Fat Injection From Filling to Regeneration

450
Part III • Clinical Applications • Face and Neck: Aesthetic
A
B
C
D
Fig. 25-7, A-D
T is patient, whose procedure involved just her glabella and lower eyelids, is presented to demonstrate
the result o placing tissue into the lower eyelid area without a signif cant cheek augmentation. T is
-year-old woman came to the o ce 1 year a er at injections into the glabella by another plastic sur-
geon. She was impressed with how the immediate postoperative swelling rom the glabellar injections
made her upper and lower eyelids look better or a ew weeks. T e other plastic surgeon elt uncom ort-
able about injecting at around the eyelids, so the surgeon re erred the patient to me.
T e patient reported that a planter ell on her ace when she was 11⁄2 years o age, which may have con-
tributed to her mid ace def ciency. She was completely healthy and underwent a complete endocrine
workup to rule out any thyroid-related eye disease.
Her major complaint was that she elt she looked masculine and that people have trouble reading her
emotions, thinking that she was angry or tired when she was not. She was most bothered by the “lack
o mass, which makes me look un ocused and eccentric” and tired-looking, pointing to her cheeks. She
then noted that her glabellar area made her look like she was rowning all o the time. She had never had
a Botox treatment and had no intention o trying it.
Although I encouraged her to bring photos o hersel when she was young, she instead brought photo-
graphs o her mother when she was young and those o a cousin; both had ull anterior malar cheeks
with no visible lower eyelid at pads.

451
Chapter 25 • Structural Fat Gra ting in the Nose
E
Fig. 25-7, E
Sitting next to the patient and looking at her photographs, we designed this plan, which involves making
a change in the shape o the areas marked in green and a restoration o subtle ullness, eathering out
into the areas marked in yellow. T e ocus o the procedure was to place enough tissue along the anterior
malar cheek and in raorbital rim to create enough mid ace projection to overwhelm the lower eyelid
at collections. o increase the size o the cheek at the level o the in raorbital rim and underlying malar
cheek so that the lower eyelid at pads were not visible. In addition, she was disturbed by the scowling
appearance o her glabella.
In the f rst two consultations, I spoke to her about augmenting her lateral malar cheeks and upper eye-
lids. Be ore we f nished the second consultation she decided to proceed with her two biggest priorities:
correction o the protuberant at pads o her lower eyelids and her rown lines in the glabella and nasion.
We decided that gradually changing the proportions o her ace was the most prudent course. We dis-
cussed that the other areas o her ace would be a uture project.
Although I recommended Botox injections into the corrugators be ore the procedure to stabilize the
area, she said that she would not consider using Botox. T ere ore the only stabilization was the tape
applied as a dressing.
Fig. 25-7, F and G
F
X
G
X
T e green markings demonstrate the area o maximal structural augmentation with eathering into the
surrounding areas. T e red marks delineate the incision sites; cc was placed in the tear trough/anterior
malar old, which included the medial orbital rim; cc was placed beginning at the middle and lateral
orbital rim eathering out into the malar cheek. Into the area lateral to the commissure o the eye, cc
was placed on each side. Into the upper quarter o the dorsum o the nose, . cc was placed. Into the
glabella, . cc was placed, with about 0. cc o that placed using a V-dissector to ree up the deep con-
nections o the central rown line.

452
Part III • Clinical Applications • Face and Neck: Aesthetic
H
I
Fig. 25-7, H and I
T e patient returned at 3 years and 9 months a er the one procedure with no intervening procedures,
acial injections, or topical treatments. Her prof le demonstrates how structural at along the in raorbital
rims has created an aesthetically appealing transition rom the lower eyelid to the malar cheek. Also in
this view, upper nose–dorsal projection has increased with a relocation o the apparent radix position.
Fig. 25-7, J-M
J

K
L

M
Again, with the patient seen be ore and 3 years and 9 months a er her procedure, not only is there a re-
markable reduction o the shadows created by the intersection o the lower eyelid at with the old cheek,
but there is also a dramatic change in the quality o her skin. I f nd these views using a macro ring ash
to be the most e ective method to evaluate changes in texture o the skin. Obviously, the f ne lines are di-

453
Chapter 25 • Structural Fat Gra ting in the Nose
minished. T e change in the quality o the pores is even more noteworthy. T e pores in the be ore photo
were not only deeper, but they were lining up to orm wrinkles. Augmentation o the area breaks up
these lines and deep pores and makes most o the pores in the area much smaller and less conspicuous.
T e central rown line in the glabella where a V-dissector was used seems to be completely ablated in
all ollow-up views, with slight persistence o the lateral rown lines in which no V-dissector was used.
Fig. 25-7, N-Q
N

O
P

Q
Looking up orces the lower lid at to herniate; by placing a structure under the at to support it, the tran-
sition rom the cheek to the eyelid is smooth without removing any tissue. T e patient’s ollow-up ront
view demonstrates a remarkably more alert and youth ul countenance with restructuring o the mid ace,
upper nose, and glabella using only structural at gra s in one procedure.
C om p l i ca ti on s
Probably the most common problem a er the placement o at is inadequate correction, although it
takes an average o 1 year a er a procedure has been per ormed to make this determination. Even i
there is a signif cant improvement, patients usually want to have more. Patients must be prepared or the
potential o a second or even third treatment.
Intravascular injection is the most eared potential complication rom injecting anything into the nose
with a sharp needle. Care should be taken to inject epinephrine, remain at a superf cial level, and place
the at in tiny aliquots when using sharp needles in the nose.
Blistering that occurs or days a er injection o any particulate substance into the nose is most likely
an intravascular event, not an in ection.

454
Part III • Clinical Applications • Face and Neck: Aesthetic
C oncl u si on
Inf ltration o autologous at gra s into the nose provides surgeons with another tool to complement
rhinoplastic procedures. Fat gra ed to the nose is surprisingly well integrated; the gra ed at assumes
the structural qualities o the part o the nose into which it is placed. By f lling and adding structural
support, at gra ed to the nose can f ll holes, change the nose’s shape, or add support to treat many prob-
lems.
T ech ni ca l P ea rl s
• Hydrodissection o the alae is o en help ul be ore placement in that region to prevent per oration o
the mucosa. T is is especially important in scarred noses.
• Even in the nose, it is important to try to place tissue rom two di erent directions.
• Blistering in the nose a er injection o any f ller or at using a sharp needle is likely to be caused by
intravascular injection.
• T e corrections with structural at gra ing are so natural (and o en subtle) that the patient has trouble
seeing them. T ere ore it is essential to document the patient’s preoperative appearance and postoper-
ative condition so he or she can appreciate the change.
REFERENCE
1. Kølle FS. Hydrocarbon prostheses. In Kølle FS. Plastic and Cosmetic Surgery. New York: D Appleton, 1911.

455
C h a p t e r 2 6
A esth eti c C on si d era ti on s
T m v v y p w m . D p -
p xp , w p w
, , j y, p .
Fig. 26-1
S p p j p y f m .
W v p p j , w m ,
p v v y .
St r uct ur al Fat Gr a t ing
in t he Nasol abial Fol d
Sydney R. Coleman
455

456
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 26-2
In this young man, the nasolabial old contributes to an expression o happiness; at the top are two dif er-
ent levels o content, whereas the two drawings at the bottom demonstrate a orced or ake smile.
Expression o these emotions is integral to communication between humans. Likewise, the uninten-
tional projection o emotions can be an impediment to accurate communication. When a person pro-
jects anger, sadness, or disgust even though he is eeling happy and rested, he will be misunderstood.

