Centrofacial Rejuvenation

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
We use an open dressing technique with a nonantibiotic ointment, consisting of

petroleum jelly m akes it less viscous and easier to apply over the wound. The
patient is instructed to continuously keep the wound m oist and well covered
with ointment.
RESULTS AND OUTCOMES
The patients shown in Figs. 4-12 through 4-17 give a good overview of all of the
perioral aesthetic features that were discussed in this chapter. The selected reju-
venation technique is based on analysis of images of the patient in a more youth-
ful stage of their lives (between age 20 and 30 years). The treatm ent is always
personalized to the individual morphology and needs. The endpoint should be
a natural perioral area that approximates the aspect of the individual’s youthful
mouth.
Fig. 4-12 A, This 73-year-old wom an had a m inim al access cranial suspension (MACS) lift with
perioral rejuvenation that included m icrofat grafting of the nasolabial folds and m arionette
grooves, sharp needle intraderm al fat grafting (SNIF) of the vertical lip rhytids, and Erbium -YAG
resurfacing. Shortening of the vertical height of the upper lip and eversion of the vermilion were
obtained by a liplift. B, One year after her procedure, she has notable shortening of the vertical
height of the upper lip and eversion of the verm ilion, together w ith complete eradication of the
vertical upper lip rhytids.
B
A

• Perioral Rejuvenation
Fig. 4-13 A, This 64 year-old wom an had facial and perioral aging. Compared with the im age
of 40 years earlier (B), the loss of volum e and lengthening of the upper lip is obvious. C, Result
3 years after combined liplift, Erbium-YAG resurfacing, and microfat and nanofat grafting of upper
and lower lips. Grafted volumes were 3 cc in the upper lip, 3 cc in the lower lip, 1 cc in the white
roll of the upper and lower lips, 0.5 cc in the philtral colum ns, 2 cc bilaterally in the nasolabial
folds with subcision, 3 cc sharp needle intradermal fat grafting (SNIF) in the upper and lower lip
barcode, and 10.5 cc nanofat in the perioral region. The intraderm al nevus of the upper lip was
ablated with the Erbium-YAG laser. She has accurate restoration of her youthful appearance, and
the result of perioral volumizing and rejuvenation is stable.
A
B

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 4-14 Left, This 58-year-old wom an had thin atrophic lips. Right, Six m onths after liplifting
combined with microfat grafting of the upper (2.6 cc) and lower (3.0 cc) lips, white roll, and phil-
tral columns. The scar is invisible, and she has an attractive improvement of the incisor show and
eversion of the upper lip vermilion.

• Perioral Rejuvenation
Fig. 4-15 A, This 55-year-old wom an had facial and perioral aging, evident when compared to
im ages of her appearance when she was in her 20s (B). C, Six m onths after she was treated with
a m inim al access cranial suspension (MACS) lift procedure; m icrofat grafting of the m alar area,
nasolabial fold, and marionette grooves; sharp needle intradermal fat grafting (SNIF) in the upper
and lower lips, and a liplift. She has improved incisor show and adequate lifting of the lateral lip
segments, similar to her appearance when she was in her 20s.
B
A

C
Fig. 4-16 A, This 62-year-old wom an had facial and perioral aging. B, One year after a m inim al
access cranial suspension (MACS) lift and liplift combined with microfat and sharp needle intra-
dermal fat grafting (SNIF) of the upper and lower lip. She has an attractive eversion of the upper
lip verm ilion and an inconspicuous scar hidden in the nasal base and nasal vestibulum .
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
PROBLEMS AND COMPLICATIONS
Many complications have been published concerning all of the techniques de-
scribed in this chapter, particularly skin necrosis after fat injections, irregulari-
ties and palpable nodules after fat grafting, and unsightly scars after liplift and
resurfacing techniques.
The techniques described in this chapter focus on patient safety and maximum
control. Conservatism is always recommended.
Fig. 4-17 A, This 54-year-old wom an had facial and perioral aging. Compared w ith the im -
age of 30 years earlier (B), -
m ilion border and philtrum , deflation of the upper and lower lips, and an accentuation of
the nasolabial and m arionette grooves are evident. C, The result 7 m onths after a com bina-
tion of m inim al access cranial suspension (MACS) lift and liplift w ith sharp needle intra-
derm al fat grafting (SNIF) in the w hite roll and philtral colum ns (2.5 cc) and m icrofat graft-
ing in the nasolabial folds (1.5 cc on the left and 1 cc on the right) and m arionette groove



colum ns is a result of the SNIF. Volum e augm entation of the lips is obviously not necessary for

A
B

C

• Perioral Rejuvenation
For perioral fat grafting,

•
acceptable to the patients.
• Malpositioning of fat is prevented by m eticulous preoperative planning,
marking, and technique.
In a liplift, the m ain problem s are caused by an incorrectly designed excision
pattern and sloppy suturing technique (Fig. 4-18):
• The scar should not visibly cross the nostril sill.
• Inadequate lateral excision results in an unnatural pouting of the central
lip.
• Overresection of lip skin can lead to impossibility of mouth closure and is
virtually irreparable.
Fig. 4-18 Incorrect design of liplift excision pattern in a m ale-to-fem ale transsexual. The scar
crosses the nostril sill, and inadequate lateral extension of the incision results in an unnatural
pouting of the central lip portion.
With resurfacing, the main problems are undercorrection, scarring, hypopigmen-
tation, and hyperpigmentation:
•
solved by a cautious touchup procedure. We never prom ise our patients

• Overcorrection may lead to scarring and can be caused by resurfacing too
-
phylaxis is routinely administered, and meticulous wound care and close
follow-up for 3 m onths postoperatively are important for infection pre-
vention. Any induration m ay lead to a hypertrophic scar and is im m edi-
ately treated with an intralesional injection of 50/50 triamcinolone and 5-

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Technical Pearls
• The surgeon should not exaggerate; patients w ill forgive the need for a
touchup procedure more easily than a reconstructive surgery for an over-
correction.
•
in terms of volume.
• Patients m ust be educated; m ost patients need to be inform ed of the dif-
ferent components of aging, and pictures of their youthful appearance are a
-
ening of the upper lip.
• Synergy between fat grafting, lifting, and resurfacing should be used; the
com bination of these is m uch m ore powerful than isolated use to correct
a single feature of aging.

Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin
North Am 15:491-500, vii, 2007.
-
tion. Aesthet Surg J 27:632-640, 2007.

volume defects and skin aging of the face and periocular region. Aesthet Surg J 35:504-
515, 2015.
Biggs TM, Anderson RD, Goldberg DJ, et al. Perioral rejuvenation. Aesthet Surg J 23:191-197,
2003.


rhytides using a new, fractionated 2,790-nm ablative erbium-doped Yttrium Scandium
Gallium Garnet Laser. Dermatolol Surg 37:776-781, 2011.
Citarella ER, Sterodimas A, Condé-Green A. Lip rejuvenation using perioral myotomies and

Cohen JL. Perioral rejuvenation with ablative erbium resurfacing. J Drugs Dermatol 14:1363-
1366, 2015.
Danhof RS, Cohen JL. A combination approach to perioral rejuvenation. J Drugs Derm atol
15:111-112, 2016.
Duncan DI. Particulate AlloDerm A permanent injection for lips and perioral rejuvenation.
Aesthet Surg J 23:286-289, 2003.
Ewart CJ, Jaworski NB, Rekito AJ, et al. Levator anguli oris: a cadaver study implicating its role
in perioral rejuvenation. Ann Plast Surg 54:260-263; discussion 263, 2005.
-
sion 474-475, 2000.
Gennai A, Zambelli A, Repaci E, et al. Skin rejuvenation and volume enhancement with the

and perioral regions. Aesthet Surg J 37:14-23, 2016.

• Perioral Rejuvenation
Glasgold M, Lam SM, Glasgold R. Autologous fat grafting for cosmetic enhancement of the
perioral region. Facial Plast Surg Clin North Am 15:461-470, 2007.

both lip voluming and reshaping procedures by means of an algorithm ic approach. Plast
Reconstr Surg 113:2182-2193, 2004.

rhytides. A randomized controlled trial with long-term blinded clinical evaluations and
non-invasive measurements. Lasers Surg Med 38:129-136, 2006.

-
tion. Facial Plast Surg Clin North Am 15:415-421, 2007.

313, 2004.
Mandy S. Art of the lip. Dermatol Surg 33:521-522, 2007.

and women. Aesthet Surg J 29:467-472, 2009.

approach to perioral rejuvenation. Aesthetic Plast Surg 39:1-7, 2015.
Perkins NW, Smith SP Jr, William s EF III. Perioral rejuvenation: complementary techniques
and procedures. Facial Plast Surg Clin North Am 15:423-432, vi, 2007.
Perkins SW, Balikian R. Treatment of perioral rhytids. Facial Plast Surg Clin North Am 15:409-
414, 2007.

perioral region. Facial Plast Surg Clin North Am 15:403-407, 2007.
-
partments for perioral rejuvenation. Plast Reconstr Surg 136:301e-309e, 2015.
Ponsky D, Guyuron B. Comprehensive surgical aesthetic enhancement and rejuvenation of
the perioral region. Aesthet Surg J 31:382-391, 2011.
Ransom ER, Antunes MB, Bloom JD, et al. Concurrent structural fat grafting and carbon diox-
ide laser resurfacing for perioral and lower face rejuvenation. J Cosm et Laser Ther 13:6-
12, 2011.

Reconstr Surg 132:543-551, 2013.
-
maxillofac Surg 42:e312-e317, 2014.
Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral subm uscular fat. Plast
Reconstr Surg 124:266-271, 2009.


Dermatol 9:66-71, 2010.

21:74-78, 2005.
Segall L, Ellis DA. Therapeutic options for lip augmentation. Facial Plast Surg Clin North Am
15:485-490, 2007.
Sforza M, Andjelkov K, Zaccheddu R, et al. The “Brazilian” bikini-shaped lip-reduction tech-
nique: new developments in cheiloplasty. Aesthetic Plast Surg 36:827-831, 2012.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

perioral mound in facial rejuvenation. Plast Reconstr Surg 126:1333-1340, 2010.

Surg 16:347-351, 2008.
Tarallo M, Monarca C, Rizzo MI, et al. Upper-lip augmentation by graft of preseptal orbicularis
oculi muscle through blepharoplasty. Aesthetic Plast Surg 34:167-171, 2010.
Trepsat F, Chavrier C. [Esthetics of the lips] Ann Chir Plast Esthet 47:601-614, 2002.
Vleggaar D, Fitzgerald R. Dermatological implications of skeletal aging: a focus on supraperi-
osteal volumization for perioral rejuvenation. J Drugs Dermatol 7:209-220, 2008.
Wall SJ, Adamson PA. Augmentation, enhancement, and implantation procedures for the lips.
Otolaryngol Clin North Am 35:87-102, 2002.
Weinkle S. Injection techniques for revolumization of the perioral region with hyaluronic
acid. J Drugs Dermatol 9:367-371, 2010.
Weston GW, Poindexter BD, Sigal RK, et al. Lifting lips: 28 years of experience using the di-
rect excision approach to rejuvenating the aging mouth. Aesthet Surg J 29:83-86, 2009.
Wollina U. Perioral rejuvenation: restoration of attractiveness in aging females by m inimally
invasive procedures. Clin Interv Aging 8:1149-1155, 2013.
-
vative technique for upper lip lift procedures. Aesthet Surg J 35:456-461, 2015.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
5
SNIF: Sharp Needle
Intradermal
Fat Grafting
Patrick L. Tonnard • Alexis M. Verpaele
The important discoveries in
medicine are generally simple…
ALFRED BLALOCK

Chapter Videos
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
Additional procedural video and author discussion of technique can be
found on Media Center.

