Fat Injection From Filling to Regeneration

900
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Epidermis
Dermis
Fat
Fascia
Muscle
Rigottomy
+
Fat graft
Fig. 47-13
In a rigottomy with at graf ing, the scar is interrupted percutaneously and small at parcels are inter-
posed inside the scar.
Fig. 47-14
A
B
T is patient had an interlabial postsurgical retractile web. T e problem is seen preoperatively (A) and
1 year af er two treatments o rigottomies with 1 cc o graf ed at (B).

901
Chapter 47 • Fat Gra ting o the Female Genital Area
Fig. 47-15
T is anular stenosis was corrected with an island f ap and multiple rigottomies o the residual ring.
Fig. 47-16
T is patient’s posterior scar stenosis ollowing a hysterectomy was treated with ultrasound-guided rig-
ottomies.

902
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Lichen Sclerosus Atrophicus
Lichen sclerosus atrophicus is an autoimmune disease resulting in progressive mucous and cutaneous
sti ness, progressive usion o the labia minora and clitoral hood, and reduction o skin and mucosal
elasticity and trophism.13 T e vaginal ostium shrinks progressively, while mucous tissues become sti
and ulcerous as a result o both the natural thinning and the local corticosteroid therapies usually pre-
scribed.
Fat gra ing is very use ul throughout all phases o the disease, either as a unique procedure14 or in com-
bination with skin gra s and ap reconstruction. T e purpose o at gra ing in this area includes regen-
erative, antiin ammatory, and immunomodulatory e ects as well as scar tissue release.
Tips and Tricks or Fat Graf ing to Treat Lichen Sclerosus Atrophicus
• T e tissue level involved in the pathologic condition must be determined.
• I lichen sclerosus involves superf cial layers only (early phases), platelet rich plasma injection or
intradermal-submucosal nano at injection can be per ormed injecting with a 7- to -gauge needle.
• I lichen sclerosus involves deeper layers but no major vulvar constriction is identif ed, blunt cannula
multilayer at gra ing can be per ormed.
• I lichen sclerosus has led to constriction, percutaneous scar release and at gra ing are needed.
Gauge of the cannula for fat harvesting
Gauge of the cannula for implantation
Amount injected
Level of placement
Number of necessary procedures
2 mm
18- and 21-gauge needles
2 to 15 cc
Subcutaneous/submucosal
1 to 5

Fig. 47-17
Fat grafting for rigottomy

903
Chapter 47 • Fat Gra ting o the Female Genital Area
Fig. 47-18
T is patient is shown be ore surgery and months af er a rigottomy plus at graf ing o 15 cc per side.
Fig. 47-19
T is patient is shown be ore surgery and 1 year af er two at graf ing procedures o 5 cc per side.

904
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
CD34 5X
CD34 20X
CD34 5X
Biopsia
Pre-lp
Biopsia
Post-lp
?
EE SX
EE SX
Fig. 47-20
T ese histologic images rom be ore and a er at gra ing show tissue repair and regeneration.
Vulvar and Perineal Pain
Vulvar pain is a requent condition with various causes: postsurgical complications, traumatic injury,
in ection, cancer, and autoimmune diseases.15 T e investigation o the cause o pain is essential to def ne
the appropriate treatment.
Fat gra ing can be use ul in the ollowing cases:
• Pain rom scar retraction
• Perineal and vaginal related pain (such as pudendal neuropathy rom pudendal nerve entrap-
ment)16
• rue vulvodynia
T e purpose o at gra ing involves the mechanisms through which the adipose at can positively inter-
act with pain syndromes, as in the ollowing scenarios:
• Freeing entrapped nerves through scar release
• Interposition o a at pad (pillow action) between nerve ending and superf cial layers
• Antiin ammatory e ect17
• Regenerative e ect18

905
Chapter 47 • Fat Gra ting o the Female Genital Area
rue vulvodynia19 is a specif c disease characterized by precise trigger points causing pain that can be
elicited when stimulated by a cotton swab. rigger points have a higher percentage o pain ul nerve
f bers as well as a higher number o mast cells. Augmentation o nerve f bers and mastocytes in trigger
points have been demonstrated.20 Subcutaneous gra ing o to cc o adipose tissue inserts a small but
e ective atty pad between f bers and skin, whereas the antiin ammatory actors render a positive e ect
on mast cells, and the regenerative actors contribute to normalization o the in amed nerve f bers.
Pudendal nerve syndrome21 is a pain ul pathologic condition that is o en connected to anal sphincter
surgery and to other perineal procedures. It is caused by hyperalgic perineal nerve f bers. rigger points
must be identif ed subjectively as well as a pudendal nerve map through nerve mapping: pudendal nerve
motor terminal latency (PNM L).
Gauge of the cannula for fat harvesting
Gauge of the cannula for implantation
Amount injected
Level of placement
Number of necessary procedures
2 mm
18- and 21-gauge blunt cannulas
1 to 10 cc
Subcutaneous/submucous
1 to 5
FAT GRAFT FOR PUDENDAL NERVE SYNDROME
Fat graft of 20 cc
(vulvar, perivulvar,
rectum muscle)
Pudendal
nerve
Fig. 47-21
T ese images demonstrate treatment o pudendal nerve syndrome.
Urinary Incontinence
Stress urinary incontinence can be treated by periurethral at gra ing,22 leading to bulging along the
urethral line and to regeneration o periurethral smooth muscles. T e method is the same one used
over many years or injecting temporary or permanent f llers around the urethra, with care ul injections
along several lines but not into one (single) adipose tissue layer.
Gauge of the cannula for sample taking
Gauge of the cannula for implantation
Amount injected
Level of placement
Number of necessary procedures
2 mm
18-gauge, 10 cm long
2 to 15 cc
Periurethral
1 to 5

906
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
C om p l i ca ti on s
Possible complications o at gra ing include the ollowing:
• In ections are rare but possible. A sterile procedure and administration o an antibiotic will reduce
its incidence.
• Seromas are possible, particularly when the labia majora are injected.
• Necrosis o the gra ed at occurs when an excessive amount o at is implanted or a mistake is
made in the gra ing method or site. It is treated by aspiration o the necrotic at. T e conse-
quences include oil cyst ormation and f brosis.
• Necrosis o the vaginal tissues is rare, thanks to the highly vascularized vulvar integuments.
• Vessel embolization is the most severe complication, which can lead to local necrosis and general
severe complications. Fat gra ing o anatomic structures with vessels o the same or larger caliber
than the cannula must be avoided, as should needle injection o these areas.
• Rectovaginal per oration o the vulvar and anal mucosa might lead to a rectovaginal f stula.
D i scussi on
Gynoplasty is a new multidisciplinary surgical f eld in which reconstruction with at gra ing and the
benef ts o regeneration play important roles. Because the vaginal tissues are highly vascular and ex-
pandable, at gra survival in the emale genital area is very high, with a low degree o at necrosis and
oil cyst ormation.
In aesthetic gynoplasty, labia majora augmentation and vulvovaginal wall narrowing through at gra -
ing are sa e and e ective procedures. In most cases a single procedure is enough to achieve satis actory
results.
In regenerative gynoplasty, at cells provide a unique source o regeneration because o the regenera-
tive, antiin ammatory, and immunomodulatory capabilities o adipose-derived stem cells. Degenerative
pathologic conditions have to be treated by a multidisciplinary team. T e patient’s general condition, im-
mune status, absence o in ammation, local symptoms, and psychological aspects need to be considered.
Radiodermatitis and scars that cause pain and discom ort can be treated with percutaneous release and
at gra ing. T e number o treatments varies greatly according to the type o scar and skin damage. T e
results are grati ying and in many cases allow patients to resume a normal sexual li e.
C oncl u si on
Fat gra ing o the emale genital area is a sa e and e ective procedure to improve aesthetic and unc-
tion that requires good knowledge o anatomy and physiology. T e multidisciplinary approach (plastic
surgeon, gynecologist, urologist, etc.) is undamental to achieve good results and to expand at gra
applications or the uture.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.