457
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Fig. 26-3
Aging can generate negative and f xed changes in acial expression. As the ace ages, it loses the subcu-
taneous ullness associated with youth. With loss o ullness comes a weakening o the radial vectors
that support and thereby tighten the skin around the mouth. As these radial vectors weaken, the now
unsupported skin sinks into olds, wrinkles, creases, and even pores. One o the consistent and more ob-
vious olds or wrinkles on the ace into which the skin retreats with aging is the nasolabial old. As these
olds become more pronounced, unintentional emotional expressions can become f xed on the ace. For
example, when the patient is listening calmly, not intending to demonstrate any emotional reaction, the
deepening nasolabial olds can convey a very di erent impression—perhaps that o disdain or even an-
ger. Fortunately, this accentuation o the nasolabial old is not always negative; the olds can also deepen
into a smiling or cheer ul countenance.

458
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 26-4
Photographs o the patient’s appearance when young are o en help ul in evaluating and planning the
treatment o nasolabial olds. T is woman demonstrates an obvious vertical old that extends down well
past the level o the oral commissure. A bare hint o a old can be seen in her younger photograph. It has
been my experience that i a person did not have deep nasolabial olds when young, there is a good like-
lihood that subcutaneous at placed directly under the old and eathered into the surrounding area will
so en the nasolabial olds back to at least the younger state. It is advisable to avoid overcorrection o the
olds, because this can sometimes result in a bizarre appearance and orce olds into the surrounding ar-
eas. Such overcorrections can make the patient eel that their smile has changed in a negative direction.
T e use o old photographs is especially important i a patient had a signif cant nasolabial old when he
or she was young, and there is now a noteworthy premaxillary def ciency with a ull anterior cheek. In
such a person, there is little hope o ablating the nasolabial old.
In many aging aces, the deepening nasolabial old leaves behind a permanent sneer that can only be
erased by smiling. T ese patients in particular are good candidates or so ening o the nasolabial olds.
For these individuals the primary goal o at gra ing in the nasolabial old and marionette region is to
so en these olds and thereby reduce the sneer.

459
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Fig. 26-5
T is early patient o mine was one o the cases that f rst underscored or me the look o disdain that the
nasolabial old can create. Although she was a pleasant lady, when she was not smiling she looked as
though she had smelled something bad. Placement o only .8 cc into the right and . cc into the le
nasolabial old with a sharp needle helped relieve this disdain ul projection. Although she demonstrated
a good correction at her 3-year postoperative ollow-up visit, the use o a sharp needle in this early case
o mine le behind an isolated linear correction on her right nasolabial old.
It is important to recognize that an individual’s nasolabial olds are not necessarily bad, and in some
aces their elimination will be detrimental to acial harmony. T e problem is not the existence o the
olds but their depth and prominence and how they a ect and alter acial expression.
A n a tomi c C on si d era ti on s
T e topical anatomy o the nasolabial and marionette olds can vary greatly rom individual to individ-
ual. At one end o the spectrum, they are almost completely absent or at. At the other end, there is a
prominent ullness lateral to the nasolabial old with a pronounced premaxillary def ciency. T e olds
and the surrounding skin should be care ully evaluated when a at gra ing procedure is contemplated.
T e nasolabial olds and marionette grooves are strongly in uenced by the surrounding structures in the
cheeks, lips and chin. In a younger person, the nasolabial olds and marionette grooves may be mani est
as deep creases surrounded by ullness. In such situations, the olds may not project any particular neg-
ative emotion despite their prominence.

460
Part III • Clinical Applications • Face and Neck: Aesthetic
I n d i ca ti on s a n d P a ti ent S el ecti on
As discussed earlier, the primary indication or correction o the nasolabial olds and marionette grooves
is aging. Older patients object to the expressions that age seems to have painted in the olds and lines
o their aces; these seem to appear more prominent and objectionable with each passing year. Interest-
ingly, younger patients who have deep nasolabial olds have a similar reaction when they perceive that
their deeper than usual olds make them appear older than they are. T e most important consideration
with marionette grooves is to be certain that the patient understands that the grooves will most likely
not disappear altogether; improvement in the texture o the marionette grooves is requently the best
improvement possible with subcutaneous placement o atty tissue. Fat tissue transplanted into an intra-
dermal or immediate subdermal plane may be indicated or additional blunting o both the marionette
grooves and nasolabial olds. T e results rom intradermal injection are quite di erent rom those o
subcutaneous f lling (see Chapter 1).
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Anesthesia
When treating the nasolabial olds and marionette grooves, in raorbital and mental nerve blocks may be
employed. However, I always inf ltrate locally .5% lidocaine with 1:2 , epinephrine rom both the
cheek and in erior incisions. Even i general anesthesia is used, I inf ltrate epinephrine or vasoconstric-
tion to lessen the chance o intravascular inf ltration o the at, especially i I plan to use a 22-gauge sharp
needle or superf cial or intradermal injection o the at.
Incisions
Midmalar
Commissure
Lateral chin or
mandibular border
Fig. 26-6
Lower midmalar incisions provide access or the perpendicular placement o tissue, and an incision
in the lateral chin or mandibular border provides access or the longitudinal placement o tissue. Fre-
quently an incision near the commissure is used or a di erent angle o placement.

461
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Inf ltration Cannulas
Type II
Fig. 26-7
In the nasolablial old and marionette groove areas, a Coleman type II cannula (7 or 9 cm) or mini-
cannula ( cm) is most commonly used to acilitate dissection while avoiding intravascular placement.
Type III
V-dissector
Fig. 26-8
However, I use a Coleman type III cannula or type III mini-cannula in areas o very f brous adhesions,
especially against the skin. I the adhesions are particularly troublesome, a V-dissector cannula is used
to disrupt the superf cial connections. However, too much disruption o the subdermal connections may
result in isolated linear protrusions, so I am rugal with the use o the V-dissector cannula in the nasola-
bial olds. My experience with sharp instruments such as needles has been disappointing: the gra ed at
does not seem to be as stable, and the correction can be visible and circumscribed rather than blending
in naturally with the surrounding area.

462
Part III • Clinical Applications • Face and Neck: Aesthetic
Level o Inf ltration
Fig. 26-9
Although some tissue is placed at every level rom submucosal to subcutaneous, the primary level o
placement in most cases is immediately subdermal to impart structural integrity to the cutaneous ele-
ment o the old and to encourage the improvement in the quality o the skin. In any case this superf cial
treatment also helps blunt the old or line better than simply adding volume deep to the old.
Deep dermal injection
Subcutaneous injection
Fig. 26-10
Intradermal or deep dermal inf ltration o the at can be use ul to urther blunt the nasolabial olds or
marionette grooves in the creases.
Volume Ranges
For correcting a minimal line in the nasolabial old, as little as cc is sometimes needed. However, cc is
rarely enough or signif cant ablation o the olds, and or deep olds that have a signif cant premaxillary
def ciency, inf ltration with as much as 10 or 11 cc per side is required to adequately block the re or-
mation o the old. o blunt a marionette groove, much smaller amounts o tissue are used: rom 1 to
3 cc. T e surgeon should always prepare the patient or the possibility o a secondary procedure or the
marionette and nasolabial olds.

