Fat Injection From Filling to Regeneration

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PRINCIPLES AND
BASIC CONCEPTS
P a r t I

(Trang không có chữ)

3
C h a p t e r 1
T b s pr p s t C t str t r t gr g v r d -
g d r r t t r d d s:
• H rv st g p r s t w t b t d syr g s g w s t
• R f t w t tr g t t t t r v v g p ts
• P rp s p t t p s ts t t r p t t ss s, s p r t g
p r s r t t r
Ad r t t s t gr g pr p s r g s g v ty, pr t s st b ty, d -
t v y t gr t s t tty t ss t t st t ss s. F t gr d t s s r t s d f -
t v str t r g t t s t gr t d d t t p s t v y t t t ss s t w t
s p d. T p s p y t C t gr g t r s d t y -
g d s ts r g p b t 1994. T C t t s t b t
w r d’s g d st d rd t gr g r t r d d s pp t . T w g s
v rv w t b s pr p s t C t , r rv st g t r g p -
t.
F tty t ss , sp y t d t d p yt p t, s r r g t st t r
t ss s d s s y d g d ts d t b dy by , b r tr , d s ts.
s rv v rv st g, tr sp rt, d p t t w t s d syr g s, t st b r-
v st d t t p r s s g t b s rt d t r g s b t rg g
s t t t t ss r t t r s t d. W t t r t tr d g y s rg s t
s r rv st g p rts d v s r f tr t s, w d t b t s d t
r y v t t g v ty t tr sp t d t r g r s g y s r p rt s. F r-
t r r , t r r y t r typ s s tty t ss t t r p rt t r tty t ss
t s rv v d t . A d v t t ss pp rs t b t t by st g d zy t
ys s, v s g t , b r tr , , r t p r t r s t r s t t
t ss s d s dy g w ks r v t s t r t r g p pt s s.
he Col eman echnique
Sydney R. Coleman
3

4
Part I • Principles and Basic Concepts
H a rvesti n g
CHOICE OF HARVESTING SITE
Decant
less-dense
oil layer
Centrifuge fat
Harvest
Wick
Release
dense aqueous
component
Transfer to
smaller syringe
Fig. 1-1
Harvest site and processing of lipoaspirate
No clear correlation between donor site location and longevity of the implanted tissues has been re-
ported. A study comparing concentrations of stem cells from common donor sites found that the highest
concentrations of stem cells were located in the fatty tissue harvested from the lower abdomen and inner
thighs.1 I select harvesting sites that enhance body contour and are easily accessible with the patient in
the supine position. Because of the evidence of increased stem cell activity in the abdomen and medial
thighs, I use these areas preferentially when possible, especially if I am trying to obtain a functional
change, such as thickening or repair of the skin.

Chapter 1 • he Coleman echnique
5
PLACEMENT OF INCISIONS
Fig. 1-2
Harvesting sites are accessed through incisions placed in creases, previous scars, stretch marks, or hir-
sute areas (circled in red) whenever possible. T e pubic region is the most use ul site, because the abdo-
men, medial thigh, and anterior thigh can be reached with ease. o harvest at rom the upper abdomen
and anks, additional incisions can be made in the umbilicus and upper abdomen. Occasionally, an
incision in the lateral hip can be used or access to the thigh as well as to the lower love handle. Incisions
in the midback and lateral sacrum provide access to the love handles and the ank.
STERILE TECHNIQUE
Meticulous sterile technique is always observed, with care ul attention to preoperative patient prepara-
tion with antiseptic soaps and an antiseptic agent such as povidone-iodine. Bacterial contamination o
the atty tissue can result in in ection.
T e choice o an anesthetic agent or harvesting depends on the donor areas and the projected volume o
at to be removed. For harvesting smaller volumes, local anesthesia using 0. % lidocaine with :200,000
epinephrine is adequate.
Fig. 1-3, A and B
A

B
T e lidocaine solution is f rst placed into the incision site through a sharp 2 -gauge needle; incisions are
then made with a No. blade. T e incisions or inf ltration o anesthetic solutions are usually the same
ones used or harvesting atty tissue. T ese incisions are just large enough (usually 2 mm) to permit in-
sertion o the tip o the harvesting cannula.

Part I • Principles and Basic Concepts
6
Fig. 1-3, C-E
C
D
E
A nine-hole Coleman harvesting cannula attached to a 10 cc syringe is used to inf ltrate the lidocaine
solution into the projected sites o atty tissue removal. T is is the same cannula that I usually use now
or harvesting o the at. T is eliminates the need or a Lamis inf ltrator that I previously used or inf l-
tration o the lidocaine solution.
T e inserted cannula is attached to a 10 cc Luer-Lok syringe by the Luer-Lok connection. T e 10 cc sy-
ringes are pre erred or harvesting; these are small enough to be manipulated manually without locking
devices. During harvesting, care is taken to minimize mechanical trauma to the ragile parcels o at.
Usually 1 ml o lidocaine is inf ltrated or every cubic centimeter o at harvested.
Propo ol or general anesthesia is pre erred or removal o larger volumes or when multiple sites are used.
For hemostasis, Ringer’s lactate solution in a concentration o 1:400,000 epinephrine is also inf ltrated in
a ratio o 1 ml o solution or each cubic centimeter o at harvested using a harvesting cannula.
umescent techniques are avoided during the harvesting phase. I believe that the motion o the har-
vested at through large amounts o liquid in tumescent techniques may disrupt the architecture and
release growth actors (see Chapter 9). T is disruption o the intrinsic tissue architecture and release
o growth actors may decrease the potential survival o the subcutaneous tissues. I less than 1 or 2 cc
o the harvested material in each syringe is at, then as many as f y 10 cc syringes may be necessary to
obtain 0 cc o at; this can prolong the procedure by hours.

Chapter 1 • he Coleman echnique
7
HARVESTING TECHNIQUE

Right oblique view
Left oblique view
Back view
B

C

D
Fig. 1-4, A-D
A
NINE-HOLE HARVESTING CANNULAS
Harvesting instruments or Coleman at gra ing should be e cient and minimally traumatic to the
gra ed tissue during both the harvesting and placement phases. Previously I used a two-hole cannula
with a blunt tip and dull distal openings placed extremely close to the end or all harvesting. However,
the nature o the opening o the “bucket handle” two-hole Coleman harvesting cannula was such that at
did not ow as easily through the cannula tip and/or Luer-Lok aperture. T is resulted in the surgeon’s
having to stop the procedure occasionally to remove the blockage.
Lateral
thigh
Abdomen
(with etching)
Inner
thigh
Anterior
thigh
Anterior
thigh
Knees
Love
handles
Lateral
thigh
Inner
thigh
Knee
Fig. 1-5
I tried using various cannulas with a variety o conf gurations o number o holes and sizes o holes and
tried them out in the lab on pigs then during a variety o procedures. I eel that the nine-hole conf gura-
tions, as pictured above, appeared to be the most e cient combination or harvesting, and they provide
a result that appears to me to give a similar or even improved result. For larger volume harvesting, I have
been using a 2-gauge nine-hole cannula in two lengths, 5 cm and 26 cm. o reduce the di culty with
passage o the condensed at through the 6, 5, and 3 cm Coleman placement cannulas, I started using a
smaller 4-gauge nine-hole cannula or harvesting at or placement into the ace.

Part I • Principles and Basic Concepts
8
T e length o the harvesting (aspirating) cannula is most o en 15 cm. Although the commonly used
26 cm cannula has a greater reach, it can place greater torque on the Luer-Lok aperture and break the
syringe tip during extraction. T e surgeon has greater control o the tip o the cannula with the 15 cm
cannula to avoid untoward incidences (see Chapter 52). It is thus advisable to use the shorter cannulas
initially and to advance to longer ones a er becoming more amiliar with the instruments. T ese are also
used or inf ltration o the harvesting uids.
Fatty tissue is harvested through the incisions made or inf ltration o anesthetic solution. T ese inci-
sions are just large enough (usually 2 mm) to permit insertion o the tip o the harvesting cannula.
Fig. 1-6, A-C
A
B
C
T e inserted cannula is attached to a 10 cc Luer-Lok syringe by the Luer-Lok connection. T e plunger is
pulled back gently to minimize negative pressure. Only 10 cc syringes are used or harvesting; these are
small enough to be manipulated manually without locking devices. Larger syringes are more cumber-
some, and pulling back even slightly on the plunger in larger syringes might create damaging negative
pressures.