907
Chapter 47 • Fat Gra ting o the Female Genital Area
REFERENCES
1. Georgiou CA, Benatar M, Dumas P, et al. A cadaveric study o the arterial blood supply o the labia mi-
nora. Plast Reconstr Surg 136:16 , 2 15.
2. Ginger V, Cold C, Yang C. Structure and innervation o the labia minora: more than minor skin olds.
Female Pelvic Med Reconstr Surg 1 :18 , 2 11.
3. O’Connell HE, Sanjeevan KV, Hutson JM. Anatomy o the clitoris. J Urol 1 ( Pt 1):118 , 2 5.
. Blondeel P, Morris S, Hallock G, Neligan P. Per orator Flaps. St Louis: Quality Medical Publishing, 2 6.
5. MacBride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc 85:8 , 2 1 .
6. Farage M, Maibach H. Li etime changes in the vulva and vagina. Arch Gynecol Obstet 2 3:1 5, 2 6.
. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 36 ( 566):1 2 , 2 .
8. Garagiola DM, Tarver RD, Gibson L, et al. Anatomic changes in the pelvis a er uncomplicated vaginal
delivery: a CT study on 1 women. AJR Am J Roentgenol 153:123 , 1 8 .
. Memar O, Nezamabadi A, Milani BY, et al. Nano at gra ing: basic research and clinical application. Plast
Reconstr Surg 133: 28e, 2 1 .
1 . Salgado CJ, Tang JC, Desrosiers AE III. Use o dermal at gra or augmentation o the labia majora. J
Plast Reconstr Aesthet Surg 65:26 , 2 12.
11. Rigotti G, Marchi A, Galiè M, Baroni G, Benati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment
o radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived
adult stem cells. Plast Reconstr Surg 11 :1 ; discussion 1 23, 2 .
12. Khouri RK, Smit JM, Cardoso E, Pallua N, Lantieri L, Mathijssen IM, Khouri RK Jr, Rigotti G. Percuta-
neous aponeurotomy and lipof lling: a regenerative alternative to ap reconstruction? Plast Reconstr Surg
132:128 , 2 13.
13. Murphy R. Lichen sclerosus. Dermatol Clin 28: , 2 1 .
1 . Boero V, Brambilla M, Sipio E, et al. Vulvar lichen sclerosus: a new regenerative approach through at
gra . Gynecol Oncol 13 : 1, 2 15.
15. Sand PK. Chronic pain syndromes o gynecologic origin. J Reprod Med (3 Suppl):23 , 2 .
16. Venturi M, Brambilla M, Boccasanta P, et al. Pudendal neuralgia: a new option or treatment. Preliminary
result in easibility and e cacy. Pain Med 16:1 5, 2 15.
1 . Akasheh RT, Pang J, York JM, et al. New pathways to control in ammatory responses in adipose tissue.
Curr Opin Pharmacol 13:613, 2 13.
18. Kokai LE, Marra K, Rubin JP. Adipose stem cells: biology and clinical applications or tissue repair and
regeneration. Transl Res 163:3 , 2 1 .
1 . Shah M, Ho stetter S. Vulvodynia. Obstet Gynecol Clin North Am 1: 53, 2 1 .
2 . Bornstein J, Goldschmid N, Sabo E. Hyperinnervation and mast cell activation may be used as histo-
pathologic diagnostic criteria or vulvar vestibulitis. Gynecol Obstet Invest 58:1 1, 2 .
21. Benson JT, Gri s K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol 1 2:1663, 2 5.
22. Lee PE, Kung RC, Drutz HP. Periurethral autologous at injection as treatment or emale stress urinary
incontinence: a randomized double-blind controlled trial. J Urol 165:153, 2 1.

(Trang không có chữ)

909
Lo er E t r emit y
Reconst r uct ion
Guy Magalon, Elie Toledano, Julien Niddam
T h g ’ h ap a al h l b ha l a d w h
h adv a f ll g h q ha l abl , w ll d f d, a d all h a l g
: al a g a g. Al h gh h h q w ap d d v l p ab v all
a al a h g , ha al ad d appl a v g h a
a d b a . Fa g a g al a v abl p p v g h a d v l l w
l b g a d .
A g a h v l h alv 1,2 a d b k 3-6 w h l pla wa f d -
b d . D p h a g a g h l b w p bl h d a d
p a l d h ha d,7,8 b k , a d alv .9-17 I h hap w w ll p h
a g a g l w x v g a d b d b C l a ,7,18-24 a d w
w ll d h v l a g a g.25-26
M
a teri a l a n d M
eth od s
INDICATIONS
V l d f h l w x a b d v d d w g al a g : ( ) h
pa w h g f a h p ph a ph a l b a g a l b w h
a , a d ( ) h pa w h l al z d l a l b v lv g v v-
al g h l b b w h p h v h p ph a ph h l b.
T a v l d f h pa h l w x ha a b a d w h a
g a g a a ll w :
• R v g
– a a a 27
– Ia g da ag , p all a p d a l b g ad h ap 28
– C g al d , h a l b la al l b h p ph 10,12
– al da ag ad h ap
– S q la
C h a p t e r 4 8
909

910
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
• Aesthetic surgery
– Fat trans er or aesthetic purposes
– Benslimane29 highlighted the beauty standards o the lower limbs. Changes in at distribution
can be addressed by combining liposuction with reinjection o atty tissue; or example, suc-
tioning o the ankles and inner aspects o the knees, with augmentation o the calves.
– Fat gra ing to improve contours a er a silicone implant is placed
ANALYSIS
wo principal parameters are analyzed clinically when at gra ing in a limb is being considered:

. T e volume def cit is compared with that o the contralateral limb. T e size o the volume def cit
is estimated by measuring the sur ace and mean depth o the de ect and by taking its general
shape into account. T e degree o asymmetry is assessed in a hypotrophic extremity. T is asym-
metry is generally caused by hypotrophy o both muscle and subcutaneous tissue. A comparative
measurement o limb circum erences at di erent levels o the limbs is use ul in planning the
procedure.

. T e quality o the cutaneous covering and its ability to stretch are decisive. T is helps the surgeon
to determine the number o procedures required to correct the estimated volume def cit.
TECHNICAL GUIDELINES
Be ore a procedure can be scheduled, all limb wounds must be healed, the patient must be ree o in ec-
tion, and the skin o the extremity must be prepared with massage or lymphatic drainage to improve its
capacity or distention.
T e donor and recipient sites are def ned and marked be ore the surgery with the patient in an upright
position. T e patient can help by showing the surgeon the areas that most concern him or her. When a
patient has limb asymmetry, we always use the contralateral limb as the donor site to reduce the asym-
metry; both liposuction o the contralateral limb and f lling o the hypotrophic limb are per ormed.
We pre er to use general anesthesia, because it allows us to work on both lower limbs or harvesting and
inf ltrating. Because the patient is under general anesthesia, we do not inf ltrate lidocaine or epinephrine
in the donor and recipient sites.
TECHNIQUE
Fig. 48-1, A and B
A

B
T is 3 -year-old woman presented with cortisone lipoatrophy o the right buttock a er injection o a
delayed-action corticoid. T e volume def cit was estimated to be 4 cc by measuring the sur ace ( cm2)
and the mean depth ( cm) o the de ect.

911
Chapter 48 • Lower Extremity Reconstruction
Markings
C
D
Fig. 48-1, C and D
T e preoperative markings determine the position o the incisions and the harvesting and gra ing areas.
T e procedure is per ormed with the patient under general anesthesia.
Incisions
E
F

G
Fig. 48-1, E-G
Fat injection is per ormed through multiple 2 mm incisions distributed in a radiating manner around
the area with a volume def cit (E), thus making it possible to crisscross the di erent injection axes in
three spatial planes. T e aim o this method is to inject the at throughout the recipient tissue in three
spatial planes with each containing a small quantity o at (F and G).