463
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Most Likely Technical Mistake
Isolated placement by injection into the wrinkle o the deepest part o the old without attention to eath-
ering into the surrounding areas can lead to a visible correction or the re- ormation o wrinkles or olds
in the areas immediately adjacent to placed atty tissue.
TECHNIQUE
T e key to placement o atty tissue in the nasolabial old and marionette groove is subcutaneous inf ltra-
tion o areas rather than individual lines. However, it is o en necessary to so en a distinct line or crease
with a combination o deep intradermal injection with a -gauge needle or superf cial inf ltration with
a type III Coleman mini-cannula.
Fig. 26-11
T e markings are made with arrows pointing to the depth o the nasolabial old crease and demonstrat-
ing f lling either on both sides o the crease or in the premaxillary region. In the premaxilla, I usually
f ll rom the medial area to the crease. In the marionette region, again the f lling is usually medial to the
marionette groove. T ere ore I delineate the outer border and show f lling on the inner border.
I start the placement perpendicular to the nasolabial olds or creases to eather over the area and or a
“stenting” o the nasolabial old. Structural at placed perpendicular to a crease creates a structural bar-
rier to the recurrence o the old. T is is important, because placement o the f laments only in a direc-
tion parallel to the old can make the old worse.
A
Fig. 26-12, A
T rough the incision in the midcheek, the cannula is inserted and is immediately brought down to a
deeper level. Next, the tip o the cannula is advanced past the actual old.

464
Part III • Clinical Applications • Face and Neck: Aesthetic
B
Fig. 26-12, B
T e syringe plunger is pressed minimally with each retreat o the cannula to express a small line o atty
tissue into the area o the nasolabial old. T e f nger o the opposite hand is used to stabilize the area
during the advancement. Approximately ⁄10 to ⁄30 cc is expressed with each retreat o the cannula in this
area.
C
D
Fig. 26-12, C and D
Cephalad, the at is placed medial to the olds. Only minimal at is placed lateral to the old, because the
area lateral to this part o the nasolabial old is usually already uller than the patient desires.

465
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
E
F
Fig. 26-12, E and F
Caudally, more tissue is placed on both sides o the old, rather than on the medial side o the old. Par-
ticular attention is paid to any f ne wrinkles or apparent weakness in the skin, since this can cause new
olds to orm as support is placed into the current old.
Occasionally, the surgeon will not be able to manipulate the cannula placed through a cheek incision
into a position perpendicular to the old. T is problem occurs when the nasolabial old curves inward
toward the chin rather than downward as it usually does. In this situation, by approaching the lower na-
solabial old rom an incision in the border o the mandible, the surgeon can place the at perpendicular
to such a old.
Initially a layer is placed deeply along the entire sur ace o the nasolabial old. Next the cannula is placed
at a more superf cial level where another layer is positioned. A er several intermediate layers are inf l-
trated, a layer is placed next to the skin. T e inf ltration is done using a anlike approach; it becomes
more superf cial with each level o passes.
G
H
Fig. 26-12, G and H
A good deal o attention is paid to the creases that are medial and lateral to the existing nasolabial olds
and crease. A correction o the old itsel without inf ltration o the surrounding tissues will accentuate
preexisting minor creases. T ese will o en be viewed as recurrences o the nasolabial old. At the con-
clusion o each inf ltration, I check or structural integrity by palpating the area.
T e opposite hand is used to guide placement, and care is taken to avoid per oration o the mucosa,
which is the most common means o introducing bacteria that can lead to in ection.

466
Part III • Clinical Applications • Face and Neck: Aesthetic
I
J
Fig. 26-12, I and J
Next the nasolabial old is inf ltrated rom below to complement the structural placement o the trans-
verse elements o atty tissue. Although the cheek approach is the most important direction or place-
ment o atty tissue, placing at in a longitudinal direction allows a more precise volume correction
immediately against the crease o the old itsel and adds structural integrity. In this situation, only blunt
instruments are used: a type II or III cannula. Occasionally it is necessary to use a V-dissector to dissect
the adherent connections.
T e cannula can be advanced along the entire length o the old. I the ref ned atty tissue is to be placed
along the entire length o the path, larger amounts o tissue can be expressed with each pass. Usually
rom 1⁄20 to 1⁄5 cc can be inf ltrated with each o the longer passes.
Again, placement should not be limited to the old itsel . Particular attention should be paid to any small
olds or creases lateral or medial to the large old. T e f lling o the larger old may accentuate smaller
surrounding olds.
K
L
Fig. 26-12, K and L
As with the approach rom the cheek incision, the cannula tip should be advanced to the desired posi-
tion longitudinally along the length o the old. T en, as the cannula is withdrawn, a small amount o
at is expressed into the retreating path. I usually begin deep and progress more superf cially. However,
or minimal corrections I start superf cially in an attempt to primarily ablate the crease, since there is no
deep old to ablate. Blanching o the area o placement into the nasolabial olds and marionette grooves
is common, especially with superf cial placement o atty tissue.

467
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
M
Fig. 26-12, M
A er placement, I pinch the area to check or structural integrity. I have ound that i the nasolabial old
can be re-created by digital manipulation, the correction has been inadequate. On the other hand, i the
crease cannot be orced back in the cheek, an adequate correction has been attained. T e endpoint o
the procedure in the nasolabial old is when the nasolabial old cannot be re-created with digital manip-
ulation.
N
O
Fig. 26-12, N and O
From the same cheek incision site that was used to place the at perpendicular to the nasolabial olds, I
begin the approach to the marionette region. Again, placement is guided with the opposite hand, with
care to avoid per oration o the oral mucosa. T e longer cannulas are a bit more unwieldy in certain sit-
uations but provide better access to this region. From the cheek, the direction o placement is primarily
perpendicular to the marionette groove, with multiple passes leaving minuscule amounts with each re-
treat o the cannula. O en the inf ltration o the marionette region is continuous with the lateral mental
region. Bridging rom the marionette groove down to the caudal chin orms a base, providing more
structural integrity to the marionette old in many instances.

468
Part III • Clinical Applications • Face and Neck: Aesthetic
P
Fig. 26-12, P
I recommend approaching the marionette area rom many directions. It can be inf ltrated rom the chin,
oral commissure, or the lateral mental region as well as the cheek. T e purpose o this multidirectional
approach is to improve the texture o the region and provide structural integrity to slightly elevate the
corners o the mouth. In my experience, the major change will be textural rather than structural. T e
upward turning o the mouth is a subtle change that may be barely evident, i it occurs at all.
Q
Fig. 26-12, Q
Fat should not be placed into the pouchy area underneath the nasolabial old, because this can increase
the pouch and the jowl. I also do not overf ll the marionette region, because the groove can easily be
enlarged in some individuals. I am always enthusiastic about improving texture in this region, but e orts
to eradicate the marionette grooves have been disappointing.
Although you can o en achieve dramatic nasolabial old changes with only one inf ltration, the patient
should be told that a secondary inf ltration might be necessary. T e patient also must understand that
while textural changes in the marionette region will be a considerable improvement, structural alteration
may be disappointing, even a er multiple attempts at at inf ltration into this area. Furthermore, the ad-
dition o tissue in this area may even emphasize the downward slant at the corner o the patient’s mouth.
T ere ore, to avoid creating unrealistic patient expectations, the surgeon should not promise too much
improvement o the marionette grooves.

