Fat Injection From Filling to Regeneration

300
Part III • Clinical Applications • Skin
Fig. 21-7
A

B
C

D
Fat is delivered directly over scar tissue that was previously treated with a ractional CO2 laser or a nee-
dle roller. A total o 16 cc o at was delivered to the acial scars (C). T e puncture wounds so produced
will carry the delivered at to within the scar tissue, greatly increasing the e ect o the ADSCs and the
contained growth actors. T e desired result is a greater decrease in hypertrophy and a major improve-
ment in malleability.
In wounds in which the entire thickness o the skin or more noble tissue (nerves, blood vessels, tendon,
bone) has been lost, at is also deposited in a zigzag pattern over the entire sur ace o the wound, using
the same cannula as or the injection. When treating scars, at can also be delivered directly to (over) the
scar, a er the area is treated with a needle roller or a ractional CO2 laser. T e needle roller or the laser
will produce minimal puncture wounds on the scar substance, through the skin epithelium, and these
holes will absorb the centri uged at and its contents directly, thus ampli ying the benef ts o at gra ing.
Fat Filling
In pressure sores (decubitus ulcers) and avulsion or crush injuries, when skin and subcutaneous tissue
are separated rom ascia by trauma, or by a hematoma, and where there are voids or contaminated
spaces, we debride all visible granulation or contaminated tissue and close the wound over the delivered
at.
For patients with pressure sores, we debride all contaminated tissue. We endeavor to remove the entire
specimen as one piece, going under this tissue and exposing viable healthy tissue—although this re-
moval is not absolutely necessary. T e wound is then closed with several suture layers with nontreated
nonabsorbable suture, and at is delivered at every suture layer level, with the tightening o the suture
knots expelling excess at. T is is continued until the wound is completely f lled. No drains are used, and
the f nal skin closure is with separated (not running) sutures.
For avulsion injuries, the obviously contaminated tissue is debrided, and some isolated sutures are placed
at the edge o the traumatized wound or debrided skin. Fat is then delivered to the cavity created. Fat
gra ing is repeated at 7- to 15-day intervals until complete adherence is obtained. Whether the volume

301
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
o at in the cavity is su cient is determined by light pressure over the injected area, just be ore applying
the dressing with f ne mesh gauze impregnated in Dakin’s solution and secured with a bandage.
In chronic wounds, typically where there is a signif cant amount o induration in the periphery o the
wound (such as one f nds in venous ulcers), we deliver at over the indurated tissue as well as gra ing
under it. In such cases, we generally use a needle roller (with 54 .5 mm long needles) to create ver-
tical tunnels in this tissue; at is then directly delivered to this area. When considering this additional
approach, the surgeon must plan to harvest enough at to yield su cient volume o prepared at to be
distributed over the area (approximately cc or every cm2), in addition to the planned volume or
injection under this tissue. T at is, or every cm2 o tissue to be treated, one will need on average
plus cc (under, or injection; over, or delivery).
Fig. 21-8
T is in ected patient’s wound was debrided days a er the patient had a motorcycle injury that re-
sulted in tibial-f bular racture in multiple ragments. Fat gra ing was per ormed a er initial debride-
ment and IV antibiotic triple coverage or week. Radiographs taken 6 weeks a er the racture healed
( 4 days) show consolidation o the medial malleolar racture. (Arrows indicate where at was injected.)

302
Part III • Clinical Applications • Skin
Positive cultures o the wound are not considered a deterrent to at gra ing; we have per ormed many
injections in wounds with gram-negative and/or gram-positive cultures. When partially treated or
poorly treated patients are re erred rom other services, we always debride the wound immediately
be ore at gra ing. For open ractures, regardless o whether internal or external instrumentation is in
place, we routinely proceed with at gra ing and delivery in all areas o the wound, injecting around
and under and delivering at in all loss-o -substance voids, including racture lines or spaces between
bone ragments.
POSTOPERATIVE CARE
Fig. 21-9
A closed dressing is applied on wounds and over at delivered to the scar tissue, with a f rst layer o Vase-
line gauze, ollowed by several layers o f ne mesh gauze which are soaked with double-strength Dakin’s
solution. A bandage f nishes the dressing. Dressings are changed every days. Note the appearance o
the Vaseline gauze in the -day-old dressing shown here; there are no secretions and one can see the yel-
low surviving at can be seen through the wound. (T is patient is also seen in Fig. 1-17.) In at delivery
areas, i the Vaseline gauze is still adherent in days, f ne mesh gauze is reapplied over the unremoved
Vaseline gauze, and the site is again soaked in Dakin’s solution, and secured by a bandage. When we in-
ject scars, we place a piece o paper tape on the puncture sites and remove it within or days.
R esul ts
BURNS, VASCULAR-RELATED WOUNDS, AND TRAUMA
In our series, healing occurred in all 68 patients with burn or trauma wounds treated with this tech-
nique. A 68-year-old woman was treated or an 8-year-old venous ulcer that healed a er two injections
15 days apart and skin gra ing (patients with venous ulcers, n = 8). However, she lost the gra while
undergoing surgery elsewhere or megacolon. wo patients with diabetic oot ulcers, (n = 68) (one with
-year-old wounds and the other with a 7-year-old wound) had recurrences o their plantar wounds,
although wounds on the borders o the plantar area and the dorsa o the eet remained healed. Both re-
currences were caused by noncompliance with temporary restrictions on weight-bearing. With trauma
cases, we have also success ully used at gra ing as an ancillary treatment or tendon repair, tendon
adhesion release, in racture lines, and in other deep wounds.

303
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
Fig. 21-10
A

B
C

D
E

F
G

H
T is 68-year-old kidney transplant patient with diabetes (A through D) sustained an ammunition ex-
plosion injury. He is shown healed 4 days af er at graf ing and month later. Please note the absence
o hypertrophy (this is the same patient as in Fig. - , E through H). In the second patient (E through
H), please note the excellent range o motion, demonstrating no adhesions (this is the same patient as
in Fig. -6).

304
Part III • Clinical Applications • Skin
Preoperative nonhealing wound
A
B

C
D

E

F
First procedure
G
11 days after first injection
H

I
Second procedure
Fig. 21-11, A-I

305
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
J
2 days after third injection
K
4 days after fourth procedure
L
Healing wound at follow-up
M
4 months later
Fig. 21-11, J-M
T is -pound, 8-year-old diabetic patient developed a spontaneous, nonhealing wound a er nail
clipping 6 months earlier. In the f rst procedure, the second toe was amputated, the wound debrided, and
at was injected under and around the wound bed and delivered over the wound. At intervals the wound
was again debrided, and a total o our at injections at to day intervals were completed. Each at
injection comprised 8 cc o at injected and 6 cc delivered/laid over the wound. T e wound ultimately
healed with no hypertrophy, and no recurrence.

306
Part III • Clinical Applications • Skin
Fig. 21-12
3 months after crush injury

15 days after skin graft, with central loss
Debrided wound with fat injection and delivery
32 days after injection with no additional
skin graft
4 months later: second injection
8 months later: 3 months after third injection
Impression after initial healing
Impression 8 months later
T is 2-year-old patient was seen months af er sustaining a riction/crush injury o the lef oot. A
skin graf harvested rom the scalp was per ormed, but a central loss o the graf occurred. T e wound
was debrided, and 8 cc o at was graf ed under the wound and within the tarsal bones, with 1 cc o at
delivered over the entire wound. Healing o the wound occurred within 2 days without any urther skin

307
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
gra ing. A second injection was per ormed 4 months a er healing with cc placed under the scar and
along the tarsal bone joints with the goal o decreasing local f brosis. T e oot is seen 8 months a er ini-
tial healing, and months a er a third at gra ing session. A plantar impression at healing is contrasted
with an impression 8 months later. In the earlier impression, there is atness o the plantar sur ace and
no toe contact. A er two additional at gra ing procedures, it is evident that there is our-toe contact
and a longer longitudinal arch, demonstrating release o interosseous f brosis.
Fig. 21-13
T is -year-old tetraplegic patient had a recurrent trochanteric ulcer, with a deep wound measuring 8
by 6 cm. T e wound was completely debrided, removing the entire ulcer sur ace down to live, “ resh”
tissue. A total o 6 cc o at, prepared through the Coleman technique, was gra ed within the periphery
o the wound, and 6 cc o at was delivered to the cavity as it was progressively closed with multiple
suture layers. T e f nal photograph shows the wound days a er healing.
BURN SCARS
All o the 8 patients with scars we treated with this technique showed improvement that was discern-
able a er each injection, except or one teenager with acial scars. In this patient, although no visible
improvement was evident a er the f rst injection, there was great improvement in suppleness o the scar.
Subsequent injections resulted in visible improvements. In this series there were also very satis actory
results with intralesional partial resection (within the scar, without reaching the subcutaneous tissue),
and primary suturing, with at injected immediately under the suture line.

