The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

The radiating pattern of placement can be clearly seen in this series of photographs
depicting placement from the radial wrist incision. The placement begins at the radial
hand at the juncture of the volar surface with the dorsal surface and progresses
through the web space, over the dorsum of the hand and wrist, to the volar surface
of the forearm. Four or more cubic centimeters of tissue may need to be placed over
this area, with each aliquot of placement less than 1⁄30 cc.
Next, the surgeon again approaches the more proximal placement into the first web
space, radiating a pattern down across the dorsum of the hand.
424
Part III  Nonsurgical Cosmetic Treatments

A cannula is then inserted through the incision in the radial index finger at the level
of the MCP joint. From here fat is placed through the first web space into the sub-
cutaneous plane of the proximal phalanx of the thumb, radiating over the
metacarpals of the thumb, index finger, and middle finger; fat is eventually placed
proximal to the MCP joints of the fingers. The incision between the middle and the
ring MCP joints is used to radiate a pattern of placement from the proximal index
and middle fingers over the back of the hand to the proximal ring and little fingers.
425
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Through the incision into the skin of the ulnar hand at the level of the MCP joint of
the little finger, a pattern is radiated gradually almost to the ulnar aspect of the palm.

426
Part III  Nonsurgical Cosmetic Treatments
Then, from the ulnar wrist incision, a pattern of placement is radiated out from the
ulnar wrist across the dorsum of the hand and wrist to the distal forearm. Usually
fat is placed to cover the wrist and may even extend onto the distal forearm if the
veins are bothersome in that area.
A curved Coleman style I or II cannula
helps to navigate the contours of the
hand and allows more controlled place-
ment into the slightly deeper planes,
such as when more tissue is needed in
intermetacarpal depressions.
Every incision is sutured with 6-0 interrupted simple nylon. In this patient, a total
of 28 cc of fat was placed into the right dorsal hand from the PIP joints to the prox-
imal forearm. At the end of the procedure the hand is a little puffy, but not remark-
ably overcorrected. The extent of the area of grafting is adjusted until the physical
appearance is pleasing, keeping in mind the patient’s expectations.

Postoperative Care
427
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Microfoam tape is placed on the skin of the infiltrated areas immediately after the
procedure and left in place for 3 or 4 days as a protective barrier. A tight layer of Mi-
crofoam tape on the skin of the infiltrated areas will create a slight compression over
the grafted areas, which may reduce edema. This tape also makes it difficult for the
patient to touch the dorsal hand and inadvertently displace the newly placed fatty
tissue through the loose areolar planes of the dorsal hand. Patients are instructed to
avoid touching the backs of their hands for at least 1 week, particularly during sleep,
and also to avoid sleeping with their heads against their hands. They are also told to
keep their hands elevated above the level of the heart as much as possible and to use
cold compresses as tolerated.
Problems and Complications
Edema is the most common postoperative sequela. Numerous passes with a cannula
create substantial swelling in the dorsum of the hand, but bruising is surprisingly
minimal after infiltration of fat with a style I blunt Coleman cannula. Within 2 to
3 weeks after the procedure, much of the swelling will have subsided, and although
the hands may be a little puffy, they usually look natural and presentable.
Before 1992, I used sharp 16-gauge needles to inject lumps of fat into the dorsum of
the hand and then massaged the fat into a smooth layer. Those patients experienced
unpredictable results and noticeable lumps. Irregularities and migration have not
been a problem since 1992, when I changed the placement technique.

428
Part III  Nonsurgical Cosmetic Treatments
The only other complication in the hand that I have experienced is unilateral scar-
ring of the dorsal hand during a simultaneous chemical peel. I have not seen any bac-
terial or viral infections in patients with fat grafts to the upper extremities. I have
also not seen a significant hematoma or even significant bruising in the dorsum of
the hand when blunt cannulas are used, and patients have not complained of sen-
sation changes. However, I have seen several patients in consultation after placement
of fat into the dorsum of the hand by other physicians. Some of these patients had
grafted fat located deep to the tendons, and fat even appeared to be present in the
intrinsic muscles of the hand.
Results
This 55-year-old woman presented with translucent skin through which one could
clearly see the blue dorsal hand veins and glistening tendons. Fat removed from her
love handles was processed down into usable tissue. At the same setting as a facial
and neck procedure, 21 cc of fat was placed into the left hand and 25 cc was placed
into the right hand. She returned 2 years later, extremely pleased with the way her
hands looked.
Preoperative
2 years postoperatively