469
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
One f nal note on technique in the nasolabial old and marionette region. Subcutaneous placement is
di erent rom intradermal placement. Intradermal at can usually be more e ective at the elimination
o discrete wrinkles or lines. However, it is not always easy to predict how much o a correction will take
place with subcutaneous placement.
POSTOPERATIVE CARE
Special Dressing
No special dressing is used.
Massage
I do not recommend massage o the nasolabial area.
Recovery
Recovery rom placement into the nasolabial olds and marionette grooves is usually better tolerated
than other areas, such as the lips or periorbital region. Bruising is usually minimal, and the swelling in
recovering patients typically looks acceptable within a ew days.
R esul ts
My initial experience with at gra ing into the ace was with the nasolabial olds. All o the f rst pa-
tients into which I inf ltrated tissue in early 1 87 seemed to retain the at. I presented a series o 1-year
ollow-ups on nasolabial old injections to the American Society o Aesthetic Plastic Surgery in 1 88. I
published the cases o some o those patients later when I reached a 7-year ollow-up. My conclusion
in that paper was that the corrections seemed to be stable a er a ew months. Now, 1 years later, that
conviction is even stronger.
CASE 1
A
B
Fig. 26-13, A and B
T is 1-year-old woman’s primary complaint concerning her nasolabial olds was that they were dis-
tracting, because they made her looked aged, even when she was younger.

470
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 26-13, C and D
C
D
VOLUMES PLACED

Right (cc)
Left (cc)
Nasolabial folds
Lateral cutaneous lip
Upper marionette groove
Lower marionette groove
14
0.5
1
2
14
0.5
1
4
At the initial consultations, not only was the primary nasolabial old identif ed, but also the secondary
and tertiary nasolabial olds. T ese olds were marked on the blueprint initially. T e lateral cutaneous lip
should also be examined. Not extending the correction o the nasolabial old into the upper cutaneous
lip will requently result in a vertical crease developing upward rom the lateral commissure.
T e markings identi y not only the depth o the nasolabial olds with the vertex o the arrows, but also
the extent o the old with the extension o the arrows away rom the vertex. T e extent o eathering
is delineated by the orange lines. T e orange markers also identi y the areas to be avoided, such as the
jowls.
Photographs taken o the nasolabial old rom above and below are use ul or documenting volume
changes. Eleven months a er surgery, a clear correction o the nasolabial old can be seen. Even though
I eathered into the lateral upper cutaneous lip on both sides, a ew millimeters rom the point that I
stopped placing at, the wrinkles or lines are more obvious than be ore the correction. T is is second-
ary to the contrast between the augmented area, which is smoother, and the area o the lip that was not
corrected.
Feathering into the cheek on this patient gives a much healthier look to the buccal cheek and her overall
ace shape. Placing much more into the buccal cheek would have resulted in a corpulent appearance.

471
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Likewise, it might have been possible to ablate the olds more with a greater volume correction, but that
would result in an appearance that most eyes would judge as too ull.
T e patient returned year later, asking or urther ablation o the nasolabial olds but complaining that
she already had a little too much ullness o the jowl area. I recommended the injection o remaining
lines, creases, or olds with intradermal injection o at. Superf cial placement into the dermis or im-
mediately subdermal helps block the o ending problem without adding signif cantly more volume to
the area. I pointed out to her that I specif cally marked the jowls to avoid placing anything there (notice
orange areas denote no placement). However, the mass e ect rom the placement in the creases had cre-
ated a subtle increase o ullness in the area, which was barely noticeable. I recommended that she have
at removed rom the jowls bilaterally.
E
Fig. 26-13, E
In the preoperative markings, note that the purple marks in the jowls running up onto the cheeks show
where the at will be suctioned and the green arrows delineate the areas o primarily intradermal place-
ment to keep the volume o injection to a minimum, while maximizing the e ect o ablating the creases
urther.
I removed 3. cc rom the le jowl with a Coleman type I cannula and a 3 cc syringe. T is was centri-
uged to veri y the amount o at removed was cc; .5 cc was also removed rom the right jowl, .5 cc
rom the le jowl, and . cc rom the pouch area, using a -gauge needle. T e placement o at was the
ollowing: 0.8 cc in the right nasolabial old, 0. cc in the le nasolabial old, 0.9 cc in the right mario-
nette, .0 cc in the le marionette, and .8 cc in the lateral chin. T e intradermal at placement was made
superf cially with a type I cannula.

472
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 26-13, F-K
F

G
H
I

J
K
Fourteen months a er the second procedure, the residual nasolabial old is diminished signif cantly, but
has purpose ully not been completely obliterated, since that would require a more signif cant correction
that might make her appear jowly and could inter ere with her acial expressions, especially smiling.
Although there are hints o the major nasolabial old remaining, the secondary olds are completely cor-
rected. T e overall e ect is to decrease projection rom the olds, which gives the patient a more neutral,
healthy, and rested appearance.

473
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
Fig. 26-13, L-Q
P

Q
M
L
O
N
T e long-term result, years our months a er the initial surgery, demonstrates the permanent ablation
o the nasolabial old, even in a severe case such as this one. T e tilted (basal) views urther demonstrate
the correction o deep lines and olds. T e suctioning o the jowls appears to have helped balance her
ace to restore a slimmer appearance. T is type o dramatic ef ect is di cult with intradermal or subcu-
taneous placement alone.

474
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 26-13, R-T
R
S
T
Finally, photographs showing acial motion should always be taken. A smiling photograph o this patient
verif es that the correction has maintained a normal appearing, relaxed smile. T e middle photograph
shows a slightly ull jowl, which is less ull in the f nal a er photograph. I usually take photos o a broad
smile, a minimal smile (both showing teeth), and a pursed-lip photograph. T is patient’s smile conf rms
that even though volume has been placed into the perioral region, a normal smile results.
CASE 2
A
B
Fig. 26-14, A and B
T is 51-year-old woman presented or correction o her nasolabial olds. She had undergone at gra ing
3 years earlier by another plastic surgeon; she claimed that the correction was no longer present within
3 months.
During her initial consultations, we discussed the repercussions o just placing tissue into the nasolabial
olds without addressing the surrounding areas. Creases were clearly present in the lateral upper lip. Al-

475
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
though in this patient they are barely visible preoperatively, these types o creases tend to be accentuated
by placement o structure into the nasolabial old laterally.
We also noted that she had some minor early wasting o the anterior buccal region. T is hollowing
would be accentuated by any addition to the nasolabial region, especially on the le side. T ere ore we
decided to place a minor amount o at into the anterior buccal cheek prophylactically. Finally, when we
analyzed her marionette region; the primary problem in that area was seen to be more o an extension o
the nasolabial old than a marionette groove.
Photographs o patients when they were younger can be immensely help ul when analyzing the nasola-
bial olds and marionette grooves initially, but these are perhaps even more important during ollow-up
appointments. Rarely do patients recall having nasolabial olds when they were young. T ere ore they
o en expect that complete ablation o the olds is necessary to restore them to a more youth ul appear-
ance. Patients are more willing to accept a remaining hint o a old as normal i they can see the old in
their youth ul photographs.
C
D
Fig. 26-14, C and D
In this patient, the photo at 1 years o age demonstrates nasolabial olds at an early age. Eliminating the
old to a greater degree than what was present at 1 years o age might create a puf y or unnatural ap-
pearance. Relating this to patients be ore the procedure allows them to have more realistic expectations
and to be more tolerant o any residual old.
Fig. 26-14, E
E
VOLUMES PLACED