912
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Level o Inf ltration
In our patients, we always graf at into subcutaneous tissue. It can also be graf ed into the muscle com-
partment, especially in cases o limb asymmetry with amyotrophy, but during an intramuscular injec-
tion, there is a risk o acute compartment syndrome, particularly in the leg. It must be prevented by a
surgical asciotomy, per ormed with two or three short incisions on the leg. Fasciotomies are per ormed
or each compartment that is injected, only when the graf ed at is placed into the muscular layer. T us,
one asciotomy is generally per ormed or the anterior compartment with a cm cutaneous incision,
which allows or the per ormance o a complete vertical asciotomy o the anteroexternal muscular com-
partment o the leg. A second asciotomy is per ormed or the posterior compartment through a cm
posterior approach, with a complete vertical asciotomy in between the two gastrocnemius muscles.
In our experience, postoperative pain and risk o acute compartment syndrome can be decreased by
avoiding the muscular placement o the at and putting it exclusively into the subcutaneous layer, during
multiples steps i required.
Volume Ranges
T e volume o at graf ed varies, depending on the indication or lower limb reconstruction. In our ex-
perience, or limb asymmetry, the mean volume injected is about 80 to 00 cc per session, usually in a
two-stage approach. For a localized lesion, the volume depends on the size o the de ect and can range
rom 4 to 80 cc.
Harvest and Surgical Technique
T e surgeon must be prepared or the need or more than one procedure to achieve the desired results.
In such cases, procedures need to be per ormed at a minimum interval o 6 months. T e key is not oper-
ating too quickly on the patient but waiting or the end result. Radiating tunnels are used or at injection
through multiple incisions.
We use the structural at graf ing technique described by Coleman.7,13-15,17-19 Fat is harvested rom the
lateral part o the thighs to the right buttock with a two-hole Coleman harvesting cannula attached to
a 0 cc Luer-Lok syringe. Fatty tissue is obtained through multiple mm incisions around the harvest
areas. We select several sites to ensure the best quality o atty tissue. A quality graf is one with the low-
est possible proportions o oil and blood residue af er centri ugation. T is can be ensured by avoiding
mechanical trauma to the tissue and by harvesting moderate quantities at each site.

913
Chapter 48 • Lower Extremity Reconstruction
I

J
H
Fig. 48-1, H-J
T e at is harvested with a 0 cc Luer-Lok syringe and a Coleman harvesting cannula. T e atty tissue is
centri uged at 000 rpm or minutes with a MediLite centri uge; this separates the components into
three ractions—oil, atty tissue, and residue, layered by density. T e residual atty tissue is trans erred to
smaller cannulas or inf ltration using a three-way Luer-Lok.

914
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Placement
Fig. 48-1, K and L
K
L
T e at is injected in multiple planes through radial incisions to create a “cross-plane” e ect. For at in-
f ltration, we use 7 or cm cannulas. We have used 5 cm cannulas in several cases in which there were
larger areas to treat. T e immediate postoperative photo shows f lling without overcorrection.
Fig. 48-1, M-P
M
N
O

P
T e comparative result is shown 2 months a er a 0 cc at gra .

915
Chapter 48 • Lower Extremity Reconstruction
Postoperative Care
T e harvest and injection incisions are covered with a tulle gras dressing. Mild compression is applied to
the harvested zone when the topography allows it, but the injection zones are never compressed.
Immobilization may be needed when the treated area is near a joint to reduce the movement o the
gra ed tissue.
MICROINJECTION TECHNIQUE
For small volumes, we use the microinjection technique with single-use equipment: a 2 mm harvesting
cannula with holes smaller than mm, f ltration with double-membrane pocket,30 and injection with a
. mm 2 -gauge cannula.
Fig. 48-2
Fat is harvested with the use o a -gauge harvesting and inf ltration cannula, a three-way valve, and a
cc double-membrane pocket (PureGra ).

916
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
A

B
C

D
E

F
Fig. 48-3, A-F

917
Chapter 48 • Lower Extremity Reconstruction
H
G
I

J
Fig. 48-3, G-J
T is patient presented with plantar oot atrophy (G). T e microinjection site was marked, and lipoaspi-
rate was harvested rom the inner aspect o the knee (H). T e local anesthesia was injected through
the entry points with a 30-gauge-needle. T e lipoaspirate was harvested with a 0 cc syringe. T e entry
points were determined with -gauge needles (G). T e purif ed at was injected with a 2 -gauge can-
nula (I), or a total o 2 cc. T e oot is shown a er the procedure (J).

918
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
R esul ts
RESULTS WITH THE TRADITIONAL TECHNIQUE
Fig. 48-4
T is 2 -year-old woman presented with a loss o volume in the so tissue o her right buttock and hip as
a result o a childhood automobile accident during which she sustained a hip racture with luxation. T is
led to so tissue necrosis and atrophy. She also had a large in ected scar that had been revised 20 months
earlier. Gra ing was per ormed with a 5 cm cannula in two procedures: 00 cc was injected in the f rst
procedure and 0 cc in the second. T e patient is shown a er the second procedure. Note how the at
gra has also improved the quality o the scar.

919
Chapter 48 • Lower Extremity Reconstruction
Fig. 48-5
T is -year-old woman presented with amyotrophy o the cal as a result o le club oot. Fat was gra ed
at the subcutaneous level, and no asciotomy was per ormed. Fat gra ing was done in two procedures:
60 cc in the f rst and 0 cc in the second. T e patient is shown 72 months a er the second procedure.

920
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Fig. 48-6, A
A
T is 43-year-old woman had a loss o volume o subcutaneous tissue as a result o excision o a ma-
lignant melanoma on her right leg up to the aponeurosis (A). T e def cit was approximately 1 cm in
diameter on the right posterior leg; this was covered with a thin skin gra . Fat was harvested rom the
abdomen and trochanteric areas. Fat gra ing was per ormed in f ve sessions: , 7 , 7 , 8 , and 6 cc
was gra ed, or a total o 37 cc.
Fig. 48-6, B and C
B
C
Partial necrosis o the gra ed skin occurred a er the third at gra ing session (B). We think that this ne-
crosis happened because the level o inf ltration was too superf cial, and probably too large a quantity o
at was gra ed. T is necrosis was easily treated by local care or 3 weeks. Six months later, we per ormed
the ourth stage o at gra ing. T e patient is shown 5 months a er the f h procedure (C).

921
Chapter 48 • Lower Extremity Reconstruction
Fig. 48-7
T is 57-year-old woman developed radiodermatitis and cutaneous atrophy and loss o volume on the in-
ternal part o the knee and the distal internal thigh a er excision o an angiosarcoma in the distal adduc-
tor muscles and subsequent radiotherapy. Fat gra ing was per ormed in two sessions: 0 cc in the f rst
and 30 cc in the second. T e result is seen 7 months postoperatively; the overall improvement in skin
quality is evident. T e improved thickness and so ness o the skin can be conf rmed with a pinch test.

922
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Fig. 48-8
T is 41-year-old woman had a loss o so tissue volume in the right leg ollowing an automobile acci-
dent, with loss o cutaneous, at, and muscular substance. T e wound site was treated with local care
only. A er the area completely healed, she underwent a scar revision in which two expanded skin aps
made it possible to correct the entire scar. However, there was still a signif cant loss o volume in the
right leg. Fat gra ing was per ormed in two procedures with a 15 cm cannula: 50 cc in the f rst and
70 cc in the second. Fat was gra ed in the subcutaneous level, and no asciotomy was per ormed. T e
result is seen months a er the second procedure. It is evident that at gra ing has augmented the
missing volume without enlarging the scar, and skin color and smoothness have improved.