Chapter 1 • he Coleman echnique
9
Fig. 1-6, D
D
1-2 cc space
Plunger provides 1 or 2 cc of
negative pressure space
T e plunger o the syringe is gently manipulated to provide or cc o negative pressure space in the
barrel o the syringe while the cannula is pushed through the harvest site. All incision sites are closed
with nylon interrupted sutures af er harvesting is completed.
T is manipulation can only be done manually; devices that distract then lock the plunger in a static
position should never be used during harvesting or transplantation. T e high vacuums created by these
devices or by pulling back too ar on the plunger (more than cc) can increase the negative pressure
dangerously, potentially to the point o vaporization (the pressure at which water boils at room tempera-
ture), which may damage the atty parcels o tissue.
Several extensive studies support the superiority o keeping the pressure or harvesting to a minimum
by using gentle, progressive syringe liposuction during the process. Pu et al2 examined adipose aspirates
collected rom traditional liposuction and concluded that af er traditional liposuction, the tissues “have
a less-than-optimal level o cellular unction and may not survive well af er they are transplanted.”
Another study rein orced that syringe liposuction with a gentle progressive distraction o the plunger
yielded a much higher level o cellular unction than machine liposuction set to a lower level ( 0 cm
H O).3
Although some studies have demonstrated that larger-bore cannulas are better or harvesting,4 more-com-
prehensive studies have shown that smaller-bore cannulas connected to 0 cc syringes yield greater at
viability.5

Part I • Principles and Basic Concepts
10
E

F
Fig. 1-6, E and F
Superf cial burns at the incision sites can occur rom the repetitive riction o the cannulas against the
skin margins o the incision during both harvesting and placement. As soon as atty tissue or oil is
available a er the centri ugation o harvested at, it can be used to lubricate the incision site, thereby
minimizing riction burns on the edges o the incision.
G

H
Fig. 1-6, G and H
I close all incision sites with nylon interrupted sutures a er harvesting.

Chapter 1 • he Coleman echnique
11
R e f i nement a n d T ra n sf er
Fig. 1-7, A-C
A
B
C
Af er the at has been harvested, the cannula is removed rom the syringe and replaced with a plug.
D
E

F
Fig. 1-7, D-F
T e pre erred plug is a dual- unction Luer-Lok plug or capping that is available in most hospitals. T is
plug is twisted on to create a seal that will prevent spillage during the centri uging process.

Part I • Principles and Basic Concepts
12
Fig. 1-7, G and H
H
YES
NO
G
T e plugs that accompany the syringe should not be used, because they requently allow the aqueous
portion o the contents to leak.
Fig. 1-7, I-K
I

J
K
Af er the Luer-Lok syringe is sealed, the plunger is removed rom the proximal end o the syringe.

Chapter 1 • he Coleman echnique
13
CENTRIFUGATION
Fig. 1-8, A
A
T e syringe without the plunger is then placed into a centri uge to separate the viable rom the nonviable
components. T e recommended centri ugation creates a gravitational orce o 00 g or minutes. On
the pictured centri uge, that needed orce is generated at 000 rpm by that particular diameter o rotor.
Fig. 1-8, B
B
o reduce the chance o bacterial contamination during the ref nement process, the rotor and sleeves o
the centri uge should be sterilized each time it is used. T e centri uge manu acturer should recommend
that the central rotor be steam sterilized. Many central rotors will rust and corrode, and the paint will
peel o when placed in an autoclave or in liquid solutions or sterilization. T e method o securing the
central rotor o the centri uge is also important. T e bolt that holds the rotor in place can rust and be-
come di cult to secure, so I recommend a central rotor that is held in place by gravity.

Part I • Principles and Basic Concepts
14
Fig. 1-8, C
C
Each 0 cc syringe is placed into an individual sleeve o the central rotor o the centri uge. T e place-
ment must be even so that each syringe is balanced on the opposite side or in every other sleeve. T ese
sleeves can be changed or emptied i the aqueous portion o the syringe spills. Care should be taken to
choose 0 cc syringes and sleeves that f t into each other easily; some types o 0 cc syringes are bigger
than others, and some o the centri uge sleeves are too small.
D
E
Fig. 1-8, D and E
T e lid on the centri uge is then closed and locked by the circulating nurse, and the timer is set. Because
the timers on centri uges vary in reliability, it is best to check the accuracy o the timer.

Chapter 1 • he Coleman echnique
15
Fig. 1-8, F
F
Af er the rotor o the centri uge has stopped completely, the circulating nurse should open the cover and
the sterile technician should remove the centri uged syringes, being care ul not to touch the cover or
other nonsterilized parts o the centri uge.
Fig. 1-8, G
Upper level
• Least dense layer
• Oil from ruptured fat cells
Middle level (30% to 70%)
• Potentially viable parcels of tissue
Lowest level
• Most dense layer
• Blood, water, lidocaine
G
T is separates the denser components rom the less dense components to create the multiple layers
noted previously. T e upper level or the less dense level is composed primarily o oil, presumably rom
ruptured cells. T e middle portion is composed primarily o potentially viable parcels o tissue, with
more oil present in the upper portion and denser connected tissue present in the lower portion. T e
lowest level is the densest layer and is composed primarily o blood, water, and lidocaine.

Part I • Principles and Basic Concepts
16
SEPARATION OF COMPONENTS
Fig. 1-9, A
A
T e oil layer is initially decanted be ore removing the plug rom the Luer-Lok syringe. I the plug is
removed be ore decanting, it will cause the vacuum that holds the contents in place to be lost, and the
contents o the syringe will leak out during the decanting process. (T is oil is used or lubricating both
the harvesting and insertion site incisions.)
Fig. 1-9, B and C
B
C
Af er the oil is decanted, the plug can be removed rom the Luer-Lok connection. A collection vessel
should be used during this maneuver, because the aqueous component will usually pour out o the
syringe. Occasionally a small wad o tissue at the opening will prevent the uid rom exiting, in which
case the proximal end o the syringe should be tapped lightly to ree the obstructing tissue and allow the
aqueous portion to drain out. On rare occasions it may be necessary to use a hemostat to pull out a bit o
tissue rom the aperture o the Luer-Lok syringe.

Chapter 1 • The Coleman Technique
17
Fig. 1-9, D and E
D

E
Wicking the most superior portion o the harvested at can make it easier to remove the oily component
o the harvested material. Codman neuropads are used or wicking and are placed into the sur ace o the
ref ned atty tissue; they allow the oil to gradually wick in a superior direction a er a ew seconds.
F
Fig. 1-9, F
A er 4 minutes the wick is replaced with another neuropad. Wicking is per ormed at least twice. Even
though it is important to spend an adequate amount o time wicking to remove as much oil as possible,
every attempt should be made to minimize prolonged exposure o any o the parcels o cells to air.

18
Part I • Principles and Basic Concepts
G
Fig. 1-9, G
Fat will o en stick to the neuropad when removed; scraping the at o the neuropad can irreparably
damage the at. I the surgeon suspects that some o the at has been damaged by excessive exposure to
air or as a result o mechanical trauma, the at should be discarded.
H
I

J
Fig. 1-9, H-J
T e plunger is replaced a er allowing the atty tissue to slide down to the edge o the syringe. A f nger
should be pressed over the Luer-Lok aperture to control the at slippage with air pressure. T e plunger is
then placed into the syringe and advanced to remove the dead space.