Right (cc)

Left (cc)
Nasolabial folds
Marionette grooves and
lower nasolabial folds
Buccal area
Outer upper lip
5
2.4
2.6
0.6
5
2.4
3
0.5
During the preoperative consultations, the patient and I decided not to completely eliminate the olds.
We elected to place conservative volumes or a so ening o the olds: cc is a low to normal amount or
placement into these types o olds. Frequently the delineation between the nasolabial olds and the mar-

476
Part III • Clinical Applications • Face and Neck: Aesthetic
ionette regions may not be easily divided into one distinct region or the other. For instance, in this pa-
tient the volumes placed into the nasolabial old and marionette grooves were di cult to separate rom
each other. T ere ore I combined the lower nasolabial old with the marionette region. T e amounts
placed into the upper outer lip are typical, although in some patients they may go to as much as 1.2 cc.
T e buccal placement in this patient is minimal.
F
G
H

I
Fig. 26-14, F-I
Changes in this patient are typical o those commonly seen a er nasolabial old correction. Although
there is a signif cant improvement, it is not the stereotypical changes that are o en anticipated by most
surgeons who per orm intradermal injections. T e most consistent change observed a er placement o
a volume o at into the subcutaneous planes o the nasolabial olds is that the old moves orward on
the ace to be arther away rom the underlying bone and dentition. T e mass e ect o the atty tissue’s
di use placement blunts the crease o the old, but a slight old remains. As noted, this type o old is
usually present in youth ul photographs o patients. T ere is also a texture change in the area o the at
inf ltration, with a decrease in f ne wrinkles and pore size. Even with care ul eathering, some increase
in the wrinkling o the skin can be seen where the eathering ends, especially in the medial marionette
region. I patients desire a greater change to specif c olds or wrinkles, adding additional ullness can
sometimes help.

477
Chapter 26 • Structural Fat Gra ting in the Nasolabial Fold
C ompl i ca ti on s
Because the most common complication a er ablation o the nasolabial old is the ormation o olds
medial or distal to the old olds, it is essential to address surrounding structures with eathering or inf l-
tration when indicated.
A
B
Fig. 26-15
Placement too superf cially or too discretely without eathering can result in visible, circumscribed cor-
rection, which is especially noticeable with acial motion. T is can easily happen especially when placing
at intradermally.
During deep placement o the at, it is possible to per orate the mucosa accidentally. T is can result in
contamination and potentially an in ection (see Chapter 5 ).
D i scussi on
SEQUENCING
I pre er to inf ltrate atty tissue into the nasolabial old be ore placing tissue into the cheek or lower
eyelid. I the cheek area is corrected f rst, the repeated insertion o a cannula through the cheek to inf l-
trate the area o nasolabial and marionette correction can create unexpected depressions. T e repetitive
movement o placing the at into the nasolabial old might disrupt the cheek at a er placement or even
precipitate the migration o structural at already placed into the cheek or lower eyelid. T ese depres-
sions may not be obvious intraoperatively because o the swelling created by the tissue placement already
per ormed in the cheek.

478
Part III • Clinical Applications • Face and Neck: Aesthetic
T ech ni ca l P ea rl s
• T e nasolabial olds and marionette grooves should be approached a er the cheek or lower eyelid.
• Placement o structural at into the nasolabial old and marionette grooves requires a complex matrix
or support. At least two layers should be placed in di erent directions.
• Feathering should always be done, except into uller areas.
• A type III 6 cm mini-cannula is requently used or superf cial inf ltration into the nasolabial olds and
marionette grooves.
• Intradermal placement o at with a 22-gauge needle may be help ul in so ening wrinkles or lines.
• Signs o vertical olds on the upper lip medial to the nasolabial old should be identif ed and eathered
over at least to that area.
• T e surgeon should take care not to create too much o a mound lateral to the old, because that can
accentuate the already existing old.
• Per oration o the mucosa should be care ully avoided; this is a primary cause o in ection.
• Fat gra ed to the subcutaneous planes does not have the same e ect as intradermal injections o at.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
RECOMMENDED READING
Coleman SR. Long-term survival o autologous at in the nasolabial old. Presented at the Con erence o the
Lipoplasty Society o North America, Seattle, Oct 1991.
Coleman SR. Long-term survival o at transplants: controlled demonstrations. Aesthetic Plast Surg 19: 21,
1995.
Gosain AK, Amarante M , Hyde JS, Yousi NJ. A dynamic analysis o changes in the nasolabial old using
magnetic resonance imaging: implications or acial rejuvenation and acial animation surgery. Plast Re-
constr Surg 9 :622, 1996.
Rubin LR. T e anatomy o the nasolabial old: the keystone o the smiling mechanism. Plast Reconstr Surg
103:6 , 1999.

479
C h a p t e r 2 7

d o o o d y od o - m o -
d ow . T m y o d o m o o m. Co -
y ood om om w o o m j d
vo m w v o m . J o x o b d by
m y m o o o o o , o o x o o y
o d b w o k ow w b d d ow
m w . W m o v y m d,
o y dj ’ om o o w m o v
y, yo , d mo .
A esth eti c a nd A na tomi c C on si d era ti on s
U d d w v ook k o o ; o m o d d
o dd o o w v o dj . I
o w y w - d , vo m dd d mo yw
y . How v , w o o w d, -
m o vo m m y o b m ov m d m y v d o m .
Fig. 27-1
A v , d bov , d y o b d o o d
w o , w om k o . T w o of om k o
St r uct ur al Fat Gr a t ing
in t he Lips
Sydney R. Coleman
479

480
Part III • Clinical Applications • Face and Neck: Aesthetic
either side o the Cupid’s bow and becomes less obvious laterally. Cephalad to the white roll, the skin
drops back rom the protuberance o the white roll to begin the slight concave curve o the upper lip.
T e upper lip has two distinct philtral columns curving in a similar concave ashion rom their origin
where the white roll hits the peaks o the Cupid’s bow to the columella. T at curve is dramatically more
concave in eriorly than superiorly. Under the Cupid’s bow, the vermilion o the lip has a well-centered,
distinct tubercle that is the most caudal element o an attractive upper lip. Medial to each commissure is
a ullness o the upper lip that is signif cantly less protuberant than the central tubercle in the vermilion.
Between the central tubercle and the lateral ullness is a concavity or slight depression.
Fig. 27-2
T e lower lip has a slightly protuberant rim like the white roll o the upper lip, but less distinctive in
color and turgidity. An attractive lower lip has elements that complement the upper lip ollowing the
shape, but the components are opposite those o the upper lip. A distinct central depression, essentially
a cle , is bordered on either side by tubercles signif cantly larger than the central protuberance o the
upper lip. T e alignment o the lower lip tubercles is oblique so that they push the central lip out into a
distinct pout. T e most important di erence between the upper and lower lip in a normal, young mouth
is that the amount o vermilion visible in the lower lip is much greater.
Placement o at into the orbicularis oris muscle is not an e ective strategy or encouraging eversion
o the lip. T is will produce a remarkable amount o superf cial swelling, which will look as though the
lip has everted to a more attractive shape. However, when the superf cial swelling dissipates, the lip is
permanently thicker without eversion o the mucosa and vermilion. T e only change that is seen on
photographs is a more protuberant lip without eversion.
Because the goal is eversion o the vermilion o the lip, care should be taken not to place any support into
an area that might oppose eversion. For instance, placement o atty tissue deep to the cutaneous element
o the lips will increase the structural support o the skin. T is may so en some o the vertical wrinkles
cephalic to the white roll or caudal to the rim o the lower lip. However, increasing the structural support
o the skin will invert the vermilion o the lips, making them appear smaller, relatively and absolutely.

