Fat Injection From Filling to Regeneration

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Part III • Clinical Applications • Face and Neck: Aesthetic
In the orehead, the most common mistakes are irregularities, especially around the insertion o the
corrugators over the mid eyebrow, where slight depressions can be seen. Even on repeated inf ltrations,
a depression in this area can be extremely di cult to correct. Usually the patient presents with a smooth
orehead and cannot see the problem in the postoperative photographs. However, when the patient
moves his or her eyebrows in any ashion, a deep depression develops in the area, which is smooth with-
out motion. When the patient looks into the mirror, there is a tendency to contract the corrugator, so the
patient thinks the problem is present all o the time.
TECHNIQUE
Fig. 24-15, A-D
A
B
C
D
T is 55-year-old woman requested a subtle restoration o ullness to her upper eyelids and temples a er
three upper blepharoplasties and a coronal browli . She had other acial surgeries to her nose and lower
eyelids also. Her primary complaint was that her eyes looked tired, drained, and washed out.

401
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-15, E-H
E
Age 22
F
Age 55
G
Age 32
H
Age 55
T is patient demonstrates typical aging complicated by iatrogenically induced skeletonization o the up-
per third o the ace. T e overwhelming ullness present in the -year-old and even in the 3 -year-old
photos has now been stripped rom her ace. In the photos o her at 55, the clear outline o the patient’s
skull is obvious. T e - and 3 -year-old temple has a subtle slope, which expands out to envelop the
temporal vessels. In the 55-year-old photo, the blood vessels appear to snake right over the bony skull,
and are barely covered by the thinning skin and so tissues.
In the photos o the patient when she was younger, one can see that her temple supports the lateral eye-
brow so that rom this view, the entire eyebrow is visible. In the older photograph, the eyebrow dives of
o the precipice o a temple and the tail is not visible on either side as it is lost in the darkness created
by severe temporal hollowing. T e shadow makes the eyebrow look as though it is plunging in a caudal
direction more that it actually is.

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Part III • Clinical Applications • Face and Neck: Aesthetic
In both o the youth ul photographs, there is less than mm o palpebral show and tissue below the
eyebrow provides a gentle connection and progression rom the eyebrow to the globe. In the older com-
parison, her globe is starkly isolated rom the supraorbital rim. T e transition rom eyebrow to eyelid is
acute and creates an unhealthy appearing hollowness, which rames and exposes her skull.
Even though she has minimal upper eyelid crêpiness, she does not look as she used to look. Although
her three blepharoplasties and orehead li have removed the signs o aging, they did not make her look
young or natural. T e only time that eyelids are as skeletal as hers are when a person is ill, anorexic, old,
or has had surgery.
Even though I explained to the patient that most o her tired appearance, almost a debilitated and un-
healthy look, was the result o her skeletonized upper eyelid and temples, she remained adamant about
not changing her appearance too much. Although she was excited about the possibility o restoring so -
ness to her upper eyelids, she asked or a conservative approach to the upper lids and even the temple.
She repeatedly told me that she did not mind returning twice, but she was a raid o proceeding with the
amount o ullness that she thought I was suggesting to her. T ere ore we decided to approach both areas
conservatively.
T e area below the eyebrow (which I will call the upper eyelid) is inf ltrated a er placement into the
nasal dorsum and glabella, but be ore placement into the temple. T e possibility o hematoma is much
greater in the temple, and any edema rom the temple or orehead may inter ere with the visual clues
essential or determining the placement into the upper eyelids.
As mentioned previously, I begin with placement o the local anesthesia using a type I cannula. T is
accomplishes some pretunneling, so that the placement o the at initially is not as likely to injure a
vessel. Keeping in mind the location o the nerves and arteries in the area, I use a type III mini cannula
or placement in the entire upper eyelid and lateral nose/medial eyelid. T e skin o the upper eyelid is
similar in thickness to the lower eyelid; there ore extreme care is taken to minimize the volume o each
aliquot o tissue placed in this area. I never intentionally place more than 1⁄30 cc with each pass and will
try to place as little as 1⁄50 cc with every pass.
During the placement I usually switch back and orth between right and le sides i they are somewhat
symmetrical. In the usual situation the two sides are not symmetrical, so I will mark the undulations or
variations o the two sides preoperatively and use those or placement o the at.
Fig. 24-16, A-C
A

B

C
In the above photos, inf ltration into the glabella, nasion, and upper nasal dorsum has already been
completed.

403
Chapter 24 • Structural Fat Grafting in the Supraorbital Area
Fig. 24-16, D-F
D

E

F
Fig. 24-17, A and B
A

B
I prefer to use a midforehead incision to begin the approach to this area. T is incision is usually well
tolerated, and the lubrication of this incision is helpful for avoiding a depression or prolonged erythema.
I usually start with placement of some fullness into the nasal dorsum and nasion using a curved style III
cannula (see Chapter 5).

404
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-17, C and D
C

D
I then switch to a straight style III cannula and through the same incision begin placement into the gla-
bella. O en I will inject with a 22-gauge needle a small amount o intradermal at into the wrinkles o
the nasion and glabella be ore placing the subcutaneous gra . Care should be taken to avoid too much
central ullness in the glabella.
Fig. 24-17, E and F
E

F
A er inf ltration into the glabella, nasion, and upper nasal dorsum, a transition can be made to the
medial eyelid–lateral nose through both o the mid orehead incisions with a straight cannula and the
medial eyelid incisions with a curved type III cannula. T is placement is to so en the appearance o the
large vein, dark color, and depression that is requently present in this area.