Chapter 1 • he Coleman echnique
19
Fig. 1-9, K
K
T e at can be stored in the 0 cc syringe in this ashion or brie periods o time be ore it is trans erred
to smaller syringes or inf ltration.
TRANSFER TO SMALLER SYRINGES
Fig. 1-10, A
A
Advancing the plunger o the 0 cc syringe with the Luer-Lok aperture placed at the base o the smaller
syringe trans ers the contents. Care should be taken to keep both syringes in a relatively vertical orienta-
tion (arrow) to avoid accidental insertion o air bubbles into the column o at during the trans er. I use
cc Luer-Lok syringes to place tissue into the ace and hands and 3 cc syringes to place tissue into the
body.

Part I • Principles and Basic Concepts
20
B
C
D
E
Fig. 1-10, B-E
As with the 1 cc syringe, the index f nger on the Luer-Lok aperture controls the slippage o the at back
to the proximal end o the syringe. A er f lling the syringe to a little less than the level o the .3 cc mark
on the barrel, the plunger is replaced and advanced to remove any dead space. T e inf ltration cannula is
then attached to the syringe, and the harvested, ref ned at is now ready or inf ltration.
BASIC EQUIPMENT
Required equipment includes the ollowing:
• Centri uge with a central rotor that can be sterilized
• est tube racks
• Valve or inf ltrating the uid and tubing
• Plastic or rubber tubing

Chapter 1 • he Coleman echnique
21
DISCUSSION OF REFINEMENT
Material harvested by syringe liposuction may contain as little as 0% or as much as 90% o atty tissue
a er centri ugation. Because each sample is composed o a di erent percentage o viable at, it can be
very di cult to accurately estimate the volume o at present. In 9 9 I modif ed the technique to in-
clude centri ugation o the aspirate. My thought at the time was that this extra step o centri ugation
allows injection o concentrated atty tissue into the recipient sites and minimal i any oil, blood and
inf ltrate solution, thus increasing the predictability and reproducibility o the result.
Clinical studies have demonstrated improved survival o gra ed at a er centri ugation. A study rom
Japan emphasized the importance o concentrating stem cells in the at to enhance gra take.6 Another
study rom Germany has conf rmed that the growth actors are isolated and present in greater numbers
in centri uged at; they also do not migrate into the aqueous or oil ractions.7
GRADED DENSITIES
A ew years ago, it became obvious to me that di erent levels o centri uged at are probably composed
o di erent cellular and biologic elements. Obviously, the upper level o centri uged at is oilier and
less dense, whereas the lower level is much denser and less oily. T ere ore I began using the denser at
pre erentially in areas that require more predictable results and avoiding the use o the less-dense, oilier-
appearing at. We undertook a study at New York University to evaluate the di erent densities o cen-
tri uged at and ound that the high-density centri uged at survived to a greater extent with less f brosis
than low-density ractions. In addition, the high-density raction had much greater stem cell activity and
a greater concentration o growth actors.8
With this knowledge in hand, I now approach at gra ing di erently. T e normal yield rom 0 cc o
harvested at is 4 to cc o ref ned at. I I have that yield, I segregate out the lowest cc o at to use
pre erentially to increase survival and predictability. In thin patients, I return the unused at back to the
harvest sites; in less thin patients, I discard the oily at.
P l a cement
ANESTHESIA
Regional blocks are o en used, with % lidocaine and : 00,000 epinephrine inf ltrated through 5-gauge
needles. For all planned incision sites on the ace or body, I place a solution o 0.5% lidocaine with
: 00,000 epinephrine with a -gauge needle. I the procedure is per ormed with local anesthesia, the
solution is bu ered. Incisions to mm long are made in the ace, neck, body, or hands; these are also
used or placement o the atty tissue. Even with regional or general anesthesia, small amounts o a dilute
solution o epinephrine are inf ltrated in most to create vasoconstriction and thereby not only reducing
bruising, but also minimizing the possibility o intravascular injections (see Chapter 5 ). In the ace,
0.5% lidocaine with : 00,000 epinephrine is di usely inf ltrated using the Coleman atty tissue cannulas
that will eventually be used or placement o the transplanted at.

Part I • Principles and Basic Concepts
22
PLACEMENT TECHNIQUE
Fig. 1-11, A-C
A
B
C
Placement o the ref ned at into the recipient site is the most challenging part o at gra ing. Fat parcels
should be positioned to ensure uni orm survival, stability, and integration into the surrounding recipient
tissue. T e key to atty tissue placement is maximization o the sur ace area o contact between the har-
vested at and the recipient tissues. By placing these small parcels o at so that they are separated rom
each other by the host tissue, the larger sur ace area o contact can be maintained.
Fig. 1-11, D and E
D

E
On the other hand, injection o a mass o at into any site may result in areas o at that are too ar rom
vascularized tissue to have a source o nutrition or respiration. In this event, much o the tissue will die
or resorb. T is may result in irregularities.

Chapter 1 • he Coleman echnique
23
F
Fig. 1-11, F
T e inf ltration cannula is inserted through each tiny incision that was used or inf ltration o the local
anesthetic and advanced through the tissues to the appropriate plane. T e skin is stabilized with the
opposite hand. Once the cannula is in the desired location, the plunger o the mm syringe is pressed
slightly while the cannula is being withdrawn. Fatty tissue is then le in the pathway o the retreating
blunt cannula, permitting more stable and regulated placement and minimizing the potential or irreg-
ularities or clumps o tissue.
Fig. 1-11, G
G
As the cannula is withdrawn, the deposited atty tissue parcels all into the natural tissue planes as the
host tissues collapse around them. Placement o minuscule amounts o atty tissue with each pass is crit-
ical to success ul Coleman at gra ing. o maximize the sur ace area o contact, the largest amount o
tissue that should be placed in the ace with each withdrawal is ⁄10 cc, and much smaller parcels should
be placed in some areas, such as the periorbital region. Intact parcels o atty tissue should be somewhat
separated by the tissues o the recipient site to maximize the sur ace area o contact between donor and
recipient tissues. Maximizing the sur ace area o contact ensures that more o the gra ed at is near a
capillary with circulating blood.
Fig. 1-11, H
H

Separating the parcels o at does more than increase the chance o survival. Placing the atty parcels with
a blunt cannula that causes minimal disruption o the natural tissue planes acilitates better at adher-

Part I • Principles and Basic Concepts
24
ence to the recipient sites. Minimal destruction o the tissue planes and maximal sur ace area o contact
combine to create a more stable relationship between the new at parcels and the surrounding tissues.
USE OF BLUNT CANNULAS
Although I switched rom sharp to blunt cannulas in to avoid injuries to underlying structures, I
have also ound blunt instruments to be superior or subcutaneous placement o atty tissue autogra s in
other regards as well. As a sharp instrument is advanced through the host tissues, it separates the tissues
in its path by disrupting the inherent connections. T is can create a space that does not necessarily con-
orm to any tissue planes, and it is into this cavity that the atty tissue parcels are expressed. T e at par-
cels crowd one on top o the other into the space rather than distributing throughout the tissue planes.
Fat placed with a sharp needle has less sur ace area contact with the surrounding tissues. T us the gra ed
tissue is less likely to obtain adequate nutrition and respiration, and it is less stable, so it is more likely to
move a er placement within the host tissues and even to extrude out the incision site.
Unlike the sharp tip o a needle, a blunt tip does not cut a swath through the tissue. As the blunt tip
is advanced, the natural tissue planes separate in a more physiologic ashion. As the blunt cannula is
withdrawn, the deposited atty tissue parcels all into the natural tissue planes as the host tissues collapse
around them. Finally, using blunt cannulas or more stable placement o atty tissues allows the surgeon
to place much larger total volumes o atty tissue.
T e placement cannulas are o a much smaller gauge than the harvesting cannulas, with only one hole at
the distal end. Like the harvesting cannula, the proximal end o the inf ltration cannula has a hub that will
f t into a Luer-Lok syringe. T e gauge o the cannula or placement can range rom -gauge to -gauge,
depending on the situation. Larger-bore cannulas can be used or corporeal at gra ing, and the small-
est gauges o placement cannulas may be appropriate in areas such as in the lower eyelids. For various
situations in the ace and body, cannulas with di erent tip shapes, diameters, lengths, and curves can
be used.9 T e most use ul cannula lengths are rom to 7 cm or use in acial procedures and rom to
cm or body contouring procedures. T e use o blunt cannulas allows placement o the at parcels in
a more stable, less traumatic manner. However, shorter cannulas may give the surgeon more control or
placement in the immediate subdermal plane, in f brous tissue, and in scars. A cannula with pointed or
sharp elements can be used to ree up adhesions.
STABILITY OF TRANSPLANTED FAT
A er the edema resolves, the texture o the gra ed tissues largely resembles that o the host tissues rather
than retaining the structural qualities o the atty tissues o the donor sites. By placing at in small parcels
and separating every parcel with the donor site tissues, the at becomes integrated with and eels like the
tissues into which it is placed.
Accuracy o the initial placement o at is important, because it is di cult to manipulate the inf ltrated
atty tissue a er the procedure is f nished. I a clump orms accidentally, digital manipulation can some-
times atten minor irregularities. However, the at tissue should never be placed with the idea that dig-
ital pressure can change the shape a er placement. In the ace, the largest amount o tissue that should
be placed with each withdrawal o a cannula is ⁄10 cc, but in some areas, such as the eyelid, the maximum
placed should be closer to ⁄30 cc or even ⁄50 cc per withdrawal. T e endpoint o placement varies widely
between anatomic areas.

