Fat Injection From Filling to Regeneration

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Part III • Clinical Applications • Face and Neck: Aesthetic
will be needed than one would use to f ll a similar de ect with a nonautologous f ller. In most cases, the
amount needed exceeds what intuition and direct observation suggest; the amount is best decided preoper-
atively, based on the degree o def ciency seen in the patient’s preoperative photographs.
As a practical matter, the degree o def ciency in each area o the ace can be rated as small, medium, or large,
and there is an empirical range o volume needed or the typical treatment o each area that is then chosen
and applied. T ese empirical ranges have been previously published by Coleman (see Chapter ), Marten,
Marten and Elyassnia, and other surgeons1-3,9; the current range recommendations appear throughout this
chapter in the sections that address specif c areas o the ace. For small, medium, and large problems, the
volumes chosen will be on the low, midrange, or high end o the empirical volume range, respectively. For
men and or women with larger aces, the recommended amounts should be increased by 2 % to %.
How Is the Fat Injected?
As the cannula is advanced in the tissue, the surgeon should eel or resistance, and i resistance is elt, a
small injection is made. Approximately . cc or less should be injected per pass. T is corresponds to
2 to 4 back-and- orth passes or more or each cc syringe o processed at. I tissue resistance is not
elt as the injection cannula is advanced, this indicates that a pass and injection has likely already been
made in that area, and no injection is placed there; the cannula is directed to another area. T e goal is to
inject the at in a way that optimizes its chance o developing a blood supply and surviving. T e surgeon’s
mental model should be one o scattering tiny particles o at into the recipient site in the target plane
in multiple crisscrossing f ne trails so that each particle sits in its own compartment and has maximal
sur ace contact with per used recipient site tissue. I at is injected in a bolus, at cells will be clumped
together, and only those on the periphery o the injected area will have tissue contact and will be likely
to survive. Most o the more centrally situated at particles will only have contact with each other, will be
less likely to survive, and can lead to the ormation o oil cysts. Put in more practical terms, the proce-
dure should be thought o as analogous to “spray painting,” not “caulking.”
Advancement and withdrawal o the injection cannula will typically be made slowly by beginning in-
jectors, but as amiliarity with the technique is acquired, the movements can and should be made aster.
Ultimately, all other things being equal, aster movements are desirable in that i the injection cannula
is constantly in motion, intravascular injection is less likely, and the likelihood is reduced that an ac-
cidental bolus injection into one area will be made. Rapid back-and- orth movements also ensure the
smoothest and most uni orm “spray painting” and inf ltration o at at the same time.
Fig. 23-10
How the syringe is held is also important to avoid overinjection and to control the volume expressed
rom the cannula with each pass. I the syringe is held in the manner one would traditionally use to give
an injection with the thumb on the end o the syringe plunger, it is easy to inject too much at i tissue
resistance changes or injection cannula resistance suddenly decreases. More control can be generally be
maintained, and overinjection more easily avoided, i the syringe is held with the end o the plunger in the
palm o the hand. Although a bit o practice is required at f rst, when the syringe is held in this manner, a
slight closing o the hand results in only a small amount o at being expressed rom it, and overinjection
o any one area can more readily be avoided.

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Although cannula obstruction is uncommon i at is harvested and processed as described, i a cannula
becomes blocked, additional injection pressure should not be applied, because this is the most common
cause o a sudden and unintentional overinjection. It is better in such circumstances to simply withdraw
the blocked cannula, pass it to the surgical assistant, and continue with a di erent one. T e assistant
can then clear the obstruction while the surgeon continues to work. ypically, the cause o the obstruc-
tion will be a particle o at or subcutaneous debris at the inter ace o the cannula and the inside o the
cannula hub, which is most easily cleared by removing the cannula rom the syringe and extracting the
syringe and extracting the particle o at or ragment tissue debris rom inside the back o the hub with
a f ne orceps.
How Deep Should the Fat Be Injected? In What Layers Should Fat Be Placed?
Injections will necessarily be made in di erent planes, depending on the areas being treated. In many
areas where multiple tissue layers are present and the overlying skin is thick, injection can be made
comprehensively at the treated site rom the periosteum to the subdermal layer. T ese areas typically
include the GMG, piri orm aperture, mid ace, cheek, and the chin. In other areas, injections must be
placed more specif cally because o the anatomic characteristics o the treated sites and to avoid creating
irregularities. T ese areas include the temples, upper orbit, lower orbit, tear trough, lips, jawline, and the
dorsum o the hands. T e easiest areas or the beginning injector to treat are the areas in the ormer cat-
egory. Initially it is wise to stay deep and place most o the gra in a predominantly preperiosteal plane.
Once the surgeon gains amiliarity with the technique, areas in the latter category can then cautiously be
treated; however, these will require very care ul and skilled placement o at.
Geniomandibular (Prejowl) Groove
Injection o the prejowl/GMG area with at has a high aesthetic payo and is a good area or the be-
ginning injector to gain experience with the technique. Although not immediately intuitively obvious,
f lling the GMG creates a strong, uninterrupted aesthetic line rom chin to the posterior mandible and
is a highly desirable improvement on both the male and emale ace. T e e ect is similar to that when a
Mittleman prejowl implant is placed, but at gra ing provides the advantages o an autologous procedure
and is arguably simpler to per orm.
Fig. 23-11
T is patient is shown be ore and a er a aceli and at gra ing; she presented with deep geniomandibu-
lar grooves. Preoperatively, her chin appears narrow and pointed, and there is poor continuity between
the chin and jawline. Fat gra ing was per ormed to f ll the GMG (prejowl sulcus) area. A chin implant
was not placed. Postoperatively, her chin appears broader and more aesthetically integrated with the
jawline. Fat was also used to strengthen the posterior jawline and lower the mandibular angle and to f ll
the lips, nasolabial old, cheeks, and in raorbital areas.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-12
Incision sites and the plan or injecting at into the prejowl/GMG areas are shown. Fat gra ing o this
area is per ormed with a 4 cm long, 0.7 mm diameter ( -gauge) cannula, and at is placed in all tissue
layers between the periosteum and skin. ypically, 1 to cc o at is placed on each side. Fat gra ing o
the geniomandibular area has a low level o di culty.
Cheek
Fat gra ing the cheek can enhance a patient’s acial shape and proportion and produce improvements
similar to those obtained when erino malar, Binder submalar, and combined malar–submalar shell
style cheek implants are placed. In some cases, it can be argued that at injections to the cheek produce
a so er, better integrated, and more natural, eminine-appearing improvement in malar contour than
implant placement (see the Case Examples section later in this chapter).
As the cheek atrophies, the lower eyelid at bags become more exposed and prominent (pseudohernia-
tion). Removing lower eyelid at in such circumstances creates a hollow and elderly appearance and a
low lid–cheek junction. A better strategy or many patients is to reconstitute the cheek with at gra s and
cover up the pseudoherniated at and to raise the lid-cheek junction and create a smooth transition rom
the lower eyelid to the cheek.
Fig. 23-13
T is patient with an atrophic cheek and pseudoherniation o her lower eyelid at is shown be ore and
1 year and 9 months a er at gra ing. Preoperatively it can be seen that lower lid at is exposed and
appears ostensibly as a bag. Postoperatively, a er at gra ing to the cheeks but no blepharoplasty, the
patient’s lost cheek volume has been restored and protruding lower eyelid at blended and integrated
with it. T is approach produced a more youth ul, f t, and attractive appearance than removing lower lid
at would have. (NO E: T e upper orbit has been replenished with at gra s as well.)

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Fig. 23-14
Fat gra ing o the cheeks is typically per ormed with a cm long, 0.7 mm diameter ( -gauge) cannula.
Fat is placed in all tissue layers between the periosteum and skin in most cases. ypically, to 7 cc o at
is placed on each side in the cheek area, depending on the degree o atrophy present, but occasionally
the need or more will be indicated. O en an asymmetrical placement o at will be required on the right
and le sides, because malar asymmetry is commonly seen in many patients. A template or the place-
ment o at in the cheek is or the surgeon to imagine f lling the area in which one would place a cheek
implant. T e cheek is a good area or the beginning injector to treat.
Chin
Fat gra ing to the chin can correct age-associated loss o chin volume, projection, and vertical height,
and in some cases can rival the kind o improvements obtained when small chin implants are placed.
Fig. 23-15
T is patient with an underprojected chin is shown be ore and 9 months a er a secondary aceli and
at gra ing. T e patient had signif cant microgenia and she had previously had a chin implant placed

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Part III • Clinical Applications • Face and Neck: Aesthetic
and removed by an unknown surgeon. A chin implant was not placed. It can be seen that injection o
the chin with at has enhanced the patient’s prof le, approaching the kind o improvement that would
have been obtained i a small chin implant had been placed. (NO E: Fat was also placed in her upper and
lower orbits, cheeks, lips, and jawline areas.)
Fat gra ing o the chin can also correct the atrophic and eeble appearance that occurs as the chin shrinks
with age by broadening and strengthening it, and f lling in the labiomental and submental creases when
indicated. ypically, treatment o the chin must be undertaken in conjunction with at gra ing to the
GMG, and the two areas will overlap in most cases.
Fig. 23-16
T is patient with an atrophic, elderly-looking chin is shown be ore and 9 months a er a secondary
aceli and at injections to the chin, GMG, and jawline areas. A chin implant was not placed. T e
age-related atrophic and eeble appearance was corrected by at gra ing to broaden and strengthen the
chin. reatment o the chin along with the GMG and jawline areas strengthened her entire lower acial
contour.
Fig. 23-17
Fat gra ing o the chin is typically per ormed with a cm long, 0.7 mm diameter (22-gauge) cannula
rom injection sites on the perioral skin used to inject the GMG, or stab incisions slightly lateral to the
area being treated. Occasionally, a third incision is used near the midline o the lower lip. Fat is placed
in all tissue layers between the periosteum and skin. ypically, 1 to cc o at is placed on each side o

