros V. Fat injection for the aging midface. Oper Tech Plast Reconstr Surg 5:129-137,
1998.
4. Little JW. Applications of the classic dermal fat graft in primary and secondary facial re-
juvenation. Plast Reconstr Surg 109:788-804, 2002.
5. Roberts TL III, Bruner TW, Roberts TL IV. 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.
6. Bensliman F. Periorbital rejuvenation: the frame concept. In Coleman SR, Mazzola RF, eds.
Fat Injection: From Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
7. Tonnard PL, Verpaele AM, Zeltzer AA. Augmentation blepharoplasty: a review of 500
consecutive patients. Aesthet Surg J 33:341-352, 2013.
-
thetic Surgery: Principles and Techniques. St Louis: Quality Medical Publishing, 2005.

10. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic upper blepharo-
plasty. Plast Reconstr Surg 113:32e-42e, 2004.
11. Flowers RS, Flowers SS. Precision planning in blepharoplasty. The importance of preop-
erative mapping. Clin Plast Surg 20:303-310, 1993.
12. de Castro CC. A critical analysis of the current surgical concepts for lower blepharoplasty.
Plast Reconstr Surg 114:785-793, discussion 794-796, 2004.

Boureaux E, Chaput B, Bannani S, et al. Eyelid fat grafting: indications, operative technique
and complications; a systematic review. J Craniomaxillofac Surg 44:374-380, 2016.


Plast Surg Clin North Am 18:385-398, 2010.
Collar RM, Boahene KD, Byrne PJ. Adjunctive fat grafting to the upper lid and brow. Clin Plast
Surg 40:191-199, 2013.

Surg Glob Open 1:e8-e15, 2013.

127, 2016.
Karim nejad K, Walen S. Complications in eyelid surgery. Facial Plast Surg Clin North Am
24:193-203, 2016.
Lam VB, Czyz CN, Wulc AE. The brow-eyelid continuum: an anatom ic perspective. Clin Plast
Surg 40:1-19, 2013.
Lee JW, Baker SR. Esthetic enhancements in upper blepharoplasty. Clin Plast Surg 40:139-
146, 2013.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Lin TM, Lin TY, Chou CK, et al. Application of microautologous fat transplantation in the cor-
rection of sunken upper eyelid. Plast Reconstr Surg Glob Open 2:e259, 2014.

417, 2010.
Oh SR, Chokthaweesak W, Annunziata CC, et al. Analysis of eyelid fat pad changes with aging.
Ophthal Plast Reconstr Surg 27:348-351, 2011.

235, 2016.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
4
Perioral
Rejuvenation
Patrick L. Tonnard • Alexis M. Verpaele
Watch your mouth.
DANIEL HANDLER

Chapter Videos
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

Grafting White Roll and Philtrum Augmentation
4-3 Microlaser Resurfacing of the Upper Lip
Additional procedural video and author discussion of technique can be
found on Media Center.

• Perioral Rejuvenation
PATIENT EVALUATION AND SELECTION
The mouth and the perioral area is, like the periocular area, a source of the emo-
tional expression and sensuality of the face. Nevertheless this area’s aging is often
overlooked, resulting in a disappointing result of a comprehensive facial rejuve-
nation. Nearly every facial rejuvenation treatment should involve some modality
of perioral rejuvenation.
Aging changes around the m outh are m ultifactorial, and contrary to com m on


lip contours should also be a consideration rather than blowing the verm ilion
up with volume. This, combined with resurfacing or liplift, delivers a more com-
prehensive restoration of the youthful appearance of the lips and perioral area.
Aging of the perioral region involves the accentuation of the nasolabial crease
and fold; changes in skin texture with the appearance of perioral rhytids (bar-
-
der, white roll, and philtrum; and increase in vertical height of the upper lip be-
tween alar base and vermiliocutaneous border (Figs. 4-1 and 4-2). Remarkably,
this lengthening of the upper lip is the only region in the central part of the face
where “sagging” is obvious, observed in long-term photographic studies of facial
aging. The treatment plan is multimodal by combining fat grafting, resurfacing
techniques, and surgical liplift. The combination of these techniques is another
example of synergy in the rejuvenation of the perioral area.
Fig. 4-1 Mouth and perioral area in the sam e wom an between, A, age 24 years and, B, age 54

-
tween the upper and lower lip. Consequently a decreased turgor and an inversion of the verm il-
ion mucosa are evident. In most cases lengthening of the vertical skin segment between alar base
and vermiliocutaneous border occurs. Vertical rhytids appear gradually in the upper lip skin and
later in the lower lip skin.
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

In general the perioral area can easily be numbed by a double nerve block of both
infraorbital and mental nerves. This usually does not anesthetize the philtrum


of lidocaine and adrenaline to provoke vasoconstriction.

