Fat Injection From Filling to Regeneration

(Trang không có chữ)

501

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St r uct ur al Fat Gr a t ing in t he
Chin and Ja l ine
Sydney R. Coleman
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Part III • Clinical Applications • Face and Neck: Aesthetic
standing can a surgeon control the shape o the chin or jaw to restore it to a more youth ul or attractive
appearance.1-3
Fig. 28-2
T e contour o a young, healthy chin has a distinct shape consisting o two distinct lateral protuberances
with a central attening or a cle . I re er to this topographic relationship as the “ball-ball” o the chin.
T e lateral bulges project orward more than the central attened or depressed area; thus it is the lateral
chin that establishes the anterior projection o the chin.
T e distance between these two “balls” determines the shape o the chin. When they are close together,
a more pointed chin results, with less attening o the midline. When the prominences are ar apart, as
is typical in a young man, the separation creates a more angular chin with more midline def nition. In
many cases the midline def nition can result in a cle , especially in younger chins.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Fig. 28-3
T e chin ages primarily by losing lateral and in erior ullness while retaining central ullness. As lateral
and in erior volume is lost rom the aging mentum, a “button” emerges in the upper middle chin area.
T is residual central bulge projects orward on the chin to become the most anterior point o the aging
chin. As the volume rom the lateral and lower chin is lost, the chin becomes more pointed and the
youth ul curvature o the lower chin attens out in an oblique path, dropping of rom the new central
point o projection down to the submentum.
Although the middle o the chin appears to protrude more, the atrophic lateral chin can sag laterally,
creating an overall appearance o chin widening rom a rontal view. From the side view the lower chin
attens out (at a slant), running rom the central button down to the shortened border o the mandible.
As the youth ul ullness o the chin is lost, the chin’s thin skin alls into creases. Sometimes these ur-
rows will develop in areas where lateral ullness has diminished, but o en their development is random,
ollowing no discernible pattern. T ese creases may project unintentional emotional expression on the
person’s ace, such as anger or rowning, which may in act be the opposite o what the person is eeling.

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Part III • Clinical Applications • Face and Neck: Aesthetic
T e young, healthy mandibular border is ull and strong and has a distinct lateral ullness cephalic to the
most caudal extent o the border. It is this lateral ullness that is especially prominent posteriorly that
catches the light to create a strong jawline shadow rom the angle to the chin.
As in the rest o the ace, generalized ullness between the skin and bones is lost with advancing age. As
that underlying ullness is reduced, the ace de ates. T e enveloping sack o skin remains the same size,
but without the underlying ullness and support. T e emptied skin drapes around the underlying struc-
tures o the ace exposing the acial muscles, the skull and many pockets o at. T is is a generalized loss
o subcutaneous ullness, not a loss o at.
A glance behind the mandible at the aging earlobe reveals a similar loss o volume, only with a di erent
type o de ation. T e earlobe resembles an empty balloon that hangs; this is a clear example o descent
directly ollowing atrophy.
Aging o the so tissue covering o the mandible is a more complex process, but the primary mechanism
is still de ation and radial entropy. As the so tissues that rame the jawline disappear, the def nition o
the jawline becomes blunted. Without the lateral projection o ullness, the angle o the mandible loses
its distinct shadow and appears to melt rom the buccal region into the neck.
Fig. 28-4
T e largest collection o at in the mandible is located at the jowl. T is collection o at is tethered with
ligamentous attachments anteriorly. As the so tissue ullness o the entire mandible recedes, the at o
the jowl, which was ormerly obscured by surrounding ullness, emerges. In other words, the at o the
jowl and the skin are the most obvious stable so tissue elements o the mandible, and the rest o the
lower ace disappears around it. T e jowl does not descend, but instead the border o the mandible as-
cends, leaving the jowl below. T us the ace does not get longer but shorter with age. It e ectively short-
ens rom the lateral and oblique views.
As the jawline so ens and retreats upward, the submental contents are exposed. T e submaxillary gland
and digastric muscles do not descend, but rather the jawline ascends to expose them. Likewise, as the
jawline narrows with loss o ullness, the structural support that distracted the lower ace laterally dis-

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
sipates. A lack o support provided by the radial expansion by the sof tissue over the mandible allows
the unsupported skin to be pulled downward by gravity. T is downward movement is almost entirely
secondary to a loss o radial support.
T e young, healthy mandibular border is ull and strong and has a distinct lateral ullness cephalic to the
most caudal extent o the border. It is this lateral ullness that is especially prominent posteriorly that
catches the light to create a strong jawline shadow rom the angle to the chin.
A n a tomi c C on si d era ti on s
T e positions o the major salivary glands, the marginal mandibular branch o the acial nerve, the sub-
mental nerves, and the acial artery should be noted. Although none o my patients has had a permanent
injury to any o these structures, there have been temporary injuries to all o them.
Parotid fascia (SMAS)
Depressor anguli oris muscle
Marginal mandibular branch of facial nerve
Platysma
Mandible
Facial vein
and artery
Masseter
muscle
Parotid
gland
Fig. 28-5
T e parotid and submandibular glands should be respected in this region. o avoid per orating and
potentially injuring the parotid gland, I do not graf at into the deep planes o the mandible rom the au-
ricular or malar incisions, because I would have to per orate the parotid gland to place tissue that deep.
For that reason, tissue is not placed into the deep planes against the bone o the posterior border o the
mandible rom any access site other than the border or midline incisions.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Depressor
anguli oris
muscle
Depressor labii
inferioris muscle
Marginal
mandibular
branch of
facial nerve
Facial vein and artery
Marginal mandibular branch of facial nerve
Depressor anguli oris muscle
Fig. 28-6
When the anterior border o the mandible is approached, I switch to the most blunt inf ltration cannula
to avoid injury to the marginal mandibular nerve. T e injuries that I have experienced were all in con-
junction with suctioning o the jowl area with a harvesting cannula attached to a 1 cc syringe; there ore
I assume that the injury to the marginal mandibular nerve was most likely rom the suction applied by
the much larger suction cannula. For that reason, I now use a Coleman type I blunt inf ltration cannula
or removing any excess jowl at, and I attach it to a much smaller 3 cc syringe.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Second
mandibular
premolar
Marginal mandibular branch of facial nerve
Orbicularis oris muscle
Mental nerve
Depressor labii inferioris muscle
Mentalis muscle
Depressor anguli oris muscle
Marginal mandibular branch of facial nerve
Orbicularis oris muscle
Mental nerve
Depressor labii inferioris muscle
Mentalis muscle
Depressor anguli oris muscle
Fig. 28-7
When approaching the chin, I also try to switch to Coleman type I inf ltration cannulas to avoid trauma
to the mental nerves. No patient has complained about anesthesia in the chin, but a traumatic injury to
this area is still a def nite possibility, and all e orts should be made to avoid the problem.

