Reoperative Aesthetic & Reconstructive Plastic Surgery

(Trang không có chữ)

377
Our knowledge of the many changes involved with aging and the improved
understanding of the surgical anatomy allows tailoring of the operation to t spe-
ci c presenting challenges. No longer is a face lift an operation to simply tighten
the skin envelope. Rather, we can now design surgical rejuvenative procedures to be
specific to the problem (or problems) at hand. These many approaches are well
covered elsewhere in this text. In this chapter we will discuss the more subtle but
equally important aspects of aging that lie, for the most part, beyond the reach of
the scalpel.We will discuss restoration of the loss in facial volume, eradication of fa-
Adjunctive Procedures
to Improve the Results
in Facial Aesthetic Surgery
Tracy M. Baker and G. Jackie Yee
C ha pter 15
Reoperative Problems
Persistent rhytids
Pigmentary irregularities
Dermal/subdermal augmentation
Actinic damage
Wrinkles should merely indicate where smiles have been.
Mark Twain

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cial lines, thickening and reorganization of the skin’s dermal collagen layers, and
correction of the aging lip and vermilion complex.The recognition and the treat-
ment modalities to address these many different aspects of aging dramatically im-
prove our results in facial aesthetic surgery.With the growth of our knowledge and
these available tools, results today are softer, more natural, and truly more complete.
Patients consult us for speci c problems of aging. When you hand them a mirror
during a consultation, they will take their free hand and physically demonstrate
what bothers them. They point, suspend, move, and mechanically reposition vari-
ous portions of their brow, eyes, face, and neck. A patient generally does not sit
across from the surgeon and request a speci c procedure.
Therefore we have organized this chapter into isolated problems within anatomic
regions. We must keep in mind that there are many ways to solve the same prob-
lem.These adjunctive procedures are complementary to the surgery and frequently
to one another. A nasolabial fold can be improved with a face lift, a fat graft, laser
resurfacing, dermabrasion, injection of hyaluronic acid, or even direct excision and
many other approaches.The speci c treatment or combination of modalities chosen
is a decision to be made between the patient and surgeon based on many factors.
Many adjunctive procedures by themselves can often provide a satisfactory im-
provement to postpone a face lift in the early phases of the inevitable aging process.
If an individual is rst seeing the signs of aging and/or is nearing the time for un-
dergoing surgery, the problem may be camou aged or temporarily xed by just
lling and replacing volume. In these patients, llers are excellent for reaching their
goals. Inevitably, the problem worsens to such an extent that surgery should be per-
formed to ideally correct the problem or may be the only option to obtain a real-
istic and believable result.
Most patients eventually require a combination of surgical and adjunctive proce-
dures to produce a satisfactory result. A good surgeon is able to assess the limitations
of the surgery and adjunctive procedures being discussed in this chapter. Good
judgment should always be used when counseling patients in borderline cases
where surgical procedures are early options. Open and honest discussion of the po-
tential results and limitations of the procedure being considered is essential so that
the patient can take an informed role in the decision-making process.

ANALYSIS OF FACIAL AGING
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This woman shows classic facial aging. No component of the face is immune from
the effects of time.These changes are often compounded by other deleterious in-
uences: sun exposure, hormonal alterations, cigarette smoking, extreme weight
uctuations, nutritional factors, and even previous aesthetic surgeries. Complete
restoration will require surgery and adjunctive techniques.
Bone undergoes resorption, muscle and fascia become atrophic, lax, and malposi-
tioned, and malar and jowl fat pads descend, with the overall facial subcutaneous fat
demonstrating substantial loss of volume. Brow ptosis with upper lid skin and fat
excess becomes evident. Anchoring and suspension ligaments elongate, allowing
soft tissues to delaminate from the underlying skeleton.The fat pads of the lower lid
fat herniate and the lower lid tissue thins to expose the orbital rim.The volume of
the orbit enlarges, and together with the lower lid tear trough, often reveals a skele-
tonized appearance. Atrophy and collapse of the soft tissues around the mouth con-
tribute to marionette lines, nasolabial folds, and the loss of full, sharp lip and vermil-
ion border anatomy. Lines of expression around the eyes and perioral wrinkles
become marked.The collagen of the dermis becomes thin and disordered and nat-
ural elasticity is diminished, while the epidermis becomes thickened and more vari-
ably pigmented. Clinically, these skin changes produce a lax, dull, atrophic, blotchy,
and irregularly pigmented appearance. Clearly these inevitable changes demand
surgical procedures as well as adjunctive techniques to complement surgical success.
With that in mind, there are speci c nuances with certain modalities that merit
separate consideration before we discuss their application by anatomic area.

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AUTOLOGOUS FAT TRANSFER
We have long been able to move autologous fat from one site to another. However,
until recent advances in our understanding of this procedure, the results were often
doomed to failure by resorption of the transferred fat within the rst few months.
In fact, we often still hear from patients the common belief that fat grafting lasts
only a short time. In reality, we are now capable of permanent results that show lit-
tle short-term resorption. Of course, there is some variability, as will be discussed;
however, a good rule of thumb is that the clinical improvements visible at 3 months
after autologous fat transfer should remain inde nitely. A few caveats deserve spe-
ci c mention.
Fat is a living cell. It must be respected as such and handled as atraumatically as
possible.The suction applied to aspiration syringes needs to be kept as low as pos-
sible:a 10 cc syringe with the plunger engaged just far enough to yield fat is ideal.
As a general rule, the aspirated material from suction-assisted lipoplasty is a poor
choice of material, because the majority of the fat cells will be damaged or ruptured
from the high negative pressures generated by the machines.
We prefer to harvest the donor material just before transfer to ensure
living, fresh fat. Frozen fat is already dead and will generally not pro-
vide a long-term correction.
Special instrumentation helps to ensure proper survival of the graft. Collection can-
nulas should keep the fat cell membranes intact and produce tiny pearls or globules
no larger than a few millimeters. This ensures maximal surface area contact of the
graft with the recipient bed and therefore better graft survival.The collected fat can
be centrifuged at very low RPMs or wicked on Telfa strips to separate the associ-
ated blood and serum from the minute intact fatty grafts.1 The injection should
also be a low pressure system, ideally created with 1 cc tuberculin syringes.The in-
jection needles are typically blunt tipped and side injecting to minimize trauma to
the recipient bed. Additionally, the internal diameter of the injection needles should
be matched to the harvest cannula for proper size and less graft injury. Graft place-
ment should be in very small increments (0.05 cc or less) deposited with multiple
passes from several access sites.
Graft donor sites have minimal bearing on graft survival. Regardless of the donor
site chosen, it should be free of previous trauma or surgery and should produce
rich golden fat grafts.Thin, watery aspirates from the donor site do not bode well
for long-term survival of the graft. Our preference for facial grafting requiring less
than 50 cc of harvest is the abdomen or anterior thigh. These sites eliminate the
need for patient repositioning and turning and will generally produce an aspirate of
satisfactory composition and volume.
Assuming all previously discussed components being equal, the biggest factor in u-
encing graft survival is the location of the recipient site. Since fat is moved as a