923
Chapter 48 • Lower Extremity Reconstruction
Fig. 48-9
T is 1 -year-old girl developed cutaneous atrophy af er a single injection o delayed-action corticoid in
the superointernal end o the right patella. She is shown 10 months af er the corticosteroid injection. In
one at graf ing session, cc was placed. T e patient is shown months postoperatively. T ere is a nota-
ble improvement in the color, thickness, and sof ness o her skin, and no retraction during knee exion.
Fig. 48-10
T is 0-year-old paraplegic woman had ischiatic bilateral scars rom a decubitus pressure sore that had
undergone repeated surgical treatment. She is shown 6 months af er cc o at was graf ed in the lef
ischiatic area and 1 cc in the right ischiatic area. Fat graf ing was per ormed to improve quality o local
tissues, not to increase volume, so we used small quantities o atty tissue. Our goal was to increase the
stability o this ragile skin while decreasing in ammation o the scar, to avoid recurrence o the lesions,
and to prevent atrophy o skin and subcutaneous tissue. At -year ollow-up, there has been no recur-
rence, but we await a longer ollow-up or additional evaluation.

924
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
RESULTS WITH THE MICROINJECTION TECHNIQUE
Fig. 48-11
T is 35-year-old man had chronic ulceration of both feet. Microfat and platelet-rich plasma (PRP) was
combined, 6 cc of fat and cc of PRP (mixture of 0%). T en 5 cc of the mixture was injected on each
foot. Healing was noted at 1 month, and results are shown at 6 months postoperatively.

925
Chapter 48 • Lower Extremity Reconstruction
Fig. 48-12
Af er amputation o the lef great toe on this -year-old woman, she had an unstable and pain ul plantar
scar. Micro at injection o cc was per ormed. Six months later, thickening and improvement o the skin
covering are evident.
Fig. 48-13
T is 3 -year-old woman had an adherent and pain ul scar on her right heel. Microinjection o cc o
micro at improved the skin thickness with reconstruction o the subcutaneous tissue.

926
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Fig. 48-14
T is 35-year-old man presented with a pain ul scar o the dorsum o the right oot and the amputation
stumps o the ourth and f h toes. Micro at injection o 7 cc was per ormed. T e reinjection allowed the
adhesions to be detached and to create subcutaneous tissue. T is allowed better mobility and improved
wearing o shoes.
Fig. 48-15
T is 48-year-old man underwent a total skin gra o the heel o his right oot. wo microinjections o
8 and 10 cc o at were per ormed months apart. Improvement in skin thickness with reconstruction
o the subcutaneous tissue is evident.

927
Chapter 48 • Lower Extremity Reconstruction
Fig. 48-16
T is 65-year-old man had ootpad (ball o the oot) atrophy with pain o the ore oot. Micro at injection
was per ormed, cc on the internal ootpad, and cc on the external ootpad, to improve the plantar
arch. T e results are shown at 6 months.
C om p l i ca ti on s
T e principal drawback to at gra ing, according to our patients, is the need to repeat the procedure
in cases o a major volume loss. T e mean number o structural at gra ing sessions per patient in our
experience is .5 (range one to f ve sessions). T e most requently encountered side e ects are postoper-
ative edema and ecchymosis, which are more likely to occur when the gra ing is superf cial. Although
hematoma and in ection are always possible, their occurrence is very rare. During an intramuscular
injection there is a risk o acute compartment syndrome, particularly in the leg. Cutaneous necrosis
can occur when the volume o gra ed at is considerable in a superf cial situation under skin that has
precarious vascularization (such as a scar or skin gra ). In our series, there was one instance o partial
necrosis, a case o f lling in the leg o a 5-year-old patient with a so tissue volume def cit a er broad
excision and skin gra ing or a malignant melanoma. Necrosis occurred a er the third procedure, which
was treated with local care until it completely healed. A para n gauze dressing was changed every other
day or weeks. A er that, two additional at gra ing procedures were per ormed.
Hematoma and in ection can be prevented by using a Coleman blunt-tipped harvesting cannula and by
practicing strict surgical asepsis. T e guidelines or managing in ection or hematoma are the same in at
gra ing as they are in other types o surgery. In intramuscular injection o at parcels, the risk o acute
compartment syndrome must be prevented by surgical asciotomy. Postoperative edema is treated by
raising the limb, massage, or lymphatic drainage.
Patients must be ully in ormed be ore the procedure about the structural at gra ing technique,7,13-19 as
well as its potential complications and drawbacks. T us the patient has time to ully consider the deci-
sion be ore committing to a procedure that may involve multiple treatment sessions.

928
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
D i scussi on
Fat gra ing to recontour calves that are too thin or to correct asymmetry o the legs resulting rom con-
genital de ects or the sequelae o in ection or trauma has become the technique o choice. It is a valuable
tool or the surgeon acing di cult indications, and corrections can be made gradually, with repeat
sessions at 6-month intervals. T e use o microinjection has increased the indications or this treatment,
primarily or correction o adherent and pain ul scars.
C oncl u si on
T e injection o at tissue in the limbs, is a sa e method with a well-established protocol. T e use o the
contralateral limb as a donor site must always be considered to improve symmetry. Signif cant limb
asymmetry or large localized so tissue de ects are o en treated by at gra ing in two or three stages; the
patient is in ormed o these potential repeat sessions be ore treatment begins.
T e use o multiple incisions with radiating, crisscrossing tunnels or at inf ltration is one o the keys to
success or this technique in limb reconstruction.
REFERENCES
1. Carlsen LN. Cal augmentation—a preliminary report. Ann Plast Surg :50 , 1 7 .
. Glicenstein J. Correction o amyotrophies o the limbs with silicone prosthesis inclusion. Rev Bras Cir
6 :117, 1 7 .
3. Aiache AE. Gluteal re-contouring with combination treatments: implants, liposuction, and at trans er.
Clin Plast Surg 33:3 5, 006.
4. Cárdenas-Camarena L, Paillet JC. Combined gluteoplasty: liposuction and gluteal implants. Plast Recon-
str Surg 11 :1067, 007.
5. Harrison D, Selvaggi G. Gluteal augmentation surgery: indications and surgical management. J Plast Re-
constr Aesthetic Surg 60: , 007.
6. Vergara R, Marcos M. Intramuscular gluteal implants. Aesthetic Plast Surg 0: 5 , 1 6.
7. Coleman SR. Hand rejuvenation with structural at gra ing. Plast Reconstr Surg 110:1731; discussion
1745, 00 .
. Aboudib Júnior JH, de Castro CC, Gradel J. Hand rejuvenescence by at f lling. Ann Plast Surg :55 ,
1 .
. de Pedroza LV. Fat transplantation to the buttocks and legs or aesthetic enhancement or correction o
de ormities: long-term results o large volumes o at transplant. Dermatol Surg 6:1145, 000.
10. Lewis CM. Correction o deep gluteal depression by autologous at gra ing. Aesthetic Plast Surg 16: 47,
1 .
11. Pereira LH, Radwanski HN. Fat gra ing o the buttocks and lower limbs. Aesthetic Plast Surg 0:40 ,
1 6.
1 . Stampos M, Xepoulias P. Fat transplantation or so tissue augmentation in the lower limbs. Aesthetic
Plast Surg 5: 56, 001.
13. Pereira LH, Nicaretta B, Sterodimas A. Bilateral cal augmentation or aesthetic purposes. Aesthetic Plast
Surg 36: 5, 01 .
14. Mojallal A, Veber M, Shipkov C, et al. Analysis o a series o autologous at tissue trans er or lower limb
atrophies. Ann Plast Surg 61:537, 00 .
15. Niechajev I. Cal augmentation with autologous tissue injection. Plast Reconstr Surg 1 3:1 1, 00 .