308
Part III • Clinical Applications • Skin
E
F
G
H
I
J
A

B
C

D
Fig. 21-14
T is -year-old man had an intralesional partial resection o a 2 -year-old keloid and injection under
the suture line (A through D). He is shown a er the partial resections and at injections, which consisted
o f ve procedures over 2 years (E through J).

309
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
In complex burns or trauma wounds, we treated patients with at injections to oster wound healing, as
well as during the posthealing phase. Surprisingly, the incidence o hypertrophic scarring was minimal
or none, and in patients with periarticular f brosis, improvement was the usual result.
Fig. 21-15
A

B
C

D
T is patient’s arm is seen month a er a skin gra was per ormed (A), which occurred 6 days a er
initial at gra ing. T e patient is shown at initial healing (B), months (C), and months (D). Note the
absence o hypertrophy at months a er healing (C) and months (D). T e f nal image at months
demonstrates no hypertrophy. (T is is the same patient as in Fig. -5.)

310
Part III • Clinical Applications • Skin
Fig. 21-16
A

B
C
D
E

F
T is 4-year-old woman with scarring in the perioral area is seen be ore and af er two injections to the
lef side o her ace (A and B), a Z-plasty to the right side (C and D), and at injection to both sides (E
and F). Please note that on the lef side, the smile immediately shows three teeth, whereas on the orig-
inally “non-injected” right side, the smile shows only two teeth (C and D). Af er injection to the right
side, when there was increased suppleness, the smile now shows three teeth (E and F).
Fig. 21-17
A
B
T is 4-year-old patient is shown 5 months af er sustaining a cooking oil burn to the ace (A). Fat in-
jections (9 cc, 8 cc, and 5 cc, respectively), which were per ormed at 2-month intervals under the acial
scars, practically made the scar appearance disappear with the hypertrophy (B). Local surgical resection
may be per ormed to complete the treatment in the preauricular area.

311
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
Fig. 21-18
T is 4 -year-old woman had scarring and severe restriction o the ability to open her mouth as a sequela
o an ethanol ame burn. She is shown months a er a f rst at gra ing session and months a er a
second at gra ing session. Note the signif cant improvement in the scar appearance and in her perioral
elasticity.

312
Part III • Clinical Applications • Skin
Fig. 21-19, A-H
A
B
C

D
E

F
H
G
T is 8-year-old patient sustained a crush/ riction injury caused by a truck tire (A and B) af er a truck
ran over her lef oot. Healing is shown at months af er two at injections and skin graf ing (C and D).
Eight months af er healing, three more injections were done under the scar and around joint spaces,
dramatically improving the appearance and unction o the oot (E and F). Note the plantar impression
at healing time (G) and 8 months af er treatment (H).

313
Chapter 21 • Treatment o Di icult Wounds and Scars With Fat Gra ts
Fig. 21-19, I-P
M

N
O

P
I
J

L
K
Radiographs o both the le and right eet show blurring o the joint spaces in the le oot at healing
time (I and J). Eight months later, one can see the evolution o the joint spaces rom “blurring” on the ra-
diographs ( rom f brosis) at healing time to normalcy a er 8 months and three at injections around the
joint spaces and under the scar (K and L). Lateral radiographs show the le oot with the longitudinal
arch higher at healing time and normal a er 8 months (M through P).

314
Part III • Clinical Applications • Skin
P otenti a l C ompl i ca ti on s
Although in ection is a common complication in burns and other traumatic injuries, we have expe-
rienced no complications related to in ection, even with injections through burned tissue and other
wounds and with at deposited over the wound.
Complications rom physical trauma to underlying structures by the cannula must be avoided. When
injecting under thick scar tissue, it may be sa er to pass the cannula under the scar in several directions,
opening the way or aster movements while injecting at on multiple retrograde passes, less than 2 mm
in diameter.18
In the rare instance in which a subdermal or deeper vessel is injured, local pressure and abortion o the
injection on that site should be the immediate response. T e ensuing ecchymosis will disappear over
time, and the patient must be reassured about the evolution and ultimate resolution o this most unusual
complication.
In patients with scars, postoperative edema is requent in the days immediately a er the at gra ing
procedure. T e patient must be warned in advance that this will occur.
A
B
Fig. 21-20, A and B
T is 2 -year-old patient trans erred 0 days a er a motorcycle accident in which he sustained a distal
ulnar racture, which was treated with an external f xator and distal bone ragment debridement at the
original institution (A). We per ormed an initial thorough debridement and surgical repair o the rup-
tured III, IV, and V extensor tendons at day 2 (B).

315
Chapter 21 • Treatment o Di icult Wounds and Scars With Fat Gra ts
C
D
E
F
G
H
I
Fig. 21-20, C-I
We per ormed at graf ing at 4 days (D), 0 days (E), and days (F). Healing is seen at days (G). At
months, no hypertrophy was present (H and I).

316
Part III • Clinical Applications • Skin
J
K
L
M
N
O
P
Q
R
S
T
U
Fig. 21-20, J-U
A comparison o initial (J) and ollow-up (K) radiographs af er bone debridement elsewhere show
that with three at injections at the racture site, new bone ormation was evident at 4 months (L) and
5 months (M). Finally, radiographs are shown at 8 months, af er our injections ( our injections imme-
diately af er healing at -month intervals) with bone connecting at the ulnar void site (N), with minimal
dorsal deviation (O). T e patient’s results with practically normal unction are shown at 8 months (P
through U) with no hypertrophy and no tendon adhesions.

317
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
A
B
C
D

E
F
G

H

I

J
K
Fig. 21-21
T is 68-year-old diabetic woman was seen 4 days af er a crush injury, which was originally treated
by irrigation ollowed by 8 cc o at graf ing and delivery o cc o at to the wound 4 days later
(A through C). A second at graf ing ( 4 cc) and delivery ( cc) procedure was per ormed (D). T e
oot is seen healed at 00 days af er our at graf ing sessions; no skin graf ing was done (E and F). Nine
months af er healing (G through K), the patient has moderate extension, ull exion, and practically no
hypertrophy.

318
Part III • Clinical Applications • Skin
Fig. 21-22
T is 22-year-old woman burned her hand on an ironing press. She was treated with debridement and
one at procedure (7 cc graf ed, cc delivered), which allowed or complete cure with minimal hypertro-
phy and practically normal skin.

319
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
Fig. 21-23
A
B
C
D
E
F
T is 6 -year-old diabetic woman with hypertension presented with a 7 ⁄2-year-old venous ulcer that was
LLE culture positive or Klebsiella pneumoniae and Pseudomonas (A and B). She is shown 4 months af er
healing and af er three injections (originally and at 5-day intervals), ollowed by skin graf ing harvested
rom the scalp days af er the third injection (C and D). She is shown at 8 months with no hypertro-
phy and no recurrences (E and F).