nonvascularized graft, a good analogy is a skin graft.When discussing recipient sites,
the best survival is obtained when fat grafts are placed into well-vascularized beds
with little or no motion. In the face, the mouth is constantly moving during facial
expression, eating and drinking, and conversation. Consequently, the closer to the
mouth a graft is placed, generally the poorer is the survival. Fat grafts to the lips and
marionette lines have high resorption rates;fat grafts to the nasolabial folds have an
intermediate survival rate; and grafts placed in the relatively nonmobile and well-
vascularized malar and periorbital regions have the highest survival rate. Grafts
placed subcutaneously do not fare as well as grafts placed into muscle or on the sur-
face of the periosteum.2
In our practice, the typical patient who undergoes fat grafting has it done con-
comitantly with a scheduled operative procedure, not as a separate procedure. Al-
though fat grafting can be performed with the use of a local anesthetic, the patient
and surgeon will be more comfortable with sedation or general anesthesia. Patients
who are not undergoing a surgical procedure are generally offered other options.
Fat is commonly used as either a pure ller to replace the lost facial volume that is
inevitable in the aging process of the malar region or as a pure ller to the isolated
depressions commonly seen in the nasolabial fold and tear troughs.
Practitioners who are beginning to incorporate fat grafting into their practices will
do well to study the concepts presented here in more detail.The reference section
contains a wealth of information, and one should ideally spend some time with an
expert in fat grafting to gain the experience required to master this powerful tool.3
RESURFACING TOOLS: DERMABRASION,
LASERS, AND PEELS
With the emergence of laser resurfacing in the 1990s, dermabrasion has increasingly
become a lost art. Lasers are modern and computerized and thought by the public
to be the final word when applied to nearly any surgery. True, dermabrasion is
messy, and there are no standard “settings” to be taught in a weekend laser course.
Rather, the expertise is learned and clinical judgment and technique are more crit-
ical. Early generation CO 2 lasers were quite effective around the mouth but had ex-
ceptionally long erythema phases and too high an incidence of posttreatment hy-
popigmentation.The evolution of the Erbium Sciton laser has greatly reduced these
side effects.4,5 The paradox is that with the advent of machines that create less tis-
sue damage and have shorter healing times and erythema phases, the ef cacy has
also diminished in eradicating moderate and deep rhytids, particularly in the peri-
oral region.
Phenol peels remain an excellent means for correcting severe rhytids and pigmen-
tation problems in properly selected patients. However, with the current array of
choices for facial resurfacing, phenol peeling has been largely relegated to histori-
cal signi cance.Trichloroacetic acid peels remain a very effective modality for treat-
ing super cial wrinkles and pigment problems.6,7
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This 51-year-old woman underwent treatment of her aging face with resurfacing
tools for upper lip rhytids and moderate sun damage. She is seen 6 months after
treatment with 35% trichloroacetic acid face peel and synchronous upper lip derm-
abrasion.
Dermabrasion in our practice remains the workhorse for moderate to severe peri-
oral rhytids in properly selected patients. Although dermabrasion results in a higher
incidence of posttreatment hypopigmentation, it remains our modality of choice in
moderate to severe perioral rhytids in Fitzpatrick I, II, and III patients. In such cases
Erbium Sciton lasers are gentler on the melanocyte but are signi cantly less pow-
erful in eradicating lines around the mouth. We use a small electrically powered,
motor-driven, hand-held unit. One distinct advantage is the unit’s portability. A
surgeon who operates in several facilities may be disappointed by the lack of avail-
ability of a laser from place to place.The RPMs are kept low (12,000 to 15,000) for
a gradual, even wound.The abrading heads are interchangeable, and ner grits al-
low the surgeon to progress at a more even and comfortable pace.The depth should
be taken no deeper than is required to eradicate the lines. Generally, this is the mid
to deep dermis for moderate to severe lines, respectively. Clinically, this is recognized
by a pinkish-red color and a rough grainy appearance of the wound. Bleeding is
pinpoint and sparse within the super cial dermis and progresses to brisk bleeding
on a rougher, redder background as the papillary dermis is approached. Universal
precautions should be employed, because the aerosolized particulate matter is capa-
ble of transmitting hepatitis and HIV. All resurfaced wounds are occluded with a
petroleum-based ointment, regardless of whether they are produced with chemicals,
lasers, or dermabraders. Patients who are undergoing facial resurfacing should have
prophylaxis against herpes viral outbreak, whether the patient has a history of her-
pes or not.8,9

Note the pretreatment appearance of this 71-year-old woman with severe perioral
rhytids. Her result is seen 8 months after extended perioral dermabrasion to the
papillary-reticular junction. Note that dermabrasion, like other resurfacing modal-
ities, is more effective on the upper lip than the chin pad complex.
When a laser is chosen for resurfacing, we currently use the Erbium Sciton laser. It
is ideal for the more super cial lines around crow’s-feet and lower lids. Because it
is a nonmechanical, no-touch instrument, it can be used safely around the eyes.
Full-face applications are superb for super cial to moderate rhytids and for pig-
mentary irregularities from sun damage or aging. However, full-face applications of
any agent during rhytidectomy should be discouraged. Staged procedures that sep-
arate face lifting from full-face resurfacing will prevent slough from injury to the
skin ap’s vital blood supply.10-13
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This 53-year-old woman shows aging and sun damage. Her concerns were pig-
mentation and abnormalities and generalized ne lines. She is shown 3 months af-
ter Erbium Sciton laser resurfacing.This treatment delayed her need for rhytidec-
tomy for several years.

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INJECTABLES: BOTULINUM TOXIN AND FILLERS
Botulinum toxin type A is a puri ed neurotoxin complex produced from Clostrid-
ium botulinum type A. It blocks neuromuscular transmission by binding to acceptor
sites on motor nerve terminals, entering the nerve terminal and inhibiting the re-
lease of acetylcholine.This results in localized reduction in muscle contraction and
activity.
Each vial of Botox Cosmetic (botulinum toxin type A; Allergan, Inc., Irvine, CA)
contains 100 units of the neurotoxin, 0.5 mg of human albumin, and 0.9 mg of
sodium chloride in a sterile, vacuum-dried form without a preservative.We recon-
stitute each vial with 2.5 ml of 0.9% sterile saline solution without a preservative.
A 30-gauge by 1⁄2-inch needle attached to a Terumo non–Luer-Lok tip tuberculin
syringe is used for injection. The amount injected for treatment will be discussed
in the anatomic discussion.
Currently, Botox Cosmetic is FDA approved for treatment of the frown lines be-
tween the brows.14 In addition to treatment of the glabellar lines, we will discuss us-
ing Botox for other lines on the face. The role of Botox used to inactivate certain
muscles of the face to obtain the resultant reciprocal action that is blocked is of great
use when rejuvenating and shaping certain aspects of the face. Botox injections last
an average of 3 months.We will also address off-label uses,including treatment of the
forehead, crow’s-feet of the lateral canthal area, and the perioral region.15
A multitude of llers ranging from nonpermanent to permanent and autologous to
nonautologous are available to correct volume loss in the aging face.The injectable
llers, other than the previously discussed fat, include collagen, hyaluronic acid, lac-
tic acid, calcium hydroxylapatite, and silicone. Our filler of choice is Restylane
(Medicis Aesthetics, Scottsdale, AZ), a brand of hyaluronic acid injectable gel.
Hyaluronic acid is a glycosaminoglycan that consists of regularly repeating nonsul-
fated disaccharide units of glucuronic acid and N-acetylglucosamine.
Restylane is a nonanimal, terminally heat-sterilized and stabilized hyaluronic acid
suspended in physiologic buffer at a pH of 7.0. The concentration is 20 mg/ml,
available in differing amounts in pre lled syringes. It is currently indicated for mid
to deep dermal implantation for the correction of moderate to severe facial wrin-
kles and folds, such as nasolabial folds.16 The current indication is limited to 1.5 ml
per treatment site. It is packaged for single patient use in disposable glass syringes
with a Luer-Lok tting.The sterile needle included in the packaging is a 30-gauge
by 1⁄2-inch. If the skin is particularly thick or repeated injections are required, the

needle can be changed to a separate sterile needle of the same size.17 Ideally, Resty-
lane is injected into the dermis or immediately subdermal. Per the package insert,
the duration is thought to be less when Restylane is injected too deep or intra-
muscularly, but depth is variable, depending on the area to be treated, such as tear
troughs and lips. On average, Restylane injections last 6 months, but the longevity
of effects differs among patients, the area injected, and the technique of the injec-
tor. Patients may return as soon as 2 months later or more than a year later to be
reinjected. It should be discussed with the patient that full correction must be
achieved before a return visit for reinjection is considered maintenance. Some of
the uses and volumes discussed are off-label uses of Restylane.
When Restylane is injected into the dermis, not only does it correct or efface the
wrinkles or folds being injected, it can also create increased turgor to the skin,
hence increasing the support and ability of the tissue to withstand compressive
forces. To obtain this effect, the proper technique is usually a crosshatching or an
overlapping pattern. This technique can act as a foundation or form a buttress in
certain areas, allowing the skin and surrounding tissues to combat the effects of the
weight of aging and sagging structures. An example would be the prejowl area of
the labiomental groove (marionette line) that has formed from the weight of the
jowl, or the nasolabial fold that has deepened by the weight of the malar unit.18
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This 50-year-old woman requested nonsurgical rejuvenation.We performed Resty-
lane injections to the vermilion border, oral commissures, nasolabial folds (Type
IIIb), and marionette lines. A total of four syringes of Restylane were used in two
separate sessions 6 months apart.

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This 73-year-old woman had undergone a rhytidectomy and perioral dermabrasion
several years earlier. Resurfacing techniques were not an option for this particular
patient because she had limited available downtime and was reluctant to undergo
surgery because of anesthesia risks and medical issues. Restylane injections to the
oral commissures, nasolabial folds (type IIIa), and marionette lines were performed
to rejuvenate the perioral area.
THE BROW AND EYELID REGION
People communicate verbally and nonverbally while making eye contact. Aside
from color, eyes vary little between individuals. It is the soft tissues surrounding
the eyes that impart expression: sadness, joy, surprise, youth, tiredness, and so on. It
follows that direct surgical and adjunctive techniques strive to favorably change
these soft tissues to impart added youth, softness, and a rested appearance.
Upper and lower lid blepharoplasties, either alone or in combination with face and
brow procedures, have their shortcomings. Frequently, Botox, fat grafting, and laser
resurfacing are used concomitantly to improve the surgical result.
Transverse forehead lines can be treated by a multitude of options: brow lift, laser,
chemical peel, Botox injection, or dermal llers. The wrinkles form from the re-
peated activation of the frontalis muscle, together with the deterioration of the skin’s
inherent structure and support.When the surgeon is assessing the patient for treat-
ment of these lines,consideration of the patient’s expectations and a full examination
are critical.This examination includes the resting tone of the forehead musculature,
degree of brow ptosis, excess eyelid skin, symmetry, lid ptosis, and other factors.
Brow positioning, shaping, and ptosis can be addressed with both brow lift and
Botox injections. If signi cant ptosis of the brow presents as the patient’s primary
complaint, a brow lift is indicated. In these individuals, the wrinkles most likely re-
sult from compensatory frontalis muscle activity to raise the ptotic brow or compen-
sate for excess upper eyelid skin. If this is not clinically recognized preoperatively or
before injection, it will certainly worsen if treated solely by Botox injections.