• SNIF: Sharp Needle Intradermal Fat Grafting
T
volum es can rejuvenate the face. Modern facial rejuvenation requires that all
these aspects be addressed. Sagging can be treated by face-lift techniques. The


subdermal plane is used to treat folds or deep wrinkles that result from under-

injections because they result from changes in the skin itself. The damaged skin
surface can be treated by skin resurfacing techniques (laser, peelings, dermabra-

-
-
sive way, often sought at a relatively young age (30 to 40 years).
-
-
able counterparts.1 Moreover these complications are often more dramatic, ir-



problem-free interval, which lures inexperienced practitioners into continu ing
-

is considered a foreign body that the hum an im m une m echanism tries to re-
-
nent problem.


of achieving a permanent correction without the perils of a synthetic permanent

the acronym SNIF.2
PATIENT EVALUATION AND SELECTION
Aging of the skin is a multifactorial phenomenon that involves intrinsic and ex-
trinsic factors. The m ajor intrinsic factor is an attenuation of derm al thickness
caused by a decrease of collagen, elastin, and hyaluronic acid content.3 The ma-
jor extrinsic factor is sun exposure, but other environm ental factors (such as
smoking and pollution) also play an important role. Mechanical factors such as
repetitive facial m ovem ents and gravity also play a role in the developm ent of
wrinkles.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Like a hinge always folding at the sam e place, m im etic m uscle action during
facial expression causes the appearance of lines on the surface of the skin. Ini-
tially, those lines are seen only during facial muscle contraction (dynamic wrin-
kles), but the repetitive nature of the m ovem ents causes the lines to becom e
permanent over time (static wrinkles).
Whether the targeted wrinkle is treatable with SNIF depends on the skin thick-
ness, mobility, and quality. Dynamic wrinkles in the glabella will primarily need
chemodenervation by botulinum toxin. Residual rhytids can later be additionally
treated with SNIF.
Atrophic craquelé of the skin of the lower eyelids is usually not a good indication

resurfacing, is the treatment of choice for this condition. Deep folds such as the
nasolabial folds and m arionette grooves are m ore am enable to blunt-cannula
microfat grafting with or without subcision.
-

INDICATIONS AND CONTRAINDICATIONS
-
m ities such as rhytids, acne scars, and atrophic scars, but not for deep volum e

facial rhytids, but after a while som e patients request a m ore perm anent cor-



available in large am ounts for a lim ited cost (Fig. 5-1). The availability and the



The am ount of m icrofat required for intraderm al fat injections is very sm all
(ranging from 0.5 to 5 cc). If intradermal fat transfer is performed without deep


even in lean patients.

blunt-cannula microfat grafting of the deep folds (such as nasolabial folds) or in
conjunction with any surgical facial rejuvenation procedure. In som e cases in-
tradermal fat injection is combined with laser resurfacing or croton oil peeling
during the same procedure. Some patients underwent intradermal fat injections

• SNIF: Sharp Needle Intradermal Fat Grafting
with subsequent skin resurfacing (Erbium-YAG laser or croton oil chemical peel-
ing). The advantage of this strategy is that the wrinkle is elevated from the inside
-
sulting in a safer procedure and quicker recovery, and less risk for hypopigmen-
tation and scar formation.


synergistic. This stands in contrast to the knowledge that laser resurfacing of


In some cases SNIF can be a viable alternative for patients who seek skin rejuve-
nation but refuse skin resurfacing.
Contraindications for SNIF are atrophic skin conditions (such as result from ste-
roid use and diabetes), bleeding disorders and anticoagulant use, and smoking.
PREOPERATIVE PLANNING AND PREPARATION
Preoperative standardized photographs are taken during the intake consultation.
In preparation patients should quit smoking at least 3 weeks before surgery and
-
scribed for any procedure around the lips.
Cost for injector
Filler
Microfat/SNIF
±5 cc
Injected volume
Fig. 5-1
-
creases in proportion with the injected volume. For microfat and SNIF the cost for the practitioner
will decrease with increasing volume. The intersection between these two curves occurs approx-
im ately at a volum e of 5 cc. Above this injected volum e, m icrofat and SNIF will be m ore cost ef-

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
TECHNIQUE



with a local anesthetic injection containing adrenaline, both for patients receiv-
ing local and general anesthesia (lidocaine 0.3%, adrenaline 1:650,000). This is
important because the vasoconstriction caused by adrenaline minimizes the risk
of intravascular injection and, to some degree, the bruising. The donor areas are
anesthetized with a classic Klein solution.
Markings

while the patient stands and makes exaggerated facial expressions (Fig. 5-2). It
is important to mark before any injection of a local anaesthetic solution as this

Donor areas are m arked with the patient in standing position. Classical donor
areas are the lower abdomen, love handles, inner thighs and knees.

The patient is usually positioned supine to allow harvesting and grafting with-
out repositioning.
Technique

intravascular injection w ith em bolization of certain vascular territories. This
can lead to adjacent skin necrosis but also to more catastrophic problems such
as blindness or cerebral stroke.1,4-9
Fig. 5-2
makes exaggerated facial expressions.

• SNIF: Sharp Needle Intradermal Fat Grafting
-
ing the needle, again to minimize the risk of intravascular injection. Squeezing the

will occlude any vessel in the injection trajectory (Figs. 5-3 and 5-4). Finally, a low
pressure on the plunger will diminish the risk for embolization. If a high resistance
is observed, the pressure on the plunger should not be increased, because this
may lead to a bolus injection of too large a volume. Instead the needle should be
-
fat, depending on the quality and consistency of the fat. Box 5-1 provides safety
pearls for SNIF injection.
Box 5-1 Safety Pearls for Sharp Needle Intradermal Fat Graft Injection
•
•
• Injection should occur during withdrawal of the needle.
•
• Low pressure should be used for the injection.
Fig. 5-3 -
tion is perform ed upon withdrawal of the needle.
Fig. 5-4 Immediately after intradermal fat injection there should be a slight blanching of the skin

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fat Harvesting Technique
SNIF can be done isolated or in conjunction with other facial rejuvenation pro-
cedures under general or local anesthesia. Fat is harvested at the sam e tim e as