405
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-17, G and H
G

H
From the contralateral brow or midline orehead incisions, the placement is under the eyebrows radiat-
ing down into the medial eyelid. Sometimes, a curved Coleman cannula will be more use ul to navigate
the curvatures. T e entire placement o structural at into the area under the eyebrow is immediately
subdermal down to and including inf ltration into the orbicularis muscle. As described earlier, I avoid
placing tissue close to the supratarsal old to avoid too much ullness caudally.
Fig. 24-17, I and J
I

J
A er inf ltrating a small amount o tissue rom the contralateral eyebrow incision or the midline ore-
head incision into the medial eyelid, I then switch to placement into the middle o the upper eyelid
through the orehead incision. I f nd that the contralateral medial eyebrow incision is use ul not only or
placement into the medial upper eyelid, but surprisingly, also the middle portion o the upper eyelid.

406
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-17, K
K
Next, the medial upper eyelid is approached through a lateral eyebrow incision. Again, this gives a di -
erent angle on approaching the medial upper eyelid, but the primary ocus o this area is gradual di use
inf ltration o atty tissue over the entire upper eyelid all the way to the lateral eyelid.
Fig. 24-17, L
L
From the mid orehead incision, I can begin to approach the lateral eyelid, again keeping the style III
cannula in an extremely superf cial plane. Gradual inf ltration continues over the entire upper eyelid
rom medial to lateral, changing incisions and directions to obtain a di use network o gra ed tissue.
T e lateral lid is much uller than the medial in most youth ul patients, so attention should be paid to
making sure that a relative ullness exists in the lateral brow and lid.
Fig. 24-17, M and N
M
N
Placement into the lateral upper lid can be accomplished rom the lateral eyebrow incision as well as
rom the lateral lower temple incision. T is allows me to urther eather the placement o ullness into
the lateral eyelid. Again, I pre er to approach any area rom at least two directions, and pre erably three.

407
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
O

P
Fig. 24-17, O and P
A er the area below the eyebrow has been di usely inf ltrated, the temple is approached through the
medial brow incision and sometimes the mid orehead incision. T e temple and even the hairline can be
reached rom a medial incision. A curved cannula will help navigate the curvature o the skull better and
help avoid too-superf cial placement into the temple, which may result in linear depositions o gra ed
tissue visible through the skin.
T e temple and lateral orehead are special challenges because irregularities can develop easily. T ere-
ore I use a technique similar to that used in the upper eyelid with placement o tiny aliquots to avoid
migration and to minimize irregularities. Also in the orehead and temple, I will switch to a style I or II
cannula to avoid damage to nerves and vessels. A hematoma in this area will seriously mask the visual
clues that allow or smooth, symmetrical placement o the structural at.
Q
Fig. 24-17, Q
Particular care should be taken to avoid damaging vessels or nerves when using a temporal or lateral zy-
gomatic arch incision. It is always advisable to switch to a style I cannula (blunt) when using an incision
that will cause the cannula to transverse the temporal region. Care should be exercised to remain in a
superf cial plane when placing rom such a long distance. Since it is such a long distance rom the eyelid,
I o en use a 9 cm cannula or this portion o the procedure.
T e loose areolar plane in this region and in the orehead provides an extremely unstable plane in which
to place tissue. A er placement in the areolar plane above the temporalis ascia or above the periosteum,
migration is easy with even a little external pressure. For that reason, I attempt to place as much o the
gra ed tissue as is possible into the superf cial temporoparietal ascia.
I also try to place some o the gra ed at into an immediately subdermal plane. Unlike the dorsum o the
hand, placing tissue between the skin and the underlying vessels in the temple is not usually possible.

408
Part III • Clinical Applications • Face and Neck: Aesthetic
ypically, linear depositions o gra ed atty tissue result rom spotty, too-superf cial attempts at place-
ment. I there ore recommend di use placement around the vessels.
T e temple is one o the more di cult areas in which to obtain a smooth result. It is inherently one o
the most irregular sur aces on the ace because o a combination o vessels and the underlying irregular
bone. Particular care should be taken with these irregularities so as not to emphasize them by placing
tissue over them.
Visual clues are important in the upper eyelid, brow, orehead and temple or determining the degree o
correction. A smooth, somewhat symmetrical result should be seen at the end o placement, as seen in
the photo on the right, and the areas should eel smooth (no lumps) to the touch.
Fig. 24-18, A-C
A

B

C
A er the area below the eyebrow has been di usely inf ltrated, the temple is approached through the
medial brow incision and sometimes the mid orehead incision. T e lateral orehead such as that on
this patient is particularly di cult to inf ltrate because irregularities can develop easily. T ere ore, I use
a technique similar to that used in the upper eyelid with placement o tiny aliquots to avoid migration
and to minimize irregularities. In the orehead and temple, I will switch to a type I or II cannula to avoid
damage to nerves and vessels. A hematoma in this area will seriously mask the visual clues that allow
smooth, symmetrical placement o the structural at.
Fig. 2 -1 , C, demonstrates the ar reach o the cannula to the temple and even the hairline rom a
medial incision. A curved cannula can help navigate the curvature o the skull better and help avoid
too-superf cial placement into the temple, which may result in linear depositions o gra ed tissue visible
through the skin.