Correction of the Nasolabial Fold
The nasolabial fold has historically been corrected w ith a m ultitude of tech-
niques, which is most often a sign that none of them is perfect. In particular the
“lifting” techniques, for which the nasolabial fold was seen as a component of
the descent of the m idface, were prone to relapse. Som e techniques even de-
scribed very extensive undermining from the facelift incision progressing under
the nasolabial fold or even m ore m edially, but they could not guarantee long-
lasting results. If the nasolabial fold is considered as an atrophying area, because

another option would be to stop the movement in this area with toxins. This can
-

because all mimic activity of the face would be disturbed. Therefore correction
of the nasolabial fold is better achieved by microfat grafting.

blunt cannulas via a puncture hole with an 18-gauge intravenous needle. A criss-
crossing approach is used, starting perpendicularly to the crease in the deep
plane to build up a foundation. This is important to prevent a sausagelike de-
-
nine fossa, with a triangular blending extension toward the corner of the mouth
Fig. 4-2 Mouth and perioral area of the sam e wom an between, A, age 50 years and, B, age 65
years. The most obvious change is in the perioral skin surface with the appearance of vertical rhyt-
ids and an accentuation of the nasolabial folds.
B
A

• Perioral Rejuvenation

fold. Finally a subdermal subcision maneuver is executed with an 18-gauge nee-
dle, used as an internal knife.
This procedure cuts all the ligam ent attachm ents from the skin to the deeper
structures (Fig. 4-3). A sm all volum e of m icrofat (0.3 to 0.5 cc) is then injected

reattachment of the skin to the deep tissues.
Fig. 4-3 Nasolabial fold fat grafting w ith the anatom ic location of the associated fat grafting
planes. A, The deep plane perpendicular to the fold. B,
SMAS,
Continued
Deep subcutaneous
fat graft placed parallel
to fold
Foundation
fat graft

Nasolabial
fold
Cross-
section
Foundation fat graft
placed perpendicular
to fold
Orbicularis oris and
levator anguli oris
Nasolabial fold
Buccinator
Buccal
fat pad
Masseter
Parotid gland
and duct
Foundation
fat graft
SMAS
Zygomaticus
major
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The average injected volumes are 1 to 3 cc of microfat per side. Undercorrection
-
rection is expected with this technique.
Lip Rejuvenation and Enhancement
Adding volume to the lips and vermilion can be very rejuvenating and feminiz-

or fat grafting, and this is true for all age categories. Lip augmentation is not only
restricted to rejuvenation procedures but also is used for younger patients who
wish to enhance the shape and volume of their native thin lips.
Cross-
section
Subcision of
ligamentous
attachment
Subdermal
fat graft
Foundation
fat graft
Subcision
and fat graft
Relocated skin
C
Fig. 4-3, cont’d C, Surgical subcision and subsequent placement of a small amount of fat graft in
the cavity created.

• Perioral Rejuvenation

when a certain volume limit is exceeded, the global result can become rather un-
natural or even ridiculous, because adding volume to the lips will augment the
anterior projection of the lip and verm ilion. When this is exaggerated, it likely
will result in a sausagelike or ducklike deformity of the upper and/or lower lip.
Eversion of the vermilion border is better achieved by adding a liplift.