320
Part III • Clinical Applications • Skin
D i scu ssi on
Because at acquisition rom very young patients is still per ormed in requently, we recommend extreme
care in harvesting it, while endeavoring to do this symmetrically and to obtain deeper at (under Scarpa
ascia) to avoid creating uture superf cial irregularities. Also, using slightly higher negative pressure
(with a cc syringe) and multi (micro)–per orated cannulas will ensure aster and more precise at
harvesting. Long-term ollow-up visits will be essential as the young patient grows.
In patients with venous ulcers, postural drainage is crucial or success ul treatment; the patient must
be instructed that the improvement o the wound does not substitute or postural measures. In pa-
tients with diabetic arterial disease, adequate ootwear and proper oot care are a must or progressive
weight-bearing a er healing to avoid recurrence.
Several studies indicate that the stromal vascular raction (SVF) within the collected at is richer in
ADSCs, and some study authors have recommended the enrichment o at gra ing with cells rom the
SVF raction; that is, cell-assisted lipotrans er (CAL). Although there apparently are advantages in doing
that, we think that there are enough stem cells in the centri uged at to produce the obvious benef ts we
have noticed in our patients who were treated with the Coleman technique.19-21
T e benef ts o the injected at in improving healing are probably related to a number o events initiated
by the ADSCs themselves and to the growth actors present in the injected at, which contribute to
diminishing f brosis and in ammation and enhance the healing processes. Among these benef ts are a
great many metabolic and regenerative processes, such as acceleration o revascularization, a decrease
in f brosis, and enhancement o the tissue regeneration process. ADSCs have a large spectrum o growth
actors, including EGF, GF-beta, HGF, PDGF, and BFGF, that act locally as at is injected or delivered
at the wound or scar site.
ADSCs are also involved in immunomodulation, antiapoptosis, angiogenesis, and regeneration. When
there is critical ischemia, ADSCs may also act on vascular recuperation by decreasing in ammatory
lymphokines, reducing endothelial leukocyte adhesion, and improving microhemodynamics.
Since ADSCs may di erentiate into diverse mesenchymal lineages and tissues such as adipogenic, osteo-
genic, chondrogenic and myogenic tissue as well as possibly neurogenic, pancreatic, hepatic, endothelial,
and other tissues, this may explain the healing enhancement that occurs when gra ed at is deposited at
racture sites.*
Similarly, the increase in malleability and elasticity ( rom an increase in number o elastic f bers) o the
scar tissue treated by at gra ing are most likely triggered by the ADSCs and growth actors contained
in the lipoaspirate. T is improvement may also be related to the number o injections and/or the time
elapsed since the injection.24
We believe that the Coleman technique provides a rather standardized method with a very short learn-
ing curve or the surgeon and a routine that is easy to learn by the entire surgical team. In addition, when
this protocol is used or harvesting and preparing the at, it is easier to compare the results presented by
di erent surgeons who are using the same technique.25
*Re erences 2-4, 8, 11, 13, 22, 23.

321
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
C oncl u si on
Fat gra ing as an adjuvant treatment or burns and other wounds enhances healing, while decreasing the
usual healing time, and osters minimal to no hypertrophic scarring. When used under scars or immedi-
ately over joint spaces, at gra ing diminishes f brosis, diminishing scar thickness and resulting in more
pliability o the skin and recovery o normal joint spaces. It may also enhance bone ormation, aiding in
the repair o bone ractures and segmental bone loss recovery as well as in the f lling o void spaces, such
as in pressure sores.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
REFERENCES
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based therapies. issue Eng 7: , 0 .
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GFP transgenic mice. Biochem Biophys Res Commun : 6, 005.
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transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 9: 409;
discussion 4 , 007.
4. Gimble JM, Katz AJ, Foster SJ. Adipose-derived stem cells or regenerative medicine. Circ Res 00: 49,
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5. Coleman SR. T e technique o periorbital lipoinf ltration. Oper ech Plast Reconstr Surg : 0, 994.
6. Coleman SR. Long-term survival o at transplants: controlled demonstrations. Aesthetic Plast Surg
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7. Coleman SR. Structural at gra s: the ideal f ller? Clin Plast Surg 8: , 00 .
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cretory actors on human dermal f broblasts. J Derm Sci 48: 5, 007.
9. Lolli P, Malleo G, Rigotti G. reatment o chronic anal f ssures and associated stenosis by autologous adi-
pose tissue transplant: a pilot study. Dis Colon Rectum 5 :460, 0 0.
0. Bene MD, Pozzi MR, Rovati L, et al. Autologous at gra ing or scleroderma-induced digital ulcers. An
e ective technique in patients with systemic sclerosis. Handchir Mikrochir Plast Chir 46: 4 , 0 4.
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scar remodeling and reduction. Aesthetic Plast Surg :465, 008.
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57: 7, 0 .
. Sultan SM, Barr JS, Butala P, et al. Fat gra ing accelerates revascularization and decreases f brosis ollow-
ing thermal injury. J Plast Reconstr Aesthet Surg 65: 9, 0 .
4. Carpaneda CA, Ribeiro M . Study o histologic alterations and viability o adipose gra s in humans. Aes-
thetic Plast Surg 7:4 , 99 .
5. Klinger M, Caviggioli F, Klinger FM, et al. Autologous at gra in scar treatment. J Cranio ac Surg 4: 6 0,
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6. Matsumoto D, Sato K, Gonda K, et al. Cell-assisted lipotrans er: supportive use o human adipose-derived
cells or so tissue augmentation with lipoinjection. issue Eng : 75, 006.
7. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotrans er or cosmetic breast augmentation: supportive
use o adipose-derived stem/stromal cells. Aesthetic Plast Surg :48, 008.
8. Carpaneda CA, Ribeiro M . Percentage o gra viability versus injected volume in adipose autotrans-
plants. Aesthetic Plast Surg 8: 7, 994.
9. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotrans er or acial lipoatrophy: e cacy o clinical use
o adipose-derived stem cells. Dermatol Surg 4: 78, 008.

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0. Gentile P, De Angelis B, Pasin M, et al. Adipose-derived stromal vascular raction cells and platelet-rich
plasma: basic and clinical evaluation or cell-based therapies in patients with scars on the ace. J Cranio ac
Surg 5: 67, 014.
1. Liao HT, Marra KG, Rubin P. Application o platelet-rich plasma and platelet-rich f brin in at gra ing:
basic science and literature review. Tissue Eng Part B Rev 0: 67, 014.
. Sultan SM, Stern CS, Allen RJ Jr, et al. Human at gra ing alleviates radiation skin damage in a murine
model. Plast Reconstr Surg 1 8: 6 , 011.
. Schlosser S, Dennler C, Schweizer R, et al. Paracrine e ects o mesenchymal stem cells enhance vascular
regeneration in ischemic murine skin. Microvasc Res 8 : 67, 01 .
4. Pallua N, Baroncini A, Alharbi Z, et al. Improvement o acial scar appearance and microcirculation by
autologous lipof lling. J Plast Reconstr Aesthet Surg 67:10 , 014.
5. Pu L, Coleman SR, Cui X, et al. Autologous at gra s harvested and ref ned by the Coleman technique: a
comparative study. Plast Reconstr Surg 1 :9 , 008.