929
Chapter 48 • Lower Extremity Reconstruction
16. Veber M Jr, Mojallal A. Cal augmentation with autologous tissue injection. Plast Reconstr Surg 1 5: 3,
010.
17. Hoppmann R, Meruane M, Gonzales D, et al. Cal lipo-reshaping. J Plast Reconstr Aesthetic Surg 66: 56,
013.
1 . Coleman SR. Long-term survival o at transplants: controlled demonstrations. Aesthetic Plast Surg
1 : 1, 1 5.
1 . Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg :3 7, 1 7.
0. Coleman SR. Structural at gra s: the ideal f ller? Clin Plast Surg :111, 001.
1. Coleman SR. Structural Fat Gra ing. St Louis: Quality Medical Publishing, 00 .
. Coleman SR. Structural at gra ing: more than a permanent f ller. Plast Reconstr Surg 11 (3 Suppl):10 S,
006.
3. Coleman SR. Facial augmentation with structural at gra ing. Clin Plast Surg 33:567, 006.
. Coleman SR, Saboeiro AP. Fat gra ing to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
11 :775; discussion 7 6, 007.
5. Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G. Development o micro-injection as an innova-
tive autologous at gra technique: the use o adipose tissue as dermal f ller. J Plast Reconstr Aesthet Surg
65:16 , 01 .
6. Alharbi Z, Oplander CH, Almakadi S, Fritz A, Vogt M, Pallua N. Conventional vs micro- at harvesting:
how at harvesting technique a ects tissue-engineering approaches using adipose tissue-derived stem/
stromal cells. J Plast Reconstr Aesthet Surg 66:1 71, 013.
7. Lapiere JC, Aasi S, Cook B, et al. Success ul correction o depressed scars o the orehead secondary to
trauma and morphea en coup de sabre by en bloc autologous dermal at gra . Dermatol Surg 6:7 3,
000.
. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment o radiotherapy tissue damage by lipoaspirate
transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 11 :1 0 ;
discussion 1 3, 007.
. Benslimane F. T e Benslimane’s artistic model or leg beauty. Aesthetic Plast Surg 36: 03, 01 .
30. Zhu M, Cohen SR, Hicok KC, Shanahan RK, Strem BM, Yu JC, Arm DM, Fraser JK. Comparison o three
di erent at gra preparation methods: gravity separation, centri ugation, and simultaneous washing
with f ltration in a closed system. Plast Reconstr Surg 131: 73, 013.

(Trang không có chữ)

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Anat omy and Hist ol ogy
o t he Fat Compar t ment s
o t he Face
Rod J. Rohrich, Smita R. Ramanadham
T k w f u ’ u -
b juv . W u w
x b u f , w -
u v u , qu b b R P .1
V u u w u u -
u . T b pseudoptosis, w v k
w bu j u f , u x
k v u .2,3 T u u , w
b w , u v , u u u .
H , ub u u w b v b u ;
juv u w b ub u u u
u w u k SMAS.4 T u w
SMAS k v v u -
qu SMAS v u SMAS . T v z ,
w v , w v qu v u
b w juv u SMAS .5
C h a p t e r 4 9
933

934
Part III • Clinical Applications • Special Problems
Fig. 49-1
Subcutaneous fat compartments
o ully understand this mechanism, we must review various anatomic studies.1,3,4,6,7 T eir work eluci-
dated a lattice o superf cial and deep acial at compartments discretely partitioned into multiple, inde-
pendent units by ascial barriers.
T irty hemi acial cadaveric dissections were per ormed ollowing injection o methylene blue into spe-
cif c regions; 8 male and 2 emale cadavers were included, ranging rom to 2 years o age.1 Find-
ings included the ollowing:
Nasolabial fat compartment: T e nasolabial at compartment is located anterior to the medial cheek
at and overlaps with the jowl. T e orbicular retaining ligament (ORL) serves as its superior border.
T e nasolabial at lies medial to the deep at o the suborbicularis. T e lower border o the zygomatic
major is adherent to this compartment.
Cheek fat compartments: Cheek at compartments include three components: the medial, middle,
and lateral temporal–cheek at compartments. T e medial at compartment lies lateral to the nasola-
bial old, superior to the jowl at and in erior to the ORL and lateral orbital compartment. T e mid-
dle at compartment is superf cial to the parotid gland. T e dense, f brous abutment o the medial
and middle at compartments corresponds to the zygomatic ligament. T e lateral temporal–cheek
compartment is also superf cial to the parotid and connects the temporal at to the cervical subcuta-
neous at. T e lateral cheek septum is just anterior to this compartment.
Forehead and temporal fat compartments: T is includes a central compartment in the midline and
the middle compartments just lateral to this on the right and le . T e previously discussed lateral
temporal–cheek compartment then lies lateral to the middle compartments.
Orbital fat compartment: T e orbital at is composed o three compartments as well. T ese include
the superior, in erior, and lateral. T e ORL, which is a truly circum erential structure, acts as a
boundary or these structures.
Jowl fat compartment: T e jowl at compartment adheres to the depressor anguli oris. T e medial
boundary is the lip depressor and in erior boundary is the membranous usion o the platysma. It is
important to note that this is separate and distinct rom the nasolabial at.

935
Chapter 49 • Anatomy and Histology o the Fat Compartments o the Face
Infraorbital fat
Deep medial
cheek fat
Superficial medial
cheek fat
Nasolabial fat
Suborbicularis
oculi fat (lateral)
Suborbicularis
oculi fat (medial)
Buccal fat
Superficial facial fat pads

Deep facial fat pads
Fig. 49-2
Deep layers exist as well, including the suborbicularis, retroorbicularis, and buccal at pads. T ese at
compartments lie below and above acial muscles and enable sliding o these muscles during animation
and mastication.1 Although loss o deep at is known to occur with aging in the temporal region, it is
now known that this occurs in the deep medial cheek at as well.4 Further cadaveric anatomic dissections
identif ed two areas o deep medial at, both lying medial to the zygomaticus major muscle; the medial-
most portion abuts the piri orm and the lateral lies directly over the maxilla.3 T is deep at compartment
supports the overlying subcutaneous at; loss o volume in this compartment results in a loss o anterior
malar projection, a prominent nasolabial old, and can create a V-de ormity o the lower lid. Further
studies have ound that the at in this deep medial cheek compartment also varies in size in comparison
to the superf cial compartments, more specif cally the nasolabial compartment. T e average adipocyte
size is signif cantly larger in the nasolabial compartment than that in the deep medial cheek.2 T is f nd-
ing may be partly a result o its location above muscles, its rich vascular supply, and the increased meta-
bolic activity here compared with areas o deep at, which are relatively inert and compressed against the
skeleton, causing a relative atrophy.2
T e acial at compartments are partitioned by a f brous condensation o connective tissue, which orig-
inates rom the underlying ascia to dermis and carries the per orator blood supply to the skin.4,8 T ese
ascial ligaments limit shearing orces on the ace, thereby, creating a “retaining system” and provides
stability or the vascular supply to the ace.4,8
T ese f ndings support the idea that acial rejuvenation should center on two key concepts: volume
restoration and acial recontouring. T is is not a new concept; Ristow described direct injection o au-
tologous at directly into the deep cheek at in .3,9 E ects are immediate, resulting in improved
anterior projection, decreased nasolabial old, and corrected V-de ormity o the lower lid creating a
youth ul cheek and lid-cheek junction.3 Fat augmentation into these specif c compartments allows or
an increased ability to precisely restore acial volume with improved control and precision. T e most
important and relevant at compartments in acial rejuvenation include the deep malar, the deep naso-
labial at compartment, and the superf cial middle and lateral (high) malar compartments.10 T is can
be per ormed separately in young patients with minimal skin excess and laxity or as a complement to
tissue li ing through the manipulation o the skin and SMAS.5 T e synergistic e ects o at gra ing o
the specif c acial compartments mentioned above and SMAS manipulation through SMAS-stacking or
SMASectomy was evaluated in a recent review by Rohrich et al.5