In the SNIF procedure the material injected is actually microfat, harvested and
prepared in the sam e m anner as for deep volum etric blunt-cannula m icrofat
grafting. The harvesting technique is described in Chapter 2. The most important
factor in this harvesting method is the use of harvesting cannulas with multiple
sharpened 1 mm holes to obtain particles small enough to be injected through
a sharp 23-gauge needle. Fat particles harvested with other harvesting cannulas
with larger holes will block a 23-gauge needle lumen.
The yield of microfat is 1:5. This means that for every 1 cc of microfat needed for
injection, 5 cc of aspirate will need to be harvested. The aspirate is rinsed and
strained through a sterile 0.5 mm pore–size nylon cloth until clean and dry. The
prepared m icrofat is transferred via a Luer-to-Luer adapter into 1 cc syringes,
which are mounted with a 23-gauge needle for intradermal injection.
The preferred donor area for fat harvesting is the lower abdomen because of the
ease of approach with a patient in a supine position. This area is marked preop-
eratively with the patient standing. Other donor areas such as the “love handles”
or the internal side of the thigh or knee can be considered as well.
Injection Technique


Linear thread injection of the fat is performed while withdrawing the needle.
Blanching of the skin over the injected w rinkle is the endpoint of injection. A
slight overcorrection is advised, because blanching and overcorrection will nor-

such as the neck the overcorrection may remain visible for more than a week but
always subsides eventually.
Deep w rinkles, sharp folds, or acne scars m ay require a subcision m aneuver
for separating the skin from its deep attachm ents to achieve an optim al result
(Fig. 5-5). Subcision is performed with an 18-gauge needle; the bevel is used as
a “knife” under the skin (Video 5-4). The 18-gauge needle is only used for the
subcision, not for intradermal injection.

• SNIF: Sharp Needle Intradermal Fat Grafting

Using SNIF together w ith certain other skin-enhancing procedures creates a

peeling), botulinum toxin/m icrobotox injections, and nanofat grafting. For in-


component of the rhytids.

Im m ediately after injection the surgeon m assages the wrinkle for even distri-
bution of the injected m icrofat. Makeup can be worn from 24 hours after the
procedure. Smoking is strictly forbidden. If ecchymoses are present a vitamin K
ointment can be applied.
RESULTS AND OUTCOMES
As in any microfat grafting procedure, after SNIF a variable resorption of the in-
jected fat occurs, which stabilizes after 4 months. The degree of resorption var-
ies from patient to patient and is also correlated with the mobility of the treated
area. Perioral wrinkles usually show a higher resorption rate than a glabella that
has been immobilized with botulinum toxin.



The simplicity of the surgery and the easy recovery convinces most patients of
the possibilities of the procedure, and the threshold for them to com e back for
treatment of any new rhytids is low.
Fig. 5-5 A, A 28-year-old wom an with seborrheic skin and acne scarring of the forehead. B, One
year after a combined treatment with sharp needle intradermal fat injection and subcision, nano-
fat grafting, and 0.4% croton oil peeling.
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy


The 44-year-old woman in Fig. 5-6 had deep microfat grafting and bilateral sub-

deep subcutaneous plane, plus 0.5 cc after subcision) combined with SNIF (0.6 cc
on the left and 0.8 cc on the right) in the dermal component of the rhytids. The
“barcode lines” of her upper lip received 0.4 cc of SNIF. The 6 months and 1-year
postoperative result shows correction of the nasolabial fold and the obliteration

Fig. 5-6 A, Preoperatively at age 44 years. B, At 6 months postoperatively. C, At 1 year postoper-
atively. D, At 2 years postoperatively.
B
A
D
C

• SNIF: Sharp Needle Intradermal Fat Grafting
The 43-year-old woman in Fig. 5-7 had heavy nasolabial grooves. She was treated
with deep microfat grafting and subcision of the nasolabial fold (1.5 cc bilater-
ally, plus 0.5 cc after subcision). This was combined with 0.7 cc SNIF bilaterally
in the dermal component of the rhytids. The result is natural-looking and stable.
Fig. 5-7 A, Preoperatively at age 43 years. B, At 1 year postoperatively.
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy


The 56-year-old woman in Fig. 5-8 had a MACS lift combined with pure SNIF on

used. The result was powerful and stable.
Fig. 5-8 A, Preoperatively at age 56 years. B, At 1 year postoperatively. C, At 24 m onths postop-
eratively.
A
B

C

• SNIF: Sharp Needle Intradermal Fat Grafting
The 56-year-old woman in Fig. 5-9 had a MACS lift combined with SNIF on her
perioral, verm ilion border, philtral-colum n, and sharp cheek rhytids. The total
volum e injected was 8 cc. At 1 year follow-up the resolution of the sagging by
the lifting procedure and the correction of the sharp lines in the perioral area
and the medial cheek skin is stable.
Fig. 5-9 A, Preoperatively at age 56 years. B, At 6 months postoperatively. C, At 1 year postoper-
atively.
B
A
C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 60-year-old wom an in Fig. 5-10 presented 5 years after a MACS lift and
Erbium -YAG laser resurfacing with subsequent hypopigmentation zones in the
upper lip. She was reluctant to repeat the laser resurfacing and underwent a
SNIF treatment with 4.2 cc injected into the upper lip and nasolabial rhytids. At
6 m onths postoperatively, the correction of the barcode lines in the upper lip
and the sharp creases in the nasolabial fold are evident.
Fig. 5-10 A, Preoperatively at age 60 years. B, At 6 months postoperatively.
B
A

• SNIF: Sharp Needle Intradermal Fat Grafting

The 56-year-old wom an in Fig. 5-11 had a m inim al access cranial suspension
(MACS) lift and SNIF in the deep derm al perioral rhytids of the nasolabial fold
and marionette groove (3.7 cc in total), supplemented with Erbium-YAG laser re-
surfacing until the rhytids disappeared (1000 mJ over a 5 mm spot) and microfat
grafting of the lips and white roll. At 1.5 years postoperatively a stable correction


The 51-year-old wom an in Fig. 5-12 had SNIF in her upper lip, nasolabial, and
m arionette groove rhytids (4.2 cc total), supplem ented with Erbium -YAG laser
resurfacing of the upper lip until the rhytids disappeared (1000 m J on a 5 m m
spot). At 1 year follow-up the result remains stable with correction of the deep
folds in nasolabial and marionette groove areas, as well as the correction of the