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Part III • Clinical Applications • Face and Neck: Aesthetic
T e key to mandibular and chin placement is understanding the three-dimensional shape o an attrac-
tive mandibular border and chin to create a strong, appropriately shaped mandibular border with a
submandibular shadow. o accomplish this goal, the “ball-ball” structure o the attractive chin must also
be reproduced.
T e jawline can be restructured to strengthen the border o the mandible and enlarge the chin, thereby
changing acial proportion to project a more cleanly sculpted prof le.
MARKINGS
Fig. 28-8
T e green markings delineate the planned areas o structural change in shape. T e red dashes indicate
the placement o incisions or access with the blunt cannulas. T e orange marking indicates areas in
which there will be no tissue augmentation.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
I n d i ca ti on s a n d P a ti ent S el ecti on
Fig. 28-9
T e f rst patients to present in my practice requesting mandibular strengthening were young men and
women, such as this patient, who simply wanted a slightly stronger mandibular border. T is young man
came to my o ce in 1 7 requesting augmentation o his jawline and lateral brow. His result is shown
7 years a er one procedure to those two areas. He also had augmentation o his anterior malar area.
A

B
Fig. 28-10, A and B
Chronic acne destroyed the mandibular border o this -year-old man. He is an excellent example o
how loss o structure in the chin and jawline can produce a sickly, portly appearance, even in a young
person.

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Part III • Clinical Applications • Face and Neck: Aesthetic
A decade o cystic acne had destroyed the subcutaneous tissue o his chin and jawline. With loss o the
subcutaneous tissues that rame the bony mandible, the border rom the chin to the angle had become
poorly def ned and the radial vectors that normally support the overlying skin were no longer present, so
the unsupported skin o the lower ace was pulled downward by gravity.
C

D
Fig. 28-10, C and D
T e patient is shown year a er structural augmentation o his chin, jawline, cheeks, and temples. T e
only procedure per ormed was structural at gra ing; no tissue was removed rom his ace. T is case
dramatically highlights the principle that in structural at gra ing, the di erence between unattractive
and handsome is only a ew millimeters.
Adding only a ew millimeters o structure to the jawline and chin has re ramed his mandible so that it
is now clearly delineated. Lowering the mandibular border hides a portion o the submental contents
and the radial vector; expanding the jaw distracts the submental excess laterally, resulting in a dramatic
change in acial proportion.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Fig. 28-11
Patients who eel that their mandibular borders are poorly def ned are good candidates or augmenta-
tion o the mandible and chin. T e most common reasons that people seek this correction are aging and
iatrogenic de ormities a er aceli s, as was the case with this woman, who presented a er a aceli le
her with a much-elevated jawline that exposed her submental contents. She is shown 3 months a er
restructuring o her mandibular border with structural at.
Although the primary reason or at gra ing in the chin has been or augmenting and reshaping the
chin, irregularities, asymmetries, and ptosis are also indications or structural augmentation o the chin.
Reconstructive indications include secondary or even primary treatment o maxillo acial and cranio a-
cial de ormities, along with restoration o mandibular so tissue lost rom trauma or neck dissections
and a large variety o mental de ormities. Caution should be exercised when strengthening the mandib-
ular borders in women, because it is easy to create a jawline that is too power ul or masculine.

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Part III • Clinical Applications • Face and Neck: Aesthetic
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Anesthesia
Fig. 28-12
Local inf ltration is done with 0. % lidocaine with
: 00,000 epinephrine, placed with a type I can-
nula. T e periosteum is di cult to anesthetize, so
sedation is almost always indicated.
Incisions
Midmalar
Commissure
Midmandibular border
Auricular
Submentum
Midmalar
Auricular
Commissure
Midmandibular
border
Submentum
Fig. 28-13
Incisions or insertion o the cannulas are made along the border o the mandible at the midline in erior
to the chin (the midline-chin incision) and between the midline and the angle o the mandible (the