936
Part III • Clinical Applications • Special Problems
P a ti ents a n d M
ethod s
Deep malar
compartment
Deep nasolabial
malar compartment
High superficial
malar compartment
Middle superficial
malar compartment
Fig. 49-3
A retrospective review was per ormed o all patients undergoing the li -and-f ll technique by the senior
author (R.J.R). T e technique includes individualized component aceli as described previously,10 open
neck li , at trans er to the deep malar at compartment, nasolabial olds, and superf cial middle and
high malar at compartments, and acial resur acing i necessary. Key at compartments relevant to the
li -and-f ll ace li are shown above. ypical volumes o at were to cc injected into each compart-
ment with the average trans erred volume being 2 cc per compartment. ypically, the at was harvested
manually rom the abdomen or thighs using a cc syringe and cannula. Once prepared, the at was
allocated into cc syringes and injected directly into these at compartments using a -gauge needle.
Care is taken to aspirate be ore injection to ensure the at is not injected directly into a vessel. T e total
average injectate per ace was 2 cc (range 8 to 4 cc). T e consecutive aceli patients who also
underwent simultaneous at compartment at gra ing ( women and our men) were then analyzed
using a computer-based system to evaluate certain data points. Inclusion criteria were at least months
postoperative ollow-up and a position-matched oblique photograph between preoperative and postop-
erative imaging.
Complications that were assessed were divided into minor and major subgroups. Major complications
included any event that resulted in a surgical revision or return to the operating room. Minor complica-
tions were all those managed conservatively.

937
Chapter 49 • Anatomy and Histology o the Fat Compartments o the Face
Fig. 49-4
Outcomes were evaluated using contour ratios o specif c acial points. Clinical assessment included the
degree o preoperative and postoperative change o the nasolabial old depth as described by Barton11
and the two-dimensional location change o the most-projected malar point on an oblique photograph.
Point A represented the most-projected malar apex, and point B showed the submalar concavity. All
distances were divided by the interpupillary distance to determine a ratio. A computer so ware program
was created to quanti y variations in these acial landmarks, as previously described.12 Data rom digital
images were analyzed based on three variables: x-axis, a horizontal line intersecting the midpupil; y-axis,
a vertical line drawn rom the midpupil on the side o ace to be measured, and interpupillary distance.
T e lateral contour o the ace was then outlined, and points A and B were identif ed manually. T e pro-
gram then generated the location o points A and B as an x- and y-axis value.
A negative variation on the x-axis corresponded to a decrease in lateral contour projection, whereas a
positive variation denoted an increase in volume and projection. Likewise, a negative variation o the
y-axis corresponded to a lowered vertical displacement o projection, while a positive variation resulted
in a higher position o the most-projected point, meaning that the point was moved vertically through
the li ing o the skin and SMAS.
Finally, a pair o plastic surgery observers evaluated preoperative and postoperative photographs and
graded the nasolabial old (NLF) and malar eminence in each case. NLF scale: 0, No visible old; , min-
imal; , moderate; , very deep old. Malar score: , Concave with projection below zygoma; , neutral
projection; , convex malar projection below the zygoma.

938
Part III • Clinical Applications • Special Problems
R esul ts
Volume augmentation occurred at the most-projected malar contour point, resulting in increased pro-
jection. Average li ing o Point A was 2.24%, whereas the projection increase was .4 %. Point B,
representing submalar augmentation e ects o deep malar at compartment f lling, resulted in a 5.64%
increase in projection, when we removed the % o cases in which this region was already convex.
Table 49-1 T e Most-Projected Malar Contour Point and the Submalar Depression
x-Axis (projection) (%)

y-Axis (lif ) (%)
Most-projected malar contour point*
Average

.4

2.24
Minimum
–4.55
–5.
Maximum

45.

4 .6
SD

5.24

5. 4
Submalar depression†
Average

5.64
Minimum

.
Maximum

4 . 5
SD

.
*T e most-projected malar contour point has a variation in the x-axis (projection increased = alling) and a variation in the y-axis (higher
position = li ing).
†T e submalar depression point has been assessed only on the x-axis or its projection. We kept the y-axis position unvariable to ocus on
the compartmental f lling e ect. T is depression is augmented by injecting the deep and middle malar compartments. T e B point was
modif ed in 93% o cases (93 o 100) and unchanged in 7 cases. T ese 7 cases had a convex submalar zone that did not require any modi-
f cation. For the 93% that changed, the observations are shown in the table.
T e average NLF score or the grade improved rom .5% to 2 .5% postoperatively. T e average malar
prominence convexity improved rom 6% to 2 % postoperatively. T e NLF improved by at least one
grade in %, and by more than one grade in %. Malar prominence improved by at least grade in
6 % and by more than grade in %.

939
Chapter 49 • Anatomy and Histology o the Fat Compartments o the Face
D i scu ssi on
Volume restoration is not a new concept in acial rejuvenation.3 In addition, although it is well estab-
lished that the SMAS must be manipulated during a aceli , much debate exists regarding the superiority
o each specif c technique. It is now apparent, that a combination o augmentation and redistribution via
specif c tissue manipulation is benef cial. T e detailed anatomic descriptions o the acial at compart-
ments has added to our understanding o these concepts and has created a topographical map which
allows or precise location, depth, and evaluation o volume de ation.5 T e deep malar, nasolabial, and
superf cial middle and high malar compartments are the most relevant to address in acial rejuvenation.
T e deep malar at is composed o smaller adipocytes and tends to de ate at a higher rate. It is there ore
critical to f ll this compartment f rst to set the oundation to later build on through superf cial augmenta-
tion and SMAS manipulation. When targeted directly, small amounts o at can be used to achieve clini-
cally relative results. T is minimizes the overdone appearance that can be seen when larger quantities are
used, especially in the superf cial compartments. T e sequence recommended includes at augmentation
o the deep malar compartment and nasolabial old initially, and the high (superf cial) lateral compart-
ment last. SMAS manipulation is per ormed through an individualized component aceli approach,
which allows or varying vectors to bridge the deep and superf cial at compartments so that a smooth
cheek contour results.5 Additional superf cial at gra ing can then be per ormed as needed or the oral
commissures, labial aesthetic units, and lateral chin depressions.
Both malar projection and malar li improved in this study. In addition, nasolabial olds and malar
grades improved during analysis by trained observers. T is urther supports the concept that at com-
partment de ation is the primary cause in the aging ace. T e li -and-f ll technique addresses this prob-
lem, in addition to the need or li ing the SMAS and skin to address laxity.
Fig. 49-5
Preoperative

Postoperative
Skin
DM
DN-L
SMAS
Fat-DM
Periosteum
SMAS-stacked

940
Part III • Clinical Applications • Special Problems
Preoperative

Postoperative
Skin
SMAS
Fat-DM
Periosteum
DM
DN-L
SMASectomy
Fig. 49-6
Preoperative planning is essential in these cases. Location o acial de ation, laxity, and identif cation
o ullness o each acial side must be identif ed preoperatively in order to correctly address these is-
sues intraoperatively. Once the deep medial at compartment has been adequately f lled, the oundation
is set, and the SMAS can then be manipulated appropriately. SMAS-stacking occurs superf cial to the
augmented deep compartment and can be per ormed in exact locations where it is needed or increased
ullness. Generally, this is per ormed on the thinner acial side. SMASectomy, on the other hand, can be
per ormed on the uller side and can decrease acial ullness. Vectors vary as well in SMAS manipulation
with a more horizontal vector on the wider side and more oblique on the narrower acial side.5 By restor-
ing acial volume prior to SMAS manipulation, the demand on the SMAS to create all o the acial shape
is lessened. T e ultimate goal is or at augmentation to complement aceli ing techniques.
T ere are limitations regarding at viability and gra survival. In addition, variability in tissue elasticity
contributes to the amount o overall acial li ing that can occur. T ese concepts can potentially chal-
lenge the predictability o the li -and-f ll technique or acial rejuvenation. Although overf lling may be
tempting in these cases to avoid clinically noticeable gra loss, this should be avoided as this results in
an overgra ed, unaesthetic appearance. Conservative gra ing o 1 to 3 cc per compartment should be
per ormed with a discussion with the patient in orming them that additional at gra ing or f llers may
be needed in the uture or maintenance.5
It is well established that SMAS manipulation is necessary during a aceli ; however, this alone ails to
address the volume de ation that occurs with acial aging. Current understanding o acial at compart-
ments, both superf cial and deep, has allowed plastic surgeons to specif cally address volume loss by
directly augmenting compartments that are de ated pre erentially. T ese include, as previously stated,
the deep malar, the deep nasolabial at compartment, and the superf cial middle and lateral (high) malar
compartments. T e SMAS can then be manipulated to li and improve the overall contour o the ace by