FACE AND NECK
Aesthetic
S e c t i o n T w o

(Trang không có chữ)

325

C h a pt e r 2 2
A Model o Aging:
A Par adigm Change
Sydney R. Coleman
N
tt w c c us v t v c , t s cu t p p t cc pt w s
w t y c c v t y cc pt w s . C s s upt v , but u t t y t s
s c st uct v t c bu u t k w t c t t w s .
H st y s p t w t x p s v u s w c t st tus qu w pu -
s s . Ev tu y, w v , sc c s su v v t t st
t . F st 000 y s A st t ’s t y t t b s t sp s p p t t t
ss w s c s ct. t st t s “ ct,” G s s t v pp tw w ts,
vy t, t L w P s , y t f t y st uck t u t t
s t . D sp t t v c , sc t sts t t c s t G ’s p c -
t u st t c tu y t t A st t ’s t s. S y, t c t G ks
k w t t t t w s u , but t t ut w s bu by c tu s us .
R sc v bv us t ut t t c t cts st b s c s t s b
cu t t t uc b kt u . T s s s t u t y s t w s G ’s
t . As p st c su s w w t t s t , t s ss s p t cu s f -
c c t us s w st v t u st t c s ss c t w t t p c ss s t t w
c p v u p t ts w t t tu juv t t y s k. It s c uc t t w b s u
t s t v ts t t s c s st t w t tu t ctu p c ss
t t w k t u t w y, w ss s u p st t p us pp c
t s p b s w t t c t v ty t c t t s b t k u sp c ty.
F st, w ust b b t “s ” t p b s b w c f w k b s ut s. T
t s c pt p s ts w t ys s c . T s w b t u -
t w c w c scuss t st t c su ’s s scu pt ss t
c . It s p u t w u ts st y t u st u p s t p ct c s t
u tu u utu v s . L t’s b w t k t u s w p st c su s
pp c t t sc c st t juv t .
O ri g i n s
W t s p st c su y? Acc t t f st E s ct y sc c (Lexicon Technicum:
Or an Universal English Dictionary of Arts and Sciences, pub s by J H s 1710), t s
325

326
Part III • Clinical Applications • Face and Neck: Aesthetic
“the Art o making Figures o Men, Birds, Beasts, Fishes, Plants, et cetera, in clay, et cetera . . . It di ers
rom Carving, because here the f gures are made by Addition usually, but in Carving always by Subtrac-
tion o what is super uous.” T us plastic was originally described as the art o building up f gures to cre-
ate new structures rather than cutting away. Dorland’s Illustrated Medical Dictionary gives a surprisingly
similar meaning. T e f rst def nition o plastic is “tending to build up tissues or to restore a lost part.”
Plastic surgeons o 100 years ago, who viewed their role as sculptors and augmenters, were in practice
much closer to that def nition than are modern aesthetic surgeons. T e literature o the early twenti-
eth century abounds with reports on e orts to augment tissues with a wide variety o injectable f llers,
such as rubber latex, gutta percha, celluloid, gold, silver, ivory, cow horn, and other materials. Frederick
Strange Kolle, author o the f rst book on cosmetic surgery, Plastic and Cosmetic Surgery, which was
published in 1911, devoted more than one ourth o the text to the use o hydrocarbon f ller injections
(para n and petrolatum jelly) or acial augmentation. He described an extensive classif cation system
or using hydrocarbons in the ace, including eight indications in the orehead, seven in the orbit, our-
teen in the nose, our in the cheek, our in the ear, ten in the mouth, six in the breast, two in the neck,
and eleven miscellaneous indications in the body. Kolle and other authors reported on the natural eel
and acceptance o the body to injected hydrocarbons, noting that they did not remain as solid when in-
jected. Instead, they would break up into microparticles: when entering the body, each particle would be
separated rom other particles by the host tissues so that they were more easily integrated, and the host
tissue remained the predominant palpable tissue.
T us at the beginning o the twentieth century subcutaneous f lling was used extensively or altering a-
cial proportions. T is practice continued during the f rst two decades o the twentieth century. However,
during that time, complications resulting rom injected para n and other substances became obvious,
and aesthetic surgeons, disillusioned with available f llers, abandoned this approach to rejuvenation a er
19 0— ailing to recognize that it was the product, not the process, that needed to be improved.
As an alternative to injectable f llers, they developed simple surgical procedures to remove the signs o
aging. T is emphasis on excising and removing has persisted as new and more elaborate procedures
have been devised or cutting away and suspending skin, at, and muscle to obliterate the wrinkles, olds,
and troughs associated with aging. T e result has been the o en-cited “stigmata o plastic surgery”—the
hollow eyes and tight-pulled aces that patients today are so anxious to avoid. Although reconstructive
plastic surgeons have remained builders and restorers, working primarily to restore humans to a more
normal, whole condition, aesthetic surgeons moved away rom building and restoring to become “carv-
ers.” For them, excision and suspension became the indisputable gospel.
P ersona l E vol uti on
As a student o history, schooled in atmospheres that encouraged independent thinking, I have taken a
di erent approach to aesthetic rejuvenation and recontouring. Augmenting and f lling always seemed
the way to approach this problem—all that was needed was a f ller that was natural, stable, and without
the complications o earlier f llers. For me, at has proved to be that medium. In 1988 I f rst spoke on at
gra ing at the annual ASAPS meeting, showing a year’s longevity o the at. Since 1990, when I began
submitting abstracts to ASAPS and ASPRS with titles such as “Maintenance o Facial Fullness: A Pri-
mary Approach to Aging,” I have attempted to get the message out that at gra ing, when done appro-
priately, can provide an excellent natural means or acial rejuvenation and recontouring, with natural
results and long-term stability. As a part o that message, I have continued to stress the importance o
rethinking how we approach acial rejuvenation, rejecting the theory that sagging is the primary prob-
lem with aging. Rather, I see aging as a process in which there is an absolute decrease in subcutaneous
acial volume leading to secondary acial changes: sagging, texture changes o the skin, and exposure o
underlying structures. Over time this message is gaining acceptance. Over the past 0 years, this way o
thinking has dramatically advanced aesthetic plastic surgery so that surgeons now are now able to de-
liver much more natural rejuvenation and enhancement o aces and bodies.

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Chapter 22 • A Model o Aging: A Paradigm Change
C urrent P ra cti ce
T e plastic surgery community over the past 0 years has at times embraced my concepts and at other
times ignored them. Regardless, the world o aesthetic surgery has changed. T e ocus in aesthetic sur-
gery is once again on augmentation: words such as volume, fullness, and structure have been added to the
title and content o almost every surgical rejuvenation lecture.
T e reasons or the modern plastic surgery community’s reservations about restructuring with at are
per ectly understandable. Plastic surgeons have been extensively trained on the many nuances o remov-
ing the signs o aging with blepharoplasties, aceli s, and orehead li s. We have been reliant on proce-
dures that excise and suspend or so long that it is di cult to totally alter our vision and our practice.
T ere are technical barriers as well. Success ul at gra ing is technically demanding and requires the
same attention to detail that one would devote to any surgical procedure. In addition, correct at gra -
ing technique requires a much higher quality o photography than other types o aesthetic surgery to
document the millimeters o change. Plastic surgeons in training are selected or their technical skills;
however, there is no guarantee that a plastic surgeon will have the ability to visualize in three dimen-
sions, let alone create a ree- orm, three-dimensional structure on the ace or body. Even i surgeons can
obtain good survival o the transplanted at, they may not be able to sculpt in three dimensions, creating
a pouty lip, a sharp jawline, a smooth lower eyelid, or an appropriately sloping orehead.
And as important as a acility in sculpting, a surgeon must have the ability to observe and document the
dramatic enhancement in the quality o overlying skin that occurs over time a er at gra ing. Many sur-
geons simply do not have the interest or ability to photograph changes in the texture o skin, especially
that which occurs over not just months, but also years and decades. Yet this is a phenomenal change,
which should be encouraged.
Possibly the biggest stumbling block to acceptance o the concepts o f lling has, until recently, been eco-
nomic. I experienced surgeons have trained or years in the principles o excision and suspension and
now have success ul practices based on traditional surgical techniques, it is di cult or them to abandon
these procedures or structural at gra ing. It is much easier or younger physicians to make the shi .
However, with the modern patient demanding a much broader range o services and treatments that are
less invasive and that produce more natural results, surgeons are incorporating Coleman structural at
gra ing along with f llers into his or her practice, both as a primary procedure and as an adjunctive one.
Aesthetic surgery is moving rapidly away rom excision and suspension procedures to augmentation
procedures or rejuvenation in particular. T e reason? T e primary event o acial aging is atrophy or
loss o ullness. T e obvious solution or atrophy is the restoration o volume or ullness. o ully under-
stand why this makes sense, we have rethought our traditional concept o aging. I propose the ollowing
model to help us really see the aging changes that we are dealing with so that we can develop the best
strategies or addressing them.
A N ew M
od el o f A g i n g
How do we age? Although the plastic surgery literature almost universally acknowledges that atrophy
plays a part in acial aging, it has until the last ew years placed ar greater emphasis on the role o
descent as a justif cation or traditional approaches to rejuvenation such as orehead li s and blepha-
roplasties. T e common models or aging ocus on the descent o skin, descent o muscle, descent o
at—everything is moving south. T e rationale is easy: anyone can tell you that i you pull back on your
cheeks, you remove the signs o aging—wrinkles, olds, and bags. Until recently, modern aesthetic plastic
surgery had been based on that simple principle—the removal o the signs o aging by excising skin, at,
ascia, and muscle and tightening or suspending the remaining tissue.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Mario González-Ulloa and others have extensively discussed at atrophy as the primary actor in aging.
Dr. González-Ulloa challenged surgeons to f nd ways o augmentation to reverse at atrophy. Although
some earlier surgeons such as Dr. González-Ulloa correctly identif ed atrophy as the primary component
o aging, they incorrectly identif ed at as the primary component o the acial atrophy that occurs with
aging. What is needed is a new model.
Fig. 22-1
Pictured here are models developed to help analyze how a ace ages. On the le is the ace o a young
woman o approximately 0 years o age; the middle ace is the woman in middle age, about 50 years old;