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
“border incision”). I occasionally make incisions in the lateral chin between the lip commissure and the
border o the mandible, but recently have been accessing the area in this direction rom the oral com-
missure incision only. I use an in erior postauricular incision also, and occasionally place tissue onto the
mandible rom the malar incisions.
Inf ltration Cannulas
Fig. 28-14
Type I
Particular attention should be paid to the acial anatomy when planning and making these incisions and
placing the cannulas. I use a 7 cm Coleman type I cannula when I begin placement through the mandib-
ular incision.
Fig. 28-15
Type II
Af er establishing the plane through the incision in the middle o the border o the mandible, I usually
switch to a Coleman type II straight cannula or placement against the bone in the posterior mandible
and a Coleman type II curved cannula or placement against the bone going to the anterior mandible.
From the postauricular, midmalar, and oral commissure approaches, the tissue is usually placed with a
type II cannula also.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 28-16
Type III
V-dissector
For particularly adherent scars or ligamentous adhesions, a Coleman type III cannula or V-dissector can
be used. oo much dissection o the underlying planes can lead to migration o the placed at.4 Attempts
should be made to gra the tissue with a type II cannula be ore using a V-dissector, and most o the de-
sired volume should be placed be ore attempting to use a V-dissector, because the tissue planes will be
much less stable.
Level o Inf ltration
Platysma
Facial vein and artery
Masseter
Parotid
gland
Mandible
Fig. 28-17
T e level o placement or most mandibular and chin placement extends rom the skin to the bone, de-
pending on the desired outcome. T e skin placement can be emphasized or the correction o accompa-
nying skin problems: scarring, wrinkling, sur ace irregularities, and adhesions. Deeper placement next
to bone provides more o a structural volume that can be used as sca olding or more subtle superf cial
placement to change the basic shape o the mandible and chin.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Volume Ranges
T e volumes that I place in the chin and mandible vary enormously, depending on the patient’s current
acial topography, the desired changes, and the age and sex o the patient. Even or the most minor cor-
rection on the posterior border o the mandible, I would place 3 or 4 cc. However, it is not uncommon
or me to place 4 cc, and I have placed as much as cc in the posterior border o the mandible.
In the chin the amounts vary enormously, depending on the change in shape or the increase in projec-
tion desired: or 3 cc may help with so ening the urrows or creases in the chin, but cc is needed to
see a change in projection, and to 0 cc is needed or a signif cant change in projection and shape.
Most Likely Technical Mistake
Suctioning the jowl at the same time as placing tissue runs the risk o having the transplanted atty tissue
migrate into the previously suctioned jowl. opical pressure on the newly gra ed areas can orce small
amounts o at into the reshly suctioned area. For that reason I requently will delay suctioning until a
later procedure.
TECHNIQUE
Placement begins through the midborder incision. A style I cannula is always used when f rst placing a
cannula through the border o the mandible incision and when proceeding deep in either direction. T e
cannula is brought down to the mandibular bone and a path is established, hope ully around the acial
artery and the marginal mandibular nerves.
Fig. 28-18, A and B
B
A
T e initial tissue is gra ed against the periosteum in a radiating ashion rom the incision site, anning
out caudally to wrap around the posterior border o the mandible and proceeding cephalic to the level
planned preoperatively. A er this f rst layer o at is gra ed against the periosteum, the plane o place-
ment switches to a slightly more superf cial layer, but just immediately above the periosteum. T is is
more o a basic ramework rom which the shape o the mandible will be developed. T e limits o place-
ment in a cephalic and caudal direction depend on the shape, which is determined preoperatively.

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Part III • Clinical Applications • Face and Neck: Aesthetic
D
Fig. 28-18, C and D
C
T e at is gra ed gradually into more superf cial layers until the skin is reached and I can see the cannula
glistening through the skin. It is this layer that determines the shape o the posterior mandibular border
and the surgeon should have a vision o the shape to be created. Placement should proceed in a prospec-
tive ashion to create the planned shapes and volumes.
E

F
Fig. 28-18, E and F
T e mandible is approached rom several angles. Accessing the mandible rom behind provides an addi-
tional direction or superf cial placement into this area. T e surgeon must maintain a three-dimensional
image o the parotid gland at all times when placing tissue rom the retroauricular or malar region, be-
cause per oration o the parotid with a cannula can result in parotitis.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Fig. 28-18, G and H
G

H
I sometimes approach the posterior mandible with an additional access point: the midmalar. From this
approach, yet another dimension can be added to this area. T e combination o the three incisional ap-
proaches allows a large volume o tissue to be placed in a more stable manner than might otherwise be
possible. T is is particularly important or placement o the large volumes in specif c three-dimensional
shapes that I hope to attain.
Fig. 28-18, I and J
I

J
Finally, a cannula inserted at the symphysis is used to place a small amount o tissue into the juncture o
the border around the area o the incision. Because the border incision usually coincides with the area o
the jowl, I am concerned about placing tissue into the jowl. However, placement o tissue under the area
o the jowl is help ul or creating a sharp, continuous mandibular shadow.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 28-18, K and L
K
L
Next, the anterior border o the mandible is approached through the incision along the middle o the
mandibular border. T e placement is initially deep against the periosteum, then wraps up along the sur-
ace to the area o the chin. Each layer becomes slightly more superf cial in tiny increments.
Fig. 28-18, M and N
M

N
It is the most superf cial placement that determines the f ne points o the shape o the chin and anterior
mandible. T is placement may be able to minimize acne scarring and chin sur ace irregularities.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Fig. 28-18, O and P
O

P
I also place a limited amount o at along the anterior mandibular border rom the midline symphysis
incision.
It is during this placement period that the surgeon must pay particular attention to the shape o the chin.
T e young, healthy chin is not a single globule, but two spherical protuberances, usually with a cle or at
least a attening in the central mentum separating the two “balls”—the “ball-ball” e ect. With age, the
ball-ball e ect gradually subsides, and both balls atrophy to leave behind a central button or a chin. A
similar process can happen with acne scarring o the mentum. T at central protuberant button replaces
the ormer depression.
Fig. 28-18, Q and R
Q
R
Next, the chin is approached rom each oral commissure. Usually a style II cannula is used and the layer-
ing is, as is usual in most areas o the ace, rom the deep tissues next to the periosteum to the superf cial
skin. From these incisions, the surgeon can help create the spherical shape o the ipsilateral chin as well
as the contralateral chin.