481
Chapter 27 • Structural Fat Gra ting in the Lips
I n d i ca ti on s a n d P a ti ent S el ecti on
T e primary indications or lip augmentation are aging (see Chapter 3) and the patient’s desire or an
adjustment o acial proportion; o en these two indications can both be present in the same patient.
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Structural at gra ing to the lips can produce long-lasting enhancement o the upper and lower lip with
purely autologous material. Structural orm is one o the primary considerations with lip augmentation.
Consistently good results are obtained by placing tissue with care ul attention to the ef ect that injected
volume will have on ultimate lip shape.
Fullness should be placed primarily below the vermilion and mucosa to create a structural expansion o
the vermilion and mucosa. T is expansion advances the vermilion to evert the lip.
Markings
Fig. 27-3
T e green pen markings outline the plan or lip augmentation. T e green line below the white roll shows
the plan or placement into the vermilion below the white roll, not into the white roll. T e placement
caudal to the white roll will extend out almost to the commissure but will end approximately mm be-
ore the oral commissure. T e blueprint on the le and the markings on the right show that placement

482
Part III • Clinical Applications • Face and Neck: Aesthetic
into the body o the lip will be emphasized centrally and laterally to create a distinct concavity o the area
not marked in green.
T e beginnings o the philtral columns are marked as a reminder that placement o the at should be
extended slightly into the base o the philtral columns to slightly increase their turgor. T e lateral oblique
balls o the lower lip are also marked. T e lower lip placement is in the vermilion next to the cutaneous
lip, with no placement at all deep to the cutaneous element o the lower lip. Slight depressions in the
lateral cutaneous lip were identif ed in this patient and marked on the skin. T is is the only place that
structure will be placed under the lower lip cutaneous portion.
Anesthesia
A solution o 1% lidocaine with 1:100,000 epinephrine is used or in raorbital and mental nerve blocks.
T en 0.5% lidocaine with 1: 00,000 epinephrine is inf ltrated into the dermis at the incision sites be ore
the incisions are made. Next, 0.5% lidocaine with 1: 00,0000 epinephrine is inf ltrated into the superf -
cial muscle and submucosal planes using a type III cannula with placement o approximately 3 or cc
into each lip.
When I make an incision near mucosa, I give the patient prophylactic intraoperative antibiotics (usually
intravenous cephalosporin). I also ask patients to gargle with Peridex preoperatively.
Incisions
Midmalar
Commissure
Lateral chin
Fig. 27-4
T e incisions or placement into the upper and lower lip are most commonly made near the commissure
o the lip entirely on the cutaneous lip. I place the incision in a wrinkle line radiating rom the lip. Access
or the white roll placement is rom the incisions near the lip commissure on either side. Occasionally,
I use the midmalar incision or mandibular incisions or placement o some o the tissue, especially to
approach the cutaneous lips.

483
Chapter 27 • Structural Fat Gra ting in the Lips
Inf ltration Cannulas
Fig. 27-5
Type III
T e sharpest o the blunt cannulas, a Coleman type III inf ltration cannula, is used almost exclusively or
placement into the entire lip. T is cannula allows me to place the ref ned at with the greatest accuracy
into the plane immediately deep to the mucosa or vermilion. Over the past 10 years, I have been using
the style III mini-cannula with greater requency; now I use this mini-cannula mainly or placement o
at into the lips.
Level o Inf ltration
Success ul enhancement o the lip is not just a matter o placing a specif c volume o at into the lip. T e
level o at placement is o paramount importance to consistently realize any planned changes. Almost all
o the gra ed at should be inf ltrated into the most superf cial level, immediately deep to the vermilion
and mucosa.
Incorrect placement into muscle

Correct superficial fat placement
Fig. 27-6
Placement o at into the deep muscle o en does little more than increase lip projection in a orward di-
rection, which e ectively increases the distance rom the cutaneous lip to the teeth but does little toward
creating a more voluptuous lip with improvement o vermilion show.
Almost all o the gra ed at should be inf ltrated into the most superf cial level, immediately deep to the
vermilion and mucosa.

484
Part III • Clinical Applications • Face and Neck: Aesthetic
Placement Volumes
T e suggested placement volumes are as ollows:
• Restructuring o the white roll: more than 0.75 cc, but rarely more than 1.25 cc
• Lower lip rim: more than 0.75 cc, and less than 1.25 cc
• Body o the upper lip: a minimum o 1.5 cc, but rarely more than cc
• Slightly more than twice the amount placed in the upper lip is placed in the lower lip body
TECHNIQUE
White Roll
Fig. 27-7
Simple aesthetic augmentation o the lip begins by placing tissue into the area o the white roll. T is is
the most di cult and requires the most precise placement. A er the cannula tip is advanced almost to
the opposite commissure through the upper lip, it is withdrawn slowly across the most cephalic vermil-
ion with gradual pressure placed onto the plunger o the 1 cc syringe. T e goal is to lay down a small
increment o ref ned at. Placement into the white roll is usually approached rom both lateral incisions.
o add structure to the philtral columns, I divert the cannula up rom the vermilion into the columns.
T is placement is extremely superf cial, and the tissue is placed immediately under the skin, avoiding
insertion o at directly into the orbicularis oris muscle when possible.

485
Chapter 27 • Structural Fat Gra ting in the Lips
Lower Lip
Fig. 27-8, A-C
A
B
C
T e approach or lower lip placement is almost identical to that used or the upper lip white roll. T e
gra is placed in the immediate subdermal layer in the vermilion just cephalic to the cutaneous border
using a Coleman type III mini-cannula. Most o the tissue is placed along the lower lip rim into the cen-
tral two thirds o the lip. Care is taken to place this tissue extremely superf cially and in the vermilion
only.
Fig. 27-8, D-F
D
F
A er establishing a turgid rim, the ocus turns to creating oblong “balls” or protuberances on each side
o the lower lip, just lateral to the center o the lip. T e depth o placement is immediately under the mu-
cosa and vermilion with a type III mini-cannula. T e key to placement is central eversion o the lower lip
while leaving a distinct def ciency, almost a cle , centrally.
E

486
Part III • Clinical Applications • Face and Neck: Aesthetic
A er an initial volume rom one side is placed, a similar amount is placed into the opposite side through
its ipsilateral incision.
T e ocus o lower lip vermilion augmentation is the ormation o lateral oblong balls with a central de-
f ciency or cle . T e ocus o mucosal placement is to encourage a central pout or eversion o the lower
lip. A er establishing the shape o the lateral oblong balls in the vermilion, some central lip placement is
eathered between the lateral balls to orce out a central prominent pout rom the lower lip while creat-
ing the lateral oblong balls. A thin layer o tissue is placed all the way to the renulum o the lower lip to
encourage eversion o the lower lip.
Upper Lip
Fig. 27-9
In the upper lip, placement starts in the central ourth o the lip with a type III mini-cannula. T e level
is against the vermilion and mucosa centrally. T e placement in the upper lip is in the same depth as the
lower lip, but the areas into which the at is placed are opposite o those used in the lower lip.
Placement continues where it le o with the white roll. T e central ourth o the upper lip is inf ltrated
under the vermilion by repeated linear injections into a level immediately under the vermilion, creating
a layer o tissue extending rom the white roll back into the mucosal lip almost to the renulum. Everting
the lip with the opposite hand allows more predictable immediate subcutaneous placement.