Chapter 1 • he Coleman echnique
25
T ere ore estimating the volume to be placed in each area can be di cult. Some compensation should be
made or resorption, as the injected material is not pure atty tissue; even a er ref nement, there will be quan-
tities o blood, lidocaine, or oil present in the ref ned atty tissue. T ere ore it is best to use small amounts o
inf ltrate in the ace, neck, and hands, increasing the amount gradually as experience is gained. T e use o
cc syringes in the ace, neck, and hands is imperative to prevent overzealous augmentation and or sa ety
reasons, as discussed in Chapter . Likewise, the use o smaller syringes in the body (such as 3 cc) dimin-
ishes the placement o transplanted at in clumps and limits the possibility o large intravascular injections.
STRUCTURAL MANIPULATION
Fig. 1-12
T e host tissues can be better manipulated to change their shape i the atty tissue is placed bluntly in
minuscule amounts with each pass. I the tissue adheres to the recipient tissue a er each pass, multiple
passes can change the intrinsic shape o a site while adding volume. On the other hand, a sharp needle
will pierce the recipient tissue repeatedly, but this does not alter the shape o the site other than to dis-
rupt the structural integrity. Fat placed into the submucosal and subvermilion planes to evert the vermil-
ion o a lip is an example o structural manipulation (see Chapter 7).
INSTRUMENTATION FOR PLACEMENT
o acilitate Coleman at gra ing, I originally developed three basic styles o blunt-tipped cannulas as
well as a V-dissector, each with its own unction (Mentor, Irvine, CA):
• T e Coleman type I cannula is completely capped on the tip with a lip extending 80 degrees over
the distal aperture. It is my workhorse, and its primary purpose is to minimize traumatic injury
to underlying structures.
• T e Coleman type II cannula is similar to the type I but is not totally capped. It has a lip extending
over the distal aperture approximately 30 to 0 degrees. T is cannula is use ul in most situa-
tions.
• T e Coleman type III cannula is at on the end, permitting dissection o tissues in specif c situ-
ations, or example, when pushing through scars or f brous tissue. It is also help ul when placing
tissue in immediately subdermal tissue.
• T e Coleman V-dissector and W-dissector are used or the release o adhesions.

Part I • Principles and Basic Concepts
26
TYPE I (GREEN)
A
TYPE II (YELLOW)
B
TYPE III (RED)
C
D

E

F
G

H

I
J

K

L
M

N

O
P

Q

R
S

T

U
Fig. 1-13, A-X
V-DISSECTOR (PURPLE)
V
W
X
T e cannula types all come in various gauges and lengths, depending on the individual application in the
ace or body (see descriptions o dif erent parts o the ace and body to ollow). Over the past 4 years, I
have developed alternative instruments or releasing adhesions and more cannulas or both harvesting
and placement.

Chapter 1 • he Coleman echnique
27
S wel
i n g
One o the most di cult tasks or the surgeon is preparing patients to expect the bruising and swelling
created by this technique. T e placement o atty tissue, as described in this chapter and book, may
create remarkable swelling in the recipient tissues. T is depends on a number o actors, including the
amount o at placed, the anatomic location to which it is gra ed, the specif c technique and instruments
used, medications the patient takes, and the age and genetic makeup o the patient.
Patient care a er at transplantation is directed at minimizing swelling and avoiding migration. Eleva-
tion and external pressure with elastic tape or egaderm help prevent swelling and stabilize the newly
gra ed at. Certain medications (Arnica montana and bromelain) may also speed recovery. T e patient
is asked to avoid heavy pressure on the gra ed areas or to 0 days to avoid migration o the gra ed at.
Swelling can be especially bothersome and prolonged in the periorbital region, particularly the lower
eyelid. Any pigmentation in the lower lid will appear darker with bruising, which can last even in a min-
imal orm or many weeks. A slight staining o the skin, possibly hemosiderin deposits or other pigment
changes, can remain or months in some patients a er minimal at gra ing to the lower eyelid.
T e prolonged swelling and recovery associated with this procedure may prove con using to physicians
as well as to patients. O en, the result is judged to be f nal at 4 or 6 weeks. T e patient or the physician
mistakenly considers this as the endpoint, even though edema is def nitely present. As the swelling con-
tinues to resolve over the next ew months, the patient and the physician may assume that at is being
reabsorbed when simply not enough at was placed. Although 4 months a er surgery the surgeon can
get a good idea o the amount o at placed, a more accurate estimate should be made a er 6 or 8 months
or even later, when the swelling has resolved completely and minimal additional changes are to be ex-
pected.

Part I • Principles and Basic Concepts
28
Fig. 1-14, A-C
A

B
C
T is patient experienced remarkable swelling and bruising at 3 days. By 14 days she was looking swollen,
but much younger.
Fig. 1-14, D and E
D

E
Her long-term follow-up, shown 3 years and 7 months postoperatively, demonstrates remarkable rejuve-
nation with excellent improvement of skin texture.

Chapter 1 • The Coleman Technique
29
Preoperative
A
Preoperative markings
B
Immediately after surgery
C
4 days postoperatively
D
10 days postoperatively
E
24 days postoperatively
F
52 days postoperatively
G
10 months postoperatively
H
Fig. 1-15, A-H
A more normal recovery from a midface and a modest lip augmentation procedure is shown.

Part I • Principles and Basic Concepts
30
I

J
Fig. 1-15, I and J
A remarkable but subtle rejuvenation is evident when the patient’s preprocedure photograph (I) is com-
pared with the one taken 1 months a er surgery (J).
HOW TO REDUCE SWELLING
In the f rst hours and days a er at placement, the primary ocus o postprocedure care is to prevent the
ormation o edema. Elevation and homeopathic medications such as Arnica montana can be an aid.
Patients are instructed to keep their head elevated above the heart. Cold compresses or ice packs are
applied on all inf ltrated sites or 6 to 48 hours postoperatively.
Patients should avoid any type o pressure on the inf ltrated areas or the f rst ew days to prevent moving
the newly placed atty tissue.
A protective barrier o elastic tape or egaderm is placed on the skin o the operated areas immediately
a er the procedure and le in position or or 4 days. Patients are instructed not to massage or manip-
ulate the area or at least 1 week. Particular attention should be paid not to press their ace to the pillow
during sleep. T e external pressure applied to the operated areas has a triple purpose: to prevent patients
rom touching the gra ed areas, to avoid the migration o the at, and to reduce swelling.
T e dressing is usually removed 4 or 5 days a er the procedure, at the same time o acial stitches exci-
sion. At this point, by applying gentle pressure in a rolling ashion, lymphatic drainage should be insti-
tuted. T is maneuver will urther contribute to the reduction o swelling.