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Part III • Clinical Applications • Face and Neck: Aesthetic
By expanding both laterally (radially) and in eriorly, the so tissue is restored rom immediately below
the ear down to the angle and then orward to the area o the jowl. T e result is a more attractive and
youth ul shadow along the jawline.
Although the chin and jawline will def nitely be swollen at the end o the procedure, the orm should still
be aesthetically appealing and resemble the f nal outcome. Every attempt should be made to create a bor-
der without undulations and irregularities. Since the structures are bound by the proximity to bone at all
points, the swelling seems to be less than occurs in the lips. Obviously, one has to account or swelling
rom the placement o lidocaine and or the local swelling. However, caution should be exercised in the
mandible and chin to avoid overcorrection.
POSTOPERATIVE CARE
Recovery rom placement o tissue into the mandible is much better tolerated than with other areas o
the ace. Patients usually like their appearance when there is slight swelling in this region, and patients’
riends and acquaintances have a tendency to notice the swelling less than in other areas. In addition,
because dental surgery is much more acceptable in many social circles, i others notice the swelling, they
will o en attribute it to a dental procedure.
Special Dressings
A strip o medium-thickness Reston oam is placed along the entire length below the border o the
mandible rom the angle to the midline. T is is a layer o oam rubber with adhesive on one side. o
supplement the creation o a cle o the chin, I will usually place a strip o the Reston oam vertically
along the central mentum.
I I suction any at rom the jowl or submentum, I also place a cutout o the Reston oam designed to
cover the area. T e Reston oam is secured only with a chin/neck bandage; however, this bandage can
cause shearing o the skin attached to the edge o the oam, in this area in particular. T e shearing can
result in partial-thickness skin loss with accompanying hyperpigmentation o the skin. For that reason
I no longer recommend the use o just Reston oam and a Velcro-secured chin/neck bandage. Instead,
I now create a subtle pressure on the Reston oam with one or two layers o Micro oam tape. Care must
be taken to avoid buckling the tape while placing it. I urther secure the Micro oam tape with a Velcro-
astened chin/neck bandage. T is combination does not seem to result in the sheering seen with the
Reston oam and chin/neck bandage alone.
As in the rest o the ace, a layer or two o Micro oam tape is placed over any o the areas into which tis-
sue has been gra ed on the lower ace or neck. T is helps reduce swelling and prevents the patient rom
manipulating the area until the placed at is stented by the onset o swelling over the next 3 days.
Massage
Patients are instructed to avoid massaging the mandible, chin, and neck or weeks, especially i the jowl
or submentum was suctioned. A er weeks, gentle massaging is recommended, especially in the areas
o suctioning, since suctioned areas remain hard or a much longer period than gra ed sites.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
R esul ts
Fig. 28-19, A and B
A

B
When this 4 -year-old woman presented to my o ce, she brought this photo o hersel taken 0 years
earlier. She complained that she now looked “tired and old.” Also, “ or vanity’s sake,” she said, she wanted
bigger cheeks, a squarer jaw, and a more signif cant chin. She specif cally noted when looking at her old
photograph, “I had a great jaw when I was young. Can I ever get it back?” She has obviously lost the ra-
dial support o her more youth ul ace back at the angle and along the anterior border o the mandible.
C
VOLUMES PLACED

Right (cc)


Left (cc)
Nasolabial folds
Marionette grooves
White roll
Upper lip
Lower lip
Chin
Anterior mandibular border
Posterior mandibular border
Cheek
Brow/forehead
Glabella
4
3.5
4.5
12
19.5
16.5
0.75
3
6
11
1.5
3
3
4.5
12.5
17.5
10
Fig. 28-19, C
T e procedure was per ormed in one session in June 994. From the thighs and the ank, 3 0 cc o sub-
cutaneous tissue was harvested and ref ned to cc. No excisional or suspension surgeries were per-
ormed. At the end o the procedure, 0 cc was aspirated rom the submentum. T is is something that I
would not do now on this patient, since it removes radial support rom the lower ace.

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Part III • Clinical Applications • Face and Neck: Aesthetic
D

E
Fig. 28-19, D and E
T e patient returned or ollow-up 4 years and 8 months later, still delighted with the results. Her lower
ace in this prof le comparison demonstrates the remarkable change possible with restructuring o the
mandibular border. In the prof le, the advancement o the chin along with the lower lip is evident, creat-
ing not only a more protuberant chin but also a complementary pouty lower lip.
T ese photos emphasize especially that this is not “f lling” the lower ace with at, but approaching a
radial vector to expand and extend the lower ace and thereby restore her acial proportion to a more
youth ul state. Instead o excising and suspending tissues, structural augmentation o the lower ace
restores the radial vector lost with aging. It is this restoration o the radial vector that “li s” the sagging
tissues by restoring the original conf guration o support tissues. Fat gra ed to restore ullness to the up-
per ace (lower eyelids, cheeks, and upper eyelids) on this patient can be appreciated in the prof le view.