355
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
the chin, depending on its size and shape and degree o atrophy, but occasionally, more will be indicated.
Another guideline or the placement o at in the chin area is or the surgeon to imagine f lling the area
in which one would place a “extended anatomic” chin implant. Fat gra ing the chin is intermediate in
di culty.
Despite suggestions to the contrary by some authors, at injections to the chin are best used or small
augmentations only and cannot substitute or chin implants in many cases. I large changes in chin pro-
jection are attempted using at injections, a globular and less sculptural appearance is usually obtained,
and patients in need o larger increases in chin projection are arguably better treated with a chin implant
with or without more superf cially placed at to so en the implant appearance.
Nasolabial Fold
One o the f rst areas most patients inquire about when considering at injections, and most surgeons
are eager to treat, is the nasolabial old. Nonetheless, one must be aware o certain misconceptions and
several limitations o the at injection technique or treatment o this area. T e f rst is that treatment o
the nasolabial olds with at is generally not as e ective as treatment with nonautologous f llers. Fat is
so er and is typically placed more deeply than nonautologous f llers. Fat is better used to treat a volume
def ciency in a region o the ace as opposed to a more discrete line, wrinkle, or old that is subject to
the repeated stress o acial muscle contraction and acial movement. Patients undergoing at injections
solely or treatment o their nasolabial olds will generally be disappointed with the outcome, as will the
surgeon. However, this is not the case when a simultaneous aceli is per ormed and cheek and mid ace
tissues are repositioned and redundant cheek skin is excised. Fat is an excellent adjunct in the treatment
o the nasolabial olds in such instances. Although it is not immediately intuitively obvious, it has be-
come increasingly more widely appreciated by those injecting nonautologous f llers into the ace that f ll-
ing the upper cheek produces a pro oundly benef cial e ect on the appearance o the nasolabial old and
that treatment o the old is more e ective when f lling o both these areas is combined. I the cheek is
f lled, less at will be needed to improve the nasolabial old, and an overall better result will be obtained.
Fig. 23-18
T is patient with prominent nasolabial olds is shown be ore and years and months a er a high-
SMAS aceli and at injections to the nasolabial olds and the combined e ect o li ing and f lling o the
nasolabial old area can be seen. Combined li ing and f lling provides a better improvement than either
procedure per ormed alone.
It is now generally accepted that the nasolabial old is also caused, at least in part, by age-related loss o
maxillary projection. T e goal in injecting at in the nasolabial areas should be thought o in many cases
as more o an augmentation and restoration o maxillary/mid ace projection than as simple f lling o the
so tissue crease. T us the surgeon’s e ort and how and where at is injected will depend on the problem
present. Injections should be made more superf cially and predominantly subcutaneously i one is treat-
ing the nasolabial old. Injections should be placed more deeply, and predominantly over the piri orm
aperture in the upper nasolabial area i one is treating age-associated maxillary recession. Many patients
are best served by a combined treatment utilizing both approaches.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-19
Fat gra ing o the piri orm aperture and nasolabial old is typically per ormed with a 4 cm long, 0.7 mm
diameter (22-gauge) cannula. Fat is placed subcutaneously and superf cially or treatment o the nasolabial
skin crease, and smaller volumes are generally used. Fat is placed preperiosteally and deeper i improve-
ment in age-associated maxillary recession is indicated and desired, and larger volumes are o en indicated.
Fat is placed in all tissue layers between the periosteum and skin i both problems are being treated. ypi-
cally, 1 to cc o at is placed on each side. Fat gra ing the nasolabial area is intermediate in di culty.
Overf lling the nasolabial area is a common eventual outcome o the rustration one will eel i the na-
solabial old is treated with at in isolation and in the same way one would inject nonautologous f llers.
Higher and higher volumes will be tried in a utile e ort to e ace the crease, but an improved outcome
will not be obtained when these larger amounts o at are injected. Instead, an abnormally heavy and
objectionable appearing unaesthetic ullness o the mid ace is the usual result. In addition, overf lling the
nasolabial area can produce changes in the posture o the patient’s mouth and the shape o the smile, and
result in a change in his or her overall appearance. For these reasons, it is important to advise patients
accordingly, or the surgeon to set reasonable goals, and to limit the at placed in the nasolabial area to
a reasonable amount.
Lips
reating the lips with at has distinct advantages and disadvantages that will both attract and repel sur-
geons and patients alike. T e advantages include that at is autologous and arguably what was present
at a younger age, and i the procedure is success ul and gra take is good, patients will be spared the
inconvenience and discom ort o having to undergo repeated pain ul and expensive treatments. Fat also
produces a so , natural-appearing improvement, and usually a slight undercorrection that we f nd to be
most appropriate and even desirable or the typical aceli patient in need o some improvement in her
or his mouth. In act, in our experience, overcorrection o the lips with at injections is nearly impossible
in one session, and unless patients undergo multiple treatments.

357
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Fig. 23-20
T is patient with loss o lip volume is shown be ore and 1 year and 1 month a er at injections to the
upper and lower lips. Postoperatively, it can be seen that her lips are uller, but so and natural appear-
ing. Nonautologous f llers, in contrast, invite overcorrection and tend to produce a more stylized lip
appearance.
Fat injections to the lips have the distinct disadvantage that they usually produce a “monstrous” amount
o swelling that is slow to resolve. In addition, the take o the gra varies rom patient to patient, and
there ore so does the eventual outcome. Patients seeking a quick recovery, a specif c lip size or shape, or
nuanced changes are not optimal candidates or the procedure. In particular, patients must be warned
that it is generally not possible to create the highly stylized “bee-stung” or “cover girl” lip appearance
seen in ashion magazines with at gra ing. Such appearances can only be obtained using nonautologous
f llers, and patients seeking such a look or their lips should be advised accordingly.
Patients seeking nuanced changes in lip appearance are also not good candidates or at injections. T ese
include patients seeking corrections o small asymmetries, patients seeking accentuation o part o the
vermilion-cutaneous junction, or those who request that specif c parts o their lip be “li ed,” “rolled out”
and the like. Although at can be placed to achieve these appearances to some degree, the result is rarely
predictable or dramatic enough to satis y most patients requesting these sorts o improvements, and
such patients are currently likely best treated with nonautologous f llers.
When the lips are to be treated, the prep o the ace should include the upper and lower gingivobuccal
sulci, the buccal sur ace o the anterior teeth, and the tongue i it rests in the surgical f eld anterior to
the incisors. ypically, the lips are treated a er all other areas have been at gra ed but be ore the aceli
is begun since it will require the surgeon to insert her or his f ngers inside the mouth. A er injection is
complete, the surgeon can remove and replace her or his outer gloves and the anterior ace and mouth
can then be reprepped.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-21
Fat gra ing o the lips is per ormed with a cm long, 0.7 mm diameter (22-gauge) cannula and at is
placed submucosally beneath the vermilion and subdermally in the white roll areas. A slightly larger can-
nula may be easier or the beginning injector, since it is harder to accidentally per orate the mucosa or
vermilion with the larger instrument, and injection is made rom access incisions at each stomal angle,
as shown. ypically, a total o 1 to 1. cc is placed in each side o the upper lip and 1. to 2 cc is placed in
each side o the lower lip. Fat gra ing the lips is intermediate in di culty.
ypically, the f rst ew passes o the cannula are used to place at subcutaneously/submucosally directly
under the vermilion-cutaneous junction, then under the red roll, and then under the white roll. Fat is
then inf ltrated submucosally beneath the wet and dry lip vermilion. I more lip protrusion is desired,
more at is placed submucosally beneath the dry vermilion. I more vertical lip show is desired, more at
can be placed submucosally along the wet-dry junction o the vermilion on the inner aspect o the lip.
A total o 1 to 1. cc (upper) to 1. to 2 cc (lower) is usually placed in each side o each lip, or a total o
2 to cc or the upper lip and to 4 cc or the lower lip. Smaller amounts generally produce suboptimal
outcomes a er initial swelling has abated. Larger amounts, in contrast, increase swelling but generally do
not result in better take or an improved outcome.
A common error to be avoided when injecting at (or nonautologous f ller) into the lips is to indiscrim-
inately f ll the lips in such a manner that a large but shapeless and unnatural appearing “sausage lip”
is produced. o some extent, the at injection technique is not prone to this, since lips treated with at
naturally tend to assume the shape o the patient’s given lip envelope once swelling abates and healing
is complete. An attractive lip is generally one that is not just big, but that has an aesthetically pleasing
shape; at can and should be injected in a way that creates these appearances to the extent possible. An
attractive lower lip typically has two tubercles; that is, two areas o ullness laterally, with a small central
depression between them. T e attractive upper lip on the other hand has three aesthetic tubercles, one
centrally and one on each side laterally, with slight depressions between them. ime taken to inject at
to create this kind o natural and aesthetic appearance is well spent. In addition, depressions between lip
tubercles can be enhanced on completion o injections by placing a f nger and thumb on the inside and
outside o the lip and gently bidigitally compressing areas between tubercles to optimize at position and
lip shape.

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
T e second common mistake that is made when injecting the lips with either at or nonautologous f llers
is to make the upper and lower lips the same size. T is is an unnatural situation that produces a “clown
mouth” or “punched in the mouth” appearance. In an aesthetic, natural-appearing, youth ul mouth, the
lower lip is distinctly larger and uller than the upper lip, and this should be the goal when augmenting
the lips with at.
Perioral Area
Yet another important use o perioral at injections is in the patient with perioral wrinkles and “pucker
lines.” raditional resur acing by peel, laser, or dermabrasion typically provides an incomplete solu-
tion or these patients in that these procedures only address the skin itsel , and do nothing to replenish
the age-associated loss o perioral subcutaneous at commonly seen in both women and men as their
hormone levels begin to all in the mid to late thirties in many patients. Patients have smoother-
appearing skin in repose a er resur acing treatments, but when speaking or moving their mouth, deep
and objectionable lines appear and perioral de ation and subcutaneous atrophy becomes plainly evident.
ypically, these appearances spoil an otherwise excellent aceli result and stand as telltale evidence that
the patient is really older than she or he otherwise appears. Fat gra ing provides a means by which such
an appearance can be avoided, and at normally situated between skin and the orbicularis oris can be
replaced. A second likely but as yet not ully scientif cally substantiated benef t o perioral at injections
rests in the stem cell e ect the procedure probably provides. Experience with combined dermabrasion or
laser resur acing and perioral at gra ing suggests that healing and the overall outcome are better when
resur acing procedures are combined with at injections, above and beyond the improvement gained by
skin resur acing alone.
Fig. 23-22
T is patient is shown be ore and years and 7 months a er a high-SMAS aceli that included com-
bined perioral at gra ing and perioral dermabrasion. Postoperatively, both atrophy and wrinkling have
been improved, and the mouth has a more youth ul, vibrant, healthy, and “kissable” appearance. T e
combined treatment produced a better appearance than either procedure would have i per ormed alone.