Chapter 1 • he Coleman echnique
31
Fig. 1-16, A-D
Immediately after surgery
with Microfoam tape
A
4 days postoperatively
B
6 days postoperatively
C
19 days postoperatively
D
T e application o external pressure during the postoperative period is shown. An elastic tape was ap-
plied to this patient’s upper and lower eyelids, cheeks, and neck immediately af er the procedure. At days
4 and 6 she is still in the “monster” stage. At day 9 she looks presentable, although still slightly swollen.

Part I • Principles and Basic Concepts
32
I ntra d erma l P l a cement o f F a t
Deep dermal injection
Subcutaneous injection
Fig. 1-17
I previously discouraged the use o any sharp needle or the placement o at gra s.10
However, in the last decade or so, I have come to realize that one o the most important advances in at
gra ing technique is the deep dermal placement o atty tissue with sharp needles. In the past, I speci -
ically discouraged intradermal placement, but in the late 99 s, as I began to use hyaluronic acid in my
practice, I became reacquainted with the advantages o intradermal augmentation.
I f rst used intradermal at gra ing in or the treatment o acne scars. A er what appeared like suc-
cess, I began placing ref ned at into other scars, rom pox marks to linear depressed scars. As with every
procedure, there was variable success, but the patients mainly elt that there was enough success to come
back or secondary and even tertiary injections.
Forcing large parcels o at through a needle is technically awkward, and the needles can block re-
quently. To my surprise, I ound that harvesting the at with the normal Coleman cannulas produces
a at parcel that usually permits placement through a -gauge needle with relative ease. I ound that
harvesting at with the at inf ltration cannulas did not noticeably reduce the incidence o clogging.
However, with the use o the smaller-bore 9-hole harvesting cannulas the at owed much more easily
through the small-bore needles. On some patients, especially when the harvested at is f brous, it may be
necessary to change the needles requently when clogging occurs.
I settled on the -gauge needle based on trial and error as the smallest bore needle through which I elt
that I could place at with some precision into the deep dermis. With larger-bore needles, I simply had a
di cult time staying in the deep dermis.
A er success with the treatment o scarring, I tried the technique to so en deep wrinkles and olds,
usually to f nish o or to complement the subcutaneous placement. It has been in these situations that I
have seen the clearest improvement over simple subcutaneous injections.

Chapter 1 • he Coleman echnique
33
Fig. 1-18, A
A
T is 60-year-old man presented with severe acne scarring complicated by subcutaneous atrophy rom
aging. T is created remarkably deep nasolabial olds, marionette grooves, and mentolabial creases.
In his f rst procedure, 2.9 cc was placed into the right nasolabial old with a 22-gauge needle intrader-
mally f rst, then 5 cc was placed into the subcutaneous planes. For the le nasolabial old, .5 cc was
placed with a 22-gauge needle intradermally f rst, then 5 cc was placed into the subcutaneous planes.
A er all o the at was placed, a V-dissector was used to ree up multiple adhesions.
In the right marionette region, 2.5 cc was placed with a 22-gauge needle intradermally f rst, then 2.5 cc
was placed into the subcutaneous planes. In the le marionette area, cc was placed with a 22-gauge
needle intradermally f rst, then 2.5 cc was placed into the subcutaneous planes. Subcision was per ormed
in the marionette region a er all o the at had been placed.
In the mentolabial crease, cc was placed with a 22-gauge needle and cc subcutaneously. In addition,
8 cc was injected in the premaxilla and 4 cc in the chin area using subcutaneous placement.
Fig. 1-18, B
B
One year later, another procedure was per ormed. Into the right nasolabial old, cc was placed with a
22-gauge needle intradermally f rst, then 6.5 cc was placed into the subcutaneous planes. Into the le
nasolabial old, cc was placed with a 22-gauge needle intradermally f rst, then 4.5 cc was placed into
the subcutaneous planes. No reeing up was per ormed at this procedure.

Part I • Principles and Basic Concepts
34
In the right marionette region, 2 cc was placed with a 22-gauge needle intradermally f rst, then cc was
placed into the subcutaneous planes. In the le marionette region, 1 cc was placed with a 22-gauge nee-
dle intradermally f rst, then cc was placed into the subcutaneous planes. Subcision was per ormed in
the marionette region again a er all at had been placed.
Into the mentolabial crease, another 2 cc was placed with a 22-gauge needle and cc subcutaneously. At
this procedure, the area above the nasolabial old was suctioned to yield 6 cc on the right and .8 cc on
the le .
C

D
E

F
G

H
Fig. 1-18, C-H
T e patient is shown be ore and 8 months a er the last procedure. Note the remarkable improvement
in the nasolabial olds, marionette grooves (especially the much deeper right side), and the mentolabial
creases. T is degree o correction o the acne scars and deep olds would be di cult by any other means.

Chapter 1 • he Coleman echnique
35
A

B
Fig. 1-19, A and B
T is -year-old man complained primarily o acne scars as well as deeper wrinkles in his orehead.
A er harvesting atty tissue and ref ning it in the usual ashion, with the patient under sedation, 0. %
lidocaine with :200,000 o epinephrine was inf ltrated into the subcutaneous planes o the orehead.
C

D
Fig. 1-19, C and D
T e tip o the 22-gauge needle was placed into the deep dermal plane and advanced under the orehead
wrinkle. T rough one puncture site, several passes were made in a linear threading ashion to place tis-
sue deep to the wrinkle.
E

F
Fig. 1-19, E and F
A er placement along the direction o the wrinkle, at was then placed in a similar plane in vertical and
oblique directions; o en this is done in the opposite direction along the wrinkle.

Part I • Principles and Basic Concepts
36
G

H

I
Fig. 1-19, G-I
T en I attempted to place the at slightly more superf cially into the specif c scar or wrinkle.
J

K
Fig. 1-19, J and K
A er deep dermal placement into the wrinkles and scars, some at was placed deep to the intradermal
placement in the subcutaneous plane.
L

M
Fig. 1-19, L and M
Finally, a V-dissector was used to break up any persistent adhesions.

Chapter 1 • he Coleman echnique
37
N
O

P
Q

R
Fig. 1-19, N-R
T e patient is seen be ore treatment with marked areas and 9 months a er this single treatment.
S

T
U

V
Fig. 1-19, S-V
In my experience, the long-term ef ect o intradermal placement o atty tissue is not as reliable as with
subcutaneous placement using larger-bore cannulas. However, I have observed a remarkable ef ect in
many patients that is simply not attainable with subcutaneous placement.