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Chapter 22 • A Model o Aging: A Paradigm Change
and the right represents the ace o the woman at more than 75 years o age. T e objective is to help the
reader to analyze his or her patients’ aces to understand how they are aging.
Fig. 22-2
Among individuals with drug-related lipodystrophies, we have an unusual opportunity to observe acial
atrophy. T ese patients give us a new appreciation o how people look when they lose acial at. T ey
do not necessarily look old; they look sick or anorexic rom loss o subcutaneous at. T e areas o atty
tissue loss are specif c: the cheeks and temples are most involved. T e lips and perioral region out to the
nasolabial old are almost entirely spared in lipoatrophy. However, the cheek, rom the malar region to
the buccal region, and extending down into the area o the jowls, shows a marked loss o almost all so
tissue ullness.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 22-3
T e model o aging presented here is based on my knowledge rom surgery, cadaver dissections, and
observation o lipoatrophy. On coronal section you can see that deposits o at (shown in yellow) are
hidden in the younger sections by ullness (purple). T e ullness (purple) is presumably colloidal uid
held in place by the proteins, hormones, hyaluronic acid, and so on. All o these substances that impart
ullness are present in a young person dif usely rom bone to skin but are gradually lost in the natural
process o aging.

331
Chapter 22 • A Model o Aging: A Paradigm Change
As a person approaches middle age, the at deposits o the jowl, above the nasolabial olds, in the eyelids,
and so orth become more visible as their surrounding ullness disappears. Not only do the at deposits
become more obvious, but also many o the underlying structures o the ace, such as the submaxillary
glands and the bony skull, are more discernible as separate entities. How each area o the ace ages is
discussed in great detail throughout this section o the book (Chapters through 9), but in almost all
areas o the ace the at remains, along with bony structures, glands, and vessels, and the inherent ull-
ness o youth disappears. And, o course, all o those changes are accompanied by a deterioration in the
quality o skin over time, with the loss o skin thickness and elasticity.
T he O nl y C on sta nt I s C h a n g e
Atrophy is the def ning characteristic o aging; it also represents a primary challenge in the evolving
quest to f nd the best approach or rejuvenating aging aces and bodies. Lessons learned rom the past
and present-day observations teach us that rejuvenation is not about suspension or sagging; it is all about
augmentation to restore youth ul ullness and contour in a natural and aesthetic ashion.
Augmentation represents the past as well as the uture o rejuvenation. It also holds the key to possible
new developments, such as tissue repair. Examination o the many be ore-and-a er photographs in the
pages o this book reveals promising posttreatment changes in the quality o the patients’ skin a er
the placement o gra ed atty tissue under it. In addition to restoration o youth ul contours, intrinsic
qualities o skin texture, elasticity, and color return to a more youth ul state or an extended period o
time. Stem cells have been shown to be present in signif cant quantities in harvested atty tissue. T ey are
involved in bringing in a new blood supply, thickening the skin, restoring elasticity, and even improving
the skin color.
Almost every new day brings new observations, new revelations, and the approach changes accordingly.
Only the principles survive. We can build on these principles to gain greater understanding o the aging
process and how we as sculptors can help to provide our patients with the natural, long-lasting rejuve-
nation they seek.

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Part III • Clinical Applications • Face and Neck: Aesthetic
R e g i ona l C on si d era ti on s
SUPRAORBITAL AREA
T e sequelae rom aging and skeletonization as a result o illness are more similar in the upper third o
the ace than in the rest o the ace, usually with more hollowing than sagging.
Fig. 22-4, A-C
As in the rest o the ace, the brow, temple, and upper eyelid are uller, not atter, in youth. T e ullness
o youth obscures and sof ens the underlying structures, such as bones, cartilage, blood vessels, the
muscles o expression, and collections o at (see Chapter ). As the ullness o youth disappears, the
structures underneath emerge. In the upper ace, the shape o the skull and o the supraorbital bony rims
becomes more apparent. T e blood vessels are no longer hidden by ullness and become more and more
tortuous (similar to the hands, as described in Chapter 4 ). T e muscles o acial expression, such as the
A

C
B

333
Chapter 22 • A Model o Aging: A Paradigm Change
corrugator and procerus muscles, are more visible because the youth ul ullness no longer impedes their
intrinsic tone. T is creates a rowning or scowling appearance in many older people.
T e eyebrow descends only a minimal amount with loss o generalized ullness rom the orehead, tem-
ple, and brow. T e most remarkable changes in the eyebrow o an older person are not descent, but loss
o lateral support o the brow and a change in the ullness caudal to the eyebrow, which creates an illu-
sion o descent.
Fig. 22-4, D-F
As the temples collapse, support to the eyebrow laterally diminishes and the lateral eyebrow gradually
disappears and may slightly descend. Essentially, the lateral f h to one quarter o the eyebrow cannot be
seen, because the support that ormerly pushed it out is missing. I tell patients that when they are young,
their eyebrows can be seen to be supported by a gently sloping hill. As they age, their lateral eyebrows
cannot be seen rom the ront, because they drop o a cli out o view. T is gives an illusion o the eye-
brow shortening and descending laterally.
Fig. 22-5
T e medial our f hs o the eyebrow appears to descend primarily as a result o a change in supraorbital
shadow position. Even with little actual descent o the eyebrow with aging, the change in the supraorbital
shadow can make the viewer think that a signif cant descent has occurred.
D
E
F

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 22-6
As ullness gradually disappears rom the upper eyelid and brow, di erent people age di erently. As
some individuals age, their eyes become more deep-set and eventually skeletal. In others the lack o ull-
ness results in an empty sac o skin hanging where the ullness once was present. In act, as these f gures
demonstrate, the two di erent types o aging can coexist in the same patient.
LIPS
As a person ages, the lips lose ullness in the subvermilion and subcutaneous region. As the ullness
between the muscle and the vermilion dissipates, the muscle comes gradually more in contact with the
vermilion and mucosa (see Chapter 27). T is results in an inversion o the lower lip and de ation o the
upper lip. Paradoxically, as the lateral ullness o the lower lip decreases, the central cle o the lower lip
disappears and the central mucosa appears uller. T is is accompanied by a attening o the attractive
central pout as the lip inverts.
T e changes that occur with aging o the lower lip are dramatic, with loss o both the central pout and
the central depression. T is is the most common presentation o the aging lower lip.

335
Chapter 22 • A Model of Aging: A Paradigm Change
Fig. 22-7
As the fullness of the lower lip is lost, the lip also descends to expose the mandibular incisors, which
exposes the lower incisors when the lip is at rest. Despite the obvious dramatic decrease in volume of the
lower lip with aging, wrinkling of the upper lip is almost always much worse.
T e best candidates for lip augmentation are those who had full lips when young; restoring lip fullness
will result in a return to youthful appearance.
Fig. 22-8
T e most challenging patient is one who has never had full, attractive lips, especially a thin upper lip. As
the individual ages, the upper lip becomes thinner, with increasing wrinkles. o create a full, attractive
lip, the fatty tissue should be placed so that the vectors of placement overwhelm the patient’s natural
anatomic tendencies.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 22-9
Aging in the upper lip is more varied in its presentation than aging in the lower lip. In a person with a
young, thin upper lip, the decrease in fullness can result in inversion, with loss of visible vermilion and
an increase in maxillary incisor show. T e loss of lateral vermilion show in particular can result in an
apparent narrowing of the overall lip.