The proportion of upper to lower lip volum e m ust be respected (Fig. 4-4 and
Table 4-1). In m ost people the lower lip is slightly larger than the upper lip in
the frontal view. When this proportion is violated by augmenting only the upper
lip, an unnatural appearance m ay occur. Therefore the upper and lower lip are
typically augmented simultaneously.
Fig. 4-4 Comparison of female youthful (left) and aged (right) lips. Virtually all characteristics of

-
jection of both the upper and lower lips, a change in upper lip shape from concave to convex, and
a lengthening of the vertical height of the upper lip skin segment is apparent with aging.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
In patients of Western European descent, in the frontal view the upper to lower
lip height ratio is approximately 1:1.618, in accordance with the golden propor-
tion. In other words, the lower lip is roughly 50% larger than the upper lip. These
proportions are important, and must be preserved when enhancing the lips. Often
patients ask for an isolated upper lip augmentation. In most cases this disturbs
the natural proportions of the upper to lower lips. The surgeon should explain to
these patients that the lower lip needs to be enhanced in proportion to the upper
lip. Often a higher volum e is needed in the lower lip than in the upper. Failure
to respect these observations may result in an unnatural appearance (Fig. 4-5).
Fig. 4-5 Isolated augmentation of the upper lip, resulting in a distortion of the 1:1.618 upper to

Ideal lip aesthetic proportions may cause some confusion:
• In the frontal view the lower lip should be approximately 60% higher than
the upper lip (the golden proportion of 1:1.618).
• In the view the upper lip should project slightly (1 to 2 mm) further
anterior than the lower lip.
Table 4-1 Comparison of Lip Characteristics in the Youthful and Aged
Female Lip



Upper to lower lip
height ratio
1:1.618
Mostly unaltered
Projection of upper lip
Upper lip 1-2 mm anterior to lower lip
Upper lip equally projected or posterior
to lower lip
Vermiliocutaneous
border




Cupid’s bow
Distinct
Faded
Nasal base to vermilion
Concave
Straight or convex
Philtral columns
Distinct
Faded
Mucosa
Soft, good turgor
Dry, loss of turgor
Skin surface
Smooth, equal tone
Rough, pigmented; rhytids
Oral com missures


Curved downward

• Perioral Rejuvenation


youthful upper lip should project 1 to 2 mm anterior to the lower lip. The con-
tour from the nasal base to the vermilion border should be slightly concave. The

be horizontal or curve slightly upward. The mucosa is soft with a distinct turgor.
The skin surface is smooth, equally toned, and without rhytids.
Aging disturbs these parameters to a certain degree: The vermiliocutaneous bor-

in the frontal view. The projection of the upper lip decreases and becomes level
or even posterior to the lower lip. The contour from the nasal base to the ver-
milion border becomes straight to convex because of lengthening of the lip and
subsequent inversion of the verm ilion. The philtral colum ns lose prom inence

mucosal surface becomes dryer and atrophic and loses turgor. The skin surface
becomes rough, pigmentary irregularities occur, and vertical rhytids appear (the
barcode appearance).

A combination of several treatment modalities will work synergistically toward
a natural enhanced appearance. The tools are volume enhancement, liplift, and
resurfacing.

Because of the high m obility of both lips, this is the area w ith the highest fat
graft resorption of the whole face. We estimate the average resorption of lip mi-
crofat grafting to be 40% to 50%. The patient must be counseled about this like-
lihood and allowed to choose between overcorrection with a prolonged down-
time (months) or rather one or two touchup procedures under local anesthesia
4 to 6 months apart. We believe that the latter option is better, and most of our
patients make this choice.
All patients are prescribed acyclovir 800 mg daily for 5 days for herpes simplex
prophylaxis.
Lip enhancem ent indications can be divided into two categories: lip volum e



latter is described with sharp needle intradermal fat grafting (SNIF) in Chapter 5.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The microfat is injected with a 0.7 or 0.9 mm blunt microfat canula via two punc-
ture holes m ade with an 18-gauge needle in both oral com m issures. The fat is
delivered in all layers, with m ost of the volum e in the orbicularis m uscle (Fig.
4-6). Bidigital palpation is used to check the homogenous distribution of the in-
jected fat. Minor irregularities can be corrected by gentle bidigital massage. The
puncture holes are not closed. Average volumes are 0.5 to 2.0 cc per hemilip. Thus
the total volume for a complete mouth rarely exceeds 8 cc. The average volume
y

Cross-section
Superior labial artery
Skin
Vermiliocutaneous
border (white roll)
Vermilion
ANTERIOR
Mucosa
Lip volume
fat graft with
blunt cannula
Lip definition:
fat graft with SNIF
(21-gauge needle)
Orbicularis oris
Inferior labial artery
Fig. 4-6 Parasagittal section of the lips, before and after enhancement with microfat, illustrating
-
(SNIF) with

superior and inferior labial arteries are a safe distance from the location of the SNIF.