Part I • Principles and Basic Concepts
38
It is important to avoid superf cial placement, because it can result in visible circumscribed corrections.
Particular care should also be paid to avoiding isolated placement since such placements may result in
circumscribed, visible corrections. Furthermore, the e ect o intradermal placement o at is di erent
rom the e ect o placement o the same volume into deeper subcutaneous planes. With intradermal
placement o minimal volume, even deep wrinkles can be so ened or sometimes even ablated. Subcu-
taneous placement would entail a much larger volume, without an equivalent e cacy. Also, scars that
would not be as a ected by simple subcutaneous placement can be improved or eliminated with intra-
dermal placement.
I do not recommend undermining or releasing adhesions or scars be ore intradermal at gra ing T e
intradermal technique o at placement described here is specif cally di erent rom the technique o
injection with a sharp needle into a subcutaneous plane described by Carraway and Mellow.11 T ey de-
scribed the use o small sharp needles to undermine and create a subcutaneous plane be ore placement
with the needle. T is may create a potential space that can destabilize the placement o at and encourage
migration and irregularities. T ere ore I do not recommend undermining be ore injection.
T e surgeon should master the basic at gra ing techniques be ore using this intradermal technique.
And every surgeon should be exceedingly cautious when injecting intradermal at to avoid intravascular
embolization by per oration o an artery or vein and injecting into the lumen o the vessel (see intravas-
cular injections in Chapter 52).
Combining at gra ing through a Coleman mini-cannula with intradermal needle at gra ing has re-
markably improved the ability o a surgeon to so en or obliterate nasolabial olds, marionette olds,
glabellar creases, in addition to depressed scars rom acne, incisions, or trauma.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
REFERENCES
. Padoin AV, Braga-Silva J, Martins P, et al. Sources o processed lipoaspirate cells: in uence o donor site
on cell concentration. Plast Reconstr Surg 22:6 4, 200 .
2. Pu LL, Cui X, Fink BF, et al. T e viability o atty tissues within adipose aspirates a er conventional lipo-
suction: a comprehensive study. Ann Plast Surg 54:2 ; discussion 292, 2005.
. Pu LL, Coleman SR, Cui X, et al. Autologous at gra s harvested and ref ned by the Coleman technique:
a comparative study. Plast Reconstr Surg 22:9 2, 200 .
4. Erdim M, ezel E, Numanoglu A, et al. T e e ects o the size o liposuction cannula on adipocyte survival
and the optimum temperature or at gra storage: an experimental study. J Plast Reconstr Aesthet Surg
62: 2 0, 2009.
5. Gonzalez AM, Lobocki C, Kelly CP, Jackson I . An alternative method or harvest and processing at
gra s: an in vitro study o cell viability and survival. Plast Reconstr Surg 20:2 5, 2007.
6. Kurita M, Matsumoto D, Shigeura , Sato K, Gonda K, Harii K, Yoshimura K. In uences o centri ugation
on cells and tissues in liposuction aspirates: optimized centri ugation or lipotrans er and cell isolation.
Plast Reconstr Surg 2 : 0 ; discussion 042, 200 .
7. Pallua N, Puls ort AK, Suschek C, et al. Content o the growth actors bFGF, IGF- , VEGF, and PDGF-BB
in reshly harvested lipoaspirate a er centri ugation and incubation. Plast Reconstr Surg 2 : 26, 2009.
. Allen RJ Jr, Canizares O Jr, Schar C, Nguyen PD, T anik V, Saadeh PB, Coleman SR, Hazen A. Grading
lipoaspirate: is there an optimal density or at gra ing? Plast Reconstr Surg J : , 20 .
9. Miller C. Cannula Implants and Review o Implantation echniques in Esthetic Surgery. Chicago: Oak
Press, 926.
0. Coleman SR. Structural at gra s: the ideal f ller? Clin Plast Surg 2 : , 200 .
. Carraway JH, Mellow CG. Syringe aspiration and at concentration: a simple technique or autologous at
injection. Ann Plast Surg 24:29 , 990.

39

D
rm g p c f c m u d v p c m c r x cu ub-
c ur c g c r qu r w -d v p d r g . B r p c b d v -
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pr r c pr c dur , m d c r , d p c pp r c . Arm d w rm -
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c ccur; rw , c c ucc u pr c dur c pr v d r u . Pr p -
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k d k , v r w r qu g d r pp r c , d d cu w m
p r r juv . B ud g r d p gr p , p c r r k d
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b c mp r d r curr pp r c .
39
C h a p t e r 2
Analysis o t he Pat ient
Sydney R. Coleman

40
Part I • Principles and Basic Concepts
Fig. 2-1
Comparing the patient’s current appearance with her appearance immediately be ore she had an aes-
thetic procedure can also be use ul. For instance, this patient’s acelif shortened her jawline. Although
the mandibular border is tighter, more submental skin is exposed. T e operative plan may include
lengthening her ace back to the way it was be ore the acelif .

41
Chapter 2 • Analysis o the Patient
Following are suggestions or obtaining the best youth ul photographs:
• Ask or photographs in which the patient is not smiling, because smiling distorts the ace, es-
pecially the cheeks, lower eyelids, and lips. However, photographs o the patient smiling can be
use ul or assessing the upper eyelids and orehead.
• Request prof les as well as rontal views because prof les can provide the best in ormation about
the jawline and chin.
• Remind patients to supply good-quality photographs that are in ocus. Wedding photographs, ex-
pired passports, old yearbooks, and driver’s licenses are good sources. However, Instamatic pho-
tographs, Polaroid shots, and others may also be help ul.
I patients are interested in enhancing their acial eatures or adjusting their acial proportions, I ask
them to bring in photographs o persons they think are attractive who have acial structures similar to
theirs. T ese photographs give me a better understanding o a patient’s aesthetic pre erences. Reviewing
photographs with patients allows me to determine the amount o augmentation necessary and to design
contour changes with the patient actively participating in the process; it also provides a springboard or
discussion. For instance, we can talk about the shape o the lips, the proportion o the upper to the lower
lip, or the size o cheeks and mandible they pre er.
I ni ti a l C on sul ta ti on
At a minimum I schedule two consultations with a patient be ore surgery. Each o these consultations
lasts rom 30 to 75 minutes. During the initial consultation I ocus on the patient’s li estyle and social
history, specif c goals and expectations, history o previous aesthetic surgery procedures, medical his-
tory, and physical appearance. I also take photographs that will be reviewed when the patient returns.
T e f rst consultation allows my sta and me to continue educating the patient about the choices avail-
able to meet her individual needs. I use brochures and computerized demonstrations to explain the
procedure and the potential o Coleman structural at gra ing.
LIFESTYLE AND SOCIAL HISTORY
A thorough understanding o the patient’s li estyle and expectations is necessary to avoid problems.
A 60-year-old retired longshoreman may dramatically di er in his perception o aging rom that o a
60-year-old investment banker struggling to survive in a rapidly changing and youth-oriented industry.
A 38-year-old happily married mother o our may have totally di erent goals rom her identical twin
who is in the process o a divorce and has no children; the ormer may be content with some minor
rejuvenation, whereas the latter may seek dramatic lip enhancement or alterations o acial proportions.
Operating on a patient who has not told a spouse, signif cant other, amily member, or riend o a
planned procedure or whose husband or lover is angry about the planned procedure will usually make
the postoperative course much more di cult. A person’s career and support system (relationships and
amily situation) can be crucial to ensure that they have realistic expectations and to help the patient
through the procedure and recovery period.
GOALS AND EXPECTATIONS
T e greatest challenge at the f rst consultation is identi ying the patient’s goals and expectations. Eliciting
the actual reasons or requesting surgery or the real source o concern can be an ordeal; however, it is
well worth the time invested. T e surgeon who ails to do so is destined to ail. For example, an aging
patient complains that her lips make her look old. Coleman structural at gra ing will give her uller,
tighter lips and eliminate the wrinkles—a completely success ul result to the surgeon—but the patient
returns months later unhappy because the corners o her mouth still droop despite all the time and
money she invested. It is a problem that the surgeon had no idea that the elimination o the marionette