Fig. 5-11 A, Preoperatively at age 56 years. B, At 1.5 years postoperatively.
B
A
Fig. 5-12 A, Preoperatively at age 51 years. B, At 6 months postoperatively. C, At 1 year postoper-
atively.
B
A

C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 54-year-old woman in Fig. 5-13 had SNIF into her upper lip, nasolabial, and
m arionette groove rhytids (3.8 cc total), supplem ented with Erbium -YAG laser
resurfacing of the upper lip until the rhytids disappeared (1000 m J on a 5 m m
spot). At 6 months follow-up the barcode rhytids in the upper lip and the sharp
creases in the nasolabial folds are resolved.
Fig. 5-13 A, Preoperatively at age 54 years. B, At 6 months postoperatively.
B
A

• SNIF: Sharp Needle Intradermal Fat Grafting


The 36-year-old woman in Fig. 5-14 with severe acne scarring had SNIF with sub-
cision of the acne scars in the cheeks and perioral and forehead regions (12 cc of
microfat in total). Blunt-cannula microfat grafting of the infrabrow (2 cc per side)
and malar area (6 cc per side) was also performed, and the skin was resurfaced
with a 0.4% croton oil–phenol chemical peeling. At 6 months follow-up, she has
a general improvement of the skin texture, pigmentation, and sharp lines, mainly
in the perioral and frontal area. The acne scars in the cheeks and perioral area
are softened.
Fig. 5-14 Left, Preoperatively at age 36 years. Right, At 6 months postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 46-year-old woman in Fig. 5-15 had a MACS lift with microfat grafting in the
malar area. She had an acne scar on her right cheek that was treated with sub-
cision, deep blunt-cannula microfat injection, and SNIF in the intradermal level.
The 1-year follow-up result shows the correction of the sagging by the lifting
procedure, the replenishm ent of the m idface and eyelids by the blunt-cannula
m icrofat grafting, and the improvem ent of the acne scars in the right cheek by
the sharp needle intradermal fat grafting treatment with subcision.
Fig. 5-15 Left, Preoperatively at age 46 years. Right, At 1 year postoperatively.

• SNIF: Sharp Needle Intradermal Fat Grafting


The 56-year-old woman in Fig. 5-16 presented for facial rejuvenation. She under-
went a MACS lift and SNIF of the deep dermal rhytids in the nasolabial area. The
injected microfat remained stable even after 7 kg of body weight loss (between
the 1- and 3-year follow-up visits) caused hollowing of her cheeks.
Fig. 5-16 A, Preoperatively at age 56 years. B, At 1 year postoperatively. C, At 3 years postopera-
tively. D, At 7 years postoperatively.
B
A
D
C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The 68-year-old woman in Fig. 5-17 had a neck correction with a MACS lift with

injected with 8 cc of SNIF, and the whole anterior surface of the neck was treated
with nanofat (see Chapter 6). At 1 year follow-up the softening of the horizontal
neck rhytids resulting from the sharp needle intraderm al fat grafting and the
improvem ent of the general skin texture and pigm entation of the whole neck
area by the nanofat are evident.
Fig. 5-17 A, Preoperatively at age 68 years. B, At 1 year postoperatively.
B
A

• SNIF: Sharp Needle Intradermal Fat Grafting
The 44-year-old wom an in Fig. 5-18 presented for neck rejuvenation. She was
treated solely with 6.5 cc of SNIF into the horizontal rhytids and 18 cc of nanofat
in the whole anterior neck region. No surgical lifting was performed. The ridges
of the SNIF injections and the edematous aspect of the whole anterior neck skin
are common and disappear within the following weeks. At 6 months follow-up,
she has a marked reduction of the horizontal rhytids and an improvement of the
general neck skin quality.
Fig. 5-18 A, D, and F, Preoperatively at age 44 years. B, The immediate intraoperative result. C, At
6 days postoperatively. E and G, At 6 months postoperatively.
B
A

C
D

E
F

G

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy



The 51-year-old wom an in Fig. 5-19 had SNIF enhancem ent (1.5 cc) of the lip
white roll and the philtral colum ns. A 21-gauge needle was used for the injec-
tions. The nasolabial fold was treated with a combination of deep blunt 0.7 mm
cannula m icrofat (0.5 cc on the right and 1.0 cc on the left) and SNIF (0.5 cc on
the right and 0.8 cc on the left). The 1-year follow-up result shows the softening
of the nasolabial creases by the SNIF injections. The white roll and philtral col-

Fig. 5-19 A, Preoperatively at age 51 years. B, At 1 year postoperatively.
B
A

• SNIF: Sharp Needle Intradermal Fat Grafting
PROBLEMS AND COMPLICATIONS
The initial downtime of SNIF is longer than that after a hyaluronic acid injection.

injection. After SNIF som e visibility of the treatm ent can be expected for 3 to
5 days because of mild swelling and bruising from the surgical trauma and local

Very few, minimal problems (redness, swelling and bruising) have been encoun-
tered with SNIF; bruising is most common. In our series of 250 consecutive cases,
this was seen in 38%. Redness with som e swelling occurred in 9% of the cases,
all of which resolved within an average of 4 days after the procedure. No surface
irregularities such as lumpiness or unevenness were observed in this series. No
hypertrophy of the fat graft resulted from weight gain. Although one patient lost
2 The problems
that are possible w ith classic nonm icrofat grafting, such as palpable nodules,

may be explained by the small amounts of small-diameter fat particles that are
injected in well-vascularized tissue. There were no infections, nor were there any
serious complications such as necrosis or fat emboli from intravascular injection.
Overcorrection and blanching of the skin over the w rinkle, which is com m on
with intraderm al fat injections, disappear after a few hours because of the re-
sorption of the suspension solution. In a few exceptional cases overcorrection
persisted more than 6 weeks after the SNIF injection. All of these occurred after
-
corrected area resolved the overcorrection in all cases.
The SNIF technique is applicable in nearly every facial rejuvenation case. Com-

-
trary to popular belief, intraderm al fat grafting can be perform ed safely w ith

withdrawal. The harvesting and injection techniques should be performed with
precision to achieve optimal results and prevent complications.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Technical Pearls
• SNIF is microfat injected intradermally through a sharp needle.
• SNIF can be used liberally in combination with any facial cosm etic proce-
dure.
• SNIF injection needs to be perform ed m eticulously, m inding the safety
pearls:

–
adrenalin.