Patients who are good candidates for Botox injections alone are those with trans-
verse wrinkles caused by the activity of the frontalis muscle from expression such
as openness, surprise or interest or as habit.These patients are good candidates for
Botox alone because no signi cant brow ptosis may be underlying and they are
seeking treatment of the lines only.
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Note this patient’s face at rest before and after Botox injections (1.5 cc total) to
the glabella, forehead, and crow’s-feet.The patient had some degree of compensa-
tory frontalis muscle activation. The results reveal improved shaping of the brow
from the slight depression of the medial brows, signi cant elevation of the lateral
brows, and inactivation of the forehead/ frontalis. Note the correction of the upper
eyelid skin excess.
In a borderline patient, a certain extent of brow ptosis can be corrected or camou-
aged with Botox injection.This is the patient with minimal brow ptosis, with or
without transverse rhytids. A certain amount of brow elevation can be obtained by
injecting the brow depressors concurrently with frontalis injections.This not only
treats the rhytids, but also gives the illusion of brow elevation, if performed in the
correct patient. The depressors of the brow that can be inactivated with Botox,
hence yielding elevation, are the procerus, corrugators, and the orbicularis oculi. By
injecting these areas in conjunction with the frontalis, the surgeon can effectively
treat the transverse furrows and elevate the brow or at least not cause brow ptosis.
When performed in a good candidate, a certain amount of shaping can be achieved
in these patients. An elegantly shaped feminine brow is arched, with its superior-
most aspect at the junction of the lateral two thirds of the brow.This shaping, which
can be accomplished in conjunction with the treatment of the wrinkles and brow
ptosis, is a much-desired effect for most female patients.
Complaints regarding the glabellar area are commonly related to the presence of
wrinkles at rest and/or during muscle activity. These wrinkles may be vertical,
oblique, or horizontal. If the wrinkles are not present at rest, then the patient most
often complains of the concerned, furrowed, frowning, or angry look associated

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with activation of the corrugators and/or procerus muscles. By inactivating these
muscles, Botox injection to this area treats the lowering of the eyebrows that the de-
pressor muscle groups produce and combats the medialization of the corrugators.
Hence the medial brow is elevated, and the brows are lateralized. This desired ef-
fect is one that patients perceive as “opening” of the periorbital area.
If the rhytids of the glabellar area have been present for quite some time and are
deep, Botox injection alone will not be an adequate treatment, and a ller may
have to be used in conjunction.We prefer to perform the Botox injection rst and
allow adequate time (2 weeks) for this to take effect. This allows the skin to re-
spond to the decreased muscle activity and the resultant defect presents itself.The
ller of choice can then be precisely injected. Fat grafts in this area are often not
precise enough to treat the dermal defect/component for some patients;thus Resty-
lane is the ller of choice for augmenting this area.
Excision of the muscle groups in this area during brow lift or blepharoplasty, includ-
ing the corrugators and procerus, has been successful in treating hyperactive mus-
cles. But complete excision of bulky muscles may not be an option, especially if re-
moving too much muscle may result in a defect or contour irregularity.Thus partial
excision may be indicated, or in the event the muscle does reform and reactivate,
Botox may be required to maintain the desired look and the inactivity of the muscle.
There are surgical remedies for the crow’s-feet associated with lateral orbicularis
function, but these treatments tend to be aggressive and fraught with return of
muscle function and thus return of the deformity. We prefer to use either laser
resurfacing or Botox injection. At times, we use both.The decision rests largely in
the discussion between patient and surgeon. Paralysis of the orbicularis function by
Botox injection during the healing and collagen proliferation phase of laser resur-
facing may help the long-term result that can be produced with laser treatment.
Laser resurfacing to treat crow’s-feet is generally chosen for a patient undergoing a
surgical procedure for which he or she intends to invest a few weeks of recovery—
blepharoplasty, brow lift, and/or face lift—the logic being that the patient is recu-
perating and out of circulation anyway.Women can cover the reepithelialized laser
wound with makeup in 10 days. Men who must return to the public eye sooner
than the 6 to 8 weeks required for postlaser erythema to resolve may well be bet-
ter candidates for Botox injections.
Although laser treatment of crow’s-feet produces a more long-term solution than
Botox injection, return of the deformity within the rst year or two following laser
treatment is not uncommon.The orbicularis muscle continues to function and the
lines will, at some point, form again. Costs are generally a wash: 12 to 24 months
of Botox treatment will run about the same as periorbital laser resurfacing.
The lateral periorbital rhytids that appear lateral to the eye and near the temple re-
spond well to Botox injections. One of the bene ts of injecting the lateral aspect of
the crow’s-feet, as mentioned previously, is that this can result in elevation of the lat-

eral eyebrow.The injections to this area inactivate the depressing action of the or-
bicularis oculi muscle because it is a natural brow depressor in this location. Thus
treatment of crow’s-feet and lateral brow ptosis can be accomplished with Botox.In-
jections to treat the wrinkles inferior to the eye can be fraught with problems.The
appearance of “swagging” is from “chasing” the wrinkles from lateral to the eye to
inferior to the eye that the patient may ask for and that an inexperienced injector
is tempted to perform.This will mimic a malar bag after the Botox has taken effect.
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This patient shows a smiling expression before and after Botox injections to the
glabella, forehead, and crow’s-feet (1.5 cc total). Note the improvement of the
crow’s-feet with expression, but not full correction or inactivation.
The tear trough deformity commonly seen in the lower lid is produced by attenuation
and weakening of the septum orbitale, which allows the lower lid fat to present as
a bulge above the orbital rim together with thinning of the skin, orbicularis mus-
cle, and subcutaneous fat along the rim itself.This produces the characteristic tear
trough deformity seen with the aging lower lid. Frequently, the appearance of a
volumetrically enlarged orbit may also be present. Removal of fat from orbits that
already appear to be empty may further exacerbate the appearance of aging.Today
there are many techniques that preserve orbital fat, preserve and turn the fat pads
over to cover the rim, and even procedures to lift the entire lid/cheek complex.
These surgical variants all seek to preserve fat and favorably reposition tissues to
cover the tear trough while maintaining a low, youthful orbital volume.
An excellent (and simpler) alternative is to perform conservative lower lid fat ex-
cision and reestablish lower lid soft tissue cover with fat grafting. Indeed, in pa-
tients over 40 years of age and in almost all cases of visible tear trough deformity,
fat grafting is used as a routine part of our lower lid blepharoplasty. Fat is trans-
ferred as previously described, with a few important variations. The lower lid tear
trough is one of the places on the face where one can count on a nearly 100%
“take” of the fat graft. Fat injections must be exact, with no overcorrection of the
depression. The surgeon should stay just on the bone hugging the surface of the
periosteum, deep to the orbicularis muscle. Grafts placed intramuscularly or in the
subcutaneous plane may be visible.

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This patient had lower lid nasal and central fat pad prominence, with the character-
istic tear trough deformity.The patient is shown 6 months after upper and lower lid
blepharoplasty with conservative fat excision. She also had fat grafting of the tear
troughs and malar complex.The mouth was restored by upper lip laser resurfacing
and Restylane injections to the upper lip and type Ia nasolabial folds.
This woman is shown 8 months after lower lid blepharoplasty and fat grafting to the
tear troughs. Note the visible bulge of the graft along the right orbital rim in the
tear trough.This resulted from too super cial a plane of deposit. Grafts here should
be kept deep just on top of the periosteum.
Typically, no more than a few tenths of a cubic centimeter is adequate. Overgraft-
ing or malposition that is recognized during transfer can be softened by massage
both during the procedure and in the immediate postoperative period.Visible grafts
that are recognized after they are well established become more problematic.Vig-
orous massage, combined with ultrasonic therapy or injection of a very dilute
steroid agent, may be helpful. Surgical excision is dif cult and should be considered
a last resort.