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Part III • Clinical Applications • Face and Neck: Aesthetic
When injecting the perioral area, care must be taken to not simply overf ll the white upper lip in the
name o wrinkle reduction as the patient’s upper lip can be lengthened, dental show can be reduced, and
an abnormal convex “simian” contour in prof le can result. A better strategy is to concentrate one’s e -
orts on and near the white roll area, where the wrinkles are typically the deepest and most objectionable
appearing, and place the most at in this area. Less at is then placed more superiorly. Results are urther
enhanced by injecting additional at at the columellar-labial angle, because injecting in this area aids in
restoring a youth ul transition rom the nose to the lip and helps create a concave upper lip shape. Injec-
tion in the perioral area is made with a .7 mm diameter (22-gauge) 4 or 5 cm long injection cannula in
a subcutaneous/premuscular plane. Placing the at deeper and intramuscularly is not help ul or creating
the type o improvement one usually seeks in this area. Fat gra ing the perioral area is intermediate to
advanced in di culty.
Jawline
Fat gra ing o the jawline border area can enhance a patient’s acial shape and produce the kind o im-
provements obtained when mandibular border and aylor-style mandibular angle implants are placed.
Fig. 23-23
T is patient is shown be ore and 1 year and 1 month a er high-SMAS aceli and at gra ing o the
posterior jawline. No implants were placed. Postoperatively, it is evident that strengthening the jawline
and posterior mandibular border has resulted in a more f t and proportionate appearance and has helped
to avert the tight and def cient mandibular contour typically seen in an elderly ace a er a aceli is per-
ormed. Fat was also injected in the chin, GMGs, buccal recess, and lips.

361
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Fat injections along the mandible can also correct an atrophic and eeble appearance that occurs as the
mandibular border shrinks with age by broadening and strengthening it. ypically, treatment o the
jawline must be undertaken in conjunction with the GMG, and the two areas will overlap in most cases.
Fig. 23-24
Fat gra ing o the jawline is typically per ormed with an 8 cm long, . mm diameter ( 8-gauge) injec-
tion cannula rom the same or similar anteriorly situated injection sites on the perioral area and man-
dibular border used to treat the GMG, and at is placed deep in a preperiosteal/submasseteric muscle
position on the sur ace o the bone.
ypically, to cc o at is placed on each side, depending on the def ciency that is present, but occasion-
ally 7 to 0 cc or more on each side will be indicated. Not uncommonly, asymmetrical volumes will need
to be placed because o jawline asymmetry. It should be noted that at is not injected subcutaneously,
into the parotid, or into the masseter muscle. Fat gra ing the jawline is intermediate in di culty.
Although not intuitively obvious, strengthening the jawline and posterior mandibular border makes one
appear more youth ul, f t, and attractive, and is an artistically power ul adjunct to a aceli that helps
avert the scrawny, def cient, “mousey” and ragile mandibular contour typically seen in the aging and
elderly ace that is usually made worse when a aceli is per ormed (see Figs. -4 through -44).
Fat gra ing the jawline is particularly use ul in a secondary aceli patient, and in a patient with a long
ace seeking acial rejuvenation or improvement. ypically, a secondary aceli patient has experienced
signif cant loss o jawline volume rom loss o or inappropriate surgical removal o acial at, and this is
typically compounded by overzealous tightening o overlying tissues. T ese e ects are readily reversed
with jawline at gra ing. Fat gra ing o this area constitutes an important part o our treatment plans or
our secondary and tertiary aceli patients. A patient with a long ace typically will benef t in a similar
way, because aceli procedures tend to narrow the lower ace and accentuate the acial length. Fat gra -
ing allows the ace to be broadened, and overall proportions are improved.

362
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-25
T is woman is shown be ore and 1 year and 1 month a er at gra ing to broaden the ace and correct
the long ace disproportion. A previous aceli per ormed by an unknown surgeon has tightened the
mandibular line and accentuated acial length. Postoperatively, the patient is seen a er at gra ing to the
jawline, chin, cheeks, mid ace, buccal recess, and lip areas. No implants have been placed. T e long acial
appearance has been improved and a more balanced and proportionate look has been obtained.
Temple Area
emporal hollowing is a consistent marker o the ourth decade o li e that is readily improved with at
gra ing.
Fig. 23-26
T e patient above is shown be ore and years and 4 months a er a er a high-SMAS aceli and at
gra ing to the temple region. Postoperatively, a signif cant improvement in the aged appearance result-
ing rom temporal hollowing has been obtained.

363
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Fig. 23-27
Injection o the temples is per ormed with a cm long, 0.9 mm diameter ( 0-gauge) cannula, and at is
placed in a subcutaneous plane rom small stab incisions that are just within the temporal hairline. ypi-
cally, 5 to 7 cc o at is placed on each side in the temple areas, but occasionally more will be indicated. In
most cases the slightly bigger and more blunt 0.9 mm diameter ( 0-gauge, cm long) injection cannula
is superior to sharper and smaller types used elsewhere. Using slightly larger, blunter cannulas helps
avoid per oration o temporal veins predictably present in the temporal area and allows at to be placed
over and around them to conceal them.
T e injection cannula is not inserted specif cally above or below the temporal veins but is allowed to pass
into the plane o least resistance in the subcutaneous plane. Experience has shown this to be an excellent
plane to inject in, and a strategy least likely to injure temporal veins. Should a temporal vein be acci-
dentally penetrated during injection despite these precautions and swelling rom the leakage o venous
blood noted, it is a simple matter to hold pressure on the temporal area or a ew moments with a surgi-
cal sponge. ypically, a er applying uni orm and continuous pressure or a ew minutes bleeding stops
and treatment o the area can be completed. Fat gra ing the temple areas is intermediate in di culty.
Buccal Recess Area
Buccal atrophy is commonly seen in the ourth decade o li e and beyond and can be readily improved
with at gra ing, as can buccal hollowing resulting rom previous overzealous excision o buccal at, or
HIV associated acial wasting. Buccal at excision is o en erroneously recommended as a way o creating
a “high-cheekbone,” more angular acial appearance. In reality, it o en produces an ill, haggard, gaunt,
and un eminine appearance, especially when per ormed aggressively.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-28
T is patient is shown be ore and 10 months a er at injections to the buccal area. T e patient presented
with buccal hollowing ollowing buccal at excision by an unknown surgeon and the resulting ill, hag-
gard, gaunt, and un eminine appearance overexcision can produce. Postoperatively, a more healthy, f t
and eminine appearance is evident. (NO E: Fat was also placed in the in raorbital, mid ace, cheek, pre-
oral, and jawline areas).
Fig. 23-29
Fat gra ing o the buccal hollow is typically per ormed with a 5 cm long, 0.7 mm diameter (22-gauge)
cannula rom injection sites situated on the mid ace and medial lower cheek and at is placed subcuta-
neously and in sub-SMAS (buccal space) locations in most cases. ypically, 2 to 5 cc o at is placed on
each side in the buccal recess area, depending on the degree o the problem present, but occasionally
more will be indicated. O en an asymmetrical placement o at will also be required on the right and le
sides because o the common occurrence o buccal asymmetry seen preoperatively in many patients. Fat
gra ing the buccal recess area is intermediate in di culty.

365
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Upper Orbit/Upper Eyelid Area
Whether the result o illness, aging, or an overzealous previous surgical procedure, f lling the hollow up-
per orbit can produce a remarkable rejuvenation o the upper eyelid and eliminate an unnaturally hollow
and elderly appearance sometimes re erred to by patients as “nursing home” or “owl” eyes.
Fig. 23-30
T is woman had an unnaturally hollow, elderly, “owl eye” upper eyelid appearance ollowing traditional
blepharoplasty per ormed by an unknown surgeon. o correct this, cc o at was placed in the upper
orbital area, resulting in a healthier, more youth ul appearance. (NO E: Fat gra ing was also done in the
lower orbital area.)
Where at should be placed in the upper orbit (upper eyelid) is a subject o debate: subcutaneous, subor-
bicularis oculi, and even subseptal (intraorbital) locations have been recommended by various surgeons.
For all but the very experienced injector, however, it is sa est to avoid the subseptal area because o the
small but potential risk o intraorbital and retrobulbar bleeding and other problems. It is also wise to
avoid a purely subcutaneous injection in this area because o the extremely thin skin present; injections
should be limited to a preperiosteal/suborbicularis oculi plane.
A common misconception in treating the hollow upper orbit is that the at is needed and should be graf ed
in the preseptal portion o the eyelid itsel . Not only would this be di cult and dangerous, it is unnecessary.
T e hollow upper eyelid is properly and more practically restored by placing at in a preorbital position
along the in erior margin o the supraorbital rim, and the process is best conceptualized as one o low-
ering the supraorbital rim and f lling the upper orbital area to push skin that has retracted up into the
orbit down onto the preseptal eyelid to create a ull and creased upper eyelid. Once one accepts that
improvement is obtained by gra ing o the orbit, and not the eyelid itsel , it becomes apparent that larger
volumes than might otherwise be expected are required.
When gra ing the upper orbit, it should be remembered that one is working in very close proximity to
the eye, and although the injection cannulas are blunt tipped, they are small and easily capable o per o-
rating the ocular globe. Considering this, two important technical considerations should be observed.
First, injection sites should be placed in such a way that the injection cannula will be passed parallel
to the globe (unlike the lower eyelid area—see section that ollows) and the supraorbital rim, and not
perpendicular to it. Directing the cannula toward the globe when injecting the upper orbit is potentially
dangerous and should be avoided.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-31
T e second important technical consideration that should be observed when injecting the upper orbit is
that the surgeon should always have her or his index f ngertip o the nondominant (noninjecting) hand
held f rmly on the in erior margin o the supraorbital rim and between the tip o the cannula and the
ocular globe as the cannula is passed into tissues and at is injected. T is f ngertip should always be kept
between the tip o the cannula and the globe.
Fig. 23-32
T e idea is to position the f ngertip so that the cannula would hit against it instead o penetrating the
globe i inadvertently misdirected. Having one’s f ngertip in this position also gives important eedback
to the injector as to where the tip o the cannula is, and helps one place at as accurately as possible.
Fat gra ing o the upper orbital area is per ormed with a 4 cm long, 0.7 mm diameter (22-gauge) can-
nula and at is placed in a suborbicularis oculi/preperiosteal plane. ypically, 2 to cc o at is placed
in each upper orbit to achieve the improvement typically sought. T e smaller injection cannulas now
available have made injecting the upper orbit easier and more predictable, because they can be advanced
more smoothly and accurately through tissues, allowing the deposition o minute aliquots o at per pass.
Fat gra ing the upper orbit and eyelid is advanced in di culty, and treatment o this area should only be
undertaken a er the injector has gained experience treating more orgiving areas. Once that experience
is obtained, at gra ing the upper orbit can be one o the most artistically rewarding uses o autologous
at, and one that is likely to become a routine part o rejuvenating the upper eyelid in the uture.