42
Part I • Principles and Basic Concepts
grooves was the patient’s major concern. Structural at gra ing will predictably reduce wrinkles around
the lip, improve lip contour, and even improve the texture o the skin in the marionette region; however,
eliminating the downward turn o the corners o the mouth is more di cult. As a result, the operation
may be a technical success, but the patient remains dissatisf ed.
I usually ask the patient, “Why are you here?” T e patient typically responds, “Because o my ace,” “my
eyes,” or “my smile lines.” I ask her to be more specif c. I a patient says simply, “I am getting old,” I re-
mind her that un ortunately I cannot change her chronologic age, but rather I need to know what acial
changes that accompany the passing years cause her distress. ypical responses include wanting the ace
smoothed out, the eyes li ed, elimination o bags and pouches, or a desire or bigger cheeks. I want to
know why the patient wants a smoother ace or bigger cheeks. I am interested in what she perceives as
the problem with her ace or nasolabial olds. Does the patient think she has “sad” or “tired” eyes? Do
her nasolabial olds make her look disdain ul or like she smells something putrid? Does she think her
ace is too masculine, or does he think his ace is too eminine? I try to avoid putting words into patients’
mouths; I pre er to let them identi y the actual problems that have motivated them to seek help.
PREVIOUS AESTHETIC PROCEDURES
Obtaining a complete history o a patient’s past aesthetic procedures that could in uence the planned
structural at gra ing is not as simple as it would appear. Many patients are not orthcoming with details
o past procedures. Even though patients are given an intake orm on which to list prior aesthetic surgery
procedures they o en provide an inaccurate account, especially i they have had many procedures.
T e surgeon should care ully review past procedures to be sure nothing has been orgotten or over-
looked. A large percentage o patients will not volunteer in ormation about a prior rhinoplasty. (“Oh,
you’re right. I orgot! But it was done such a long time ago that it really doesn’t matter.”) T ey requently
ail to mention orehead li s and upper eyelid surgery. Many o these patients consider eyelid and brow
surgery to be parts o a aceli and do not think to mention them separately. Many do not remember
having had a chin implant until I point it out to them. Most commonly patients ail to list revisions o
procedures: “Oh, I orgot to tell you that I have our revisions o my nose surgery; but each one was just
a little procedure . . . except or the hip bone gra .”
I the patient has solid cheek or chin implants, the surgeon should try to f nd out what types o implants
were used. It is particularly important to determine whether silicone gel–f lled implants were used be-
cause o the risk o per oration. Also, a history o in ection around the implants may indicate the pres-
ence o signif cant scarring, which will make structural at gra ing more di cult.
In my experience, injections o silicone and even at are the procedures that patients most o en neglect
to mention. Many women who have had silicone injections will not volunteer this in ormation unless
asked directly. Even i they disclaim any injections on the intake orm, it is advisable to ask i they have
had silicone, other f llers, or at injections. O en a patient when directly queried will suddenly remem-
ber that she had a series o 15 injections o silicone 10 years ago. Previous procedures can in uence the
success o any planned procedure. For example, placing structural at under silicone can push out and
tighten the lumps o scars surrounding the silicone, causing unpredictable sur ace irregularities.
Because the presence o scars on the skin can in uence the approach or placement o at gra s, the his-
tory should include in ormation about skin biopsies, punch biopsies, and so on.
MEDICAL HISTORY
Because Coleman at gra ing is invariably an elective procedure, candidates with a poor general health
status should be approached with caution. T e primary physician and anesthesiologist should conf rm
the patient’s ability to undergo the chosen type o anesthetic.

43
Chapter 2 • Analysis o the Patient
Other special considerations are relevant to candidates or structural at gra ing. Problems with bleed-
ing, bruising, and unusual swelling a er prior procedures should be addressed to prepare the patient and
surgeon or similar problems. O particular importance is the e ect o certain medications on platelet
unction. A list o medications to avoid is given to the patient at least weeks be ore the planned proce-
dure date. An example o such a list is given in Box -1, but the surgeon is responsible or ensuring the
accuracy and currency o this in ormation at the time o each patient’s procedure.
A neurologic history is essential. Fat inf ltrated into the muscles o a patient who has recovered rom
a acial nerve injury or Bell’s palsy may act as a stent, inhibiting movement in the a ected areas o the
ace. Any history o psychiatric problems and the current status o these may require special attention
to prepare patients or the postoperative period. A history o any outbreaks o ever blisters on the lips is
solicited to determine i herpes simplex prophylaxis is indicated. Obviously, a history o allergy to peni-
cillin and especially to cephalosporin is important, because these are the drugs o choice or prophylaxis
or treatment o in ections. Because smoking may impede the neovascularization o the gra s, and sub-
sequent persistence o the gra ed at, I actively discourage patient smoking be ore and a er at gra ing.
It is also important to inquire about the patient’s use o holistic medications. oday many patients use
herbs and supplements, and the physician needs to be knowledgeable about these substances and their
possible e ects on the surgical patient. T ese agents should be treated as drugs that may have an impact,
either negative or positive, on the procedure and the patient’s recovery. I recommend supplements to
aid in healing and recovery; these recommendations vary rom month to month, depending on current
scientif c studies and anecdotal in ormation. I also provide patients with a list, which is requently up-
dated, o herbs and supplements that are potentially harm ul to any patient undergoing surgery; a recent
version o this list is provided in the Box - .
Body weight is a actor that must be addressed. I patients have any plans or weight reduction, I consider
delaying the procedure until they have attained their desired weight. T e amount o acial at should re-
main constant over a period o time so that the volume that will need to be placed can be assessed accu-
rately. I rarely advise a thin person to gain weight be ore the procedure. I have ound that such a person
will return to her ormer weight in a relatively short period o time. Obviously, as body weight uctuates
so will the volume in the areas in which at is placed. T e volume lost will be a combination o both in-
trinsic at and transplanted at. In any case, the patient will have been undercorrected or her usual body
weight. Similarly, I advise patients against gaining signif cant weight because the transplanted at may
expand.
Although I have success ully transplanted at in several patients with autoimmune diseases (ulcerative
colitis, rheumatoid arthritis, and systemic lupus erythematosus), I have noted unusual postoperative
problems in several patients with chronic atigue syndrome, specif cally prolonged swelling and pain
in donor and recipient sites. T ere ore, it is important to identi y a history o chronic atigue or similar
syndromes and orewarn such patients o possible complications.
PHYSICAL EXAMINATION
T e physical examination o the ace supplements the photographic documentation. Photographs can-
not capture the relationship o the underlying structures to the skin. Palpation is used to establish such
landmark relationships as the height o the in raorbital rim in comparison to the eyelid and the rela-
tionship o the angle o the mandible to the actual shadow o the jawline. Silicone and other injectables
are usually palpable even i the patient ails to mention them or denies their presence. Also, solid cheek,
chin, and jawline implants should be palpated to determine their size and orientation. Facial movements
are assessed to detect any asymmetries o motion or the presence o palsies.

44
Part I • Principles and Basic Concepts
I you are taking any steroid and/or medication or arthritis,
please call our of ce.
Box 2-1 Medications to Be Avoided Before Surgery
T e ollowing drugs either contain aspirin and/or have undesirable side ef ects that may af ect your surgery (abnormal bleeding
and bruising). T ese drugs should be avoided or two weeks prior to surgery. I you need to take something or the relie o
minor pain, YOU MAY AKE YLENOL or another “acetaminophen product.” Please let us know i you are currently taking
any o these medications.
Advil
Alka-Seltzer
Alka-Seltzer Plus
Anacin
Anaprox
Anadynos
Ansaid
A.P.C.
Argesic
Arthropan Liquid
Arthritis Pain Formula
Arthritis Strength Buf erin
A.S.A.
A.S.A. Enseals
Ascriptin
Ascriptin A/D
Ascriptin with Codeine
Ascriptin Extra Strength
Asperbu
Aspergum
Aspirin
Atromid
Axotal
Azolid
Bayer Aspirin
Bayer Aspirin Maximum
Bayer Children’s Aspirin
Bayer Children’s Cold
Bayer ime-Release Aspirin
B.C. ablets and Powder
Buf -a-Comp
Buf -a-Comp No. 3
Buf erin Arthritis Strength
Buf erin Extra Strength
Buf erin with Codeine No. 3
Buf ets 2
Bu nol
Bu - abs
Butazolidin
Cams Arthritis Pain Reliever
Carisoprodol
Cheracol Capsules
Chlortrimeton
Clinoril
Congesprin Chewable
Cope ablets
Cosprin ablets
CP-2 ablets
Damason P
Darvon Compound
Darvon Compound-65
Darvon N with A.S.A.
Darvon with A.S.A.
Pulvules
Di-gesic
Disalcid
Dolobid
Dolprin
Dristan
Durasal ablets
Easprin
Ecotin
E cin
Elavil
Emagrin
Emprazil
Empirin with Codeine
Encaprin
Endep
Equagesic ablets
Etra on
Excedrin
Feldene
Fiorinal
Fish Oil
Flagyl
Flexeril
Four Way Cold ablets
Gaysal-S
Gelprin
Gemnisin
Goody’s
Ibupro en
Indocin
Indomethacin
Lanorinal
Lioresal
Lortab
Magan
Magsal
Marnal
Maximum Bayer Aspirin
Measurin
Medomen
Methcarbamol with
Aspirin
Micrainin
Mobidin
Midol
Mobigesic
Momentum Muscular
Backache Formula
Motrin
Mysteclin F
Nal on
Naprosyn
Naproxen
Neocylate
Nicobid
Norgesic
Norgesic Forte
Nuprin
Ora ex
Orudis
Pabalate-SF
Pamelor
Parnate
Pepto-Bismol ablets
Pepto-Bismol
Suspension
Percodan
Percodan Demi ablets
Persantine
Persistin
Phentermine
Phenylbutazone
Ponstel
Propoxyphene
Compound 65
Robaxisal
Ru en
Ru- uss
S.A.C.
Saleto
Salocal
Sine Aid
Sine-of Sinus Medicine
Sinutab
SK-65 Compound
Stanback
Stendin
St. Joseph’s Aspirin or
Children
St. Joseph’s Cold
ablets
Sulindac
Surmontil
Synalgos
agamet
alwin Compound
enuate Dospan
etracycline
olectin
olmetin
riaminicin
riavil
rigesic
rilisate ablets and
Liquids
Uracel
Vanquish
Verin
Vibramycin
Vitamin E
Voltaren
Zomax
Zorprin