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
F
G
Fig. 28-19, F and G
T e lips can best be evaluated when separated. T ere is a slight increase in central eversion o the lower
lip along with more ullness lateral to the midline in the vermilion. T e eversion o the upper lip under
the Cupid’s bow changes the curvature o the philtral columns to create more in erior concavity.
Fig. 28-19, H and I
H
Preoperative
I
4 years 8 months postoperatively
T e oblique views more accurately reveal what the patient sees: an attractive, strong mandibular border
with a distinct, continuous shadow underneath. Expansion o the lowest part o the augmented border
helps to def ne the new shadow. Restoring the structural volume o the chin and jawline demonstrates
a more youth ul cervicomental angle. Also, she now has a uller, more youth ul malar and brow region.
With added ullness over the brow and under the eyebrow, the eyebrow appears to be in a more cephalic
position relative to the eye. In addition, the minimal addition to the area below the brow restores ullness
to the lateral eyelid.

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Part III • Clinical Applications • Face and Neck: Aesthetic
A
B
Fig. 28-20, A and B
T is 30-year-old man presented primarily seeking treatment o his nose a er a rhinoplasty. He wanted
his nose to become narrower, straighter, and more streamlined. He volunteered the ollowing plan or
reducing the size o his nose by adjustment o relative proportions o his ace: he postulated that by mak-
ing his lips, cheeks, and jawline bigger, his nose would appear smaller.
C
D
Fig. 28-20, C and D
T e angle o his mandible was repositioned with 7. cc on the right and 10 cc on the le ; the border o
his mandible was lowered and def ned with 10 cc on the right and 7. cc on the le , and his chin was
enlarged with 10 cc. A erward, 18 cc was suctioned rom the submental area. His lower lip was everted
to show more vermilion with 6. cc; this was done primarily to keep the lower lip in proportion with the
much-enlarged chin. Four cubic centimeters was placed into his upper lip. His cheeks were augmented
with 11 cc on the right and 1 cc on the le . T e nasolabial olds had . cc on the right and . cc on
the le . T e marionette region had . cc on the right and . cc on the le . By advancing the glabella
and nasion, and augmenting the superior dorsum, the nose appears to be much smaller. In addition, an
elliptical columellar excision was per ormed to decrease columellar show. Into the lower eyelids 0.9 cc
was placed on the right and 0.7 cc on the le .

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Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
Fig. 28-20, E-H
E

F
G

H
Comparison photos are shown at this patient’s 10-month ollow-up a er one procedure. From the ron-
tal view, a change in proportion is obvious. His ace has been lengthened by placement o structure along
the in erior mandibular border up to the chin. Lengthening o the ace along with the widening o the
border o the mandible and widening o the malar cheek imparts a much healthier athletic appearance
to his ace, compared with the portly and much older appearance he previously projected. By creating
lateral protuberances o the chin, this provides the beginning o a stronger, much more power ul jawline.
Central eversion o the lower lip can be appreciated, but because o the enlargement o the chin simul-
taneously, the absolute increase in size o the lower lip is di cult to appreciate. Also, in the tilted view,
one can see a signif cant diminution o the in raorbital darkness with the placement o only a minimal
amount o tissue. In addition, in these postoperative views his nose looks straighter and shorter than it
did preoperatively.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 28-20, I-L
I

J
K
L
T e degree o augmentation o the border o the mandible can be better appreciated in these photos.
Surprisingly, the texture o the transplanted tissue is amazingly natural and in this patient does not eel
atty. In the oblique view, the central pout o the lower lip, along with an obvious central def ciency or
cle , can be appreciated. T e change in the shape o the cheek is also clearly visible in the oblique view.

527
Chapter 28 • Structural Fat Gra ting in the Chin and Jawline
M

N
Fig. 28-20, M and N
Finally, on the closeup prof le one can appreciate a remarkable change in the shape o the nose, with ad-
dition to the dorsum to disguise the supratip de ormity and to the glabella to shorten the nose. Excision
o the columellar septum also decreased the columellar show.
C om p l i ca ti on s
LIKELY COMPLICATIONS
Frequently, small amounts o at are removed rom the jowl, submentum, and cervical regions at the
same time that structural at is placed. Suctioning an area or the purpose o removal creates a potential
space. I that potential space is immediately adjacent to an area o placement, there is the potential or
the placed at to migrate into the area being suctioned.
I tissue is removed rom the lower ace or neck, any suctioning to be per ormed is done at the end o the
case, a er all o the inf ltration is completed. T en a layer o Reston oam is placed over the suctioned
areas as soon as I have closed the incision sites. T e Reston oam is secured with Micro oam tape and an
elastic chin/neck bandage.
UNUSUAL COMPLICATIONS
A er reeing up a superf cial scar in the posterior buccal region with a 16-gauge needle, one patient
had a signif cant parotitis, which resolved a er conservative treatment with antibiotics and warm com-
presses. I have not experienced this complication using blunt instruments, but I am care ul to avoid
per orating the parotid (or submandibular) gland during placement.
Marginal mandibular nerve injuries can also occur. Although I have not heard o any intraarterial em-
boli below the lip, they are def nitely possible. Special care should be taken around the acial artery. See
Chapter or more in ormation about potential complications.