409
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Particular care should be taken to avoid damaging vessels or nerves when using a temporal or lateral zy-
gomatic arch incision. It is always advisable to switch to a type I cannula (blunt) when using an incision
that will cause the cannula to transverse the temporal region. Care should be exercised to remain in a
superf cial plane when placing rom such a long distance. Since it is such a long distance rom the eyelid,
I o en use a cm cannula or this portion o the procedure.
Fig. 24-18, D-F
D

E

F
As in almost every area, I pre er several di erent directions o placement into the temple. I use a type
I cannula. Only with extreme adhesions and a er attempting blunt cannulas would I attempt to use a less
blunt cannula in the temple.
T e loose areolar plane in this region and in the orehead provides an extremely unstable plane in which
to place tissue. A er placement in the areolar plane above the temporalis ascia or above the periosteum,
migration is easy with even a little external pressure. For that reason, I attempt to place as much o the
gra ed tissue as is possible into the superf cial temporoparietal ascia.
I also try to place some o the gra ed at into an immediately subdermal plane. Unlike the dorsum o the
hand, placing tissue between the skin and the underlying vessels in the temple is not usually possible.
What usually happens are linear depositions o gra ed atty tissue resulting rom spotty, too-superf cial
attempts at placement. I there ore recommend di use placement around the vessels.
As it is, the temple is one o the more di cult areas in which to obtain a smooth result. It is inherently
one o the most irregular sur aces on the ace because o a combination o vessels and the underlying
irregular bone. Particular care should be taken with these irregularities so as not to emphasize them by
placing tissue over them.

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Part III • Clinical Applications • Face and Neck: Aesthetic
G
H
Fig. 24-18, G and H
Fig. 2 - 8, G, shows the patient a er completion o her nose, glabella, upper eyelid, le brow, lateral
orehead, and le temple, and be ore the lower eyelids and right temple have been treated. Note the de-
pression on the right temple and the smooth, attractive shape o the le completed temple. Visual clues
are important in the upper eyelid, brow, orehead, and temple or determining the degree o correction.
A smooth, somewhat symmetrical result should be seen at the end o placement, as seen in H, and the
areas should eel smooth to the touch (no lumps).
Fig. 24-18, I and J
I
J
VOLUMES PLACED

Right (cc)

Left (cc)
Temples
Upper eyelids
Lateral eyelids
Glabella
Dorsum
Malar cheek
Anterior malar fold
Lateral infraorbital rim
Lateral cheek
4
2
0.8
0.5
2
2
1
1.5
2
3.5
2
0.8
0.9
2
2
1
T e amounts inf ltrated were purposely conservative; I would have placed about 3 % or % more into
the upper eyelids and temples under other circumstances.

411
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-19, A-D
A
Age 22
B
Preoperative
D
1 year postoperatively
C
4 months postoperatively
T e patient returned months a er the procedure or routine ollow-up, pleased with the results. She
was now enthusiastic about the subtle but signif cant change in her appearance to a much calmer coun-
tenance. She had panicked about her appearance in the f rst or 3 weeks a er the procedure, but about
the ourth or f h week began to like the way she looked, especially the upper eyelids and the way the
ullness o her brow now obscured the vessels and gave better support to her eyebrows. She was particu-
larly impressed by the improvement in the texture o the upper and lower eyelid skin that was achieved
without any topical therapies. At months, she wanted to consider adding the tiniest bit more to her
upper eyelids and temples.
She returned again at year or routine ollow-up. She elt that the texture o her upper and lower eyelid
skin had improved even more over the last 8 months and that even her temples looked better. On care ul
examination o the photographs, she was correct. In many patients there appears to be a stabilization o
volume around our months, but the skin texture continues to improve long a er that time.

412
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-19, E-G
E
Preoperative
F
4 months postoperatively
G
1 year postoperatively
T e ring ash views urther conf rm the subtle improvements in not just supporting structural volume
but also in the texture o the skin. As in the previous series o photographic comparisons, these photos
conf rm a change between months and year in the nature o the temples, especially on the patient’s
right, as well as some evidence o improvement in texture.
Fig. 24-19, H-M
H

I

J
K
Preoperative
L
4 months postoperatively
M
1 year postoperatively
ilted-down and tilted-back views acilitate volume evaluation. Obviously, there is a large di erence
between the pretreatment and -month posttreatment temporal ullness, but there seems to be an even
better correction at year.

413
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-19, N-S
N

O

P
Preoperative
Q
4 months postoperatively
R

S
1 year postoperatively
T e oblique and prof le views demonstrate the extent o additional ullness in the upper eyelid at
months and what appears to be a slightly uller upper eyelid with less show o the temporal vessels at
year as compared with the -month postoperative view. T is improvement o skin overlying gra ed at
is ascinating and deserves our attention.
POSTOPERATIVE CARE
Similar to the cheeks, the temples and orehead exhibit only minimal swelling at the end o the proce-
dure. T is appearance can be complicated by unusual amounts o bruising, swelling, or even hemato-
mas. As with the cheeks, the surgeon can become adept at estimating the f nal outcome or the temples
rom the postprocedure condition. Dips, lumps, or irregularities should be recognized and every attempt
made to remove them be ore the procedure ends.
On the other hand, the upper eyelids sometime swell dramatically, even without extenuating circum-
stances such as hematomas or unusual swelling. Still, care should be taken to avoid skipping areas or
leaving obvious lumps.
All incision sites are closed with 6-0 interrupted nylon sutures.
Special Dressings
Although I have used many types o dressings in the past, I currently do not place any dressings on the
upper ace a er at gra ing.
Massage
Unlike the lower eyelids, I do not routinely recommend massage or the upper eyelids or temples.