Hyaluronic acid may also be used to correct a tear trough.This is a good option for
a patient who wants minimal downtime or who has just the beginnings of a tear
trough that may not require signi cant enhancement. Generally, reinjection is re-
quired to maintain the correction, but the product tends to last longer in this loca-
tion than when injected in other areas.Tear trough implants present another choice
for permanent correction but have their own subset of issues.
The malar area is subject to the changes of aging. Commonly, the tear trough graft
is carried out laterally as far as required to soften the rim and reestablish lost vol-
ume and obliterate the skeletonization (see p. 390).
Similarly, tear trough grafts continue inferiorly and are blended with malar grafting
to complete the lower lid/orbital rim/malar complex rejuvenation. Loss and de-
scent of malar fat with aging produces the classic midface de ation. The youthful
triangular shape created by the mandibular-malar relationship is replaced by a rec-
tangular aged and de ated appearance. Face lifts and procedures for the “central
oval” have blossomed to address the problem of midface descent and volume loss.
Most procedures have varying success. Malar grafting has been routinely incorpo-
rated into our face-lift regimen for the last 8 years.19
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This patient shows the typical findings in facial aging 8 years after a primary
rhytidectomy. Note the redescent of the malar and jowl fat pads, producing a de-
faulted rectangular appearance. She is shown 9 months after secondary rhytidec-
tomy with fat grafting to the malar, marionette, and nasolabial folds.
The technique described in this chapter is used.The plane of deposit is as close to
the periosteum as possible on the malar complex. The anterior process of the zy-
gomatic bone is followed as far posterolaterally as required. Feathering into the
muscle, fascia, and even subcutaneous planes may be required in some presenta-

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tions.The volume of grafting varies greatly and may be as little as 2 to 3 cc and as
much as 20 to 25 cc or more per side. Asking patients to bring in photographs of
themselves when they were in their twenties or thirties may be helpful in determin-
ing the volume and precise location of grafting sites.The surgeon can count on ex-
cellent “take” in the malar region because of the reliable vascularity and relatively
immobile bed of the site. The malar region is one of the most forgiving, and also
the most rewarding. Because injection with autologous material in this area is rel-
atively simple and is long-lasting, the use of cheek implants, with their associated
costs and problems, is a second choice. Other llers such as hyaluronic acids have a
place for patients who are not undergoing general anesthesia, but their drawback
continues to be their relatively brief effectiveness.
THE PERIORAL REGION
The nasolabial fold is perhaps the single most common region pointed out by pa-
tients who seek surgical rejuvenation of the aging face.This area is a watershed re-
gion of aging. Many factors affect and compound the appearance of the nasolabial
folds;thus many treatments serve to improve them. Most face lifts are conceived to
improve the nasolabial folds, but in reality, success in this region can frequently be
elusive and incomplete. Results of surgery can fall well short of both the surgical
plan and patient expectations.Thus the nasolabial fold is an area in which adjunc-
tive techniques can dramatically improve success.
This 64-year-old woman had undergone a rhytidectomy several years earlier. Resur-
facing techniques were not an option for this patient,because she had limited down-
time available and required a rapid recovery. Restylane was injected into the na-
solabial folds (type IIIa), oral commissures, vermilion border, and marionette lines.
Almost every adjunctive treatment in this chapter, excluding botulinum toxin, is a
reliable tool for improving the nasolabial fold.The adjunctive method (or methods)
chosen will depend on the speci cs of the fold, the skill set of the surgeon, and the
choices of the patient.

We classify folds into three basic categories to help analyze the problem and to bet-
ter organize the discussion of treatments.Type Ia patients have nasolabial folds that
are little more than creases in the skin, similar to a rhytid. It originates at the alar
crease and is limited to at or above the oral commissures. These patients have little
or no valley beneath the crease and the defect is relatively two-dimensional.They are
ideal for either Restylane injection or resurfacing, because the defect is not substan-
tially volume de cient, and this category of fold will respond poorly to face-lifting
techniques. Fat grafting in these individuals may efface the crease, but without a val-
ley to ll, the graft may become visible as a tubular fullness beneath the fold. At the
completion of the face lift, patients with type Ia folds who are not undergoing
resurfacing of any other region are selected for Restylane injection alone. Patients
who are having laser treatment or upper lip dermabrasion will be selected for resur-
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Classi cation of Nasolabial Folds
Type Ia
The fold is a dermal/epidermal rhytid with little or no underlying defect or
“valley.” Type Ia folds are limited regionally between the alar crease and just
lateral to the oral commissure (see below).
Type Ib
Identical to Type Ia, but extends inferiorly below the oral commissure into
the chin pad complex (see p. 394).
Type II
The fold is composed of a visible trough or valley creating a depression with-
out a skin crease of signi cance.Type II nasolabial folds may have redundant
tissue accumulated superolateral to the valley (see p. 394).
Type IIIa
The fold is a combination of type Ia and type II.The defect is a visible, signi -
cant valley with a skin crease in its oor limited from the alar crease to the oral
commissure (see p. 395).
Type IIIb
The fold is a combination of type Ib and type II.The defect is a visible, signi -
cant valley with a skin crease in its oor extending inferiorly into the chin pad
complex (see p. 395).

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facing of the nasolabial fold. Frequently we perform resurfacing followed immedi-
ately by detailing with Restylane while the patient is still under anesthesia. Com-
bination approaches on type I nasolabial folds are very powerful.
This 38-year-old woman disliked the aged appearance of her nasolabial folds and
perioral region. Resurfacing techniques were not an option for this patient because
of her lifestyle, which included daily exposure to the sun and limited downtime.
Restylane injections to the vermilion border, oral commissures, nasolabial folds
(type Ib) and marionette lines were performed to correct and rejuvenate the peri-
oral area. Injections to the vermilion border de ned and reestablished the lip bor-
der and corrected her rhytids.
Type II defects are true valleys with no skin crease.There is better success in patients
undergoing face lift for these problems, but generally a volume de cit will still ex-
ist.These individuals are ideal for fat grafting at the time of face lift. Resurfacing is
not applicable here because the problem is beyond the reach of any resurfacing
modality. Of course, Restylane is also an option during the initial operation; how-
ever, we generally use hyaluronic acid for touch-up improvements at 3 to 6 months
in patients who have a persistent fold.

Type IIIa folds are depressions with an associated overlying skin crease limited to at
or above the lateral oral commissure.This patient’s treatment consisted of both ex-
tended SMAS face lifting and fat grafting to the underlying valley of the fold.
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Type IIIb folds are identical to IIIa in appearance but extend more inferiorly to
involve the chin pad complex.This patient was treated with the combined modal-
ities of extended SMAS face lift, fat grafting the nasolabial folds and malar region,
and second-stage full-face CO 2 laser resurfacing.
Type IIIa and IIIb patients, like Type Ia and Ib patients, are candidates for a multi-
ple-modality treatment plan. Typically these patients will undergo face lifting, fat
grafting, and skin resurfacing (see the patient above), with or without Restylane
injections into the dermis of the crease itself. On occasion, if the lip or lower lids
are also being resurfaced, the wound can be carried to encompass the skin fold and
produce additional improvements. Direct excision of type IIIa and IIIb folds in
properly selected patients remains an excellent means of treating these difficult

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problems. This method is generally reserved for severe or refractory folds in male
patients or individuals who do not want formal face lifting. Consideration of direct
excision should be weighed against the type of scar the patient is likely to form. Be-
cause the resultant scar mimics a crease, we are essentially converting a type III na-
solabial fold to the more favorable type I fold.
Severe type IIIa and IIIb patients may be well treated by direct excision. Used pre-
dominantly in males, excision can be a powerful tool for men who desire correc-
tion of the fold without a face lift.This patient underwent upper lid blepharoplasty
with direct excision of the nasolabial folds. No face lift was performed.
There is no right or wrong method. Each patient presents with a
slightly different variation of the nasolabial fold. Likewise, each sur-
geon develops skills and preferences for those unique problems.
Perioral agingcan consist of slight super cial wrinkles that originate in the dry ver-
milion and encroach just across the white roll or may represent extensive perioral
wrinkling with profound volume loss and dermal collapse.With proper selection of
adjunctive procedures, the surgeon can customize treatment based on the individ-
ual patient’s problem.
Patients with more super cial upper lip rhytids can be very well treated with the
Erbium Sciton laser (see p. 390).This laser is chosen when lower lid and crow’s-feet
laser resurfacing is being performed. One tool is easier and the wounds appear and
heal similarly. However, as the upper lip lines become deeper and or the chin pad
and lower lip becomes involved, dermabrasion becomes the preferred tool. Mod-
erate to severe lines, particularly in the lower lip and chin pad, simply respond bet-
ter to the dermabrader (see p. 383).