528
Part III • Clinical Applications • Face and Neck: Aesthetic
D i scu ssi on
By increasing the size o the chin and mandible, the lip will relatively decrease in size. T is can be urther
complicated by the physical e ect o placing tissue into the chin, which o en causes the lip to ip in. In
any case, even small chin augmentations can create a dramatic change in the size o a lower lip. For that
reason, it is important to discuss this potentiality with patients during the initial consultations and as a
part o the in ormed-consent process. I recommend that most men and women who want a signif cant
change in the size o their chins consider lower lip augmentation as well.
C oncl usi on
T e key to mandibular and chin placement is understanding the three-dimensional shape o an attrac-
tive mandibular border and chin to create a strong, appropriately shaped mandibular border with a
submandibular shadow. o accomplish this goal, the “ball-ball” structure o the attractive chin must also
be reproduced.
T ech ni ca l P ea rl s
• A er placement o structural at in ront o and behind the jowl and along the mandibular border, the
jowl area in which one does not place at may still be too protuberant.
• Occasionally, it will be necessary to suction this area, especially i it has palpable at present. T e
surgeon should prepare the patient or a secondary procedure to remove a small amount o jowl at
6 months a er the procedure.
• Suctioning the jowl at the same time as placing tissue runs the risk o having the transplanted atty
tissue migrate into the previously suctioned jowl. opical pressure on the newly gra ed areas can orce
small amounts o at into the reshly suctioned area. For that reason I requently will delay suctioning
until a later procedure.
REFERENCES
1. Coleman SR. Discussion: Free at transplantation or acial tissue augmentation. J Oral Maxillo ac Surg
:169, 000.
. Coleman SR. Structural at gra ing. Aesthet Surg J 1 :3 6, 199 .
3. González-Ulloa M, Flores ES. Senility o the ace: basic study to understand its causes and e ects. Plast
Reconstr Surg 36: 39, 196 .
4. erino EO. Alloplastic acial contouring: surgery o the ourth plane. Aesthetic Plast Surg 16:19 , 199 .

529
C h a p t e r 2 9
A , k s o o s s o yo d b y. Ev o d p sv s v
s s m y b p s yo , d p o zo o ds k s y o s d d d s -
b y . W v s bd m ss d s pp s d sk x d y
d o s, v b d s ppo d, p y sk . W s ss s dd d o
k, p ov d s d y s ppo o sk o s o mo yo ss. R o o
o k w s p ov d m by d s s p om k
s.
A estheti c C on si d era ti on s
Fig. 29-1
P o o p s o p yo mos w ys v . I s p o o p s,
sv s v s s p s yo p o o, b s wom d, s b -
m mo p om d o d b d by f .
St r uct ur al Fat Gr a t ing
in t he Nec
Sydney R. Coleman
529

530
Part III • Clinical Applications • Face and Neck: Aesthetic
A n a tomi c C on si d era ti on s
In the neck the potential or damage to underlying structures is minimal i only a Coleman type I can-
nula (the most blunt) is used at all times. With purpose ul placement in the subdermal layer between the
platysma and skin, ew anatomic structures are exposed to trauma. T e trauma to even the veins is so
minimal using this technique that I have rarely seen dramatic bruising af er structural at graf ing to the
isolated neck. As in the hands, the primary potential anatomic problems can be created by manipulation
o at af er placement. Strong digital pressure on a lump o at might push the newly graf ed tissue deep
to the platysma.
T e key to structural at graf ing o the dorsum o the neck, as in the hands, is purpose ul placement
o a smooth layer o tissue against the undersur ace o the dermis. Placement o much more under the
neck creases will help to diminish them also. In persons with prominent neck cartilages, extra placement
around the neck cartilages to sof en the Adam’s apple may be appropriate.
I n d i ca ti on s a n d P a ti ent S el ecti on
ypically, patients who present or at graf ing o the neck have complaints similar to patients who re-
quest hand rejuvenation. T ey complain that their necks make them appear older than their aces would
suggest. Individuals with noticeable loss o subcutaneous ullness o the neck and apparent crêpiness
and thinning o the skin are the best candidates or neck rejuvenation with at graf s. Un ortunately, the
change that occurs with restoring structure to the supporting matrix o the neck is not as dramatic as in
the ace or even the hands, and the patient should not expect dramatic changes—only subtle improve-
ment in texture and contours.
Many patients are bothered by prominent neck cartilages, either as a result o aging or because they eel
that their Adam’s apple makes them look too masculine, even at a younger age. T ese patients usually
seek sof ening o the prominent cartilages with three-dimensional volume placement around the carti-
lages. Another indication in younger patients is deep transverse neck creases.

531
Chapter 29 • Structual Fat Grafting in the Neck
Fig. 29-2
T is 48-year-old woman presented for augmentation of her lip. She was also interested in correcting her
jawline and neck, especially the creases of her neck.
In comparing her youthful photographs to recent ones, the transverse neck creases clearly visible in both
old photos have deepened with age and are interrupted by the inferior extensions of vertical platysma
bands. In addition, there has been a remarkable diminution in the size of her lower lip, much more than
in her upper lip.

532
Part III • Clinical Applications • Face and Neck: Aesthetic
MARKINGS
Fig. 29-3
T is patient’s neck was marked with borders o placement as delineated by the yellow marks. T e places
where I planned to place more tissue, such as lateral to the neck cartilages, were marked in green, and
the incision sites in red.
T e neck should be approached in a similar ashion to the dorsum o the hand: primarily with placement
o a di use thin layer o tissue immediately subdermal over the entire sur ace to be treated. Like the
hand, specif c def ciencies or depressions should be treated di erently, with a thicker placement. T ese
are usually deep horizontal neck creases and depressions caused by particularly obvious neck cartilages.
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Anesthesia
A solution o 0. % lidocaine with 1: 00,000 epinephrine o inf ltration is placed with a type I cannula. I
also use intravenous sedation administered by an anesthesiologist. T e inf ltration is per ormed at a ratio
o about 1⁄2 cc o local anesthetic or every 1 cc o at to be placed.

533
Chapter 29 • Structual Fat Gra ting in the Neck
Incisions
Neck (multiple)
Auricular
Submentum
Fig. 29-4
Primary access to the neck is rom incisions made in the neck creases. T ey are usually in the midline
and over the area o the sternocleidomastoid muscle. Because I try to place tissue rom several di erent
directions, access to the upper neck rom a di erent direction can be obtained by the mandibular and
auricular incisions commonly used in jawline placement.
Inf ltration Cannulas
Type I
Fig. 29-5
A blunt 17-gauge Coleman type I cannula is used or placement to avoid damage to underlying struc-
tures, particularly the neck veins. T is blunt inf ltration cannula is completely capped on the tip with a
lip that extends 180 degrees over a solitary distal aperture. For at placement into the neck I use both
straight and curved cannulas that are 7 or cm long with a 17-gauge lumen.