414
Part III • Clinical Applications • Face and Neck: Aesthetic
R esul ts
I suggest orehead recontouring, as presented in the ollowing three patients, as a potential early case or
surgeons who have not per ormed this technique yet. issue inf ltration into the temple and mid rontal
regions is one o the simplest areas or predictable results. T e expectation o patients desiring changes
in these portions o the orehead is usually realistic, and a satis actory result is attainable on even the f rst
attempt.
A
B
Fig. 24-20, A and B
T is -year-old man presented to my o ce a er a massive weight loss. With the weight loss, he elt that
his temple and lateral parietal regions appeared collapsed, giving his orehead a bizarre shape that did
not match the rest o his ace. He elt the new shape combined with the newly exposed veins in his tem-
ples made him look much older than his years. From his abdomen, 90 cc was harvested and ref ned
down into 57 cc; 25 cc was placed into the right orehead and 32.5 cc into the le .
Fig. 24-20, C and D
C
D
He returned year postoperatively, pleased with the results. Not only had the shape improved, but also
the texture o his skin appeared healthier. As you will see on most o the patients in this chapter, even
though the temple and rontal regions are usually smoother a er the procedure, some intrinsic irregu-
larities almost always are present.

415
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area

A
B
Fig. 24-21, A and B

T is 0-year-old man presented complaining o a protruding orehead. He elt that expanding his brow
and temple would make the bossing o his brow region less prominent by smoothing out the superior
and lateral areas. His central brow bossing was especially accentuated by inadequate temporal ullness.
O particular importance, his upper eyelids are much more deep-set than usual.
T e vertical linear markings in the orehead demonstrate the area o primary placement, and the dotted
line demarcates the limits o eathering to blend the correction. T irty-f ve cubic centimeters o at was
harvested rom each anterior inner thigh through an incision in his pubic region. T e 70 cc was ref ned
into 8 cc, all o which was inf ltrated into the orehead above and lateral to the isolated area o bossing
(see the markings). T e tissue was inf ltrated entirely through two . mm incisions hidden in each eye-
brow. T e level o placement was subdermal, intramuscular, and galeal.
C
D
Fig. 24-21, C and D
Note the change in the patient’s prof le contour 6 months later. T e method o placement integrates the
at parcels with the surrounding tissues. T ere ore palpation o the larger orehead eels like skin, muscle,
and bone, not subcutaneous at.

416
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-21, E-J
E

F
G

H
I

J
Frontal and oblique views show a healthier-appearing, more athletic orehead. T e change in coun-
tenance is more than just rom sof ening the central brow bossing. Even though no tissue was placed
below the eyebrow, the upper eyelid has less palpebral show in every view and looks uller. T is change
in the upper eyelid transmits a healthier, calmer appearance.

417
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
A

B
Fig. 24-22, A and B
T is 3 -year-old actor presented complaining that people always thought that he looked tired and that
his acting career was hampered by his “strung-out,” unhealthy appearance.
Fig. 24-22, C
C
VOLUMES PLACED Right (cc)
Left (cc)
Temple/forehead
Infraorbital rims
Malar cheek
15
7.5
12.5
15
7.5
10
Markings made directly onto his ace delineate areas o proposed placement o structural at. T e large
asterisks mark specif c depressions. Sequential arrows (as in the tear trough and temples) demarcate
troughs to f ll. Dotted lines show the limits o placement and eathering. Diamonds mark the proposed
position o the most protuberant area o the cheek.
wo hundred cubic centimeters o at was harvested rom the patient’s abdomen and ref ned. Placement
o structural at into the brow and temple so ened the brow and parietal bossing and helped to re rame
his eyes. T e lateral malar cheeks were restructured, eathering up into the temporal region and down
into the buccal region. issue was placed along each in raorbital rim and anterior malar supporting the
lower eyelid at to create a smooth healthy-appearing lower eyelid.

418
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-22, D-F
Preoperative
D
1 year postoperatively
E

F
4 years postoperatively
T e tilted-back ollow-up photos are especially help ul or evaluating temple volume. At year postop-
eratively, note the expansion o the temple and mid rontal orehead leading down to a larger but well-
def ned cheek. Placing structure along the in raorbital rim smoothes out the lower eyelid and cheek. At
years a er the procedure, the correction appears to be present completely and may even have im-
proved.
Fig. 24-22, G-J
G
Preoperative
H
3 months postoperatively
J
4 years postoperatively
I
1 year postoperatively
By strengthening the brow, ablating the tear trough, redef ning the malar area, augmenting the premax-
illa, and slightly lowering the anterior mandibular border, a dramatic trans ormation occurred. Note
the improvement in projection o baseline emotion and condition. A tired, sad, unny-looking ace is
trans ormed into a much more attractive, rested, and healthy ace.

419
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-22, K-P
Preoperative
K

L
M
1 year postoperatively
N
O
P
4 years postoperatively
Radial expansion o the lower eyelid helps support the lower eyelid at and tightens the cheek skin to
sof en wrinkles at -year and -year ollow-ups. At years, all o the volume appears to still be present;
however, some return o the crow’s- eet is apparent.