941
Chapter 49 • Anatomy and Histology o the Fat Compartments o the Face
bridging the di erent compartments. Assessment o overall acial shape and contour is key to achieving
optimal results and must be assessed continually during the preoperative, intraoperative and postoper-
ative phases. Although many gains have been made over the years in our understanding o acial anat-
omy, which has permitted improved control o volume restoration, uture advances rely on developing
techniques that can improve the precision o volume restoration, perhaps through the use o volumetric
three-dimensional imaging and calculation o compartment-specif c de ation.
C l i ni ca l C a ses
Fig. 49-7
2 cc
3 cc
2 cc
1 cc
2 cc
2 cc
Preoperative
2 cc
2 cc
1 cc
1 year postoperatively showing fat
injection placement
1 year postoperatively
T is 60-year-old woman underwent a li -and-f ll aceli . Fat gra ing volumes were 3 cc to the right
deep malar at compartment and 2 cc to the le ; 2 cc to the right superf cial lateral (high) malar
compartment and cc to the le . In addition, the prejowl area received 2 cc bilaterally. Bilateral
SMAS-stacking was per ormed with an oblique vector on the shorter/wider right side and in a horizon-
tal vector on the longer le side.

942
Part III • Clinical Applications • Special Problems
Fig. 49-8
2 cc
2 cc
2 cc
2 cc
2 cc
3 cc
Preoperative
2 cc
3 cc
2 cc
1 year postoperatively showing fat
injection placement
1 year postoperatively
T is 6 -year-old woman underwent a li -and-f ll aceli and an open neck li . Facial at gra ing in-
cluded 3 cc o at injected into the nasolabial old on the le and cc on the right. T e deep malar at
compartment received cc on each side; however, in hindsight, the patient might have benef ted rom
slightly more on the le side. T e superf cial high (lateral) malar compartment also received cc on each
side. A bilateral SMASectomy was per ormed based on an individualized component aceli analysis to
minimize her acial ullness. T e vector was oriented horizontally on the le and obliquely on the right,
with more skin undermining on the right, since it was the short/wide acial side.

943
Chapter 49 • Anatomy and Histology o the Fat Compartments o the Face
C oncl u si on
T e identif cation o the superf cial and deep acial at compartments has greatly added to our under-
standing o acial aging. Fat gra ing into these specif c compartments—and specif cally the deep ma-
lar, nasolabial, superf cial middle, and high malar compartments—permits targeted volume restoration.
T is, in combination with SMAS treatment based on an individualized component acial analysis, acil-
itates improved aesthetic outcomes in acial rejuvenation.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
REFERENCES
1. Rohrich RJ, Pessa JE. T e at compartments o the ace: anatomy and clinical implications or cosmetic
surgery. Plast Reconstr Surg 11 :221 , 2007.
2. Wan D, Amirlak B, Giessler P, Rasko Y, Rohrich RJ, Yuan C, Lysikowski J, Delgado I, Davis K. T e di -
ering adipocyte morphologies o deep versus superf cial mid acial at compartments: a cadaveric study.
Plast Reconstr Surg 1 :615e, 201 .
. Rohrich RJ, Pessa JE, Ristow B. T e youth ul cheek and the deep medial at compartment. Plast Reconstr
Surg 121:2107, 2008.
. Rohrich RJ, Pessa JE. T e retaining system o the ace: histologic evaluation o the septal boundaries o the
subcutaneous at compartments. Plast Reconstr Surg 121:180 , 2008.
5. Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Li -and-f ll ace li : integrating the at
compartments. Plast Reconstr Surg 1 :756e, 201 .
6. Rohrich RJ, Pessa JE. T e anatomy and clinical implications o perioral submuscular at. Plast Reconstr
Surg 12 :266, 200 .
7. Pessa JE, Rohrich RJ. Facial opography: Clinical Anatomy o the Face. Boca Raton: CRC Press, 2012.
8. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomic boundaries o the
subcutaneous at compartments. Plast Reconstr Surg 12 :6 5, 200 .
. Ristow B. Personal communication, Sept 2001.
10. Rohrich RJ, Ghavami A, Lemmon JA, et al. T e individualized component ace li : developing a system-
atic approach to acial rejuvenation. Plast Reconstr Surg 12 :1050, 200 .
11. Barton FE Jr. Rhytidectomy and the nasolabial old. Plast Reconstr Surg 0:601, 1 2.
12. Rohrich RJ, Ghavami A, Mojallal A. T e f ve-step lower blepharoplasty: blending the eyelid-cheek junc-
tion. Plast Reconstr Surg 128:775, 2011.

(Trang không có chữ)

945
C h a p t e r 5 0
A u c z c c v u v v .
I c c z c ( c ) uc u -
w k c f b . T u c uc
b . A u c u u u c . I u c b
k ( ubcu u ), u (v c ), b w ( w b
w), b u , bu b w u c
.
I u , bu u v u c c , , x, c , ,
, v uc c c .
T f bu b v b w u x w k ,
w c - -c u x - - . B 8 w k , bu c b -
c u v v c ubcu u c .1
M v w u : w u (WA ) b w
u (BA ). R c , c u c brite (“b w -
-w ”), k w beige, inducible brown, recruitable brown, b f . I
b “ u ” c . I c u b
b w c b u u . H w v , w u b
c c c x u ( c c b - c u ), b -
c u cu b .2
Anat omy and Hist ol ogy
o t he Fat Compar t ment s
o t he Body
Andrea Sbarbati, Maria Rosaria Marinozzi,
Giamaica Conti