• Perioral Rejuvenation
for a standard vermilion lip augmentation is between 5 and 6 cc. The white roll
can be enhanced with a 21-gauge sharp needle injection or a blunt 0.7 mm can-
nula inserted im m ediately subderm ally, threading the roll and injecting upon
withdrawal. On the average a volume of 1 cc is injected in the white roll of both
the upper and lower lip. The philtral columns can be enhanced by sharp needle
intradermal fat grafting (SNIF) with the same needle. An average volume of 0.25
cc per column is used.

The upper lip is the only feature in the central part of the face that actually
descends, resulting in an increase of the vertical height of the lip (nasal base–
vermilion border). This is very commonly overlooked, but careful analysis of the
aging face reveals that most of these patients demonstrate a ptosis of the upper
lip (Fig. 4-7). This is another good reason for comparing the patient’s present
face w ith pictures taken at a m ore youthful age. A liplift is a very simple and


segm ent between the nasal base and verm ilion border. Because of its simplic-
ity and its very lim ited m orbidity and complication rate, this is one of the few
procedures that we suggest to our patients even if they do not request it. Most
people are aware of this aged feature of their mouth.
Fig. 4-7 This patient is shown at, A, age 20 years and, B, 48 years. Nearly all anatomic landmarks
(eyebrow, pupil, orbitomalar groove, nasal tip, nasal base, labiomental crease) stay exactly in the
same position. The only feature that truly lengthens in the central part of the face is the upper lip,
which can be corrected by a liplift.
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The combination of a liplift with microfat grafting of the vermilion works syner-
gistically: the fat grafting results in an increased anterior projection, whereas the
liplift creates an eversion of the vermilion (Fig. 4-8). Any attempt to evert the lip

Fig. 4-8 Patient consultation for a secondary rhinoplasty with a patient who requested perioral
rejuvenation. She presented with a long, m asculine, unattractive upper lip. The secondary open
rhinoplasty was com bined with a liplift, including resection of 3 m m of skin at the nostril base.
The anterior lip projection was enhanced by 3 cc of intram uscular m icrofat grafting. Shortening
of the vertical height of the upper lip and attractive eversion of the vermilion border are evident.
Projection:
fat grafting
Eversion:
liplift
A liplift consists of resecting a segment of subnasal skin at the base of the nose.
Many pattern shapes have been described, the m ost popular ones being gull-

-

crease, w ith the purpose of creating a concentric lift of the lateral portions of
the upper lip.

• Perioral Rejuvenation
The upper excision line follows the alar base, and then turns inside the nostril

at the columellar base. The lower excision line is then tailored to the desired lip
shape. Most commonly the lower line is almost straight. This causes a maximal

lateral aspect of the lip, the lower excision can be curved slightly downward,
or in som e cases the excision can be extended into the nasolabial fold. On the
average a 3 to 6 m m w ide segm ent is excised. Skin only is excised, and only
1 to 2 mm of undermining is performed at the caudal skin edge to promote skin
edge eversion. After thorough hem ostasis the skin is closed in two layers with

polygalactin suture. The knots of the skin suture are hidden in the nostril base.

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at postoperative day 6.
Fig. 4-9

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
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respect the inward curving of the excision line into the nostril sill to prevent a
disturbing scar at the nostril base. This is similar to a pretragal versus retrotra-


4-10. We believe that only pattern A delivers a satisfactory result.
Fig. 4-10 Correct and incorrect excision patterns for liplift. A, Correct pattern of liplift. The upper
incision starts along the alar groove, curves along the alar base into the nostril sill, and crosses
the colum ellar base. The lower incision curves out in the lateral portion around the alar groove;
the m edial section is straight. This creates an adequate lift of the lateral lip and an accentuation
of the Cupid’s bow. B,
the Cupid’s bow. C, Straight incision crossing the nostril sill. This pattern results in a visible scar.
D,
in an unnatural “puppetlike” pouting of the central lip and overaccentuation of the Cupid’s bow.
A
Correct
B
Incorrect
C
Incorrect
D
Incorrect



introduced the CO2 laser. Because of prolonged erythema and a high incidence