420
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-22, Q-T
Q
Preoperative
R
3 months postoperatively
T
4 years postoperatively
S
1 year postoperatively
Finally, comparison of the preoperative image with the 3-month, 1-year, and -year results from this
view yields some puzzling questions. Obviously, with a suntan and lightened hair, the patient looks
much healthier. T e volumes appear to be similar between 3 months and 1 year, and any change one
might attribute to skin color or photography. However, between 1 year and years, even though the
patient did not gain weight, there appears to be a slight increase in the volumes. For instance, at the far
lateral brow on both sides above the eyebrow, a slight increase in volume can be noted that looks similar
to the volume in the 3-month photo. T e texture of the skin also appears to have improved between 1
year and years postoperatively.

421
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
A
B
Fig. 24-23, A and B
T is 3 -year-old presented primarily or treatment o her acne scarring, but with many other perceptive
observations about her own ace. Her only procedure had been a CO laser resur acing o her entire ace
years earlier. When discussing her appearance, she noted, “People always think that I am sad or mad.”
She elt that was probably due to the appearance o her eyes, in particular the lack o ullness above the
eyes. She also noted that the acne scarring had decreased the volume in her ace so that she was def cient
in her temples, glabella, and nasion. Finally, she noted that the pores in her cheeks medially were so large
that they looked like acne scars.
Fig. 24-23, C
C
VOLUMES PLACED

Right (cc)

Left (cc)
Midforehead
Glabella/nasion
Nasal dorsum
Spreader grafts
Temple
Upper eyelids
Lower lid infraciliary
Tear trough
Infraorbital
Malar cheek
0.25
6
5
0.4
1.5
4.5
7
5
8
3
0.75
4
5
0.3
1.5
4
5

422
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-23, D-I
Preoperative
D

E
1 year postoperatively
F

G
3 years postoperatively
H

I
T e patient returned at 1 year or photographs. Note the change in the volume present under the lateral
eyebrows along with a subtle expansion o the temples and cheeks. She had a signif cant reduction in
the pore size over her entire upper ace, and her acne scars are so er. I did not per orm any intradermal
injections at the time o her initial surgery, and would now consider that or serial excision or the re-
maining scars.

423
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Radial expansion o the orehead has not only exposed more o the lateral eyebrow on this patient, but
also it has raised the lateral eyebrow. By expanding the brow, the skin above the eyelid is relocated down-
ward to decrease scleral show, which imparts a so er, calmer, and healthier appearance.
In this case, and in most patients in whom structural at is placed caudal to the eyebrow, the brow ap-
pears to be elevated. Some o this is an illusion created by an increase in ullness under the eyebrow and
a decrease in palpebral show. However, at least a minimal amount o the elevation o the brow appears to
be secondary to the expansion o the so tissue o the brow.
By placing most o the tissue immediately caudal to the eyebrow, and not toward the supratarsal old,
the skin as it touches the eyelid is slightly oppy or loose, not expanded and ull. T is is a more natural
conf guration.
In the photographic comparison that ollows, the improvement in pore size is also clear. In the pretreat-
ment photograph, the pores o the medial cheek and glabella have become so deep that they have lined
up into early wrinkles. Radial expansion appears to have decreased the size o the pores, which seems
to have broken up their old linear nature. In the cheek, the minimal addition o subciliary ullness in
addition to adding di use ullness to most o the lower eyelid creates an attractive ullness immediately
under the lower lid eyelashes with a hint o depression caudal to the ullness. T is not only restores a
more youth ul and attractive appearance, but in combination with the changes to the supraorbital area,
it also converts the viewer’s perception o the shape o the eyelid aperture rom a rounder to a more al-
mond appearance.

424
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-23, J-O
Preoperative
J

K
1 year postoperatively
L

M
3 years postoperatively
N

O

425
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Preoperative
P

Q
1 year postoperatively
R

S
3 years postoperatively
T

U
Fig. 24-23, P-U
T e upper eyelids in the preoperative photographs appear to have extra skin. In actuality, there is not an
excess o skin, but a def ciency o ullness. Radial expansion o this area addresses the relative def ciency
to restore her eyelid to a healthier, younger appearance.
Attention to the curvature o the orehead is important. Increasing the projection o the brow slightly on
this patient gave her a more aesthetically pleasing slope to her orehead. Combining the change in shape
above the eyebrow with the restoration o ullness below imparted a much more attractive and healthy
appearance to her ace.

426
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-24, A
A
T is 55-year-old man presented with a hollow, unnatural appearance (“caving in”) o his upper eyelids
a er a blepharoplasty.
B
VOLUMES PLACED Right (cc)

Left (cc)
Central forehead
Glabella/nasion
Nasal dorsum
Brow
Upper eyelids
Lower lid
Malar cheek
Buccal cheek
6
1.3
1
12.5
11
5
3
3
6
1.7
1
12.5
13
Fig. 24-24, B
While only minimal ullness was restored to the upper eyelids, on this patient more signif cant amounts
were placed into the brow above the eyelids, but not into the temples.