534
Part III • Clinical Applications • Face and Neck: Aesthetic
Level o Inf ltration
Platysma
Thyroid
gland
Sternocleido-
mastoid
muscle
Sternohyoid
muscle
Sternothyroid
muscle
Tracheal
cartilage
Fig. 29-6
T e level o placement is almost entirely in the immediate subdermal plane superf cial to the veins and
platysma, where it can provide support to the skin. In patients with particularly crepey necks I have
placed some into the subplatysmal plane, but I was not impressed with the change that occurred. I
believe that the skin texture change that patients desire most is achieved rom immediately subdermal
placement.
INTRADERMAL PLACEMENT
Fig. 29-7
Deep neck creases may require not only subdermal placement, but may also need intradermal placement
directly into the length o the crease. T is is accomplished with a 22-gauge needle.

535
Chapter 29 • Structual Fat Gra ting in the Neck
Placement Volumes
Although volumes as small as or 10 cc o ref ned at can provide so ening or even ablation o specif c
neck creases, in general I place more than 40 cc over the entire neck, and I have placed as much as 6 cc.
T e larger volumes are usually used i the placement extends to the clavicle or sternal notch and past the
sternocleidomastoid or i an attempt is being made to disguise the neck cartilages.
Most Likely Technical Mistake
Placement o tissue evenly over the entire neck sur ace will result in persistence o the neck creases.
T ere ore the neck creases should be inf ltrated with signif cantly more tissue than the rest o the neck.
TECHNIQUE
Fig. 29-8, A and B
A

B
Since the placement is usually rom the anterior border o one sternocleidomastoid muscle to the an-
terior border o the other sternocleidomastoid, I begin placement rom an incision located along the
border o the sternocleidomastoid placed at the level o the neck creases. In this case I began with the
superior neck crease into the crease itsel . Usually the neck creases require at least twice the thickness o
placement into the surrounding skin.
Fig. 29-8, C and D
C

D
From these incisions many passes were made radiating out over the sur ace o the neck so that a thin
layer was placed, with extra thickness under the neck creases and around the neck cartilages.

536
Part III • Clinical Applications • Face and Neck: Aesthetic
E

F
Fig. 29-8, E and F
Next, tissue is placed under the lower neck crease, gradually radiating the placement above and below
the neck creases. In this patient, a straight 9 cm cannula orces placement to be as close to the skin as
possible. T e straight cannula compels me to scrape along the curved undersur ace o the skin. Only
type I cannulas are used or placement to avoid per oration o the large external jugular veins in this
area. T e placement is superf cial to the platysma and anterior to the sternocleidomastoid muscle.
G
H
Fig. 29-8, G and H
A er laying down a thin layer rom a horizontal and oblique orientation, I use the incision to place tissue
in a perpendicular ashion rom all o the incisions into the surrounding areas.

537
Chapter 29 • Structual Fat Gra ting in the Neck
I
Fig. 29-8, I
I repeat this layering rom incisions at the level o the creases rom the midline and opposite neck. Again,
the objective is a smooth structural layer to support the skin spanning the sternocleidomastoid rom one
side to the other. T e overall look at the end o the procedure is that o dif use ullness extending out well
into the surrounding areas. Since the mandibular border is requently treated at the same time as the
neck, the submentum may become remarkably swollen.
T e endpoint o the neck is similar to that o the hand. T e neck will look dif usely swollen, but in the
absence o bruising, not as alarming as other parts o the ace a er at gra ing. However, the neck will
require a thicker layer o ullness rom the gra ed at. T e placed layer should eel much thicker to pal-
pation than the completed dorsum o the hand.

538
Part III • Clinical Applications • Face and Neck: Aesthetic
J
K
L
M
N
O
Fig. 29-8, J-O

539
Chapter 29 • Structual Fat Gra ting in the Neck
Fig. 29-8, P and Q
P

Q
VOLUMES PLACED Right (cc)


Left (cc)
Malar cheek
Nasolabial folds
Marionette grooves
White roll
Philtrum
Upper lip
Superficial upper lip
Lower lip
Angle of mandible
Anterior mandibular
border
Chin
Neck
7
4
1.8
1
4
4
1
0.75
2
6
10
41
9.5
3
1.8
0
4
4
T e patient returned years a er one procedure in which the volumes listed were inf ltrated into her
neck, lips, and lower ace. On the f rst oblique views, one can see a clear expansion o the neck rom the
middle o one sternocleidomastoid to the other side. T e slight residual transverse crease o the neck
might be urther erased by intradermal placement o at into the crease itsel . T e lowering o the man-
dibular border helps obscure the platysma bands and adds to the e ect o a uller, so er ace.

540
Part III • Clinical Applications • Face and Neck: Aesthetic
R

S

T
U

V

W
Fig. 29-8, R-W
Comparison o the patient’s youth ul photograph with preoperative photos and those taken 2 years af er
one procedure emphasize how much a ace is rejuvenated when the radial vector is approached by selec-
tively restoring ullness to the subcutaneous tissues.