As a rule, no tool completely eliminates perioral lines, particularly inferior to the
oral commissures.
Dermabrasion results in a higher incidence of postresurfacing hypopig-
mentation than does the Erbium Sciton laser.Thus the surgeon should
take wounds only as deep as they need to go to solve the problem.
These issues should be discussed with the patient. As with all resurfacing tools, as
the baseline pigment in the skin increases, postresurfacing hypopigmentation in-
creases as well.Thus Fitzpatrick III patients may be better approached with the Er-
bium laser, accepting slightly less ef cacy.
If a patient is not a good candidate for resurfacing procedures because of skin type,
lifestyle, sun exposure, or the downtime required, llers should be considered. Cer-
tain aspects are especially amenable to correction or rejuvenation with ller. Loss of
lip volume occurs with age and is usually perceived more in the upper lip than in
the lower lip, especially when the individual is smiling. Additional aspects include
loss of the lip border and pout, which leads to the appearance of an elongated
philtrum/upper lip and a less pouty appearance of the mouth.
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This 38-year-old woman complained of the aged appearance around her mouth.
Two syringes of Restylane were injected to correct the wrinkles, soften and ll the
nasolabial folds (type IIIb), and reestablish volume to the lips.
As mentioned previously, perioral rhytids can be adequately corrected with resur-
facing tools, but the added bene t of llers includes the volume replacement to
the lips, reestablishment of the pout, and the appearance of a shortened upper
lip/philtrum by volume replacement.Vertical rhytids around the vermilion border
can be treated partially and/or completely with llers. Mild to moderate lines are
amenable to treatment by volume replacement or ller placed along the vermilion
border.20 The vertical rhytids may be injected if they are deep enough, with care

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taken to not over ll these, since this may result in a ridge instead of a wrinkle.Very
severe lines may need to be addressed with resurfacing and a ller.21
Another aspect of perioral facial aging is ptosis of the oral commissures. Ptosis in
this area gives the appearance of sadness or anger. Attempts to correct this area with
face-lift procedures can be distorting or incomplete. Perioral rhytids will often
siphon into the marionette lines, and this, combined with the ptosis of the oral
commissure, usually requires multiple corrective techniques.
This 59-year-old woman was bothered by her perioral rhytids, marionette lines, and
the downward turn of her mouth. Restylane was injected in the vermilion border,
oral commissures, and marionette lines to correct and rejuvenate the perioral area.
Injections to the vermilion border reestablished the lip border and partially cor-
rected the rhytids. No injections to the nasolabial folds (Type IIIa) were done.
CONCLUSION
For any challenge in facial aesthetic surgery, there are always several ways to pro-
ceed.The nal decision will be a product of discussion between the patient and the
surgeon. It is a pleasure that today we have a multitude of treatment options that
can be individualized to meet the goals in a more customized fashion.The adjunc-
tive tools discussed in this chapter can create the subtle nishing touches on surgery
that may well be beyond the reach of the scalpel. For each anatomic problem, we
have covered several techniques to improve the overall result. In most situations,
there is not a right and wrong, but rather a surgeon or patient preference.
There are few similarities between this chapter and the original one written for the
rst edition just 11 years ago. We are excited to think that in just another decade
from now, our choices will again be greater and more powerful.

References—With Key Annotated References
1. Kuran I,Tumerdem B. A new simple method used to prepare fat for injection. Aesthetic Plast
Surg 29:18, 2005.
In this report, the authors present their 5-year clinical experience with facial fat grafting by isolated
and combined procedures using a simple method they developed for fat preparation.This technique in-
cludes fat harvesting with syringe aspiration and ltration of the fat aspirate instead of centrifugation.
2. Stuzin JM, Baker TJ, Baker TM. Discussion of Kitzmiller WJ, Visscher M, Page DA, et al. A
controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of peri-
oral wrinkles. Plast Reconstr Surg 106:1373, 2000.
3. Stuzin JM, Baker TJ, Baker TM. Expert commentary on Karp RB, Teimourian B. Laser skin
resurfacing: The high-energy “peel” of the twenty- rst century? Perspect Plast Surg 10:38,1996.
4. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Invited discussion of Perkins SW, Sklarew EC.
Prevention of facial herpetic infections after chemical peel and dermabrasion: New treatment
strategies in the prophylaxis of patients undergoing procedures of the perioral area. Plast Re-
constr Surg 98:434, 1996.
5. Stuzin JM, Baker TJ, Baker TM, et al. Histologic effects of the high-energy pulsed CO 2 laser
on photoaged facial skin. Plast Reconstr Surg 99:2036, 1997.
To delineate the histologic effects of laser resurfacing at photoaged skin, a protocol was designed to
biopsy laser test sites in conjunction with adjacent actinically damaged skin at the time of rhytidec-
tomy. Five patients with photodamaged skin underwent resurfacing of the preauricular region to ex-
amine the effect of increasing pulse energy and increasing number of passes on depth of dermal pen-
etration.The histologic effects of laser resurfacing are microscopically similar to those of phenol peeling
in terms of the amelioration of photodamage.The distinction between these two treatment methods lies
in their apparent effect on epidermal melanocytes, which appear to function normally following laser
resurfacing.
6. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to
midface rejuvenation. Clin Plast Surg 22:295, 1995.
To obtain consistent results, face-lifting should be approached not just as a tightening or lifting proce-
dure but also as a reconstructive procedure, reversing the anatomic changes that occur in aging.The abil-
ity to bring aesthetic harmony back into the aging face requires the blending of surgical technique,
anatomic knowledge, and artistic sensitivity to individualize the surgical approach for a given pa-
tient.To obtain surgical rejuvenation while minimizing signs of surgical distortion remains the ulti-
mate goal of the authors’face-lifting procedures.
7. Fitzpatrick RE,Tope WD, Goldman MP, et al. Pulsed carbon laser, trichloroacetic acid, Baker
and Gordon phenol, and dermabrasion: A comparative clinical and histologic study of cuta-
neous resurfacing in a porcine model. Arch Dermatol 132:469, 1996.
8. Baker TJ.The ablation of rhytides by chemical means: A preliminary report. J Fla Med Assoc
47:451, 1961.
9. Baker TJ, Stuzin JM, Baker TM. Facial Skin Resurfacing. St Louis:Quality Medical Publishing,
1997.
10. Carruthers J, Fagien S, Matarasso SL, Botox Consensus Group. Consensus recommendations
on the use of Botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 114
(6 Suppl):1S, 2004.
The use of botulinum toxin type A for facial enhancement is the most common cosmetic procedure cur-
rently undertaken in the United States. Overall clinical and study experience with botulinum toxin type
A treatment for facial enhancement has con rmed that it is effective and safe in both the short and long
term. Nevertheless, consistent guidelines representing the consensus of experts for aesthetic treatments of
areas other than glabellar lines have not been published.Therefore a panel of experts on the aesthetic uses
of Botox Cosmetic was convened to develop consensus guidelines.This publication comprises the recom-
mendations of this panel and provides guidelines on general issues, such as the importance of the aesthetic
399
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evaluation and individualization of treatment, reconstitution and handling of the botulinum toxin type
A, procedural considerations, dosing and injection-site variables, and patient selection and counseling. In
addition, speci c considerations and recommendations are provided by treatment area.The review of each
area encompasses the relevant anatomy, speci cs on injection locations and techniques, starting doses (to-
tal and per injection point), the in uence of other variables, such as the patient’s sex, and assessment and
retreatment issues. Factors unique to each area are presented, and the discussion of each treatment area
concludes with a review of key elements that can increase the likelihood of a successful outcome.
11. Botox Cosmetic (botulinum toxin type A) purified neurotoxin complex (package insert).
Irvine, CA: Allergan Inc., Jan 2005.
12. Stuzin JM, Baker TJ, Baker TM. CO 2 and erbium:YAG laser resurfacing: Current status and
personal perspective. Plast Reconstr Surg 103:588, 1999.
13. Baker TM. Chemicals and lasers for skin resurfacing. Aesthetic Plast Surg J 19:325, 1999.
14. Baker TM. Dermabrasion. Clin Plast Surg 25:81, 1998.
Dermabrasion remains an effective and reliable resurfacing option for perioral rhytids, acne scars, trau-
matic facial scars, and rhinophyma. It is inexpensive, portable, and widely available. It is well taught
in most plastic surgical training programs and therefore does not require expensive secondary training
courses. Dermabrasion requires no specialized accessory equipment and poses no re hazard in the op-
erating room. Extensive literature and clinical experience document its ef cacy. Proper patient selec-
tion and recognition of planing depth are both essential to successful outcome. Despite the recent pop-
ularity of the carbon dioxide laser, dermabrasion should remain a fundamental working skill for all
plastic surgeons.
15. Guyuron B. The armamentarium to battle the recalcitrant nasolabial fold. Clin Plast Surg
22:253, 1995.
16. Matarasso S, Carruthers J, Jewell M, Restylane Consensus Group. Consensus recommenda-
tions for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast
Reconstr Surg 117(3 Suppl):3S; discussion 35S, 2006.
17. Ergun SS, Cek DI, Baloglu H, et al.Why is lip augmentation with autologous fat injection less
effective in the vermilion border? Aesthetic Plast Surg 25:350, 2001.
18. Restylane injectable gel (non-animal stabilized hyaluronic acid [NASHA]) (package insert).
Scottsdale, AZ: Medicis Aesthetics, Jan 2005.
19. Hester TR, Codner MA. Discussion of Gunter JP, Hackney FL. A simpli ed transblepharo-
plasty subperiosteal cheeklift. Plast Reconstr Surg 103:2036-2039, 1999.
20. Fulton JE, Parastouk N. Fat grafting. Dermatol Clin 19:523, 2001.
Autologous adipose tissue has been used for tissue augmentation for more than a century.The tech-
nique still remains controversial, and some investigators have given up on fat transfer.The authors’ob-
jective is to improve the retention of the fat graft by using less traumatic methods to collect the fat, con-
centrate it, and reinject it to obtain more reliable augmentations for the cosmetic improvement of tissue
defects. Other than bruising, a rare case of bacterial infection, or an occasional divot at the donor site,
autologous fat transfer has proved a useful method to improve contour defects.
21. Baker TJ. Chemical face peeling and rhytidectomy: A combined approach for face rejuvena-
tion. Plast Reconstr Surg 29:199, 1962.