427
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
Fig. 24-24, C-F
Preoperative
C

D
5 years postoperatively
E

F
T e patient returned 5 years a er one inf ltration into the upper eyelid, brow, and central orehead. Sub-
tle expansion o the brow and upper eyelid is apparent in the photographic comparison, but it is much
more obvious in the images that ollow.
Notice that the orehead wrinkles are remarkably diminished, but remain. T e overall texture o the skin
has also improved over the 5 years.
G

H
Fig. 24-24, G and H
With the patient’s eyes closed, one can appreciate the changes o the upper eyelid and brow. Placing tis-
sue close to the eyebrow, not close to the supratarsal old, has relieved the sunken, hollow appearance.
In act, as has been mentioned many times be ore, a oppiness o the area immediately superior to the
supratarsal old is pre erred. One can clearly see that in this patient.

428
Part III • Clinical Applications • Face and Neck: Aesthetic
I
J
Fig. 24-24, I and J
T is ring ash comparison demonstrates the restoration o ullness o the upper eyelids that has been ac-
complished by the addition o structural at to the upper eyelids and brow region. An apparent elevation
o the brow has been accomplished, especially laterally.
C ompl i ca ti on s
Likely complications include hematomas and bruising.
D i scu ssi on
VASOCONSTRICTION
T e blood vessels in this area o the ace are particularly ragile. It is in the temple and lateral supraor-
bital regions where the debilitating intraoperative complication o hematoma is likely to occur. For that
reason, I almost never use any cannulas other than the most blunt (type I) cannula, especially when inf l-
trating local anesthetic into the ace. Formerly, when I used 5-gauge sharp needles to inf ltrate the ace,
particularly the temples, I had a high number o hematomas, which led me to switch to blunt cannulas.
HEMATOMAS
Even with great nerve blocks or general anesthesia, I think it is prudent to inf ltrate epinephrine into the
periorbital region. T e inf ltrated epinephrine will not only reduce the diameters o the arteries so that
the lumens are more di cult to cannulate and embolize, but also it reduces the possibility that a hema-
toma will develop.
IRREGULARITIES
T e temple is an area which naturally has many irregularities. With tortuous veins and acne scarring, the
temples are naturally irregular. Even i the placement o at gra s disguises some o the irregularities, the
areas may still not be smooth. Photography should document the condition o the area be orehand, as
many patients will not remember the veins in their orehead. T e use o botulism toxin in the upper ace
should be planned care ully, depending on the condition o the patient (see Chapter 5 ).

429
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
T ech ni ca l P ea rl s
• When gra ing at to the eyelids and orehead, the most important technical consideration or stability
and a smooth appearance is placing tissue in miniscule aliquots without signif cant manipulation or
molding o the placed at.
• Use only blunt cannulas or placement into the temple to avoid damaging the rontal branch o the
acial nerve and creation o hematomas.
• I you precipitate a hematoma in the temple, go to the opposite side and place the appropriate amount
to create an adequate visual correction or comparison. T e photographs will help to determine the
shape and size di erence between the two sides. Using that in ormation, place tissue into the hema-
toma again, staying in the temporoparietal ascia and subdermal planes.
• Undercorrect in the upper eyelid and temple. It is much easier to add a small amount more than to
remove tissue rom these areas.
• Study the aces o people who are considered attractive. Observe the shape o their brow and the ull-
ness o the tissue under their eyebrows. Determine whether those shapes or others will please your
patients. Only i you have a vision o the shape you are creating can you expect to obtain predictable
results.
• Photograph your patients meticulously and requently. T e in ormation that can be obtained rom the
care ul review o good photographs is invaluable.
REFERENCES
1. Carraway JH, Coleman SR, Kane MAC, et al. Periorbital rejuvenation. Aesthetic Surg J 1:337, 001.
. Coleman SR. My view: structural at gra ing. Aesthetic Surg J 18:386, 1 8.
3. Coleman SR. T e technique o periorbital lipoinf ltration. Oper ech Plast Reconstr Surg 1: 0, 1 .
. González-Ulloa M, Flores ES. Senility o the ace: basic study to understand its causes and e ects. Plast
Reconstr Surg 36: 3 , 1 65.

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431
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m z b j p V . A j p
v b d mp , d q
j b , bb d p . I 970 j d -
, b d v y d v p d. M y, mp y f
y d d yd xy p v b d.
A esth eti c a n d T o p o g ra p h i c C on si d era ti on s
AGING
T b d m y . A
p , m p b m v y . T p p-
p w p y pp d p. A pp , p m y pp
p .
SHAPE
A q q p y y p w d b y
p v b p d y . T v
p p p b d v v b k d m.
D m b p . T k
m p b m z y v b , m y
m p d b p y v b y.
St r uct ur al Fat Gr a t ing
in t he Nose
Sydney R. Coleman
431

432
Part III • Clinical Applications • Face and Neck: Aesthetic
I n d i ca ti on s
T e most obvious and simplest use o structural at gra ing to the nose is to f ll in irregularities and div-
ots. Placing a thin layer subcutaneously provides support or the skin and can disguise visible irregulari-
ties o the cartilage and bone. Concentrating the at gra s into def ned areas can improve the line o light
re ection on the dorsum or subtly change the proportion o one part o the nose to another part. T e
structural application o at gra s can improve alar notching or close an open roo . Finally, structural at
placed in the nasal valve may act like a spreader gra to relieve nasal airway obstruction. But at gra ing
to the nose does much more than f ll de ects. It not only provides so tissue coverage o the bony and
cartilaginous ramework under the skin, but it also thickens the skin o the nose and trans orms it to
healthier, more elastic skin.
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Anesthesia
Anesthesia is obtained in most cases with local inf ltration o 0.5% lidocaine with 1:100,000 epinephrine
and sedation. Epinephrine is always use ul or causing vasoconstriction and thereby decreasing the pos-
sibility o intravascular emboli.
Incisions
Fig. 25-1
Incisions are usually made in the central orehead, medial eyebrows, cheek, or alar base and through the
central lip.
Cannulas
Harvesting is per ormed using Coleman cannulas, as described in Chapter 1. Inf ltration into the nose is
per ormed mainly with Coleman style III cannulas. T e at tip o the style III cannula or mini-cannula