– -
cutaneous plane.

– Injection should occur during withdrawal of the needle.

–

– Low pressure should be used for the injection.
• The SNIF endpoint is slight overcorrection with blanching of the skin.
• Gentle massaging immediately after injection improves the smoothness of
the result.
•
REFERENCES

3:2-15, 2004.
2. Zeltzer AA, Tonnard PL, Verpaele AM. Sharp-needle intradermal fat grafting (SNIF). Aesthet
Surg J 32:554-561, 2012.
3. Farage MA, Miller KW, Elsner P, et al. Intrinsic and extrinsic factors in skin aging: a review.
Int J Cosmet Sci 30:87-95, 2008.


5. Inoue K, Sato K, Matsumoto D, et al. Arterial em bolization and skin necrosis of the nasal

6. Georgescu D, Jones Y, McCann JD, et al. Skin necrosis after calcium hydroxylapatite injec-
tion into the glabellar and nasolabial folds. Ophthal Plast Reconstr Surg 25:498-499, 2009.
7. Peter S, Mennel S. Retinal branch artery occlusion following injection of hyaluronic acid
(Restylane). Clin Experim ent Ophthalmol 34:363-364, 2006.

indications, technique, and complications. Semin Cutan Med Surg 22:107-114, 2003.

-
constr Surg 26:289-291, 2010.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
6
Nanofat Grafting
Patrick L. Tonnard • Alexis M. Verpaele
It’s kind of fun to do the impossible.
W ALT DISNEY

Chapter Videos
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.)
Additional procedural video and author discussion of technique can be
found on Media Center.

• Nanofat Grafting
L
The indications for fat grafting are increasing steadily.
For the past 20 years, aesthetic and reconstructive plastic surgeons have safely


decade, m ost reports suggested that the goal was to obtain as pure adipocyte
cellular grafts as possible, isolated with minimal trauma, and transplanted into
adipose-containing tissues. A high num ber of case reports and sm all series re-
ported trophic changes in the overlying skin, and som e surgeons described re-
markable results after lipotransfer in atrophic and radionecrotic ulcers. Person-
ally we could perceive changes in quality, pigmentation, and texture of the facial
skin of m any patients, m onths after they had fat transferred into certain re-
gions of the face. Clinically, however, it was not easy to determine whether these

than to intrinsic structural changes of the skin.

biocellular regenerative medicine has recognized the potential value and avail-
ability of stem cells in adipose tissue. More and more, adipose tissue is no longer
seen as a simple layer of insulation material and a storage organ of caloric energy.
Fat tissue is now recognized to be a complex endocrine organ that is intrinsically
involved in m etabolism and im m unom odulary activities and that provides an
-
volved in homeostasis and regeneration. Although adipocytes represent 90% of
the volume of fat tissue, they only account for 20% of the number of cells in the
fat. The function of the other 80% population of sm all cells in adipose tissue is
still under investigation.
Two important concepts in this context involve stromal vascular fraction (SVF)
and cell-assisted lipotransfer (CAL). SVF -
poaspirate except mature adipocytes. The SVF of adipose tissue is a rich source
of preadipocytes, m esenchym al stem cells (MSC), endothelial progenitor cells,
T cells, B cells, m ast cells, and adipose tissue m acrophages. To obtain the SVF,
fat isolated by liposuction is classically processed by collagenase treatment and
centrifugation. CAL is an autologous stem cell procedure that is basically a fat
transfer procedure with a boost of SVF to increase its potency. Whether the re-

of the SVF from the adipose tissue by enzymatic treatment and centrifugation is
still time-consuming, expensive, and in many countries clinically not permitted
because of regulatory issues of “biological drugs.”

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
-
ture reconstructive and regenerative tissue engineering applications. In recent
years, many researchers and clinicians began to understand the complexity, con-
tents, and paracrine functions of the adipose-derived SVF. Some researchers and
-
vironm ental m ixture of components within the lipoaspirated sample without
any manipulation. The clinical results obtained with nanofat grafting support our
-
tracellular matrix, perivascular structural tissues, and intracellular messengers)
may be of greater value than any of the components of SVF used separately. The
complex signaling and paracrine activities of intercellular cross-talking may be
hard to reproduce if these isolated elements are injected separately.
With the nanofat grafting technique, we inject regenerative cells and elements
in the clinical setting by processing adipose tissue with a very simple mechani-
cal manipulation. This technique destroys the mature adipocytes and leaves the
complex m ixture of perivascular sm aller-sized cellular components intact and
in their native paracrine environment. Nanofat grafting may open possibilities
of adipose tissue as a primary source of mesenchymal cells and SVF in biocellu-
lar therapies in the future.
Our experience with fat grafting started with Coleman’s standard lipostructure
technique to correct volume losses caused by disease, trauma, or aging. Fat was
initially injected with relatively large blunt cannulas of approximately 2 mm di-
ameter. Inspired by Coleman and several other authors who promoted fat graft-
ing as an essential part of facial rejuvenation, we started to incorporate lipostruc-
ture in our cosm etic facial cases. For delicate areas such as the eyelids and lips

diameter, also called m icrofat grafting, was described in Chapter 2 of this book.
Also, these sm all-particle fat grafts proved to be applicable for sharp 23-gauge
needle intraderm al fat grafting, published as the SNIF technique (Chapter 5).
Our ambition was to inject fat through even smaller needles (27 gauge) in even

and to improve the quality of the skin. To allow passage of the fat graft through
these 27-gauge needles, we emulsify the microfat mechanically. We refer to these
extrem ely reduced m icrofat particles as nanofat. Surprising clinical changes in
the quality and texture of the treated skin areas led us to investigate the content
of this nanofat. This chapter describes the technique and our experience with
nanofat grafting. It also explores the basic research on the cellular content of
the nanofat.