45
Chapter 2 • Analysis o the Patient
PHOTOGRAPHS
Meticulous photography is essential to success ul Coleman at gra ing. Photographs document the pa-
tient’s preoperative appearance and serve as a basis or three-dimensional analysis. A er a care ul history
and examination, I take photographs o the patient rom a variety o angles and views. Photographs are
taken o the ull ace in many views to assess proportions, a er which closeup photographs are taken to
isolate and analyze individual areas o the ace.
T ese photographs are reviewed with the patient at the second consultation and are used or comparison
during and a er the procedure. T ey are also used as an educational tool that allows patients to evaluate
their current appearance and participate in creating a plan or the procedure. Intraoperatively, they serve
as a re erence point or the three-dimensional changes. T e photographs demonstrate and document the
changes postoperatively. I the surgeon has not taken accurate photographs, it will be impossible to eval-
uate the contour changes. T e volume and structural changes e ected by Coleman at gra ing are usu-
ally subtle and natural appearing. When the at is placed properly, it becomes integrated with the tissues
and is extremely di cult to palpate a er the edema has subsided. Even the most observant patients may
not remember the exact size and shape o their aces be ore the procedure and may complain that some
or all o the at is gone. Even i all o the at survives and the structural goals are achieved, the procedure
will be a ailure i the physician cannot document the presence o atty tissue.
Photographs o the body should be taken be ore the procedure on every case to document the condition
o the harvest site. Photography o the hands, body, and breast require special views, which will be dis-
cussed in their respective chapters that ollow.
Guidelines for Photography
Equipment
I use a single-lens re ex camera with a macro 10 mm portrait lens or all acial photographs, because
this lens helps prevent central distortion. o avoid areas being out o ocus, an -stop o greater than
11 should be used and the camera should be set on aperture priority. Automatic ocusing can produce
less-than-optimal photographs.
Box 2-2 Supplements to Discontinue During the Preoperative Period
T e “natural products” listed below may be benef cial or a variety o ailments, but their use around the time
of surgery may not be desirable. T ere ore it is advisable to stop taking these products to avoid problems
with surgery and anesthesia. I time permits, discontinue the use o these products two weeks be ore surgery
and two weeks a er surgery.
Bilberry (Vaccinium myrtillus)
Cayenne (Capsicum annuum)
Dong Quai (Angelica sinensis)
Echinacea (Echinacea augusi olia)
Fever ew (Tanacetum paithenium)
Fish Oil Capsules
Garlic (Allium sativum)
Ginger (Zingiber of cinale)
Ginkgo Biloba
Ginseng (Panax ginseng/Panax quinque olium)
Hawthorne (Crataegus laevigata)
Kava Kava (Piper methysticum)
Licorice Root (Glycyrrhiza glabra)
Ma Huang (Ephedra sinica)
Melatonin
Red Clover (Tri olium pratense)
St. John’s Wort (Hypericum per oratum)
Valerian (Valeriana of cinalis)
Vitamin E
Yohimbe (Corynanthe yohimbe)

46
Part I • Principles and Basic Concepts
A single-point ash mounted on the top o the camera provides a consistent source o illumination. Be-
cause the postoperative photographs may be taken in a di erent room or even a di erent acility years
later, the ash is standardized or reproducibility. T e position o the ash with respect to the subject
must be appreciated at all times. o evaluate symmetry, the ash should be placed centrally above or be-
low the camera. o obtain oblique and prof le views, the ash is usually placed on the side o the camera
toward the ront o the ace. A macro ring ash is use ul or documenting the skin texture in closeup
views and or placing light into cavities, such as the orbit or mouth. A dark sky-blue nonre ective back-
ground provides a good backdrop or skin tones.
Visualization
You must see the ace to photograph it! Accurate evaluation is impossible i a portion o the ace is cov-
ered with hair or clothing. T e entire orehead, most o the ears, and the neck must be visible or assess-
ment o acial proportions.
Fig. 2-2
A headband, elastic band, or clips o some sort are almost always necessary to pull hair back rom the
ace and ears, even or male patients. Collars should be pushed down or clothing covering the neck
should be removed. I ask emale patients to remove their lipstick so an accurate assessment can be
made o the size and shape o their lips in relationship to the rest o the ace. I usually do not ask them
to remove the remainder o their makeup or this f rst set o photographs; this permits them to evaluate
their ace more objectively, because they are accustomed to viewing their ace with their makeup on. T e
photographs taken the day o the procedure are with the patient ree o any makeup so that the color and
texture o the skin can also be documented.
S econ d C on sul ta ti on : P l a nni n g a n d F urth er A na l ysi s
When patients review their photographs at the second consultation, they are seeing their real image
rather than the reverse image they are accustomed to seeing in the mirror. T e brain is accustomed to al-
tering such reverse images, sometimes making eatures more attractive and sometimes less so. However,
when patients look at a real image photograph, they are con ronted with an image that the brain has
not altered. T is is why patients who see photographs o themselves requently think the images do not
resemble them. Multiple views o the entire ace as well as macroscopic magnif cations are essential or
ormulating a three-dimensional analysis o the ace. From this analysis I develop a potential blueprint
or the procedure in the patient’s presence.

47
Chapter 2 • Analysis o the Patient
Some experts pre er clinical evaluation over photographs, relying on the patient’s and physician’s per-
ceptions rather than on photographic documentation. Admittedly, patient satis action is one o the most
important measures o the value o a procedure, but meticulous photographs are a more objective means
o evaluating results.
racings or drawings o the patient’s ace are made to aid in evaluating perceived problems, discussing
them with the patient, and planning the procedure. I use them to predict the volumes required, the level
o placement, and the structure needed to achieve the desired changes. T e tracings also serve as a type
o in ormed consent to document the planned changes during the consultation. T ey show the areas o
atty tissue placement and removal as well as the incision sites. T e essential point is that they serve as a
re erence or making the markings immediately be ore surgery and during the procedure.
Fig. 2-3
T ese tracings are o the patient seen in Fig. -1; she is shown throughout the chapter. Using the pho-
tographs taken at the f rst consultation, I trace the image with a pencil. racings o the two prof le and
rontal views are most o en used.

48
Part I • Principles and Basic Concepts
Fig. 2-4
I use copies o the tracings to document the patient’s complaints and applicable history during the sec-
ond consultation. I ask the patient to repeat her aesthetic surgery history rom the f rst consultation.
Frequently the history will have changed and I will discover at least one procedure that has been omitted.
As we review the history, I note in chronologic order all the procedures the patient remembers with the
date, the surgeon, and the operations per ormed.
Fig. 2-5
On a separate tracing I summarize the operations over the acial eatures involved. For instance, this pa-
tient had two upper blepharoplasties, so I make a notation on the upper eyelid: “Upper Bleph X2.” I also
ask patients to describe all procedures in which collagen, silicone, or other substances were injected into