433
Chapter 25 • Structural Fat Gra ting in the Nose
helps push through the requently encountered f brous tissues o the nose, especially a nose that has
scarring rom a previous operation. Although I use straight cannulas most o en, curved cannulas help
navigate the curvature o the nasion and glabella as well as acilitating di erent approaches to the alae. I
use mini-cannulas in most nose cases, as I have in the periorbital region. Finally, I f nd intradermal in-
f ltration o at with a sharp needle sometimes help ul. However, the injection o at or f llers in the nose
must be approached with great caution to avoid intravascular emboli.
Level o Inf ltration
Procerus
muscle
Frontalis
muscle
Aponeurosis
Lateral nasal
cartilage
Greater alar
cartilage
Fig. 25-2
Fat is layered rom the periosteum/perichondrium to the intradermal level.
Fig. 25-3
Grafted fat
spreader graft
In particular, a signif cant layer o gra ed at can be placed into the muscles o the upper nose, nasion,
and glabella. Occasionally at can even be placed posterior to the cartilage to help expand the nasal valve,
as a “spreader gra .”
Volume Ranges
T e volume placed varies widely, depending on the de ect, but can be as little as 0. cc in the alar rim to
as much as 9 cc in a saddle-nose de ormity.

434
Part III • Clinical Applications • Face and Neck: Aesthetic
TECHNIQUE
T e key to placement o at into the nose is meticulous placement in every layer available: intradermal,
subcutaneous, and intramuscular; into f brous tissues; and above and even below the perichondrium
and periosteum.
Fig. 25-4, A-D
A
B
C

D
T is patient had undergone at least 12 previous nasal procedures, including placement and removal
o Gore- ex, numerous ear cartilage gra s, and not only autologous but also homologous rib cartilage
gra s. In spite o the many procedures with well-known and respected plastic surgeons, she was le with
a marked irregular nasal sur ace which was easily visible through the thin skin o her nose.

435
Chapter 25 • Structural Fat Gra ting in the Nose
Drawings/Blueprints
Fig. 25-4, E
E
T is patient primarily wanted to increase the projection o her nasal tip, but she understood that this
was di cult to accomplish with at gra ing. She also wanted the nasal dorsum straightened more, with
placement o more tissue down the center o the dorsum to obtain a more central light re ection. She
also specif cally wanted to have still less alar notching and more columellar show.
T e goals re ected in the blueprints, developed during earlier consultations, were then trans erred to her
nose using colored markers immediately preoperatively. T e red marks indicate the incision sites; the
green marks indicate a planned structural change in the area; blue marks indicate planned intradermal
placement o at as well as subcutaneous placement; and orange marks are used to delineate the limits o
placement (no at is usually placed in the areas marked with orange).
Fig. 25-4, F-H
F
G

H
T e plan was primarily to create so tissue coverage to disguise the many irregularities le rom her
previous procedures, especially the cartilage gra s. In the glabella the ocus was on rejuvenation, calling
or placement o subtle amounts over the entire area, rom orange markings to orange markings, plus
some placement directly into the skin o the rown lines (blue). Incision sites were marked in red in her
orehead, medial eyebrow, anterior malar cheeks, and vermilion in the middle o the upper lip.

436
Part III • Clinical Applications • Face and Neck: Aesthetic
Placement
I
J
Fig. 25-4, I and J
In another patient with a similar presentation, inf ltration is shown with a 0-gauge needle into the
incision sites, ollowed by inf ltration o the local solution into the entire nose with a type III Coleman
cannula.
Fig. 25-4, K-M
K
L
M
T e dorsum is approached f rst with a curved Coleman cannula through the orehead incision. T e at
in this case was layered, beginning against the periosteum/perichondrium, and was gradually brought
through the layers to the immediate subdermal layer.

437
Chapter 25 • Structural Fat Gra ting in the Nose
Fig. 25-4, N and O
N

O
Fatty tissue was then layered in a similar ashion into the right lateral nose def ciency through the same
orehead incision.
Fig. 25-4, P and Q
P

Q
T e tip was approached through the same incision to provide the f rst direction or layering into the tip
to try to increase tip projection.

438
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 25-4, R-U
R

S
T

U
From the alar base, tissue was layered or structural support into the area o the alar notching. T is
structural approach should start at the alar rim through the middle alae. From this approach, urther
augmentation o the nasal tip can be attained to increase tip projection.
V
W
Fig. 25-4, V and W
T e right lateral nasal def ciency that was approached rom the orehead now could be approached rom
the alar base. Adding a second direction o placement is always advised when possible.

439
Chapter 25 • Structural Fat Grafting in the Nose
X
Fig. 25-4, X
Before proceeding with another direction of placement into the nose, the incisions already made should
be closed to prevent leakage of the fat out the incision sites.
Fig. 25-4, Y-BB
Y

Z
AA

BB
An incision was made in the vermilion of the lip to access the tip from another direction and to allow
placement into the columella to increase columellar show.