337
Chapter 22 • A Model o Aging: A Paradigm Change
Fig. 22-10
However, in many other cases the upper lip hangs as it loses ullness. Depending on the youth ul conf g-
uration, this de ation o the lip can result in an increase o the visible vermilion, which can obscure the
maxillary incisors. T ere ore in many patients the upper lip on a rontal photograph looks bigger than
in a prof le or oblique view.
In these drawings the upper and lower lips have become more similar in size on rontal view; that is, the
upper lip has more vermilion showing, whereas the lower lip inverts to reveal less vermilion.

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Part III • Clinical Applications • Face and Neck: Aesthetic
NECK
Fig. 22-11
T e process o aging in the neck is not as complicated as that o aging in the ace. Although the mecha-
nisms are similar, the end result with the neck is easier to understand intuitively (see Chapter 29). T e
neck, like the hands, loses subcutaneous and subplatysmal dif use ullness—not at. As the neck de ates,
it is somewhat like the earlobe in that it gradually and only slightly hangs in the direction that gravity
pulls it. However, the underlying platysma stabilizes the skin so that a descent like that o the earlobe is
not possible. Again, gravity is not a primary actor, but only a er the loss o the supporting underlying
ullness does the skin o the neck ever so slightly “descend” and then begins to drape. T is process is
accentuated by the loss o elasticity which occurs with age and sun exposure.
With advancing age, the hints o horizontal creases in the neck deepen, and the intrinsic tone o the
platysma muscles creates vertical bands o muscle running rom the submentum down toward the neck
cartilages. T e subcutaneous atrophy gradually exposes the cartilaginous structures in many maturing
necks, and in some individuals this can become the primary evidence o aging.

339
C h a p t e r 2 3
T he A g i n g F a ce a nd the N eed f or F a t G ra f ti n
R z pp p -
y p p
pp p . I p , p :
k ; , k y, y ;
w , p y, / - p y p y. Op w p
yp p p , p ’ p , , , xp
w p .
P p y w surface aging k y q p
p y p y -
k . P p y w , k x ,
loss of facial contour w y p , w ,
y p y . T y w q w p
x p p y p ,
- pp , p .1-9
P w f facial atrophy - w w p -
y p p k
. S k w w w pp ,
- pp y p
y w . R -
p w q p w p p
. F w k w y p p y
k j . P p y p ,
p p -
p pp y .
Simult aneous Facel i t and Fat
Gr a t ing: Combined Li t ing
and Fil l ing or Re uvenat ion
o t he Aging Face
Timothy Marten, Dino Elyassnia
339

340
Part III • Clinical Applications • Face and Neck: Aesthetic
WHY PERFORM A FACELIFT PLUS FAT INJECTIONS?
Why per orm a aceli plus at injections? Why not per orm just the aceli ? T e answer to these ques-
tions lies in the multi actorial origin o acial aging, and the act that at is predictably lost rom the ace
and the ace becomes hollow as one ages, in addition to sagging, drooping, and other gravitational e -
ects. A aceli procedure alone, even when per ormed aggressively and comprehensively, only addresses
tissue ptosis, redundancy, and excess and o en produces a li ed but telltale hollow, underrejuvenated
look. Fat gra ing, on the other hand, allows the loss o acial at to be treated simultaneously with the
aceli . All things being otherwise equal, concomitant aceli and at injection procedures will produce
a better result than either technique per ormed alone, and when a aceli is per ormed in conjunction
with at injections, loss o contour and acial atrophy can be corrected, and optimal improvement can be
obtained.
Fig. 23-1
T is 55-year-old patient is shown be ore and 1 year and months a er combined aceli and at gra -
ing. Preoperatively, it can be seen that she presented with tissue ptosis, skin redundancy, and acial atro-
phy. Postoperatively, she is shown a er a high-SMAS aceli , neck li , orehead li , lower blepharocan-
thoplasty, and pan acial at injections. Combined li ing and f lling o her ace have produced a better
outcome than either technique could have alone.*
*All procedures shown in this chapter were per ormed by imothy Marten, MD.

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
VOLUMETRIC REJUVENATION, TISSUE INTEGRATION,
AND THE STEM CELL EFFECT
Fat gra ing has other previously unavailable advantages or surgeons who per orm aceli s. Fat gra ing
provides volumetric rejuvenation—a new and di erent means by which to improve acial appearance,
and a new dimension or plastic surgeons to work in. And unlike nonautologous injectable f llers, at ac-
tually integrates with acial tissues and becomes a part o the ace, promoting a more natural appearance
during acial movement and producing a more sustained and long-lasting improvement. In addition,
mounting scientif c evidence supports the o en-cited clinical observation that at gra ing may actually
induce an improvement in acial tissue quality through a “stem cell e ect,” and when per ormed with a
aceli may constitute, or the f rst time, rejuvenation in the true sense o the word.
NOMENCLATURE
Con usion has been created or both patients and surgeons by the term stem cell acelif , a procedure
in which at is variously injected into the ace with the purported but as yet unproven benef t o tissue
rejuvenation mediated through a stem cell e ect. In most cases, at only is injected and a aceli is not
actually per ormed, but in some such procedures, limited traditional aceli s are simultaneously carried
out. Currently, it is a stretch o the available scientif c act to call at gra ing a “ aceli ,” and it is medi-
cally more correct to re er to the two procedures simply as combined but separate and distinct surgeries.
DRAWBACKS OF FAT GRAFTING
Per orming at gra ing in conjunction with a aceli has certain disadvantages that must be acknowl-
edged, including the learning curve associated with mastering any new procedure, an increase in operat-
ing room time, increased postoperative edema, a longer period o recovery, the uncertainty o gra take,
and the potential or problems and complications such as asymmetries, lumps, and other irregularities.
Certain patient misconceptions must also be overcome, including misguided notions held by many that
injected at can migrate or all, or that at gra ing will make the ace “look at.”
WHY NOT JUST GRAFT FAT?
Age-related loss o acial at rarely exists as an isolated event in healthy patients, and thus patients trou-
bled by it can rarely be logically or appropriately treated by at gra ing alone. Isolated at gra ing is
also arguably o questionable benef t to a patient with signif cant acial sagging and skin redundancy.
Whereas aggressive f lling o the sagging ace with at can yield improved contour and a smoother-
appearing skin sur ace, it generally results in an unusually large, overf lled “f ller ace” that appears both
unnatural and un eminine. Such an overf lled ace is hard to correct in an attractive manner at a later
date, and it is both more logical and practical to per orm at injections in conjunction with ormal surgi-
cal li s i needed, or a er ptotic tissue has been repositioned and redundant tissue has been removed. In
this way, a more natural distribution o at is obtained and less overall at gra ing is required.
WHERE SHOULD THE FAT BE INJECTED?
Areas in need o at gra ing will vary among patients, and planning at gra ing procedures requires
looking at the ace in a di erent way—more as a sculptor and less as a tailor, as we have done in the past.
Any area success ully treatable with nonautologous injectable f llers is potentially treatable with at gra s,
however, including, but not limited to, the orehead, temples, brow, glabella, radix, upper orbit (upper
eyelid), lower orbit (lower eyelid), the tear trough, cheeks, mid ace, buccal recess, lips, perioral area, sto-
mal angles, nasolabial old, geniomandibular groove (GMG), jawline, chin crease, submental crease, and
chin areas, and experience with f llers is a use ul point o re erence or planning at additions to the ace.
Perhaps the best way to decide where at is needed is or the surgeon to study her or his previous aceli
outcomes care ully and to identi y areas in which the procedure has allen short. In most cases, the most
signif cant shortcoming or the experienced surgeon will be evident as a ailure to replenish lost volume.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Opportunities to see nonsmiling photographs o patients when they were younger are highly valuable
and one o the best ways to gain an appreciation o volume loss and its contribution to changes that
occur as the ace ages. T ese photos are also very help ul or educating patients as to how their ace has
changed with age and or explaining the need or at gra ing.
In time, and a er engaging in thought ul study o the aging ace, one will gain a deeper appreciation
o acial atrophy and an increasing desire to correct it. T e ollowing images show a patient be ore and
a er a aceli (and related procedures) and at gra ing, and the areas where at was placed. It serves as a
use ul starting point in understanding age-related acial atrophy and how to correct it.
Fig. 23-2
T is 7-year-old patient had no prior surgery; she is shown be ore and a er a combined aceli and at
gra ing. She presented with tissue ptosis, skin redundancy, and acial atrophy. She is shown 1 year and
1 month a er a high-SMAS aceli , neck li , orehead li , upper blepharoplasty (levator reinsertion),
lower blepharoplasty, upper lip li , and a total o 8 cc o at injections. T e shaded areas in the center
photograph show where at was placed: 1 cc was placed in each upper orbit, cc was placed in each
temple, 1 cc was placed in each tear trough, cc was placed in each in raorbital area, cc was placed in
each cheek, 1 cc was placed in each nasolabial old, 1 cc was placed in each stomal angle, 1 cc was placed
in each geniomandibular groove, cc was placed along each jawline, and 1 cc was placed in each lip
(0.5 cc in each side). Combined li ing and f lling o her ace has produced a better outcome than either
technique could have alone.
SEQUENCING FAT GRAFTING WITH OTHER PROCEDURES
Although there is no consensus on when at gra ing is best per ormed during aceli surgery, as a prac-
tical matter, it is most expedient to inject at at the beginning o the procedure, be ore the aceli itsel
has been per ormed. T e reasons or this include the act that it is easier to harvest the at at the begin-
ning o the procedure be ore the ace has been prepped or draped and when the patient is typically in
a deeper plane o anesthesia. In the beginning o the procedure, the tissue planes o the ace have also
not been opened, the ace is not swollen, and preoperatively made pen markings and acial landmarks