367
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Lower Orbit/Lower Eyelid Area
Injecting the in raorbital (lower eyelid) area is in some ways analogous to injecting the upper orbit in
that there are similar misconceptions as to where the at should be placed, similar technical consider-
ations as to which tissue layers at should be injected into, and similar concerns regarding injury to the
ocular globe. In addition, and like injecting the upper orbit, the artistic payo is high i the procedure is
carried out correctly.
Fig. 23-33
T is patient is shown be ore and 1 year and 8 months a er a aceli and at injections to the in raorbital
area. Preoperatively, she had a hollow lower orbit and an unnaturally hollow and elderly in raorbital
appearance. T e lower eyelid appears long, and there is a distinct line o demarcation between the lower
eyelid and the cheek. Postoperatively, there is a smooth transition rom the lower eyelid to the cheek
and the patient has a more healthy, youth ul and attractive appearance. (NO E: T e upper orbit, radix,
cheek, and nasolabial old were also treated with at injections, and the patient has undergone ptosis
correction.)
Fat gra ing the in raorbital area allows correction o age-associated hollowness that lends the ace an
ill or haggard appearance, shortens the apparent length o the lower eyelid, and produces a youth ul,
attractive, and highly desirable smooth transition rom the lower eyelid to the cheek, which is generally
unobtainable by traditional lower eyelid surgery, at transpositions, “septal resets,” mid ace li s, ree at
gra s, and other like means.
As is the case in treating the upper orbit, at need not and should not be injected in the pretarsal lower
eyelid. Fat should be injected deep in a submuscular/preperiosteal plane, and the technical goal o the
procedure should be thought o as raising up and anteriorly projecting the in raorbital rim, rather than
f lling the lid itsel . And like the upper orbit, volumes required to obtain corrections in the lower orbit
are typically more than one might initially expect, and to cc, and occasionally more, are usually
necessary to produce the desired e ect. Unlike the upper orbit, however, experience has shown that at
is best and most easily injected perpendicular to the in raorbital rim, and while we cannot speak rom
personal experience, it is our observation that surgeons injecting at parallel to the in raorbital rim have
more problems with irregularities, lumps and bumps, and untoward results. Fat should not be injected
parallel to the lid-cheek junction in the infraorbital area.

368
Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 23-34
Fat gra ing o the in raorbital area is per ormed with a 4 cm long, 0.7 mm (22-gauge) cannula and at
is placed deep in a suborbicularis oculi/preperiosteal plane. Until considerable experienced is obtained
more superf cial injections should be avoided. ypically, 2 to cc o at is placed on each side.
Fig. 23-35
As is the case in injecting the upper orbit, when injecting the lower orbital (lower eyelid) area the surgeon
should always have her or his index f ngertip o the nondominant (noninjecting) hand held f rmly on the
in erior margin o the in raorbital rim as the cannula is passed into tissues and while injections are made.
As the injection cannula is advanced perpendicular to the orbit and towards the f ngertip through in ra-
orbital tissues the orbitomalar ligament can be elt along the in raorbital rim and the cannula tip allowed
to penetrate it slightly. T is is an important landmark that helps guide the injector as to exactly where
most o the at needs to be placed i an optimal result is to be obtained. ypically, a er the placement o
cc o at in this manner, minimal or no resistance will be elt along the course o the ligament, and it

369
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
is assumed that the multiple passes used to place the gra have lysed and e ectively released it, urther
improving the overall outcome. Another guideline or the placement o at in the in raorbital area is or
the surgeon to imagine f lling the area in which one might place an in raorbital implant, as the goal o
treatment is essentially the same.
It is wise to avoid any subcutaneous injection in the in raorbital area until considerable experience has
been obtained because o the extremely thin skin present in this area, and to limit initial injections to a
preperiosteal/suborbicularis oculi planes, as recommended earlier.
Fat gra ing the lower orbit and eyelid is advanced in di culty and treatment o this area should be re-
served or those with experience in treating more orgiving areas. Once that experience is obtained, at
gra ing the lower orbit is another artistically rewarding use o autologous at, and one that is likely to
become a routine part o rejuvenating the lower eyelid in the uture.
Tear Trough
Where the in raorbital area ends and the tear trough and cheek areas begin is hard to def ne. In reality,
the in raorbital, cheek, and tear trough areas must be corrected concurrently, and the treated areas will
overlap to a certain extent. It must always be remembered that the ultimate goal o the procedure is cre-
ation o a youth ul, attractive contour, not simply f lling o a specif c area.
Fig. 23-36
Fat gra ing o the nasojugal (tear trough) area is per ormed with a 4 cm long, 0.7 mm diameter
( -gauge) injection cannula using incisions situated in erior to the medial orbit, placing at perpendic-
ularly, as in the cheek and intraorbital areas. Fat is injected deep in a preperiosteal/suborbicularis oculi
plane—especially superiorly and medially, where the skin is thinnest. Until the injector gains experience
in this area, more superf cial injections should be avoided. Typically, 0.5 to 1.5 cc o at is placed on each
side, depending on how ar in eriorly and laterally the tear trough extends onto the cheek.

370
Part III • Clinical Applications • Face and Neck: Aesthetic
With care, at can be sa ely placed more superf cially, especially in the lower, more lateral part o the tear
trough, which is requently seen to run down into and onto the cheek. When this is done, improved
outcomes are obtained. Although at gra ing o the tear trough ostensibly seems simple to per orm, in
reality this procedure is advanced in di culty.
Fig. 23-37
T is woman is shown be ore and 1 year and months a er at gra ing o the tear trough and in raorbital
areas. She presented with a hollow nasojugal groove (tear trough), which lent an unnaturally hollow,
elderly in raorbital appearance. Postoperatively, the patient is shown a er 1 cc o at was placed in the
tear trough area, in addition to the 2 cc in the in raorbital area. (NO E: Fat gra ing was also per ormed
on the radix, upper orbit, and cheek areas).
Final Touches
Fat gra ing is continued until the desired volume o at has been added to each target area. ypically,
a one to three old overcorrection must be made compared to volumes that would be used or nonau-
tologous f llers. T us the process is time consuming and technically and artistically demanding, and its
di culty should not be underestimated. T at said, it is likely that it will also become an enjoyable one or
the surgeon that will yield great benef ts to patients.
A er at has been inf ltrated, the treated areas are palpated lightly to ensure that the at has been distrib-
uted smoothly in the target tissue, and any lumps or irregularities are gently pressed out. T e lips, somal
angle, and nasolabial areas can be bidigitally palpated and molded by inserting a gloved f nger inside the
mouth, and i the orbits have been treated, the ocular globe should be gently depressed and any irregu-
larities assessed in the in raorbital area.

371
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
Documenting What Was Done
Fig. 23-38
FAT INJECTION DATA SHEET
Patient weight (lbs/kg) ________________
FAT INJECTION SITE:

RIGHT
LEFT

Forehead
____________
___________

Temples
____________
__________

Glabella
_____________

Radix
_____________

Brow/supraorbital
____________
__________

Infraorbital
____________
__________

Tear trough
____________
__________

Midface
____________
__________

Cheek
____________
__________

Preauricular
____________
__________

Buccal recess
____________
__________

Nasolabial crease
____________
__________

Piriform aperture
____________
__________

Columellar-labial angle
_____________

Upper lip
____________
__________

Lower lip
____________
__________

Stomal angle
____________
__________

GMG/perimental
____________
__________

Chin
____________
__________

Jawline
____________
__________

Labiomental (chin) crease
_____________

Submental crease
_____________

Miscellaneous intradermal
_____________

Other (list)
____________
__________


____________
__________


____________
__________


____________
__________
Total Fat Injected - Face __________________
FAT HARVEST SITE (check all that apply)
FAT HARVEST DATA

Outer thighs
Total fat harvested (cc)
____________

Hips

Inner thighs
Total fat after centrifuging (cc)
____________

Knees

Abdomen
Centrifuge time
3 minutes

Anterior thighs

____ minutes

Waist/flank

Other (list)
Centrifuge speed
____ RPM
_____________________________________ ___________________

Nurse signature
Date
A member o the operating room team should keep a detailed record o the areas treated and the
amounts o at injected in each site; a at injection treatment record is use ul or this purpose. Using a
at injection data sheet simplif es the documentation o what was done and provides a clear and easily

372
Part III • Clinical Applications • Face and Neck: Aesthetic
accessible record o the patient’s treatment. ypically, a mark is entered on the record by the circulator
or each 1 cc syringe o at injected.
Fig. 23-39
In the absence o a circulating nurse, a copy o this record can also be sterilized and a temporary tally o
the at injected kept by a scrubbed member o the operating room team using a sterile surgical marker.
T e in ormation recorded can later be transcribed to the patient’s o cial at injection treatment record
a er the procedure has been completed.
L ea rni n g th e P roced ure
Box 23-1 Learning the Fat Injection Procedure
• Acknowledge atrophy as part o the aging de ormity.
• Learn the basics o the at injection technique and obtain the needed equipment to properly per orm the
procedure.
• Make the needed commitment o time to properly per orm the procedure.
• Do not underestimate the technical and artistic di culty o the procedure.
• Make small additional corrections at f rst to gain amiliarity with the technique.
• Critically analyze outcomes.
• Continue to improve technique and results.
T e f rst step in learning the at injection technique and adding it to one’s aceli procedure is appreciat-
ing atrophy as a signif cant part o the aging process and learning to recognize it. T is is more easily said
than done, and will take some time to master. T en one needs to learn the basics o the at injection tech-
nique and obtain the needed equipment to properly per orm the procedure. Once problems have been
identif ed, the required equipment to per orm the procedure obtained, and basics o the technique mas-
tered, one must analyze patient problems care ully and budget the appropriate amount o time needed to
carry out the procedure in a technically and artistically appropriate ashion.