487
Chapter 27 • Structural Fat Gra ting in the Lips
Most Likely Technical Mistake
Placement o at immediately subdermal and cephalic to the cutaneous white roll creates an unattractive
pu y appearance o the skin and at least partially reverses the intended eversion o the vermilion.
POSTOPERATIVE CARE
No dressings are used on the lips. Patients are told that the wet mucosa will undergo keratinization and
become dry mucosa or vermilion. During this process, the lips may peel. Moisturizers or ointments are
help ul during this process. Patients should not massage the lips in the f rst weeks; however, they are
encouraged to move the orbicularis oris muscle in an attempt to promote lymphatic drainage. T ere are
no urther restrictions on lip motion a er the procedure.
7 days postoperatively

44 days postoperatively
4 days postoperatively
Fig. 27-10
Recovery rom at gra ing to the lips is usually one o the most di cult o any part o the ace, because
o the degree and duration o swelling.
When per orming several procedures on a patient, the surgeon should save the lips or last to avoid con-
taminating the other areas o the ace or body. o accomplish lip augmentation with increased vermilion
show, at should not be placed deep to the vermilion or mucosal portion o the lip, because it can expand
this area and actually decrease the amount o vermilion show. Because the white roll o the upper lip
does not extend all the way to the commissures, placement o at to strengthen or recreate a white roll
should not be extended all the way to either lateral commissure. Small lumps are amazingly well toler-
ated in the lip; large ones are not.

488
Part III • Clinical Applications • Face and Neck: Aesthetic
Initial fat grafting procedure: March 2003
July 2004
January 2007
February 2016
Fig. 27-11

489
Chapter 27 • Structural Fat Gra ting in the Lips
T is 3 -year-old woman presented with subcutaneous atrophy and scarring as a result o chronic acne
as well as iatrogenic de ormities caused by attempted acne corrections. She also had some aging-related
acial atrophy. o address these concerns, structural at gra ing, small needle additions, and the lysis
o adhesions were per ormed in the ollowing areas: the upper nose, the glabella, the orehead temples,
the lower and lateral eyelids, the cheeks, the nasolabial and marionette olds, the lips, the chin, and the
jawline.
Fat was harvested rom the patient’s lateral thighs and abdomen. Into the cutaneous portion o the up-
per lateral lip, 0.3 cc was placed on each side. Into the white roll o the upper lip, 0. cc was placed with
a -gauge needle, and .5 cc was placed into the lip itsel . In the lower lip, 0. 5 cc was placed with a
-gauge needle, and 6.5 cc more was placed using a type III cannula.
Six months later, the patient returned or additional structural at placement to treat her severe acne
scarring and iatrogenic acial de ormities. Fat was harvested rom the patient’s abdomen and placed in
a ected areas o her ace, with 1.0 cc placed in the upper lip, .5 cc placed in the lower lip, and 0.3 cc
placed in the philtrum.
About a year a er the f rst procedure, the patient underwent urther treatment o the nose and lip areas.
Fat was again harvested rom the lateral thighs and processed in the usual ashion. During this proce-
dure, . cc o at was suctioned rom the le anterior border o the lip.
Four years a er the initial procedure, the patient returned or structural at placement to the lip and to
other areas o the ace to continue to treat iatrogenic de ormities and acne scarring. Fat was harvested
rom the patient’s abdomen and anks, processed, and then placed with a sharp -gauge needle or a
type III cannula. During this procedure, the ollowing amounts were placed into the lip area: right upper
lip body, 1.5 cc; le upper lip body, 1.0 cc; white roll, 1.0 cc; and le upper lip scar, 0. cc.
T e f nal row shows the patient approximately 13 years a er the initial procedure was per ormed. Note
the longevity o the result.

490
Part III • Clinical Applications • Face and Neck: Aesthetic
R esul ts
CASE 1
Fig. 27-12
In March 1 87, I placed 1 cc o autologous subcutaneous tissue into the upper lip o this patient, thereby
producing distinct changes in the lip’s size and shape. Note the bif d le nasolablial old. I injected only
the lateral branch o the old, and le the medial old as a control; 2.5 cc was inf ltrated into each naso-
labial old. She returned 3 days postoperatively showing moderate bruising and swelling. T e upper lip
demonstrated a slight eversion, and the white roll appeared tightened. O particular note, the medial le
branch o the nasolabial old was obvious, and the lateral branch was completely corrected. I was able to
ollow this patient or 77 months, and she was one o the early patients that allowed me to believe that
transplanted at had the potential to be permanent. She maintained the correction commensurate with
the small amount o at placed. I have ollowed thousands o other patients over the past 3 years with
similar longevity.
By 1 5, a er attempting numerous approaches to augmentation o the lips with at, I arrived at a spe-
cif c technique that acknowledges that the lip has def nite contours that must be respected or enhanced
to produce an aesthetically appealing change.

491
Chapter 27 • Structural Fat Gra ting in the Lips
CASE 2
Fig. 27-13, A and B
A
B
In 5, this 50-year-old patient presented with lips that were already aesthetically appealing but no
longer as everted as when she was young. T e lower lip was no longer the dominant larger lip, and the
upper lip was not as ull as in her youth.
Fig. 27-13, C and D
C
D
As always, more attention was directed to planning the shape than in considering the volume. T e mark-
ings made on the patient’s lip re ect the plan. T e approach to the lower lip emphasizes the dramatic
eversion o the central lip while minimizing placement into the central lip. T is is accomplished by
primary placement into the previously described oblong balls o the lower lip. T e alignment o these
oblong structures is such that their axes converge above the most protuberant point o the pouty lower
lip. On this patient, the upper lip markings were drawn to emphasize eversion o the central tubercle o
the upper lip. However, some eversion o the lateral upper lip is desirable. It is this eversion o the lateral
upper lip vermilion show that establishes the apparent width o a lip.
A total o 6 cc was placed into the lower lip. Into the upper lip, f rst . cc was placed caudal to the white
roll, then .5 cc was placed into the upper lip, emphasizing the central and lateral tubercles, but with
some at placed in the concavity between them. Finally, . cc was placed to emphasize the philtral col-
umns.