• Nanofat Grafting
INDICATIONS AND CONTRAINDICATIONS
Nanofat is not
injectable substance. Nanofat is applicable in a wide range of indications to im -
prove the skin quality.
There are three categories of indications for the use of nanofat:

1. Trophic skin changes caused by age and sun damage

2. Pigmentary skin conditions

3. Scarring and atrophic skin conditions
Presently nanofat is an integral component of our facial rejuvenation strat-


grafting, sometimes in combination with microfat or SNIF.
Because of the simplicity and safety of the procedure, nanofat grafting has no

PATIENT EVALUATION AND SELECTION
• Trophic skin changes caused by age and sun damage

– Thin dermis (cheek, lower eyelids, lip mucosa)

– Atrophy

– Craquelé surface

– Spotted pigmentary changes
• Pigmentary skin conditions

– Dark circles under the eye caused by a com bination of translucency of the
skin because of thin dermis and a degree of melanin pigment deposits (both
components appear to improve after nanofat grafting)

– Mottled pigmentation of the face
• Scarring and atrophic skin conditions

–

– Atrophic scars

– Postradiotherapy skin atrophy

–
PREOPERATIVE PLANNING AND PREPARATION
Microfat is harvested with the multiholed microcannulas and processed as de-
-

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
of the fat is achieved by vigorously shifting the microfat between two 10 cc sy-
ringes, connected to each other by a purple, 2.4 mm diameter female-to-female
Luer-Lok connector (Figs. 6-1 and 6-2). After 30 passes the fat becom es m ore
liquid and whitish (see Fig. 6-2, C). This num ber of passes is arbitrary but has

green, 1.2 m m diam eter connector, also for 30 passes. This ensures that even



-
tion process the fatty liquid is passed through a strainer cartridge w ith a dual


It is transferred from the 10 cc Luer-Lok syringes into 1 cc syringes for injection.
Fig. 6-2 A, B, The second



B
A
Fig. 6-1 Tools used for nanofat processing. A and B, Luer-to-Luer connectors, 2.4 and 1.2 m m di-
-
tion. C,
C
A
B

• Nanofat Grafting
Fig. 6-2, cont’d C, (left) has a m uch whiter
aspect and is m ore liquid than the yellow m icrofat (right). D, Assem bly of the Nanotransfer: The
(bottom right), with the golden surface facing upward for correct
E, The emulsi-

the receiving empty 10 cc syringe is inserted on the other end. The fat is passed one time through
the Nanotransfer, resulting in processed nanofat in the right syringe. F and G, Opening the lid of
It is essential for the nanofat
process that these strands be extracted, because they would prevent injection of the solution through
H, The nanofat is transferred
into a 1 cc syringe. I, The nanofat can now be injected through a 27-gauge needle. The liquidity of

D
C
E
F

G
H

I

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
NANOFAT ANALYSIS

We analyzed the content of three samples of lipoaspirate obtained from the same



• Sample 1 (Fig. 6-3, A and B): Aspiration with a standard 3 mm “Mercedes”
liposuction cannula w ith three large side holes (2 by 7 m m ) to produce
macrofat
• Sample 2 (Fig. 6-3, C and D): Aspiration w ith a m ultiport 3 m m cannula
with multiple sharpened 1 mm side holes, processed by saline rinsing and

• Sample 3 (Fig. 6-3, E and F): Microfat processed into nanofat as described
previously
Fig. 6-3 A and B, Liposuction m acrofat sample harvested with a standard 3 m m Mercedes can-
nula; the green staining shows viable adipocytes. C and D, Microfat harvested with a m ultiport
3 m m “grater” cannula and processed by saline rinsing; green staining shows viable adipocytes.
E and F, Microfat processed into nanofat by sequential em ulsification through a 1.2 to 2.4
Luer-to-Luer connector; hardly any viable adipocytes are detected. (A, C, and E From Tonnard P,
Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applications. Plast Reconstr
Surg 132:1017-1026, 2013; B and D Courtesy Tulip Medical Products, San Diego, CA.)
B
A
D
C
F
E

• Nanofat Grafting
-
rescence microscopy after a live-dead staining. The adipose tissue of the macrofat
and the m icrofat had a norm al histologic structure, with preserved viability of
most of the adipocytes (green color on Fig. 6-3, A, C, and E). In the nanofat, how-
ever, no viable adipocytes were observed, and the adipose tissue structure was
histologically completely destroyed and replaced by an oily emulsion.
Cell Culture

Stem cells in the three samples were isolated with a standard method using col-
lagenase and centrifugation, and a cell count was perform ed. The SVF and iso-

the CD34+ surface antigen, detected by bioassay. SVF cells and viable stem cells
derived from the SVF were abundantly present in macrofat, microfat, and nano-

only killed the adipocytes, which are up to 100 tim es larger than SVF cells that
were preserved. The number of CD34+ cells (stem cells) in the SVF also was com -
parable in all three samples (Fig. 6-4). These stem cells were then cultured in a

samples, which is a typical feature of adipose-derived stem cells.


cell lines. To dem onstrate the stem cell nature of the SVF and CD34+ fractions,

After 10 days of culture, phase-contrast microscopic evaluation showed spher-


-
-
cessing method.
B
A

C
Fig. 6-4 A, m acrofat, B, m icro-
fat, and, C,
Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applications.
Plast Reconstr Surg 132:1017-1026, 2013.)

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
NANOFAT CLINICAL IMPLICATIONS
-

living adipocytes were found in the nanofat sample. SVF and stem cells could be
isolated from all the lipoaspirate samples including the nanofat, and were viable.



The term nanofat is perhaps misleading, because nanofat does not contain living
adipocytes. Nevertheless it originates from fat tissue and consists of SVF cells,
which represent more than 80% of the cellular content of subcutaneous fat. Thus
it still can validly be referred to as fat tissue.
m
A
m
B
m
C
Fig. 6-5
A, Macrofat. B, Microfat. C, Nanofat. (From Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting:
basic research and clinical applications. Plast Reconstr Surg 132:1017-1026, 2013.)

• Nanofat Grafting
TECHNIQUE

-
-


is necessary.
Markings
The skin marking usually does not follow anatomic landmarks, but instead cov-
ers the skin area to be treated, regardless of anatomic units.