373
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
It is wise to make small additions o at at f rst to sa e areas such as the geniomandibular groove and the
cheeks to gain amiliarity with the technique. Less orgiving areas such as the upper and lower eyelids
(orbits), tear troughs, and temples should initially be avoided. By starting out conservatively in this man-
ner, i problems occur, they are likely to be minor and easily managed. Finally, treated patients should be
ollowed up care ully, outcomes critically evaluated, and ways to improve one’s technique and make the
next case better should be sought.
C om p l eti on o f C oncurrentl y P l a nned P roced ures
Once at gra ing is complete, attention is turned to the ace, neck, orehead, upper blepharoplasty, lower
blepharoplasty, perioral dermabrasion, and other planned procedures are per ormed, as indicated. Be-
cause the majority o at is needed and will be gra ed in the anterior ace and other areas that do not
overlap the areas dissected in these other procedures, per orming them a er at is injected does not
inter ere with carrying them out, or compromise outcomes.
One area where the at gra ing and aceli procedures will o en overlap is the lateral cheek and the area
around the origin o the zygomatic major muscle. In a typical high-SMAS procedure, approximately
1 cm o the origin o the zygomatic major muscle must be exposed i restraining ligaments are to be ade-
quately released, and at can o en be seen when this area is dissected. I at is properly injected, however,
the tissue will be saturated with at, much like water in a sponge, and at particles will be anchored by
autologous tissue “glues” secreted by the tissues into which at is injected. T us the at will be seen to be
stable and will remain relatively undisturbed by a care ul dissection.
T e lower orbit is another area o concern or many surgeons who have understandable anxiety that
per orming a lower blepharoplasty a er at gra ing the in raorbital area will be di cult or would disturb
the at gra s placed earlier in the procedure. Despite this concern however, the lower orbit can be and is
routinely at gra ed in our practices when lower blepharoplasty is simultaneously per ormed. T e rea-
son this is possible is that when the in raorbital area is at gra ed at is placed along the anterior ace o
the in raorbital rim in a preperiosteal and preseptal location. Although at is and should be placed deep
in a suborbicularis oculi/preperiosteal position as previously described, it is not placed in a subseptal
plane, and at will not be encountered in a subseptal location when the septum is opened and orbital at
pads are exposed and resected.
DRESSINGS
A er all planned procedures have been completed and all incisions have been closed, the patient’s hair
is washed with shampoo and rinsed. No dressing is required or applied. Patients are typically discharged
with a hat, scar , and sunglasses.
POSTOPERATIVE CARE
Most patients having combined aceli s and at gra ing are discharged to the care o an a ercare special-
ist the f rst night a er surgery, with specif c written instructions as to how they are to care or the patient.
Patients are asked to rest quietly and apply cool but not ice-cold compresses or ice packs to their eyes
and other treated areas or 15 to 0 minutes o every hour they are awake or the f rst days a er surgery
( or most patients, edema peaks at about this time). Excessive cold is now known to cause adipocyte
apoptosis and is likely to be injurious to gra ed at and to compromise outcomes. Patients may also use
a commercially available thermostatically regulated, water-cooled mask (AqueCool; Aqueduct Medical,
San Francisco, CA).

374
Part III • Clinical Applications • Face and Neck: Aesthetic
All patients are provided with oral analgesics, sleeping pills, antiemetic suppositories, and are instructed
to sleep at on their backs without a pillow. A small cylindrical neck roll is permitted i the patient
requests it. T is posture ensures an open cervicomental angle and averts neck exion and dangerous
olding o the neck skin ap, as well as the obstruction o regional lymphatics that inevitably occurs i
the patient is allowed to elevate his or her head on pillows, as is commonly recommended. In addition,
swelling will drain to the back o the head instead o the anterior neck and submental region in this po-
sition, where it is not harm ul, less noticeable, and is more rapidly transmitted away rom the head and
neck area to the torso when the patient sits upright.
Patients are advised to be on a so diet that is easily chewed and digested a er surgery. It should consist
largely o simple carbohydrates to maintain an insulin-rich environment that is likely to reduce meta-
bolic stress on gra ed at cells. Patients are encouraged to drink small, requent amounts o ruit juice
or other carbohydrate-containing beverages, even i they are not hungry the f rst ew days a er surgery.
T ey should be encouraged to eat and they should avoid a calorie-restricting diet at this time. Patients
are advised to avoid salty, dry, and di cult to chew oods or 2 weeks and to abstain rom the intake
o alcohol or 2 weeks a er surgery, until they are no longer taking analgesics (including acetamino-
phen) or sleeping medication. Showering and shampooing are not harm ul and are permitted even when
drains are in place.
RECOVERY AND HEALING
When patients are able return to work and to their social activities will depend on how aggressively
their procedure was per ormed (how much at was injected), their tolerance or surgery, their capacity
or healing, the type o work they do, the activities they enjoy, their need or secrecy, and how they eel
overall about their appearance. Patients are asked to set aside 2 to weeks to recover rom surgery, and
additional time o is recommended be ore an important business presentation, amily gathering, or
similar event.
It is important or patients to know that at injections will signif cantly increase acial swelling and o en
add several weeks to their overall recovery. In some cases, swelling may persist and be troubling to the
patient or a longer period o time. Swelling is most pronounced and noticeable in the lips and eye areas,
and while makeup can hide bruising, it cannot conceal swelling. Patients having their lips at gra ed are
given a “cone” ace mask and are encouraged to use it to conceal swelling in the mouth area in the early
postoperative period. Ecchymosis is generally light and less o an issue or most patients than edema.

375
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
I the patient is doing well and not experiencing problems, she or he is allowed to return to light o ce
work and casual social activity 9 to 10 days a er surgery. It is o en wise that they begin with a limited
workday at f rst and to adjust their schedules therea er. I a patient’s job entails more strenuous activity
or physical labor, a longer period o convalescence will likely be required. Patients are advised not to
drive or the f rst 10 days a er surgery until they are eeling well, their vision is clear, and they no longer
require analgesic medications.
Patients are advised to avoid all strenuous activity during the f rst weeks a er surgery including heavy
li ing, stooping, straining, and bending orward. T ey should be in ormed that aerobic activities and
exercise can result in internal bleeding and hematoma ormation. wo weeks a er surgery, patients may
begin light exercise and gradually work up to their presurgical level o activity. Four to 6 weeks a er sur-
gery, they can engage in more vigorous activities, including most sports, as tolerated.
Patients are in ormed that it will o en take to months be ore they have a natural appearance in a
photograph. T ey are also advised to expect some f rmness in the ace and submental areas or 6 to
9 months.
Patients o en mistakenly interpret the resolution o swelling and the return o some acial wrinkles as
poor gra survival and o en comment once healing is complete that “the at went away.” Such comments
arise out o the joy most patients experience when they initially see their aces ull and smooth a er
initial healing takes place postoperatively. T e act that volume has been added to the ace o en pro-
duces subtle three-dimensional changes, and most patients simply orget the extent to which volume was
lacking in the treated areas be ore the procedure. T e physician can also sometimes initially experience
similar disappointment or similar reasons, and it can take time to train one’s eye to recognize how the
ace has been subtly enhanced. T e key to assessing outcomes is to take well-matched preoperative and
postoperative photographs in multiple views and to learn to recognize improvements. Reviewing pre-
operative photographs with the patient a er surgery is an excellent way to assure them that a benef cial
improvement has been obtained, and that the procedure was productive and worthwhile.
SECONDARY PROCEDURES
Most o the change in acial contour seen on the patient’s ace 4 to 6 months a er their procedure is likely
to consist o living at and comprise a persistent improvement, and patients can be in ormed that “what
they see is what they get” at that point, because swelling and induration has largely resolved by that time.
Four to 6 months a er surgery is also the time at which most surgeons per orming at gra ing eel that
acial edema, induration, and in ammation have resolved su ciently that retreatment can be considered
i indicated and the patient requests it.
Because there is a limit to the amount o at that can be properly inf ltrated into a thin, atrophic ace, the
need or second-stage at gra ing should not be viewed as a ailure o the primary procedure; it is simply
an inherent limitation o the technique as it is currently per ormed. I the patient obtained improvement
with the primary treatment, a secondary procedure will typically be equally or more benef cial, and can
o en be ar less comprehensive than the f rst.

376
Part III • Clinical Applications • Face and Neck: Aesthetic
C a se E xa m p l es
Fig. 23-40
T is woman, age 45, presented with mild overall acial
laxity and pan acial atrophy. She had had no previous
plastic surgery. She is shown 2 years and 4 months
af er a high-SMAS acelif , neck lif , closed orehead
lif , lower blepharoplasty, and at trans er to the
temples, cheeks, lips, nasolabial olds, GMG, stomal
angles, and upper and lower eyelid areas. A total o
50 cc o at was placed. Note the sof , natural a-
cial contours and the absence o a tight, pulled, or
acelif ed appearance. Facial atrophy has also been si-
multaneously corrected, and the patient has a health-
ier, more youth ul, sensual, and eminine appearance.
T e combined acelif and at graf ing procedures
produced a result that could arguably not be obtained
by either procedure alone.