492
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 27-13, E-G
4 days postoperatively
E
17 days postoperatively
F
1 year postoperatively
G
Swelling at days and at 17 days a er surgery is alarming to patients. I always warn them that they will
not look recognizably human, but more like a monster or at least a week. Recovery rom at gra ing in
the lips is the most di cult, because it can take up to weeks be ore the patient eels somewhat com ort-
able. Although visible swelling in this patient had completely resolved by 3 months, the patient claimed
to eel changes in the texture as well as the size o her lips or up to 8 months.
Fig. 27-13, H-M
H
I

J
Preoperative
K
L
1 year postoperatively
M
8 years postoperatively
T e patient returned at 8 years with little i any change rom her f rst-year ollow-up. She had had no
procedures per ormed on her lips and had no f llers placed. She maintained obvious eversion o the lips
in good orm. I anything, the eversion is slightly more than I would want. In the last ew years, I have

493
Chapter 27 • Structural Fat Gra ting in the Lips
tended to place less atty tissue, trying to emphasize eversion over volume. I I were to augment the lips
on this patient now, I would place less than hal o the 1. cc placed into the philtral column, and I would
place less than 1 cc into the area o the white roll.
N
O
P
Q
Fig. 27-13, N-Q
T e ring ash oblique views allow a dif erent analysis o the augmentation. One can see that despite the
sizable volume added to the upper lip, there appears to be more incisor show as the lip is everted. In
addition, the length o the upper lip is shortened both by the eversion and by the relative increase in the
vermilion o the upper lip, which makes the cutaneous portion less o the overall lip.

494
Part III • Clinical Applications • Face and Neck: Aesthetic
CASE 3
Fig. 27-14
T is 2 -year-old woman presented with a desire or uller lips. A total o 0 cc o at was harvested rom
her lower back, processed to yield 10 cc, and then placed as ollows: white roll o upper lip, 1 cc; border
o lower lip, 1 cc; body o upper lip, 2.3 cc, and body o lower lip, 2 cc. T e patient is shown preopera-
tively and 1 year af er treatment.

495
Chapter 27 • Structural Fat Gra ting in the Lips
CASE 4
Fig. 27-15
T is -year-old patient presented or the treatment o dif use subcutaneous acial atrophy that was
treated with structural at placement to the lips, in addition to other procedures. A total o . cc o at
was placed into the upper lip, and . cc was placed into the lower lip. Five months later, a second-stage
procedure was per ormed to address residual atrophy, and another 1.3 cc was placed in the upper lip.

496
Part III • Clinical Applications • Face and Neck: Aesthetic
About 11⁄2 years a er the f rst procedure, the patient’s acial atrophy was addressed again: 1 cc was placed
in the right upper cutaneous lip, and 0.3 cc was placed in the right upper lateral lip. Another 3 cc was
placed in the lower lip muscle, 0.5 cc in the right lower lateral lip, and 0.5 cc in the le lower lateral lip.
Almost years a er the original procedure, the patient returned or additional structural at gra ing.
Several areas o the ace were addressed, including 0. cc o at placed in the line o the upper cutaneous
lip, 0.1 cc placed in the line o the le upper cutaneous lip, 0. cc in the body o the le upper lip, 0. cc
in the lower lip, 0. cc in the right lateral corner o the lip, and 0. cc in the le lateral corner o the lip.
C om p l i ca ti on s U
ni q ue to th e L i p
SPLITTING OF THE LIP
Fig. 27-16
In my practice I have had patients who experienced rupture o the skin o the lower lip several times.
T is is a situation in which tension placed on the lower lip creates enough internal pressure to create
spontaneous lacerations that split the lip open in several locations. Such lacerations are closed with sim-
ple interrupted sutures. Because this lip splitting has happened only in the lower lip, when it occurs it
limits the volume o at gra ed in that case. For that reason, I usually place at into the body o the lower
lip f rst, a er which I place at into the body o the upper lip.
UNUSUAL COMPLICATIONS
Scarring
I have seen one signif cant scar in the lip o a patient a er superf cial placement o at with a sharp needle
into the white roll area at the same time as a deep trichloroacetic acid ( CA) peel was per ormed. Since
then I have restricted topical therapies done at the same time as at placement in the lip to occasional
dermabrasion o the cutaneous lip above the white roll.

497
Chapter 27 • Structural Fat Gra ting in the Lips
Pyogenic Granulomas
Fig. 27-17

A pyogenic granuloma can develop a er at gra ing to the lip. T ese granulomas probably develop sec-
ondary to trauma to the mucosa and can be treated with excisional biopsy and electrodesiccation o the
resulting de ect.
Necrosis of the Lip
Fig. 27-18

T is patient presented 1 year a er signif cant necrosis o her lower lip occurred ollowing injection o
at into the marionette lines with a -gauge needle. I am also aware o cases o patients who developed
signif cant necrosis o the lip a er Restylane injections. Presumably, in these cases the embolus caused
by an intraarterial injection o the f ller precipitated the necrosis.
I have never personally witnessed or heard a report o lip necrosis with at gra ing when a blunt cannula
has been used. It would be very di cult to cannulate an artery in any plane using a type III cannula.
Furthermore, no signif cant arterial branches are usually present in the extremely superf cial level I rec-
ommend or placement o the at. With deep placement into the muscle or when a sharp needle is used,
intraarterial injection can be per ormed more readily.

498
Part III • Clinical Applications • Face and Neck: Aesthetic
D i scussi on
Meticulous planning is paramount in determining proper placement o at in the lip. Placement o at
into di erent levels or parts o the lip leads to di erent results. o precipitate a change in the intrinsic
shape o a lip, the surgeon should pay particular attention to the level and anatomic areas into which
the at is placed. o attain consistent results with lip enhancement, the surgeon should devise a care ully
considered strategy that aims at a specif c shape or the lip.
C oncl usi on
T e goal o lip augmentation is to ip out the vermilion o the lips to create attractive, pouty lips with the
least volume possible. T is is accomplished by superf cial layering o structural at immediately under
the mucosa and vermilion to increase the exposed sur ace area o the lip.
T ech ni ca l P ea rl s
• o accomplish lip augmentation with increased vermilion show, at should not be placed deep to the
cutaneous portion o the lip because it can expand the lip and actually decrease the amount o vermil-
ion show.
• Small lumps are amazingly well tolerated in the lip; large ones are not.
• Flipping out the lip can shorten the upper lip in two ways: (1) By actually shortening the distance rom
the columellar base to the height o the Cupid’s bow—the action o turning up the lip; or ( ) probably
most important, by increasing the amount o vermilion visible—the relative proportion o the cutane-
ous lip to the vermilion lip is adjusted.
• Maxillary incisor show will be in uenced by lip augmentation. With eversion o the upper lip, it is
possible to attain a signif cant increase in maxillary incisor show as in the last patient. However, in
some patients, even with signif cant eversion the maxillary incisors may show less because o a slight
descent o the upper lip.
• Mandibular incisor show can also be changed during lip augmentation. Because the aging lip leads to
increased visibility o the lower incisors, it is desirable to push the entire lip up slightly to hide them
by placing more into the submucosal plane o the lower lip, and sometimes into the orbicularis oris
muscle itsel .
• T e philtrum is approached in one o two ways: (1) By simply running the type III mini-cannula up
into the philtral columns while placing tissue below the white roll. Although the -degree angle may
appear sharp, it is usually easy to navigate; or ( ) by making a central incision in the vermilion about
1⁄2 cm in erior to the Cupid’s bow and passing the type III mini-cannula up through the base o the
philtral column to the columella. As described previously, I start placing the tissue deep using f ve to
eight passes to deposit less than 1⁄30 cc each time.
• Augmentation o the muscle will initially cause eversion o the lip vermilion and mucosa by creating
edema o the tissues overlying the muscle. As the swelling subsides, so does the eversion o the vermil-
ion and the apparent augmentation.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.