440
Part III • Clinical Applications • Face and Neck: Aesthetic
CC
DD
Fig. 25-4, CC and DD
Intradermal injections into the central dorsum can sharpen the straight line o re ected light and add
extra dorsal projection and maybe even tip projection.
Fig. 25-4, EE-HH
EE

FF
GG

HH
Further support in the alar rim can be created by supplementing the subcutaneous placement with in-
tradermal injection rom a dif erent direction. T e surgeon should avoid injection into the deeper struc-
tures with a sharp needle to avoid intravascular cannulation o arteries.

441
Chapter 25 • Structural Fat Gra ting in the Nose
Volumes Inf ltrated in T is Patient
Into the nasal dorsum, tip, alar rim, and right lateral nose, 3 cc was placed with a Coleman style III
cannula, cc with a Coleman style I cannula and 3. cc with a -gauge needle intradermally. Into the
columella, cc was placed with a Coleman style III cannula and .0 was placed with a -gauge needle
intradermally.
Dressings
Fig. 25-4, II-KK
II
JJ

KK
T e appearance o the patient is shown immediately af er the procedure.
Fig. 25-4, LL and MM
LL

MM
Reston oam was applied to the glabella and base o the columella and secured with egaderm to prevent
migration o at out o the directions o entry.

442
Part III • Clinical Applications • Face and Neck: Aesthetic
POSTOPERATIVE CARE
Dressings vary, depending on the specif c procedure per ormed. T e dressings are aimed at reducing any
migration o the at out o the injected areas through the placement tunnels. T is can involve placing
pressure between the incision sites and the area o inf ltration, or providing protection to the nose with a
splint to prevent manipulation o the newly transplanted at. T e patient should be told to avoid aggres-
sively touching the nose to prevent any migration o at.
R esul ts
CASE 1
Fig. 25-5, A-D
A
B
C

D
During the procedure, 0.5 cc was placed in each alar region with a Coleman type III cannula, and 0.5 cc
was placed into the dermis o the columella with a -gauge needle. Into the dorsum 3.5 cc was placed
with a Coleman style III cannula and 1 cc into the midline with a -gauge needle to increase the light
re ection; 0.5 cc was placed di usely with a Coleman type III cannula and 1.0 cc placed into the glabel-
lar rown lines and the central vertical wrinkle into the skin with a -gauge needle. At the end o the
procedure, a small V-dissector was used to ree up some o the scarring present between the skin and the
underlying bone or cartilage.

443
Chapter 25 • Structural Fat Grafting in the Nose
Fig. 25-5, E-G
E
F

G

444
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 25-5, H-P
K

L

M
H
I

J
1 year postoperatively
O
Preoperative
N
9 years postoperatively
P

445
Chapter 25 • Structural Fat Gra ting in the Nose
Q

R

S
Preoperative

1 year postoperatively
T
U

V
9 years postoperatively
Fig. 25-5, Q-V
One year a er the f rst at gra ing to the nose, so ening o the angular edges rom the nasal cartilage
and bone can be seen, along with an apparent thickening o the skin, especially over the dorsum. T e
glabella is slightly uller, with a diminution o the rown wrinkles. However, the wrinkles lateral to the
areas o placement are more obvious. T e lateral view shows that the amount o placement was minimal.
At 9 years, the results demonstrate a so , elastic, thicker skin and a so ening over the whole nose.

446
Part III • Clinical Applications • Face and Neck: Aesthetic
CASE 2
A
B
Fig. 25-6, A and B
T is 5 -year-old woman had had our rhinoplasties on both coasts o the United States, and silicone
injections to the nose. She also had undergone two aceli s, a coronal browli , and, at least our times,
at gra ing by another surgeon to her lower eyelids and cheeks. Surprisingly, she had undergone no
blepharoplasties or any procedures to her upper eyelids, except or the browli .
C
D
Fig. 25-6, C and D
A photograph o the patient when she was younger reveals a much so er nose and uller periorbital re-
gion. Closing the open roo was a priority to visually connect the bony and cartilaginous portions o the
nose. I planned reconstruction o the alar rim with an attempt at medialization o the nasal tip, as well as
f lling o the lateral osteotomy sites.

447
Chapter 25 • Structural Fat Gra ting in the Nose
E
Fig. 25-6, E
Markings delineate the planned procedure: 3. cc was placed into the dorsum f rst using a Coleman style
III cannula, ollowed by 1 cc with a -gauge needle to increase the light re ection; 3.3 cc was placed into
the right alar region and cc into the le ; 1 cc was placed into the lateral nose on each side, eathering
into the lower eyelids. T e adhesions were so strong that a V-dissection was necessary to release them.
Fig. 25-6, F-I
F

G
H

I
Comparison o these photographs reveals that the remarkable swelling and bruising present at 6 days
postoperatively (G) had resolved completely by the f h week (H). T e di erence between the -week
and 1-year ollow-up (I) is minimal; primarily there has been urther so ening o the osteotomy site cor-
rections. T e improvement o the periorbital region in general is evident, with remarkable improvement
in the quality o the skin and lightening o the skin color.

448
Part III • Clinical Applications • Face and Neck: Aesthetic
J

K
N

O

P

Q
L

M
4 years postoperatively
T
R
Preoperative
S
1 year postoperatively
U
6 years postoperatively
Fig. 25-6, J-U