377
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
T is man, age 68, had sagging cheeks, deep cheek
olds, and jowls. Loss o acial volume was evident in
his cheeks, in raorbital area, and perioral, chin, and
GMG areas. He is shown 1 year and 9 months a er a
high-SMAS aceli , neck li , closed orehead li , up-
per and lower blepharoplasties, partial acial at gra -
ing, and earlobe reduction. A total o 8 cc o at was
placed. Note the restoration o youth ul and mascu-
line acial shape without a tight or pulled appearance.
Facial atrophy was simultaneously improved. em-
ple hollowing was corrected, an improved transition
rom the lower eyelid to the cheek is evident, the
cheek and mid ace can be seen to be uller, the chin
is broader, and its vertical height has been increased.
In the oblique view, it can be seen that the GMG has
been f lled and the posterior jawline strengthened,
creating a healthier, more youth ul, virile, and mas-
culine appearance. T e combined aceli and at
gra ing procedures have produced a result that could
arguably not be obtained by either procedure alone.
Fig. 23-41

378
Part III • Clinical Applications • Face and Neck: Aesthetic
T is woman, age 5 , was initially seen with an
overall loss o acial contour, malar hypoplasia,
ocular proptosis, and poor jawline. Although her
ace appears ull at f rst glance, a care ul exam-
ination shows regional atrophy in the temples,
cheeks, in raorbital, perioral, GMG, chin, and
jawline areas. T e patient had undergone prior
upper and lower blepharoplasties per ormed
by an unknown surgeon. T e patient is shown
1 year and 5 months a er a high-SMAS aceli ,
neck li , temple li , canthopexy, and at trans er
to the temples, cheeks, in raorbital, nasolabial,
perioral, GMG, chin, and jawline areas. A total
o 66 cc o at was placed in combination with
the aceli and related procedures. Note the so ,
natural acial contours and the absence o a tight,
pulled, or aceli ed appearance. Facial atrophy
has also been simultaneously improved. emple
hollowing has been corrected, orbital atrophy
corrected, an improved transition rom the lower
eyelid to the cheek is evident, the cheek and
mid ace can be seen to be uller, and the chin
is broader and ows seamlessly into the jaw-
line. In the oblique view, it can be seen that the
GMG has been f lled and the posterior jawline
strengthened, creating a healthier, more youth-
ul, attractive, and photogenic appearance. Her
acial shape has been signif cantly improved, and
she now has a more youth ul and attractive ap-
pearance. Although at has been added to the pa-
tient’s ace, it has a more trim, f t, and eminine
look. Note also that her lips are uller but natu-
ral appearing. An unwanted mole was removed
rom the le upper lip. T e combined aceli and
at gra ing procedures have produced a result
that could arguably not be obtained by either
procedure alone.
Fig. 23-42

379
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
T is woman, age 6 , had undergone a previous
aceli , neck li , blephoroplasties, and other
procedures per ormed by an unknown surgeon.
Note the residual acial sagging and neck and
jowl ullness. Although the patient’s ace appears
ull at f rst glance, a care ul examination shows
that regional atrophy is present in the temples,
cheeks, orbital, perioral, GMG, chin, and jawline
areas. T e patient is shown 1 months a er a
high-SMAS aceli , neck li , small incision ore-
head li , CA lower eyelid peel, earlobe reduc-
tion, perioral dermabrasion, and at gra ing o
the temples, glabella, radix, upper orbital, lower
orbital, cheek, mid ace, nasolabial, perioral, lips,
geniomandibular groove, stomal angle, chin, and
jawline areas. A total o 0 cc o at was placed si-
multaneously with the aceli and related proce-
dures. Note restoration o youth ul and eminine
acial shape without a tight or pulled appearance.
Facial atrophy has also been simultaneously im-
proved. emple hollowing has been corrected,
orbital atrophy corrected, an improved transition
rom the lower eyelid to the cheek is evident, the
cheek and mid ace can be seen to be uller, and
the chin ows smoothly and aesthetically into
a smooth jawline. Although at has been added
to the patient’s ace, it has a more trim, f t, em-
inine, and photogenic appearance. Note also
that her lips are uller but natural appearing. T e
combined aceli and at gra ing procedures
have produced a result than could arguably not
be obtained by either procedure alone.
Fig. 23-43

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Part III • Clinical Applications • Face and Neck: Aesthetic
T is woman, age 75, had undergone multiple
prior aceli s and related procedures, includ-
ing laser resur acing, per ormed by unknown
plastic surgeons. Note her marked cheek laxity
despite the prior surgeries, and her rail, elderly
appearance, resulting rom uncorrected pan a-
cial atrophy. Another aceli would predictably
produce a gaunt, haggard or even ill appearance.
She is shown 1 year 7 months a er a high-SMAS
aceli , neck li , orehead li , upper and lower
blepharoplasties, canthopexy, and at gra ing
o the temples, upper and lower eyelids, cheeks,
mid ace, buccal recess, lips, nasolabial olds, sto-
mal angles, GMG, chin, and jawline. A total o
9 cc o at was placed in conjunction with the
aceli and related procedures. No skin resur ac-
ing, acial implants, or other ancillary procedures
were per ormed. In these situations, at gra ing
is arguably more important to the overall out-
come than the aceli itsel . Her acial contour
has been signif cantly enhanced and acial vol-
ume restored. T e patient has a healthy, f t, and
eminine appearance, and one that could not be
obtained by either procedure per ormed alone.
Fig. 23-44

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Chapter 23 • Simultaneous Faceli t and Fat Gra ting
C om p l i ca ti on s
No major complications attributable to at gra ing have been seen while per orming the procedure si-
multaneously with aceli s over the past 0 years, including in ection and embolus, tissue in arction,
or blindness. T ese devastating problems have been reported, however, and are known to occur when
at injections are per ormed. Clinical experience has shown that embolization is extremely uncommon
when at is injected with a blunt cannula and in accord with currently recommended technique, but
more cases might be seen as inf ltration cannulas become smaller and more surgeons per orm the pro-
cedure. Embolization and the majority o related complications including blindness have been reported
with sharp needle injection, and these and other complications o at injections have been discussed in
detail by Coleman and others.
Complications o simultaneous aceli and at gra ing attributable to the at gra ing procedure itsel all
largely under the heading o “minor” and “aesthetic problems” and include lumps, oil cysts, asymme-
tries, undercorrection, overcorrection, and donor site irregularities. T ese are more accurately consid-
ered inherent risks o the procedure, much like breast implant encapsulization in breast augmentation
procedures, in that even i the procedure is technically per ormed properly and with care, variations in
take can occur with any gra , and these are beyond the surgeon’s control to prevent. T is is particularly
true in at gra ing, because at has shown itsel to be comparatively ragile tissue.
Certain patients seem to be at higher risk or problems and complications largely as a result o com-
promised condition o at donor and recipient sites. T ose at risk or this include smokers and ormer
smokers, patients who have undergone previous acial liposuction, those who have undergone radio-
therapy, and patients who have undergone intense pulsed light (IPL), radio requency, and ultrasound
“skin-shrinking” treatments. Unlike laser resur acing procedures, where energy is dispersed on the skin
sur ace, these latter procedures disperse energy in the deep dermis and subcutaneous areas, which can
cause damage to tissue microcirculation that appear to compromise gra take. Compromise o a similar
sort seems to also be present in patients who have had large volumes o in ammatory f llers (such as
PLLA and calcium phosphate), and in patients who have large volumes o HA-based f llers present or
a long time. Simply dissolving HA f llers enzymatically when present with hyaluronidase does not seem
to eliminate this problem, because residual in ammation seems to still be present, which can result in
suboptimal gra take. All such patients should be approached with caution, and it is prudent that they
be in ormed that they are likely to be at an increased risk o problems and complications.
In patients who have undergone previous liposuction, especially laser or ultrasound procedures, will typ-
ically be more di cult to harvest rom. In addition, the at harvested will typically have an increased oil
(ruptured at cell) raction and will be more likely to have f brotic tissue ragments that clog injection
cannulas.
Most complications will be small and easily managed i at injections are per ormed properly and con-
servative additions o at are made. Oil cysts can usually be simply aspirated or unroo ed. Lumps have
been exceedingly rare in our own practices, but are now being increasingly seen in patients treated by
other physicians. T ese can usually be treated by microliposuction, direct excision, or overgra ing with
more at. Asymmetries and undercorrections are generally treatable by additional at injections, and
donor site irregularities can be improved with touchup liposuction and/or at gra s. Overcorrection is
uncommon in single-stage treatments and is typically seen in patients undergoing multiple at injection
procedures. In addition to improving the orbital area, when overcorrection occurs, improvement can be
made through judicious extraction o at rom overcorrected areas by a microliposuction technique us-
ing a 0.9 or 0.7 mm cannula attached to a cc syringe. Irregularities or overf lling o the orbital areas are
best treated by opening the eyelid and removing the o ending at under direct vision, and small lumps
and bumps on the lips are readily treated by direct excision using a radially situated incision made in a
vermilion wrinkle.

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Part III • Clinical Applications • Face and Neck: Aesthetic
T e best way to treat complications is to avoid them altogether, and the surgeons with the ewest are
likely to be the ones who take the time to learn to per orm the procedure properly, obtain the needed
equipment necessary to do so, and who introduce it into their practice gradually and in a conservative
manner.
D i scu ssi on
DOESN’T THE FAT GO AWAY?
Although many surgeons recognize volume loss as part o the aging process, they cling to the excuse
that “the at doesn’t last” as a way o not having to learn and per orm the procedure. T is assertion has
now been proved to be meritless and is no longer a valid justif cation or denying the patient the many
important benef ts o at gra ing. Unlike temporary f llers, at is living autologous tissue that neovascu-
larizes and establishes itsel as part o the ace. It is analogous to hair transplantation and other gra s
per ormed by plastic surgeons. Furthermore, i the gra s did not persist, there would not be overcor-
rected patients.
Fig. 23-45
Does the at last? T is patient is seen be ore and years and 7 months a er a aceli and at gra ing in
which 5 cc o at was placed. It can be easily seen that the in raorbital, cheek, mid ace, buccal recess,
nasolabial old, lips, stomal angle, chin, GMG, and jawline areas are all distinctly uller almost 4 years
a er these procedures and that the at has persisted in each area treated.