343
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
are easier to identi y. In addition, surgical principles suggest that it is best to limit the time the at gra
is out o the body. Perhaps the most important reason to per orm at gra ing f rst, however, is that the
surgeon is more technically and artistically energetic in the morning and will do a better job than i the
procedure is per ormed at the end o a long aceli procedure.
M
a teri a l a n d M
eth od s
T e technique or simultaneous aceli and at gra ing has been described previously,1,3,10,11 and the prin-
ciples set orth by Coleman (see Chapter ) are observed when simultaneous aceli ing and at gra ing
are per ormed.
LOGISTICS OF SIMULTANEOUS FACELIFT AND FAT INJECTIONS
Fat gra ing is o en mistakenly regarded as a simple procedure that can be per ormed in a ew minutes’
time. T is is rarely the case, however, and such an attitude will lead to rustration, disruption o work-
ow, and suboptimal outcomes. Fat must be harvested in a specif c, atraumatic manner i viable tissue is
to be obtained that can be expected to survive and take at the acial donor site. It must then be processed
and injected in a technically demanding and time-consuming process. Fat gra ing is also an artistically
demanding activity that will require a considerable amount o the surgeon’s creative energy. When any-
thing other than a ew areas o the ace are being treated, the entire procedure can encompass an hour or
more, something that can overwhelm an already overburdened surgical team engaged in a long and de-
manding aceli operation consisting o multiple procedures. ime must there ore be care ully planned
and allocated appropriately.
EQUIPMENT
Special instruments are required to harvest and inject at, in addition to other pieces o equipment to
process and organize it.
Fig. 23-3
Poor outcomes are typically obtained i sharp hypodermic needles are used to harvest at, or i at is not
processed, or i the at is injected in a manner similar to that used to inject nonautologous acial f llers. In
addition, i sharp hypodermic needles are used to inject at (other than or a true intradermal injection),
there is the potential or intravascular injection, at embolization, and other serious problems including
tissue in arction, visual impairment and blindness, and embolic stroke, and there ore their routine use
is not recommended.

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Part III • Clinical Applications • Face and Neck: Aesthetic
CHOOSING A FAT HARVEST SITE
Currently, there is no scientif c consensus as to where the “best” at or gra ing should be obtained
or documented evidence o one donor site being def nitively superior to another. Fat harvest sites are
typically chosen and marked in conjunction with the patient in such a manner as to improve her or his
silhouette, although the ideal locations are arguably those areas o diet- and exercise-resistant at collec-
tions, where the at is biologically programmed to be stubbornly persistent throughout the patient’s li e.
For women, this is typically the hip, outer thigh, or abdomen, and or men it is the “love handle” and
“spare tire” areas.
In thin patients, small harvests rom multiple areas may be required, including the inner thighs, inner
knees, upper buttocks, and anterior axilla, and the additional time this will add to the procedure must
be actored into surgical planning. Preoperative assessment o the patient’s at stores will allow proper
allocation o time or the harvesting process, and appropriate pricing o the procedure.
We recommend that the harvest sites and site markings be photographed preoperatively to document
what was agreed on in preoperative consultation with the patient. T is helps to avoid any dispute over
the preoperative condition o harvest sites a er surgery.
PREOPERATIVE MARKING OF THE FACE
Faceli and at gra ing cannot be per ormed arbitrarily; a care ul plan must be marked preoperatively
with the patient seated in an upright position. Marking requires concentration on the surgeon’s part; it
consumes a signif cant amount o time, and it is best carried out in a private area that is ree rom dis-
tractions. Creating an initial plan on a li e-sized laser print o a photograph o the patient’s ace is help ul
or organizing one’s thoughts and acilitates f nal discussions with the patient as to which areas will be
treated. In most cases, marks are made in conjunction with the patient while she or he holds a hand
mirror. T e goal is to create a topographic map o the def cient and atrophic areas o the ace to guide the
surgeon during the procedure—essentially a reverse plan o that used when liposuction is per ormed.
Because the aging ace is undergoing a process o lipodystrophy—that is, at is def cient in some areas
and excessive in others—marks are also made where at extraction needs to be per ormed when indi-
cated. T ese areas can be marked in a di erent color or designated by some other means.
Once markings are complete, additional photographs o the marked ace are taken and printed or use
during the procedure, and these become part o the patient's medical record.
INFORMED CONSENT
Some surgeons have the patient sign and date a laser print copy o the marked acial plan to avert any
postoperative debates about what the patient’s preoperative requests were and what was agreed on and
consented to. A companion strategy is to include language in the in ormed consent document stating
that the discussions and designations regarding where at is to be placed are necessarily approximate and
are carried out or in ormation and education, and that the patient consents to placement o at during
the procedure in any area that the surgeon eels, in her or his judgment, is necessary to obtain the desired
e ect.
ANESTHESIA
Most contemporary aceli s are time consuming and technically demanding, and the addition o at
gra ing to the procedure will test the patience and composure o most surgeons. We highly recommend
that the services o an anesthesiologist or other anesthesia provider be enlisted when combined proce-
dures are per ormed. T is is particularly important when the procedure is to be per ormed on a patient
who is apprehensive or has a history o anesthetic di culties, hypertension, or other signif cant medical
problems.