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1. Brow shaping cannot be manipulated by which muscle?
a. Corrugators
b. Frontalis
c. Procerus
d. Orbicularis oris
2. Perioral rhytids can be addressed with which of the following?
a. Erbium laser
b. Dermabrasion
c. Restylane
d. Dermal ller
e. All of the above
3. Nasolabial folds:
a. Can always be corrected with rhytidectomy
b. Can always be corrected with fat grafts
c. Can always be corrected with resurfacing
d. None of the above
4. Fat injections:
a. Always survive 100%
b. Should always be overgrafted
c. Survive equally regardless of the recipient site
d. Should be injected with a 30-gauge needle
e. None of the above
5. A nasolabial fold that has no signi cant skin crease is:
a. Type Ia
b. Type Ib
c. Type II
d. Type IIIb
R EVIEW QUESTIONS

(Trang không có chữ)

403
IATROGENIC AESTHETIC DEFORMITIES
OF THE LOWER EYELID AND CHEEK
It has long been assumed in plastic surgery that removal of the signs of aging in the
eyelid and cheek would rejuvenate our patients’aging faces. Surgeons extensively
trained in the nuances of blepharoplasties and cheek lifts have operated under the
premise that excising lower eyelid fat pads, ironing out the skin wrinkles, and at-
tening or skeletonizing the cheek would restore youthful contours. However, rather
Revisional Fat Grafting
of the Cheek and Lower Eyelid
Sydney R. Coleman
C ha pter 16
Reoperative Problems
Excessive orbital fat excision
Tear trough depressions after fat
excision
Inadequate excision of lower eyelid fat
Scleral show
Malpositioned lower eyelid
Persistent eyelid rhytids
Hyperpigmentation after
blepharoplasty
If you don’t have time to do it right,
when will you have time to do it over?
John Wooten
Deeper pores after blepharoplasty
Residual malar fat pad
Inadequate cheek shape or volume
Asymmetry of cheeks after face lift
Asymmetry of cheeks after silicone
implants
Visible silicone cheek implants
Deformities of cheek size and shape
after excision or suctioning

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than rejuvenating, these procedures sometimes deformed these areas, transforming
their appearance into something that is neither old nor young. This chapter ex-
plores the correction of lower eyelid and cheek deformities secondary to proce-
dures designed to enhance and rejuvenate these areas.1,2
AESTHETIC CONSIDERATIONS
Although the perception of a beautiful cheek varies among different cultures, most
consider a full cheek with distinct projection of the upper malar cheek to be the
most attractive con guration.The green line in the lateral face marks the most promi-
nent protuberance of the attractive cheek.This ridge begins in the midmalar region
and runs posteriorly along a line drawn from the alar base to the base of the helix.
Immediately cephalic to this line, the cheek gently curves inward to merge into the
temple or into the lower eyelid. Caudal to this line, the malar cheek gradually slopes
inward to form the buccal cheek. As the cheek slopes from the malar prominence
to the eyelid in a youthful attractive cheek the fullness continues up until about
4 or 5 mm below the base of the eyelashes. At this level, a slight depression about
2 mm wide leads into the fullness that runs the length below the lower eyelashes.
This depression and the fullness cephalic to it are more obvious on smiling.
The anterior malar region in the young person is an area of variable fullness, sim-
ilar to the fullness seen in the midmalar region.This fullness is considered attractive
and youthful. Emptiness or a hollow appearance in this area, especially in the up-
per anterior malar along the tear trough region produces a tired and sad appearance,
even in a young person.

NORMAL AGING
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Because malar cheek prominence occurs at the location of the boney cheek (the
zygomatic arch), this prominence remains in the same location throughout most
people’s lives. As fullness is lost in the cheeks, the skin drapes over the remaining fat,
muscle and bone the exact shape of the zygomatic arch and other bones become

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more obvious and the subtle fullness that separates the facial muscles from the skin
of the cheeks dissipates. Removing this physical stint of fullness has two obvious ef-
fects. First, the intrinsic tone of the orbicularis oculi muscles on the overlying skin
becomes more prominent. Without the physical barrier of subcutaneous fullness,
the resting orbicularis oculi muscles affect the skin by forming crow’s-feet. Sec-
ond, as the fullness of the lower eyelid dissipates and the skin is in closer proximity
to the dark muscle and darker veins, the color of the thin eyelid skin darkens.
As the lower eyelid ages, the subcutaneous fullness of youth no longer hides the
anatomical infraorbital contents. Muscles, fat and bones emerge to create a differ-
ent topography in the region. The minimal transverse depression described above
running slightly under the eyelashes deepens with age to extend down often to
the infraorbital rim. As the fullness ebbs from this area, infraorbital fat pads, which
were hiding under the youthful fullness, begin to emerge. Depending on the loca-
tion and size of these fat pads, significant deformities (affectionately known as
“bags”) can appear. This process has been improperly described as “herniation” in
the past. However, this is not a weakening of the orbital septum; rather it is the
natural loss of fullness that exposes the fat pads, which were always there. As the fat
emerges, depressions form around the bulge.These typically are located in the tear
trough in an oblique line running from the lateral nose at the level of the medial
canthus down to the anterior malar cheek below the middle of the eyelid.
As fullness is lost from the lower eyelids, the globe and orbital contents become
more isolated from the surrounding face.3 Even though some enophthalmia oc-
curs with aging, there is more loss of the surrounding orbital contents, so the globe
becomes isolated from the boney orbital rim and the rest of the face. The loss of
fullness of the malar prominence will result in a less youthful and healthy facial
proportion, with the jowl area becoming more obvious. As this loss in fullness of
the midface occurs, the malar prominences can become skeletonized, and progres-
sive buccal hollowing further skeletonizes the face.
Loss of facial fullness is a normal process. It can make a face appear more angular,
but it also can make a face look anorexic or unhealthy. Adding dramatic fullness to
the buccal area and feathering up into the lower eyelids creates a healthier appear-
ance.4-7 Removing fullness accentuates the problem.

EVALUATION AND TREATMENT
R ESTORING FATTY TISSUE
Generalized, diffuse loss of fullness from the lower eyelid and cheeks occurs most
commonly with advancing age.This is not necessarily fat. However, a lack of fatty
tissue can occur in iatrogenic or drug-related situations, and occasionally the cause
is idiopathic.
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This patient presented after a face lift that further skeletonized her face. Her friends
felt that she looked as if she had a terminal illness after the procedure. One year af-
ter one fat grafting session to the buccal cheeks, feathering up onto the malar
cheeks and lower eyelids, the patient appears much healthier.

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PROVIDING LOW ER EYELID SUPPORT
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Depending on the patient’s intrinsic anatomy, along with his or her previous pro-
cedures and scarring, adding support to the lower eyelid and cheek can also elevate
the position of the lower eyelid to relieve scleral show, as was done in this patient,
who presented with scleral show and wrinkling of the lower eyelids after a
transconjunctival lower blepharoplasty. He is shown 3 years after one session of
structural fat grafting over the cheeks and the eyelids up to the ciliary margin of the
lower eyelid. A dramatic elevation of the lower eyelid diminishes his scleral show.
Note the softening of his wrinkles and lling of the infraorbital troughs.

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IMPROVING NORMAL EYELID COLOR AND TEXTURE
With loss of subcutaneous fullness in the infraorbital region, the thin skin of the
lower eyelids wrinkles and the color of the orbicularis oculi muscles and blood
vessels can be seen through this thinned, poorly supported skin. Restoration of full-
ness to the lower eyelids and cheeks will soften wrinkles and crow’s-feet and can
lighten infraorbital darkness.
In areas of thicker skin of the periorbital region, pores can deepen with loss of full-
ness. When the pores deepen enough, they will begin lining up into wrinkles.
Restoration of fullness will lessen the size of the pores and stop the deepening pores
from lining up into wrinkles.
This woman complained that after an upper and lower blepharoplasty she was left
with deep troughs running through her lower eyelids and cheeks that were worse
than before the procedure. Fourteen months after the second of two fat grafting
procedures, she has remarkable lightening of her skin with lessening of her pore size
in the thick skin of her anterior malar region.