383
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
ISN’T THE FAT LUMPY?
Asserting that at gra s are “lumpy” has also been a common excuse surgeons have used to not learn or
per orm the procedure, and this too has now been proved to be alse and no longer remains a valid ex-
cuse to deny the patient the many important benef ts o at gra ing. I proper technique and equipment
are used, lumps and irregularities will be ar less common than complications seen a er almost every
other aesthetic surgery procedure we per orm. Unlike f llers, at actually integrates with the tissues it is
inf ltrated into, and there is a natural smoothing e ect, since at must be scattered in the tissue to survive.
I at is injected in clumps, the central at typically undergoes necrosis and does not survive. Fat gra ing
has been our secret weapon or obtaining aces smoother than can ever be obtained by aceli ing alone.
T at is not to say that irregularities are not possible. Fat must be injected with meticulous care in the
appropriate planes or the areas treated i contour irregularities are to be avoided. Simply put, this means
injecting deep in any thin-skinned area until considerable experience has been obtained.
Fig. 23-46
Is the at lumpy? T is woman is seen be ore and 11 months a er a aceli , neck li , orehead li , lower
blepharoplasty, and at gra ing. I proper technique and equipment are used, lumps and irregularities
will be ar less common than complications seen a er almost every other aesthetic surgery procedure
per ormed in the ace. Practically speaking, at gra ing is the surgeon’s secret weapon or obtaining aces
smoother than can ever be obtained by aceli ing alone.

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Part III • Clinical Applications • Face and Neck: Aesthetic
WHAT IS THE EFFECT OF WEIGHT GAIN OR LOSS?
A large weight gain will compromise almost any plastic surgery procedure, and that is arguably the case
with at gra ing as well. Despite this, a number o anecdotal case reports have been endlessly recycled at
meetings and con erences and among plastic surgeons regarding patients with large lips, over ull cheeks,
and so on as a result o large weight gains a er at gra ing. T e reality is that such large weight gains
would spoil the result o almost any aesthetic surgery procedure, and thus any argument to this e ect
constitutes alse logic and a hypocritical double standard.
Fat gra ing in a child or younger patient does hold the potential or a change in gra volume with age
and weight gain, but most patients in the typical aceli age group have reached a stable weight that
uctuates only modestly during the rest o their lives. T ere ore the concern about areas treated with at
becoming objectionably large with weight gain is essentially un ounded and again alls into the category
o excuse-making by surgeons not interested in learning or taking the time to per orm the procedure.
Weight gain may actually a ord the aceli patient some benef ts, in that i weight is gained and the
gra s are seen to grow, growth is experienced in areas where the increase in volume maintains acial
proportion. Without at gra s, weight gain tends to occur in areas that create a disproportionate, un-
attractive, and objectionable appearance, such as the jowl and the neck. A er at gra ing, weight gain
occurs in all areas, and the ace remains proportionate and more attractive appearing. T at is to say, the
ace may become bigger, but it remains proportionate and attractive.
C oncl usi on
Recognizing the changes that occur as the ace ages and appreciating the underlying anatomical prob-
lems responsible or them is essential to properly advising patients and planning o surgical procedures.
In most patients problems will all into three general categories: aging and breakdown o the skin sur-
ace, tissue sagging, skin redundancy, and loss o youth ul acial contour, and acial hollowing and atro-
phy. Skin care and skin resur acing procedure address changes in the f rst category. Our traditional li s
o the ace, neck, orehead, and eyes address the second. Fat gra ing allows us to treat atrophy, some-
thing we have previously been unable to do, and at gra ing is now acknowledged by surgeons treating
the aging ace as the most important advance in aesthetic surgery in several decades or more. Properly
per ormed, the addition o at to areas o the ace that have atrophied rom age can produce a signif cant
and sustained improvement in appearance unobtainable by other means.

385
Chapter 23 • Simultaneous Faceli t and Fat Gra ting
T ech ni ca l P ea rl s
• Patients with signif cant acial atrophy will generally achieve suboptimal improvement rom both sur-
ace treatments o acial skin and surgical li s. T e addition o at to areas o the ace that have atro-
phied due to age or disease can produce a signif cant and sustained improvement in appearance that
is unobtainable by other means.
• Isolated at injections are o questionable benef t to the patient troubled by signif cant acial sagging
and skin redundancy. Although aggressive f lling o the sagging ace with at can produce improved
contour and a smoother appearing skin sur ace, an isolated at injection generally results in an unusu-
ally large, overf lled ace that appears both unnatural and un eminine.
• A common misconception in treating the hollow upper orbit is that the at should be injected in the
preseptal portion o the eyelid itsel . Volume is more properly restored by placing at in a preorbital
position along the in erior margin o the supraorbital rim.
• Filling the upper cheek produces a pro oundly benef cial e ect on the nasolabial old, and this treat-
ment o the old is more e ective when there is combined f lling o both these areas. I the cheek is
f lled, less at is needed to improve the nasolabial old and a better overall improvement will be ob-
tained.
• A common error to be avoided when injecting at into the lips is to f ll the lips in such a manner that a
large but shapeless and unnatural appearing “sausage lip” is produced. T e attractive lower lip typically
has two areas o ullness laterally with a small central depression between them. T e attractive upper
lip, on the other hand, has three areas o ullness, one centrally and one on each side with a slight de-
pression between them. An adequate amount o time should be taken to inject at to create these sorts
o appearances.
• In the young, natural appearing, aesthetic mouth, the lower lip is distinctly bigger than the upper lip
as def ned by the golden ratio 1.61 :1. Overf lling the upper lip, or making the upper lip the same size
as the lower lip, will result in an unnatural appearance.
• Injection o the geniomandibular groove with at has a high aesthetic payo and is a good area or the
beginning injector to gain experience with the technique. Filling the geniomandibular groove creates
a strong, uninterrupted aesthetic line rom the chin to the mandible, and this is a highly desirable im-
provement on both the male and emale ace.
• It is wise to make small additions o at to “sa e” areas at f rst to gain amiliarity with the at gra ing
technique. Less orgiving areas should initially be avoided. Starting out conservatively in this manner
will mean that problems, i they occur, will be minor and easily managed.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.

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Part III • Clinical Applications • Face and Neck: Aesthetic
REFERENCES
1. Marten J, Elyassnia D. Fat gra ing in acial rejuvenation. Clin Plast Surg 42:219, 2015.
2. Coleman SR. Fat Injection: From Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
. Marten J. Simultaneous aceli and at gra ing: combined li ing and f lling o the ace. In Nahai F, ed.
T e Art o Aesthetic Surgery: Principles & echniques, ed 2. St Louis: Quality Medical Publishing, 2011.
4. Marten J, Elyassnia D. Secondary de ormities and the secondary aceli . In Neligan P, Warren RJ, eds.
Plastic Surgery, vol 2, ed , St Louis: Elsevier, 201 .
5. Marten J. Lamellar high SMAS ace and mid-li : improved design o the SMAS aceli or better results
in the mid ace and in raorbital region. In Nahai F, ed. T e Art o Aesthetic Surgery: Principles & ech-
niques, ed 2. St Louis: Quality Medical Publishing, 2011.
. Marten J. Faceli with SMAS aps. In Guyuron B, Eriksson E, Persing JA, eds. Plastic Surgery: Indica-
tions and Practice. Philadelphia: Elsevier Saunders, 200 .
7. Marten J. High SMAS aceli —combined single ap li ing o the jawline, cheek, and mid ace. In Paul
M, ed. Clinics in Plastic Surgery. Philadelphia: Elsevier Saunders, 200 .
. Marten J. Secondary rejuvenation o the ace. In Mathes S, ed. Plastic Surgery. Philadelphia: Elsevier
Saunders, 200 .
9. Marten J. Maintenance aceli : early aceli or younger patients. In Marten , ed. Faceli : State o the
Art. Seminars in Plastic Surgery. New York: T ieme Publishers, 2002.
10. Marten J. Faceli : planning and technique. In Paul M, ed. Clinics in Plastic Surgery. 1997.
11. Marten J, Elyassnia DR. Simultaneous aceli and at gra ing. In Connell BF, Sundine MJ, eds. Aesthetic
Rejuvenation o the Face and Neck. New York: T ieme, 201 .

387
C h a p t e r 2 4
T s s d v y d s d m d s
s y. A d f ss s s ss s s , y -
, y s s s v s y d d s ss v
m s , s s . L k w s , sk z y d, w, d m
j s s k ss d s v , y s s v s d “ j v ” d s
m v d f .
U k w d m s, s d j v w s
. Us y m y m w d s d m y
s m s s m s ss d ss s d y d s ss
y . T s s s w k s s s d y s s d
m s s. W , v m ss s s y d m s
v s y sm s w d s m v s d. H w v ,
m , s m s v m s s w y s . F
s I v d d s s d f -
s d d w k s. T d w k s d w m s,
d B x, d m j , V-d ss , d s s .
St r uct ur al Fat Gr a t ing
in t he Supr aor bit al Ar ea
Sydney R. Coleman
387

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Part III • Clinical Applications • Face and Neck: Aesthetic
A esth eti c C on si d era ti on s
Fig. 24-1
Fullness characterizes the young brow, cheek, and temple. Young eyebrows have so much ullness be-
neath them that there is always a distance between the shadow o the supraorbital old and the eyebrow
itsel . T e intrinsic nature o the brow is that it is inherently more taut than the eyelid skin. T e brow
ullness expands the skin immediately caudal to the eyebrow, producing a turgidity that extends or a
ew millimeters cephalad to the supratarsal old where the skin becomes f accid. T ere is at least a hint o
loose skin above the supratarsal old, even in teenagers.1-4
T e amount o upper eyelid visible under the brow can be variable in youth; the most requent presen-
tations are o the skin touching the eyelashes (with no eyelid visible) or with only a millimeter or two
o palpebral show. A young, healthy person can occasionally present with deep-set eyes, but rarely with
hollow eyes.
T e eyebrow is supported laterally by temporal ullness. It is that temporal ullness that allows one to see
the lateral quarter o the eyebrow in a youth ul ace and that supports the eyebrow into its lateral arch.
T e temporal ullness and lateral rontal ullness also produce the smooth, strong brow essential to a
youth ul appearance.

389
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
I n d i ca ti on s a n d P a ti ent S el ecti on
Fig. 24-2
When I returned to exas to visit my grandmother, Mary Coleman, during my plastic surgery residency,
I was struck by how much she looked like one o the patients that I had just recently seen with a history
o three upper blepharoplasties. My grandmother never had any acial surgery; she was just simply old.
Her photos at 0 years o age and at years demonstrate the aging changes that had taken place over
the years.
When I returned to my residency a er visiting my grandmother in 1 , the AIDS epidemic had f lled
San Francisco General Hospital with 0-year-olds with hollow eyes and temples. T ey had lost their
periorbital ullness because they were terminally ill. It was at that point that it became obvious to me
that excisional aesthetic procedures o the upper third o the ace skeletonize the periorbital region in an
unhealthy manner. I began to realize that procedures that skeletonize the upper third o the ace make
patients appear sick, anorexic, or old.