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Most o our aceli s are now per ormed with the patient under deep sedation administered by an anes-
thesiologist using a laryngeal mask airway (LMA). T is allows the patient to be heavily sedated without
compromise o the airway, but the patient need not receive muscle relaxants and can be allowed to
breathe spontaneously. It is also easier to harvest at rom a heavily sedated patient, especially when at
must be harvested rom multiple sites; in addition, comprehensive treatment o the ace with at is acili-
tated under these conditions. However, any skill ully administered anesthetic is adequate or per orming
the procedure.
HARVESTING FAT
Fat is harvested the day o surgery and should be harvested in a thought ul and artistic manner that im-
proves the patient’s f gure. T us it must typically be removed bilaterally and symmetrically, unless body
contours dictate otherwise.
It is prudent to examine the patient’s body at the time o her or his consultation, unless it is obvious that
plenti ul donor at is present. T in patients with limited at stores or patients who have undergone prior
liposuction o en present signif cant challenges when harvesting at, and extra time and e ort will be
required to obtain at rom them. Anesthesia and operating room times and the surgeon’s ee must be
calculated accordingly.
Fig. 23-4
Fat is harvested a er anesthesia is initiated, but be ore prep o the ace. In all but the unusual case, a
complete prep o the torso is not necessary. ypically, a limited prep o the marked area is made and a
sterile f eld is established about the prepped area.
I at is to be harvested rom the hip and/or lateral thigh, as is usually pre erred, the patient is turned to
a semilateral decubitus position; prep, drape, and harvest are per ormed, and the patient is then turned
to the opposite side, where the harvest procedure is repeated. I the patient is positioned care ully, this
technique can be used to simultaneously harvest at rom multiple additional sites, including the inner
knee, posterior inner thigh, outer thigh, upper buttocks, hip, waist, and ank area. Obtaining at rom
multiple sites is particularly important in thin patients with minimal at stores.
Areas rom which at is to be harvested are conservatively inf ltrated with 0.1% lidocaine with 1:1,000,000
epinephrine solution using a specially designed multiholed local anesthetic inf ltration cannula, allow-
ing adequate time or a proper anesthetic and hemostatic e ect. Approximately 1 cc o this dilute local
anesthetic solution is injected or every cc o anticipated at removal. It is not necessary or desirable to
inf ltrate in a tumescent ashion, because overwetting the donor site will result in an overdilute harvest
and more time spent in the harvesting process. Local anesthetic should be injected, even i deep sedation
or general anesthetic is used, to limit the overall amount o inhalation anesthetic and narcotics used.
Fat is then harvested with a special harvesting cannula attached to a 10 cc syringe using gently ap-
plied syringe suction to avoid vacuum barotrauma to the tissue. Fat harvested with these cannulas easily
passes through injection cannulas as small as 0.7 mm. I at is harvested with too much applied suction,
poor gra survival and compromised outcomes are possible.

346
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-5
On the le , shown rom the top down, are a 10 cc Luer-Lok syringe, a 1.9 mm local anesthetic inf ltration
cannula, a 2. mm ulip ri-port harvesting cannula (a similar Caraway harvester is also requently used),
and a 2. mm Coleman harvesting cannula. A closeup o the instruments’ tips is shown on the right.
In general, at least twice as much at is harvested as is anticipated will be used to ensure that an adequate
supply o processed at will be available or use on the ace. Even larger amounts are harvested i the sur-
geon wishes to use more high-density stem cell–rich at (see discussion that ollows).
Once at harvest is complete, the stab incision used to obtain the at is closed with a simple interrupted
suture o -0 nylon. T e harvest site is then washed ree o prep solution, and the sutured site is covered
with a egaDerm dressing.
PROCESSING HARVESTED FAT
Harvested at is almost never uni orm in character and concentration as extracted rom donor sites,
since each syringe will contain a variable amount o at, blood, local anesthetic, and ruptured at cells
(“oil”), and some type o processing is necessary to consistently obtain uni orm material or injection.
Although at can be separated rom the oil and water ractions using a “tea strainer” type o sieve or
rolling it on el a gauze, the majority o “growth actors” and “cellular messengers” are likely lost when
this is done. In addition, it is now known that not all at cells are the same and that the “high-density
adipocytes” are the most stem cell rich, and processing at through a sieve or by rolling it on el a gauze
does not provide a means o concentrating these.
Centri ugation, as advocated by Coleman, conversely allows separation o the oil (ruptured at cells)
and water (blood and local anesthetic) ractions rom the at cells, while simultaneously concentrating
these other potentially important components, and has been our avored method o at processing or
almost two decades. In addition, centri ugation concentrates the high-density adipocytes and allows the
surgeon to use this “supercharged” at, which is thought to be superior in quality and higher in “stem
cells” or gra ing into critical areas (such as the orbits and lips), or even the entire ace i an adequate
overharvest o at is done.
Be ore centri ugation is begun, a sterile, disposable plastic Luer-Lok cap is placed on the end o the sy-
ringe to keep harvested at inside it, and the syringe plunger is removed rom the syringe barrel. Capped
syringe barrels containing unprocessed at are then loaded into the centri uge rotor in a balanced ash-
ion and centri uged or 1 to minutes at 1000 rpm. Most small, portable centri uges available or this
purpose are inexpensive and have rotors or rotor syringe sleeves that can be sterilized so that the at-
containing syringe barrels remain sterile and can be handled by the scrubbed surgical team a er cen-
tri ugation.

347
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Fig. 23-6
A small, portable countertop centri uge typical o that used or operating room processing o at is
shown on the le . On the right is a closeup view o a centri uge rotor being loaded with unprocessed
at in 10 cc syringes. Note that the tip o the syringe barrel has been sealed with a disposable plastic cap.
T e removable and sterilizable metal sleeves shown f t into the rotor to keep syringe barrels containing
at sterile and allow them to be handled in the sterile f eld a er centri ugation. Other centri uges are
designed to allow the entire rotor to be sterilized.
Fig. 23-7
Oil
Fat
Water
Once centri uged, syringe barrels containing spun at are removed; they will be seen to contain an upper
oil, central at, and a lower water (blood and anesthetic solution) raction.

348
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-8
T e typically blood-tinged water/local anesthetic component is separated by simply removing the sy-
ringe tip cap and allowing it to run out, and the cap is then replaced. T e oil raction is then poured o
out o the top o the syringe. el a sponges can also placed inside the syringe barrel to wick up the small
amount o residual oil present a er the majority has been poured o . I at overharvest is done, this
wicking o residual oil with el a sponges need not be per ormed, and the top 1 or 2 cc o at rom each
syringe is simply discarded. A test tube type o rack to hold the syringes containing at greatly acilitates
at-processing activities. T e rack also conveniently holds 1 cc syringes, syringe components, and other
equipment used in the at gra ing procedure.
T e bottom 2 cc o at present in the syringe a er centri ugation consists o stem cell–rich high-density
adipocytes (or adipose-derived stromal cells [ADSC]) and this at can be segregated and used pre eren-
tially in the procedure and or critical areas such as the orbits, lips, and tear trough area. I adequate do-
nor at is available and overharvest is done, enough high-density at can be obtained that the entire acial
at gra ing procedure can be per ormed using it. Such a strategy is currently regarded by many surgeons
as one that holds the most potential or the best stem cell e ect. In patients with limited at stores, un-
used at can be reinjected into the buttocks or a like area, essentially to “bank” it or possible uture use.
FAT AND PLATELET-RICH PLASMA
A number o surgeons have advocated mixing harvested at with platelet-rich plasma (PRP), asserting
that this enhances gra take and improves overall outcomes. Mounting evidence suggests that this is not
true, however, and currently at gra ing is best thought o as an art project, not a science experiment.
PATIENTS WITH PREVIOUS FILLER USE
Patients who have previously received f ller injections present a specif c challenge to the surgeon per-
orming at gra ing and are arguably suboptimal candidates or the procedure. O en more f ller is pres-
ent than patients are aware o or admit to, and the presence o f ller hides the extent o the actual de or-
mity. T e presence o residual f ller will also likely compromise gra survival, make a uni orm take less
likely, and compromise the ultimate outcome o the procedure. Experience has shown that even f llers
placed several years previously can make procedures more di cult and the outcomes less predictable.
Filler patients are a moving target and are di cult to assess and treat. Patients who have undergone HA
f ller treatments are more likely to have suboptimal gra survival, uneven take, and may require mul-
tiple staged treatments. HA-based f llers can be dissolved with hyaluronidase (Vitrase, Wydase), and it
is recommended that HA f ller be removed a ew days or more be ore treatment. I f ller is removed at
the time o the procedure, the patient does not have the opportunity to see what he or she really looks