Using a ring ash further delineates the improvement in pore size and con gura-
tion as well as in color and shape of the lower eyelids and cheeks. In this patient, as
in others, the signs of aging may be exaggerated by lower lid blepharoplasty when
lower eyelid fat is removed, thereby emphasizing the progressive loss of fullness and
further deepening the infraorbital region.7 When the swelling from the blepharo-
plasty has subsided, the lower eyelid can be left with increased wrinkling, deeper
pores, deeper infraorbital troughs, and a malpositioned lower eyelid, as was evident
in the patient pictured above.
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Restoration of Fullness to the Lower Eyelid
and Cheek
1,8-10
PREPARATION FOR HARVESTING
CHOICE OF HARVESTING SITE
Since I have observed no clear correlation between donor site location and longevity
of the implanted tissues, I select harvesting sites that enhance body contour and
provide maximal accessibility to the patient in the supine position, which is the
position used for almost all facial augmentation procedures. I most commonly use
the abdomen and medial thighs as donor sites.
When there is a paucity of abdominal or medial thigh fat because of prior liposuc-
tion or low body fat levels, the suprapubic region, the anterior thighs, and the area
above the knees are the next choices. If the patient is placed in the prone position,
the posterior medial thigh, the lateral thigh, and the love handles are primary op-
tions for donor tissue.
The abdomen and love handles are the most common donor sites in men. As in the
previous patient, I remove extra tissue from the central midline abdomen and ab-
dominis rectus decussations to etch a “six-pack.” In patients with low body fat, es-
pecially men, the abdomen and love handles may consist mostly of brous tissue
with little available fat. Using the thighs as donor sites in these men is an alterna-
tive. Even if there appears to be little fat present, harvesting blindly from the lateral
thigh and inferior lateral buttocks can yield large quantities of fat. Care is taken to
avoid the protuberance of the buttock since unsightly dimpling can result.
PLACEMENT OF INCISIONS
Harvesting sites are accessed through incisions placed in creases, previous scars,
stretch marks, or hirsute areas (circled in red) whenever possible.The pubic region is
the most useful site since the abdomen, medial thigh, and anterior thigh can be
reached with ease.To harvest fat from the upper abdomen and anks, additional in-
cisions can be made in the umbilicus and upper abdomen.With the patient in the
supine position, the knee can be reached through a buttock crease incision. Occa-
sionally an incision in the lateral hip can be used for access to the thigh also as well
as the lower love handle. Incisions in the mid-back and lateral sacrum provide ac-
cess to the love handles and the ank.
STERILE TECHNIQUE
Meticulous sterile technique is always observed with careful attention to preoper-
ative patient preparation with antiseptic soaps and an antiseptic agent such as povi-
done iodine. Bacterial contamination of the fatty tissue can result in infection that
causes resorption of the grafted material.

The choice of anesthesia for harvesting depends on the donor areas and on the pro-
jected volume of fat to be removed.For harvesting smaller volumes,local anesthesia us-
ing 0.5% lidocaine with 1:200,000 epinephrine is adequate.The lidocaine solution is
rst placed into the planned incision site through a sharp 25-gauge needle. Incisions
are then made with a No. 11 blade. A blunt Lamis in ltrator attached to a 10 ml sy-
ringe is used to in ltrate the lidocaine solution into the projected sites of fatty tissue
removal. Usually 1 ml of lidocaine is in ltrated for every milliliter of fat harvested.
Epidural or general anesthesia is preferred for removal of larger volumes or when mul-
tiple sites are used. To ensure hemostasis, Ringer’s lactate in a concentration of
1:400,000 epinephrine is also in ltrated in a ratio of 1 ml of solution for each cubic
centimeter of fat harvested using a blunt Lamis in ltrator. Superwet or tumescent
techniques are not used during the harvesting phase. I believe that the motion of the
harvested fat through large amounts of liquid may break up the parcels of fatty tissue
into even smaller components of tissues and cells.This disruption of the intrinsic tis-
sue architecture will decrease the potential survival of the subcutaneous tissues. If
less than 1 or 2 cc of the harvested material in each syringe is fat,then as many as fty
10 cc syringes may be necessary to obtain 60 cc of fat.This can prolong the procedure
by hours.
HARVESTING
INSTRUMENTATION
Instruments for structural fat grafting should be ef cient and minimally traumatic
to the grafted tissue both during the harvesting and placement phases. A two-holed
cannula with a blunt tip and dull distal openings placed extremely close to the end
is used for harvesting.
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Revisional Fat Grafting of the Cheek and Lower Eyelid
The tip of the cannula is completely blunt and has a shape reminiscent of a bucket
handle. Sharp edges are minimized around the distal openings to encourage har-
vesting of small parcels of fat. The other end of the cannula is attached to a 10 ml
Luer-Lok syringe. The distal openings of the harvesting cannula are the correct
size and shape for harvesting the largest intact fatty tissue parcels that can easily
pass through the lumen of the Luer-Lok syringe.
Lumen

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Parcels that can pass through the lumen of a Luer-Lok syringe will usually pass
through the much smaller (17-gauge) lumen of the in ltration cannulas without
clogging. If open or sharp cannulas are used, the fat may be harvested in long strips,
which are dif cult to in ltrate through a small cannula.
Lumen
The length of the harvesting cannula is usually 15 or 23 cm. On most cases, I nd
that curved harvesting cannulas are helpful for navigating the curves of the thigh
and back or to better angle the cannulas into a super cial or deep plane.
TECHNIQUE
Fatty tissue is harvested through the incisions made for in ltration of anesthetic
solutions. These incisions are just large enough (usually 2 to 3 mm) to permit in-
sertion of the tip of the harvesting cannula.
15 cm
23 cm
Blunt tip
Dull opening
Blunt tip
Dull opening

The inserted cannula is attached to a 10 ml Luer-Lok syringe by the Luer-Lok con-
nection.The plunger is pulled back gently to minimize negative pressure.Only 10 ml
syringes are used for harvesting;these are small enough to be manipulated manually
without locking devices. Larger syringes are more cumbersome, and pulling back
even slightly on the plunger might create damaging negative pressures.
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During the removal of fatty tissue, care is taken to minimize mechanical trauma to
the fragile parcels of fat.
The plunger of the syringe is gently manipulated to provide about
1 or 2 ml of negative pressure space in the barrel of the syringe while
the cannula is pushed through the harvest site.This manipulation can
only be done manually; plunger-locking devices should never be used
during harvesting for transplantation.
The high vacuums created by these devices or by pulling back too far on the
plunger (more than 2 ml) can increase the negative pressure dangerously, potentially
to the point of vaporization, the pressure at which water boils at room temperature,
which may damage the fatty parcels of tissue.
Initially excess uid (from in ltrated local or other solution) may be noted in the
harvested material.When substantial uid is present, the syringe is placed on a table
for several minutes to allow the fatty tissue to separate from the liquid component.
Then the aqueous portion can be expressed by pressing on the syringe. The sy-
ringe with the re ned fat is then reconnected to the cannula and harvesting con-
tinues until a greater quantity of fat has been obtained. This approach permits a
larger amount of re ned fat to be harvested and centrifuged at the same time and
avoids wasting time by centrifuging a number of 10 ml syringes that yield only
1 or 2 ml of usable fatty tissue.
1-2 cc space

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REFINEMENT AND TRANSFER
To predict the volume of fat to be placed, the material in ltrated is mainly viable
fatty tissue. As much of the oil, blood, water and extracellular components should be
removed as is possible without causing signi cant damage to the tissues to be trans-
planted. After the fat has been harvested, the cannula is removed from the syringe
and replaced with a plug. The preferred plug is called a dual-function Luer-Lok
plug for capping and is available in most hospitals.This plug is twisted on to create
a seal that will prevent spillage during the centrifuging process. A dual-function
Luer-Lok plug for capping is preferred. After the Luer-Lok syringe is sealed, the
plunger is removed from the proximal end of the syringe.
CENTRIFUGATION
The lid on the centrifuge is then closed and locked, the timer is set at 3 minutes,
and the centrifuge spins at about 3000 RPMs (the standard for most hematology
centrifuges).
After the rotor of the centrifuge has stopped, the technician can then remove the
centrifuged syringes.
This separates the denser components from the less dense components to create the
multiple layers noted previously.The upper level or the less dense level is composed
primarily of oil, presumably from ruptured cells.The lipid portion is composed pri-
marily of potentially viable parcels of tissue, with more oil present in the upper por-
tion and denser connected tissue present in the lower portion.The lowest level is the
densest layer and is composed primarily of blood, water, and lidocaine.
Upper level
Least dense layer
Oil from ruptured fat cells
Middle level (30% to 70%)
Potentially viable parcels of tissue
Lowest level
Most dense layer
Blood, water, lidocaine