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Part III • Clinical Applications • Face and Neck: Aesthetic
RESTORATION OF HEALTHY PROPORTIONS
As discussed in Chapter 22, loss o subcutaneous at or ullness commonly seen with iatrogenic de or-
mities a er surgery, with acne, and most recently with lipoatrophy are primary indications or structural
at gra ing.
Fig. 24-3
Just as the ullness o youth projects health, the absence o ullness warns the observer o sickness, age,
or starvation. T e upper eyelid/brow area is one o the f rst areas to project deteriorating health. Just 1 or
2 mm o hollowness at the upper eyelids and temples can have a dramatic impact on how well a person
looks.
In healthy individuals, surgical removal o at rom the upper eyelids or rom any part o the ace can
create the appearance o sickness. Likewise, acne scarring in the temple and glabella can accelerate at-
rophy o the involved areas and create bizarre proportions. Drug-related lipoatrophy can a ect not only
the mid ace, but also the upper ace, temples, and upper eyelids.
Skeletal abnormalities o the rontal, parietal, and temporal regions can give a ace an unattractive or
even unnatural appearance. Signif cant temporal and lateral rontal def ciencies will make the central

391
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
parietal or lower rontal skull unattractively prominent. However, the solutions to these problems in
plastic surgery have been prohibitively risky: cranio acial procedures or alloplastic implants. Structural
at gra ing to the temporal and lateral rontal region (and many other def cient areas) is a sa e, predict-
able way to approach these sometimes di cult problems.
Fig. 24-4
When hanging skin is a component o supraorbital aging, it may need to be excised. However, I rarely
see an indication or excising muscle or at rom the upper eyelids. T is was done in this patient, seen
preoperatively and 7 years a er excision o skin, muscle, and at rom her upper eyelids. Although many
surgeons think their patients want such a look, this is removing the signs o aging without rejuvenating.
Excision o muscles such as the corrugators, the procerus, and especially the orbicularis oculi needs to
be care ully considered in view o the reduction o the underlying supportive tissue and thereby their
contribution to the atrophic process o aging.
On the other hand, excision o the eyelid skin alone approaches the radial vector by making the ratio
between the overlying skin and the underlying structures more closely approximate the youth ul pro-
portions that exist between the two areas. Excising muscle and at rom the underlying structures, on the
other hand, always skeletonizes the area.
Adding to the supraorbital region is an extremely complex maneuver, and the biomechanics o this
region are poorly understood. Restoring the volume o the orehead or merely adding to the brow itsel
creates a radial vector with a strong mechanical advantage that elevates the eyelid skin.
T e importance o the concept o radial vectors has yet to be recognized or the orehead. By adding
tissue over a large sur ace area to the orehead, one can have a remarkable e ect on the brow and upper
eyelid: a “li ing” without excision. T e traditional elevation o the brow by excising skin or scalp creates
a vector in a superior or superolateral direction. T is moves tissues away rom the orbit, and thereby re-
duces some o the excess skin or crêpiness o the area. However, a orehead li o any type can elevate the
brow in an o en-unattractive ashion and can skeletonize the upper orbit. It does not create the so , ull
eyelid o youth. Structural at gra ing provides a tool that f nally allows the recreation o a youth ul up-
per eyelid by f lling the orehead, brow, and upper eyelids to replace the missing underlying structures.
T e f lling and supporting o the periorbital region along with judicious skin care to maintain elasticity
are the primary tools or maintaining a youth ul appearance o the eyes. Excisional and suspensory
surgeries should be secondary procedures to be executed a er the primary maneuvers are no longer
su cient.

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Part III • Clinical Applications • Face and Neck: Aesthetic
A na tomi c C on si d era ti on s
A thorough knowledge of the anatomy of the upper eyelids, brow, and temple is essential for the surgeon
operating on the upper third of the face. Preventing injury to nerves and avoiding inadvertent cannula-
tion of arteries or veins are primary concerns.
Frontalis muscle
Supraorbital nerve
Supratrochlear nerve
Procerus muscle
Corrugator muscle
Orbicularis oculi muscle
Frontalis muscle
Supraorbital nerve
Supratrochlear nerve
Procerus muscle
Corrugator muscle
Orbicularis oculi muscle
Fig. 24-5
Around the supraorbital foramen, the surgeon should use blunter cannulas to avoid injury to the supra-
orbital and supratrochlear nerves or cannulation of the vessels. I use a Coleman type I cannula when

393
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
placing tissue next to the bone in this area, although it has become my common practice to place tissue
in a more superf cial plane when I am near the supraorbital rim.
However, acne scarring and other types o adherent scars are requently present in the central orehead,
brow, and especially the glabella. Freeing up more deeply adherent scars can damage the supraorbital or
supratrochlear nerves.
Zygomatic arch
Frontal branch
of superficial
temporal
artery
Temporal
branch of
facial nerve
Temporal
branch
of facial
nerve
Frontalis
muscle
Fig. 24-6
Likewise, in the area o the temporal branch o the acial nerve, the bluntest cannulas should be used
or almost any placement. Paralysis o the rontalis muscle with unilateral brow ptosis and asymmetrical
lack o animation o the involved orehead will result rom damage to the nerve.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Loose areolar tissue
Frontal branch of
superficial temporal artery
Temporoparietal fascia (SMAS)
Zygomatic arch
Deep temporal fascia:
Temporal branch of facial nerve
Superficial layer
Deep layer
Temporal fat pad:
Superficial layer
Deep layer
Fig. 24-7
As in the glabella, acne scarring is requently present in the temple; reeing up more deeply adherent
scars can damage these nerves. I recommend limiting the release o such adhesions in the temple to the
most superf cial planes.
Injury to nerves is not the only concern in this area. T e rich network o blood vessels in the temporo-
parietal ascia and around the eyes is easy to disrupt during inf ltration o at or even local anesthetic. In
act, the reason I switched to use o the at inf ltration cannulas or placing the local anesthetic was the
high incidence o hematomas that I had with 25-gauge needles in the temple. I now use only type I can-
nulas or inf ltration o local anesthesia in the upper ace, since the use o sharper cannulas (especially a
type III) will requently result in large hematoma ormation in the temple and brow.
Hematomas are not the only potential vascular phenomenon that can occur. Injecting in these areas
with a sharp needle should be avoided because it could cause arterial or venous cannulation and possible
embolization (see Chapter ).
Not only does superf cial placement create an aesthetically pleasing result, it eliminates the possibility o
damaging the lacrimal gland and the levator mechanisms o the upper eyelids.

395
Chapter 24 • Structural Fat Gra ting in the Supraorbital Area
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Markings
Fig. 24-8, A
A
T e blueprint is used not only or planning the procedure, but also to help document in ormed consent.
Please note the re-marking in the upper part o the sheet.
B
Fig. 24-8, B
T e plan or correction is shown. Changes in shape to restore subtle ullness are marked in green, while
eathering out to areas is marked in yellow. T e planned incision sites are marked in red.
Anesthesia
A solution o 0. % lidocaine with 1: 00,000 epinephrine is inf ltrated to provide anesthesia, placing the
least amount that is still e ective to avoid signif cant distortion. Local anesthesia should be placed into
the periorbital region using only the bluntest style I cannula. T is is done to avoid damaging structures,
such as nerves and blood vessels, but also to avoid entering the lumen o an artery or vein during the
injection o local anesthetic. Damaging an artery or vein that results in a hematoma during inf ltration
o the local anesthetic will inter ere signif cantly with the surgeon’s ability to judge volumes and distribu-
tion o the gra ed at during placement.

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Part III • Clinical Applications • Face and Neck: Aesthetic
T e vasoconstriction caused by the inf ltration o epinephrine reduces the possibility o the cannula
entering an artery or vein during the placement o at. Epinephrine should be inf ltrated into the peri-
orbital region in every case to reduce the possibility o intra-arterial injection. Even i the procedure is
per ormed under general anesthesia, epinephrine should be inf ltrated.
Incisions
Fig. 24-9
Central forehead
Malar cheek
Eyebrows
Temple
Central forehead
Malar cheek
Eyebrows
Temple
I make one incision into each ar lateral and medial brow, as well as the lateral in erior temple. From
these incisions, the entire upper eyelids can be reached (both through the ipsilateral and contralateral
incisions) as well as the temple and orehead. I o en make an incision in the midline o the orehead
above the glabella, especially i I plan to approach the nose or glabella.
On a rare occasion, an incision is made in the hairline o the orehead or temple or better access. T is
would most o en be to access areas that were scarred because o previous procedures.

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Chapter 24 • Structural Fat Grafting in the Supraorbital Area
Inf ltration Cannulas

Type I
Fig. 24-10
I use the mini-cannulas in the upper face. For the placement of local anesthesia, I always use a Coleman
type I cannula in the 5 or 6 cm lengths in the upper face with the exception of using a Coleman mini III
cannula in the upper eyelid and nose. When I approach any areas through a temple incision or when I
am going to be placing tissue above the brow or in the temple, I use a type I cannula or mini I for place-
ment.

Type III
Type I
Fig. 24-11
In the upper eyelids below the eyebrow and in the medial nose, I frequently use Coleman type III cannu-
las, because they give me better control to remain between the orbicularis oculi muscle and the skin in
these areas. I can use the , 5, or 6 cm, depending on the situation.

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Part III • Clinical Applications • Face and Neck: Aesthetic
Fig. 24-12
Type II
Type II
When the temple has acne scarring or scarring rom previous procedures, and I f nd it di cult to push
the cannula through the area, I will switch to a Coleman type II cannula. To ollow the curvature o the
bony orehead, I requently use a slightly curved cannula o a type II variety when I am trying to place
tissue close to the bone.
Level o Inf ltration
Fig. 24-13
Into the upper eyelids, I try to remain superf cial at all times, remaining immediately subdermal or into
the orbicularis oculi muscles. Into the orehead and above the brow, I primarily place tissue superf cially.
However, I also place a little more tissue into the rontalis muscle than I do into the orbicularis oculi.