541
Chapter 29 • Structual Fat Gra ting in the Neck
T e lips are particularly interesting in these photos. T e amounts o tissue placed into the lips are the
usual volumes with a normal distribution. T e volumes placed everted the lower lip signif cantly to
replicate the appearance o the lip when she was young. In addition, one can see the e ect o placing
tissue into the cutaneous upper right lip to prevent rolling up o the vermilion and adding to the already
present sneer.
POSTOPERATIVE CARE
Recovery rom placement o tissue into the neck is extremely well tolerated, since bruising is almost
always minimal or nonexistent. T e neck is usually easy to cover with turtleneck sweaters, collars, or
scarves. While the swelling is present during the f rst ew weeks or even months, patients will requently
complain about a “ropey” eel under the neck creases where more tissue was placed.
Special Dressings
As in the ace, no dressing is placed over any o the neck into which tissue has been gra ed.
Massage
Patients are told to avoid massage o the neck or weeks. A er weeks gentle massaging is recom-
mended, especially in the areas o suctioning, since they remain hard or a much longer period o time.

542
Part III • Clinical Applications • Face and Neck: Aesthetic
R esul ts
A
B
C
D
E
F
Fig. 29-9, A-F

543
Chapter 29 • Structual Fat Gra ting in the Neck
Fig. 29-9, G and H
G
H
VOLUMES PLACED

Right (cc)
Left (cc)
Angle of mandible
Anterior mandibular
border
Chin
Neck crease
2
4
11
11
2
4
VOLUMES SUCTIONED Right (cc)
Left (cc)
Jowl
Submentum
5
30
3.5
T is -year-old woman requested suctioning o the jawline and a smoother neck. She had no prior
procedures o the lower ace or neck. She had considered a acelif but was rightened by the appearance
o many o her riends who had undergone acelif s. I placed 11 cc into the largest neck crease (arrow),
eathering above and below the crease. Af er most o the tissue was placed, I used a V-dissector to ree
up the crease somewhat, since it appeared to be resistant to correction. I also placed structural tissue
rom her lateral chin to her jowl and rom her jowl back along the mandibular border to the angle. A
small amount o tissue was also removed rom the jowl on each side and the submentum. She returned
1 months af er this procedure delighted with her new appearance. Filling o the neck crease with eath-
ering into the surrounding areas lef her with a more youth ul neck contour and texture. T e lowered
border disguised the submental contents so that they were more di cult to see, and the expanded man-
dibular border distracted out the submental contents to tighten the neck slightly with a radial vector.

544
Part III • Clinical Applications • Face and Neck: Aesthetic
A
B
C
D
E
F
Fig. 29-10, A-F

545
Chapter 29 • Structual Fat Gra ting in the Neck
Fig. 29-10, G and H
G
H
VOLUMES PLACED

Right (cc)
Left (cc)
Angle of mandible
Midmandibular border
Anterior mandibular
border
Chin
Submentum
Neck
11
2
3
7
5
9
10
3
4
Even small amounts o at placed in the neck can enact subtly dramatic changes. T is -year-old woman
presented af er a acelif complaining o skeletonization o her ace and neck. I placed only a modest
amount into her neck crease ( cc) but eathered the correction up into the submentum, where I placed
cc. She returned 18 months af er the procedure, claiming that the at was no longer present because
she could not eel it in the neck. However, the comparison photographs clearly demonstrate a sustained
augmentation on the neck crease as well as o the mandibular border.
C om p l i ca ti on s
T e risk o complications rom at graf ing in the neck is minimal compared with graf ing in most other
areas. Following the technique described, I have not encountered any unusual problems.
D i scu ssi on
As mentioned earlier, the changes rom placement o structural tissue under the skin o the neck are not
dramatic. T ere is an obvious but subtle improvement in the texture o crepey skin. T e physician should
prepare the patient to expect a subtle, not dramatic, improvement.

546
Part III • Clinical Applications • Face and Neck: Aesthetic
T ech ni ca l P ea rl s
• Neck creases that do not correct with subdermal structural at may require intradermal at or urther
ablation.
• T e endpoint with neck creases is similar to that o the nasolabial old correction. A er the neck
crease can no longer be recreated with digital manipulation, the surgeon should place a small amount
more o tissue in the crease.
• Do not use the V-dissector in the neck.
RECOMMENDED READING
Carraway JH, Coleman SR, Kane MA, et al. Periorbital rejuvenation. Aesthetic Surg J 21:337, 2001.
Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 2 :3 7, 1997.
Coleman SR. Structural at gra s: the ideal f ller? Clin Plast Surg 28:111, 2001.
Coleman SR. Structural at gra ing. Aesthetic Surg J 18:38 , 1998.
Coleman SR. T e technique o periorbital lipoinf ltration. Oper ech Plast Reconstr Surg 1:120, 199 .
Coleman SR, Buncke H. Reconstruction o the mandible with vascularized cranial bone gra s. Presented
at the Plastic Surgery Senior Resident’s Con erence, American College o Surgeons, 198 . Published in
Surgical Forum o the ACS, 198 .
González-Ulloa M, Flores ES. Senility o the ace: basic study to understand its causes and e ects. Plast Re-
constr Surg 3 :239, 19 .
Hamra S . T e role o orbital at preservation in acial aesthetic surgery: a new concept. Clin Plast Surg 23:17,
199 .
Hurwitz D, Coleman SR, Katz A. Structural at gra ing o the ace: lessons rom a teacher and his student. Key
Issues Plast Surg 17:1 , 2000.
Little JW. Volumetric perceptions in mid acial aging with altered priorities or rejuvenation. Plast Reconstr
Surg 1:2 2, 2000.
erino EO. Alloplastic acial contouring: surgery o the ourth plane. Aesthetic Plast Surg 1 :19 , 1992.

FACE AND NECK
Reconstructive
S e c t i o n T h r e e

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