SEPARATION OF COMPONENTS
The oil layer is initially decanted before removing the plug from the Luer-Lok sy-
ringe. If the plug is removed before decanting, it will cause the vacuum that holds
the contents in place to be lost, and the contents of the syringe will leak out dur-
ing the decanting process. After the oil is decanted, the plug can be removed from
the Luer-Lok connection. A collection vessel should be used during this maneuver,
since the aqueous component will usually pour out of the syringe. Occasionally a
small wad of tissue at the opening will prevent the uid from exiting. If this hap-
pens, a light tap on the proximal end of the syringe will usually free the obstruct-
ing tissue and allow the aqueous portion to drain out. On rare occasions, it may be
necessary to take a hemostat and pull out a bit of tissue from the aperture of the
Luer-Lok syringe.
Wicking the most superior portion of the harvested fat can facilitate further re-
moval of the oily component of the harvested material. Codman neuropads, used
for wicking,9 are placed into the surface of the re ned fatty tissue.They will allow
the oil to gradually wick in a superior direction after a few seconds. After 4 min-
utes, the wick is replaced with another piece of nasal packing. Wicking is per-
formed at least twice. Even though it is important to spend an adequate amount of
time wicking to remove as much oil as possible, every attempt should be made to
minimize prolonged exposure of any of the parcels of cells to air. The plunger is
then replaced after allowing the fatty tissue to slide down to the edge of the syringe.
A nger should be pressed over the Luer-Lok aperture to control the fat slippage
with air pressure.The plunger is then placed into the syringe and advanced to re-
move the dead space.
The fat can be stored in the 10 ml syringe in this fashion for brief periods of time
before transferring to smaller syringes for in ltration. I only use 1 ml Luer-Lok
syringes for placement of the tissue into the face and hands and 3 ml syringes for
the body.
As with the 10 ml syringe, the index nger on the Luer-Lok aperture controls the
slippage of the fat back to the proximal end of the syringe. After lling the syringe
to a little less than the level of the 0.3 ml mark on the barrel, the plunger is replaced
and advanced to remove any dead space. The in ltration cannula is then attached
to the syringe.The harvested, re ned fat is now ready for in ltration.
ANESTHESIA FOR THE LOWER EYELID
AND CHEEK
A solution of 0.5% lidocaine with 1:200,000 epinephrine is in ltrated to provide
adequate anesthesia of the area placing the least amount that is still effective to
avoid signi cant distortion. Local anesthesia should be placed into the periorbital
region using only the bluntest (Coleman type I) cannula. This is done to avoid
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damaging structures such as nerves and blood vessels, but also to avoid entering
the lumen of an artery or vein during the injection of local. Damaging an artery or
vein during in ltration of the local will interfere signi cantly with the surgeon’s
ability to judge volumes and distribution of the grafted fat during placement.
The vasoconstriction caused by the in ltration of epinephrine reduces the possibil-
ity of the cannula entering an artery or vein during the placement of fat. Epineph-
rine should be in ltrated into the periorbital region in every case to reduce the
possibility of intraarterial injection.12 Even if the procedure is done under general
anesthesia, epinephrine should be in ltrated.
THE INCISIONS
For the cheek and lower eyelids, I use four primary incisions on each side: in the
lateral eyebrow, in the lateral inferior temple at the level of the zygomatic arch, in
the lower midmalar, and in the lateral lip.
Commissure
Midmalar
Eyebrow
Low temple
Commissure
Midmalar
Eyebrow
Low temple

INFILTRATION CANNULAS
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For periorbital placement of local anesthesia, for placement against the periosteum
of the anterior malar region and for lateral malar placement, I use a type I Coleman
cannula to minimize the chance of hematomas and to avoid damage to nerves.The
use of type I cannulas when near arteries and veins reduces the possibility of can-
nulating a vessel and embolization.
Type I
Type II
Type III
When placing quantities of tissue deep, I will use a transition cannula, the type II.
To follow the natural curvature of the maxilla and zygoma, I frequently will use a
slightly curved cannula.
In the lower eyelids, I use type III Coleman cannulas during super cial placement.
This allows better control when placing a thin layer of tissue between the orbicu-
laris oculi muscle and the skin in these areas.

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LEVEL OF INFILTRATION
Placement of fat in the im-
mediately subdermal plane
not only provides structural
support to the skin, which
helps eliminate wrinkles and
reduce pore size, but also af-
fects skin color. It has been
my experience that placement
of tissue immediately subder-
mal can lighten the eyelid
skin. Presumably, this can be
from providing a barrier to
subdermal vessels and muscle or perhaps even a physical action of lightening the
skin due to the yellow color of the fat. Unfortunately, this advantageous lightening
can be obscured in the early weeks or even months of recovery by bruising, edema,
and even hemosiderosis.
In the anterior malar folds, tissue is placed in every level from the perios-
teum to the skin; this pattern is continued over the entire malar region, ex-
tending out to the far lateral malar region and down to the buccal region.
In the lower eyelids superior to the infraorbital rim, the goal is to remain su-
per cial at all times. In the in ltration of the lower eyelids themselves, tissue
is placed immediately subdermal or in the orbicularis oculi muscles.8
In the midmalar and lateral malar cheeks, the placement is primarily deep to
create structural support, but some tissue is usually placed super cially as well.
In the buccal cheek, the placement is primarily super cial. This helps with
skin texture and lessens the possibility of damage to the underlying facial
nerves.
Approximate volume ranges for each area:
Super cial anterior malar fold: 1 to 2.5 cc
Between the anterior malar fold and nose: 0.25 to 1 cc
Infraorbital rim lateral to the anterior malar fold: 1 to 3.5 cc
Lateral eyelid: 0.025 to 1 cc
Anterior malar region: 1 to 4 cc
Midmalar cheek: 1 to 7 cc
Lateral malar cheek: 1 to 8 cc
Buccal cheek: 1 to 8 cc
Special care should be taken in the lower eyelid, where even 0.1 cc is
easily visible through thin eyelid skin. Only miniscule amounts should
be placed with each withdrawal of the cannula. If a visible lump of fat
is noted after in ltration, immediate measures should be taken to en-
sure that this “lump” will not be left behind after the swelling subsides.
Maxilla
Orbicularis oculi
muscle
Infraorbital
fat
Orbital septum

Digital pressure to alter the offending lump is usually the most reliable approach.
However, if the visible piece of fat cannot be easily attened or dispersed, removal
by suctioning with an in ltration cannula may be indicated.
Not feathering over the nose and leaving an area of depression between
the nose and the anterior malar cheek are likely technical mistakes.
PLACEMENT TECHNIQUE
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This 46-year-old woman presented 1 year after an “upper face lift” and a lower lid
transconjunctival blepharoplasty. A few months after the procedure, she could see
that “it would not be right . . . it would be worse than before.” She complained of
looking tired, and not being able to recognize herself.

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With the patient’s input, a plan was designed for correction of her lower eyelids as
well as her upper eyelids. Changes in shape were planned in the areas marked in
green to restore subtle fullness, feathering out into the areas marked in yellow. The
planned incision sites are marked in red. On the day of the procedure, we decided
to also place a small amount of tissue into the lateral eyelid,especially on the left side.
Green is used again on the markings directly on the face to delineate a change in
shape.The orange delineates the limits of placement, as the yellow did in the draw-
ings.The incisions are again indicated by the dark red marks at the commissures of
the mouth, the midmalar region, anterior to the sideburns, and in the lateral brow.
To avoid injury to the infraorbital nerve and vessels, a relatively blunt, simple, curved
cannula (type I or II) is used for fat placement into the deeper levels in the ante-
rior malar fold.The curvature of the cannula allows the surgeon to hug the perios-
teum against the maxilla during the rst passes so that fat can be placed along the
maxilla’s curved surface up to within millimeters of the lateral commissure of the
anterior malar fold (tear trough). Fat should be placed primarily under the actual
fold, although some feathering is done above and below the fold against the perios-
teum. In this patient 0.5 cc was placed into the anterior malar fold deep primarily
next to the periosteum with a type II curved cannula.

After establishing a small structural volume from the deep anterior malar fold, I
bring the cannula to a more super cial level with each successive advancement and
withdrawal of the cannula. As the placement becomes more super cial, the danger
of harming the infraorbital nerve or vessels diminishes. Switching to a straight type
III cannula gives the surgeon more control over the level of placement.The atter
surface at the end of the type III cannula allows the surgeon to guide the cannula
under the muscle, into the muscle, and eventually against the skin.
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Revisional Fat Grafting of the Cheek and Lower Eyelid
Although some placement into the orbicularis oculi is desirable, I usually place a
signi cant amount into a more super cial plane immediately subdermally. As the
cannula becomes more super cial, blanching of the skin overlying the advancing
cannula can be seen. The glistening steel-gray aperture of the cannula can be de-
tected through the thin skin of the lower eyelid during many of the superficial passes.

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Although most tissue should be grafted
centrally into the depths of the tear
trough, feathering should occur super-
cially medial and lateral to the upper
tear trough.
Feathering is critical anterior to the
tear trough deformity toward the nose.
A slight tissue de ciency usually exists
between the anterior malar fold and
the nose, which can be accentuated by
the placement of an isolated volume
into the anterior malar fold. Feathering
extends medially to the anterior malar
fold and should be extended much fur-
ther than the surgeon might usually
expect to cover deficiencies and pro-
mote a smooth surface appearance. Even if a de ciency is not noticeable at all pre-
operatively, the feathering should extend almost to the nose.
In this patient 1 cc was placed into the anterior malar fold super cially next to the
skin with a type III cannula.
Placement continues laterally in all the
layers from super cial to deep against
the periosteum, when present, and
along the infraorbital rim. I usually
graft tissue from the midmalar incision
first before changing to the lateral or
oral commissure approaches. More
than half of the planned placement
volume is placed from the midmalar
incision along the infraorbital rim.