946
Part III • Clinical Applications • Special Problems
B rown A d i pose T i ssue: A T h ermogeni c T i ssue
BA is mainly located in the visceral area, and brown adipocytes represent the major part o BA . Brown
adipocytes contain multiple smaller (multilocular) lipid droplets. Brown adipocytes are rich in mito-
chondria and reside in depots that are highly innervated and vascularized.
BA is a thermogenic tissue.3 T ermogenesis is mediated by an oxidative phosphorylation o ree atty
acids, regulated by expression o tissue-specif c mitochondrial brown at uncoupling protein 1 (UCP1).4
BA activation depends on sympathetic (noradrenergic) stimulation. T ermogenesis can be vital in ne-
onates exposed to the cold, because they are unable to shiver and require this process to keep warm.
However, with aging, the BA disappears and sets up an unilocular lipid deposit. In this case, it strongly
resembles WA , but it maintains the capability to respond a er physiologic stimuli. T e interest in BA
unction has increased in the past 20 years, because hypo unction or hyper unction o BA is involved
in the pathogenesis o obesity5 and in other pathologic conditions.6 T e biochemistry and cell biology o
BA have been extensively investigated, and excellent descriptions are available.7
W
hi te A d i pose T i ssue: A H eterogeneous T i ssue
T e major part o human adipose tissue is composed o WA . It orms pads between organs and has
di erent unctions. Its primary purpose is energy storage in the orm o triglycerides. It can also act as
a thermal insulator and can protect other organs rom mechanical damage.8 WA ’s unctions are reg-
ulated by endocrine signals and the sympathetic nervous system. In particular, energy metabolism in
adipocytes is controlled by hormones such as insulin, catecholamines, and glucocorticoids produced by
other organs. T ese hormones bind to adipocytes and trigger the hydrolysis o triacylglycerol, resulting
in the release o energy-rich atty acids and glycerol, the process known as lipolysis.
WA is also involved in the immune response, antiin ammatory blood pressure control, blood clotting,
and thyroid and reproductive unctions. T ese processes are coordinated mainly through the synthesis
and release o bioactive peptides called adipokines (such as adiponectin, leptin), which act locally and
distally through autocrine, paracrine, and endocrine e ects.9
wo main cellular components may be identif ed in the WA : white adipocytes and the stromal vascular
raction (SVF). T ey are morphologically di erent but unctionally related. T e remaining part o the
adipose tissue is composed o water ( % to 0%) and protein ( % or less).
White adipocytes represent 0% o the mass o the WA , and 0% to % o their weight is represented
by lipids— or the most part triglycerides and ree atty acids, diglycerides, cholesterol, phospholipids,
and small amounts o cholesterol esters. T e principal atty acids are myristic, palmitic, palmitoleic,
stearic, oleic, and linoleic acids.
White adipocytes are large, spherical, and tightly packed and are supported by richly vascularized loose
connective tissue. T e size o adipocytes is based on the cells’ lipid content, ranging rom 0 to 1 0 µm

947
Chapter 50 • Anatomy and Histology o the Fat Compartments o the Body
in diameter; their volume varies in relation with their activity. T ey contain a unique, large droplet sur-
rounded by a phospholipid monolayer enhanced by a cagelike structure o vimentin network, perilipin,
and proteins.10 T e nucleus is attened and located on the periphery, and its nuclear lamina is coupled
to the vimentin network.11 Near the nucleus the cytoplasm gets thicker and contains a Golgi appara-
tus, smooth and rough endoplasmic reticulum, ree ribosomes, and large, elongated mitochondria with
densely packed transverse cristae.12 T e amount o mitochondria and their enzymatic equipment varies
between di erent at depots, contributing to the diverse physiology o the adipose tissue.13 White adi-
pocytes have a pro ound actin cortical network.11 T e cytoplasm o white adipocytes contains also lipid
structures, called lipid droplets, lipid bodies, or adiposomes. T ey are highly intracytoplasmic organelles
composed o a core o neutral lipids surrounded by a phospholipid monolayer and associated proteins
that regulate their size and lipid tra c.14
T e plasma membrane is specialized in atty acid protein-mediated transport.15 It contains various types
o receptors or hormones, neurotransmitters (mainly noradrenaline), cytokines, and other signaling
molecules.16 Adipocytes express toll-like receptors, which are responsible or the recognition o patho-
gen-associated molecular patterns and other signaling molecules o innate and adaptive immunity.17 T e
plasma membrane is covered by glycocalyx.12
SVF consists o multipotent stem cells, preadipocytes, f broblasts, pericytes, endothelial cells o blood
and lymphatic vessels, macrophages, mast cells, and other inf ltrating immune cells.16 Lymphoid cells are
also present.18 SVF cellular compartments and their role are summarized in able - .
Table 50-1 Cellular Components of the Stromal Vascular Fraction
Stem Cells

Mast Cells

Preadipocytes

Lymphocytes

Macrophages
Multipotency (can
di erentiate in bone,
cartilage, muscle,
adipose cells)
Related to
in ammatory
processes, remodeling
processes, and obesity
Di erent proli erative
potentials, depending
on the at pad o origin
CD + cells, INF-
gamma+ , CD +
cells, and beta
cells, and regulatory
cells ( regs) as
antiin ammatory cells
Are bone marrow–
derived cells that
have an active role in
starting in ammation,
apoptosis and
recruitment o
in ammatory cells.
Largely employed
in regenerative and
reconstructive surgery,
particularly or skin
regeneration, scar
correction, and breast
reconstruction
Involved in cytokine
secretion in adipose
tissue, insulin
resistance mechanisms,
and oxidative
metabolism regulation
Di erentiate in
adipocytes or
adipocyte precursors
that could stimulate
the adhesion
mechanism in
neoplastic cells
T eir presence in
adipose tissue is
related to obesity,
a high leptin level,
reg downregulation,
and susceptibility to
autoimmune diseases
T eir numbers
increase in pathologic
conditions such as
obesity. T is process
is led by paracrine
activation o
macrophages and other
cell types and involves
several mechanisms
such as angiogenesis,
modulation, and
di erentiation o
adipocyte precursors.

948
Part III • Clinical Applications • Special Problems
VISCERAL ADIPOSE TISSUE
Visceral adipose tissue (vWA ) is associated with internal organs. It can be divided into three major
depots. T e f rst is the omental at that is associated with the intestines; the second is the mesenteric at
that is more deeply buried around the intestines and the retroperitoneal at, which is located near the
kidneys, at the dorsal side o the abdominal cavity. T ird, smaller amounts o vWA are localized in the
mediastinum (intrathoracic or pericardial at) and around specif c organs, such as the heart (epicardial
at), stomach (epigastric at), and blood vessels (perivascular at).19 T e at lobules o vWA , especially
in the greater omentum, are large, irregular, and not surrounded by collagen septa. In act this adipose
depot is composed in prevalence by mature unilocular adipocytes.20
vWA accumulation has been closely related to a cluster o metabolic alterations, including insulin re-
sistance, hyperinsulinemia, elevated triglyceride levels, low high-density lipoprotein (HDL) cholesterol,
and hypertension.21 T e adipocytes o the vWA show high lipogenic and lipolytic activities and produce
proin ammatory cytokines. In addition, molecules involved in innate immunity, acute phase response,
and in complement actors are overexpressed in vWA .
SUBCUTANEOUS ADIPOSE TISSUE
Subcutaneous adipose tissue (sWA ) is distributed over the body’s sur ace in the hypodermal layer o
the skin and it is sandwiched between dermis and deep ascia. Fat lobules o the sWA layer are generally
organized in a regular ashion. Connective sca olding o sWA varies according to anatomic site and
unction.22
Classif cation o the Subcutaneous Adipose Tissue
sWA appears structurally homogeneous, but actually the di erences in the morphology among the
various at depots are qualitative and quantitative. T e structure o sWA can vary, depending on the
body location, age, sex, weight, race, and nutrition. For instance, elderly patients have a larger amount o
collagen in the connective mesh o the sWA than younger individuals, and there is a moderate thick-
ening o vascular walls during aging. In the abdomen and hips, the deep layer appears rich in f brous
components.
Table 50-2 Subcutaneous Adipose Tissue Classif cation
Deposit sWAT

Structural sWAT

Fibrous sWAT

Lobular sWAT

Nonlobular sWAT
Poor collagenic
component
More stroma is
present
Fibers are thick and
abundant
Fibers are very
abundant and thick
Present in tissue
characterized by a
maximum degree o
f brosis
Unilocular
adipocytes o
- µm
Adipocytes o
µm embedded in
muscular tissue
Adipocytes o
µm in diameter
embedded in a dense
collagen matrix
Well-vascularized
tissue with capillaries
characterized by thick
endothelium
T e presence o
capillaries and
vessels is variable
but generally not
abundant
Extracellular space
very slim; thin-walled
capillaries and rare
stem niches
Observed in
particular in
trochanter,
suprapubic area,
arm pits, inner ace
o knee, thighs,
arms, pectoral and
mammary areas
Observed in particular
in depots subjected to
mechanical stress
Adipocytes o
- µm
organized in clusters
surrounding collagen
f bers
Adipocytes are
characterized by very
scarce lipid content