Patient is positioned based on the donor area for the nanofat. If this requires
a prone position, the patient is turned into the supine position after the fat is
harvested.



mucosal areas an im mediate submucosal injection plane is the goal. The zones
marked for treatment are injected with a threading technique upon withdrawal
of the needle. This further reduces the risk of an intravascular injection, which

bevel up and may be bent 60 degrees to facilitate the ease of manipulation. The
area to be treated is covered in several adjacent fan-shaped patterns (Fig. 6-6).
Fig. 6-6 The nanofat is injected in adjacent fan-shaped patterns (arrows).

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

Nanofat is often applied in com bination with m icrofat for restoring facial vol-
-
ing techniques such as Erbium laser and trichloroacetic acid (TCA) or croton oil
chemical peels.

The slight yellowish color seen immediately upon injection because of the oily
fraction of the nanofat or blanching w ill disappear w ithin the hour after the
-
sides in a few days but may persist for several weeks in very thin skin areas, such
as the lower eyelid skin. The neck or décolleté skin usually recovers more swiftly.
-
ies. Both erythema and ecchymoses can easily be covered with a concealer cream

RESULTS AND OUTCOMES

in a w ide range of indications in which improvem ent of the skin quality is de-
sired, including generalized facial skin improvement, repairing craqueléd perior-
bital and perioral skin, atrophic lip mucosa enhancement, removing lower eyelid
dark circles, correcting sun-damaged skin of the décolleté, improvement of the
dorsum of the hands, and scar improvement.

Nanofat is applied as an adjunct to perioral rejuvenation for enhancing the qual-

must be considered an in vivo tissue regeneration cellular therapy. Therefore it
can be applied in conjunction with other modes of perioral rejuvenation such as
SNIF, microfat, resurfacing, and lip lifting.

• Nanofat Grafting
The 60-year-old wom an in Fig. 6-7 sought correction of upper lip aging. Treat-
ment consisted of SNIF injection into individual vertical rhytids (red circles) and
the vermilion border and nanofat injection of the whole upper lip skin. The im-
provem ent of skin quality can be observed on the left side of the im age (green
circles). A volume of 4 cc of nanofat was used for the whole upper lip. The result
is shown 6 months postoperatively.
Fig. 6-7 Correction of upper lip aging in a 60-year-old woman, preoperatively and 6 months post-
operatively. Red circles
directly into the rhytids. Green circles
Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applications.
Plast Reconstr Surg 132:1017-1026, 2013.)
The 71-year-old woman in Fig. 6-8 sought correction of aging in the perioral area
and lip vermilion. Treatment included a combination of fat injection techniques:
SNIF with a 23-gauge needle into the individual rhytids of the upper lip and na-
solabial fold (1.5 cc), SNIF with a 21-gauge needle into the philtral columns and
the white roll (2.7 cc), and nanofat injection of the whole upper lip surface and
dry lip verm ilion (Video 6-1). A total of 4.5 cc of nanofat was injected into the
skin, and 2 cc was injected into the vermilion. The result is shown 2 years post-
operatively.
Fig. 6-8 Correction of lip perioral aging in a 71-year-old woman, preoperatively and 2 years post-
operatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The 41-year-old wom an in Fig. 6-9 requested noninvasive facial rejuvenation.
We proposed an upper and lower augm entation blepharoplasty with chemical
browlift by botulinum toxin and full-face nanofat grafting. The upper blepha-
roplasty consisted of resection of skin and m icrofat grafting of the m edial hol-
low (1.5 cc per side). Tear trough and orbitom alar groove correction consisted
of microfat grafting of the orbitomalar area (7 cc per side). Botulinum toxin was
injected into the corrugator and procerus muscle (21 Dysport units per side) and
frontal m uscle (31.5 Dysport units). Full-face nanofat grafting was perform ed
-
jection described previously). A total of 22 cc of nanofat was injected. The re-
Fig. 6-9 A 41-year-old woman who had upper and lower augmentation blepharoplasty, botuli-
num toxin injection, and full-face nanofat injection. Left, Preoperatively. Center, At 6 months post-
operatively. Right, At 24 months postoperatively.

• Nanofat Grafting
sult is shown 6 and 24 m onths postoperatively. Skin lightening and correction
of blotchy pigmentation resulted. The 24 month postoperative result was also 6
weeks after botulinum injection.

The 33-year-old woman in Fig. 6-10 presented with baggy eyelids with dark pig-
mented circles she had experienced since childhood. Treatment involved a lower
fat redraping blepharoplasty through a subciliary incision and nanofat injection
(1.6 cc per side) of the lower eyelid and the pigmented nasojugal groove (Video
-
tion in the nanofat-treated skin in the early postoperative follow-up and com -
plete disappearance of the dark skin pigmentation by 7 months postoperatively.
Fig. 6-10 This 33-year-old wom an presented w ith baggy eyelids w ith dark pigm ented circles.
Nanofat grafting of the lower eyelids was performed. A, Preoperatively. B, At 4 months postoper-
atively. C, At 7 months postoperatively. D, At 5 years postoperatively.
A

B
C

D

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The appearance of the lower eyelids immediately after nanofat injection can be
quite concerning and has the aspect of a giant xanthelasma (Fig. 6-11 and Video

is simply the result of the oily fraction of the disrupted cells and disappears
within a few hours after injection. By postoperative day 7 it appears as a slightly
B
several weeks.
Fig. 6-11 A, Intraoperative view of nanofat injection. B,
(From Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applica-
tions. Plast Reconstr Surg 132:1017-1026, 2013.)
B
A
The 42-year-old woman in Fig. 6-12 requested correction of periorbital aging and
hollowing. The treatment consisted of an augmentation blepharoplasty, which
involved microfat grafting of the medial hollow of the upper eyelid without skin
resection (3 cc per side). The lower eyelid was treated with a fat redraping bleph-
aroplasty through a subciliary incision complemented with a nanofat injection of
the lower eyelid skin and nasojugal groove (1.7 cc per side). The result is shown
1 year postoperatively. Note the lightening of the lower eyelid skin.