This 62-year-old woman presented with crêpiness of the skin of her hands and in-
creasingly noticeable veins and tendons. She specifically wanted to place a small
amount of fat onto the middle phalanx to decrease the boniness of her PIP and MCP
joints. Twenty-nine cubic centimeters of refined fat was placed into her left hand and
28 cc into her right hand, from the distal forearm over the proximal phalanges and
onto the middle phalanges, almost to the distal interphalangeal joint. The patient re-
turned at 39 months, enthusiastic about her results.
429
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Preoperative
39 months postoperatively

This 44-year-old man presented with the perception of thin forearms, which he
thought made him look older and unhealthy. Eighteen months earlier, another plas-
tic surgeon had placed AlloDerm into both forearms. The patient believed that the
AlloDerm was completely resorbed within 6 months, although he had a hint of scar-
ring in the midforearm. I layered 47.5 cc of refined fat into his right forearm and
50 cc in the left forearm proximal to the wrist over slightly more than half of his
volar forearm. He returned at 1 year, delighted at the thickening of the circumfer-
ence of his distal forearm and the smoothing of his volar forearm skin.
430
Part III  Nonsurgical Cosmetic Treatments
Preoperative
1 year postoperatively

Nose
Fat grafting to the nose is an effective method for complementing rhinoplasty pro-
cedures. Fat grafted to the nose is surprisingly well integrated; the grafted fat assumes
the structural qualities of the part of the nose into which it is placed. By filling and
adding structural support, grafted fat can fill holes, alter the nose’s contour, or add
support to address a number of problems.
Aesthetic and Topographic Considerations
The aging nose loses fullness in the glabella and nasion more than in any other lo-
cation. As this area atrophies, the remaining parts of the nose become relatively
larger. Therefore the tip appears larger, and it may also seem to droop.
A frequent sequela of rhinoplasty surgery is an open roof in which the cartilaginous
and bony parts of the nose have been repositioned so that they are no longer con-
tinuous. This leaves an open roof that is palpable and often even visible through the
thin skin of the nasal dorsum. Deformation of the cartilage or bone occurs in other
situations after rhinoplasties. The skin of the nose in some patients is so thin that ir-
regularities can be amazingly visible, so that many malpositioned subcutaneous struc-
tures are painfully evident after nasal surgery.
Indications
The most obvious and simplest use of fat grafting to the nose is to fill in irregularities
and divots. Placing a thin layer subcutaneously provides support for the skin and
can disguise visible irregularities of the cartilage and bone. Concentrating the fat
grafts into defined areas can improve the line of light reflection on the dorsum or
subtly change the proportion of one part of the nose in relation to another part. The
structural application of fat grafts can improve alar notching or close an open roof.
Finally, structural fat placed in the nasal valve may act like a spreader graft to relieve
nasal airway obstruction. But fat grafting to the nose does much more than fill de-
fects: it provides soft tissue coverage of the bony and cartilaginous framework un-
der the skin.
Anesthesia
Anesthesia is obtained in most cases with local infiltration of 0.5% lidocaine with
1:100,000 epinephrine and sedation. Epinephrine is useful for causing vasocon-
striction, thereby decreasing the possibility of intravascular emboli.
431
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

432
Part III  Nonsurgical Cosmetic Treatments
Incisions
Incisions are usually made in the central forehead, medial eyebrows, cheek, or alar
base and through the central lip.
Infiltration Cannulas
Infiltration into the nose is performed mainly with Coleman style III cannulas. The tip
of the style III cannula helps push through the frequently encountered fibrous tis-
sues of the nose, especially a nose that has scarring from a previous operation. Al-
though I use straight cannulas most often, curved cannulas help navigate the curva-
ture of the nasion and glabella as well as facilitating different approaches to the alae.
Style III

Mini Cannulas
433
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Deep dermal injection
Recently I have started using mini-cannulas. Although I still prefer the larger bore
cannulas for many areas, I have changed to 19-gauge (external measurement) can-
nulas with a style III tip for most applications in the periorbital and nasal regions.
These instruments are named mini Coleman cannulas.
Intradermal Infiltration
Finally, I sometimes find intradermal infiltration of fat with a sharp needle helpful.
This needs to be approached with great caution to avoid intravascular emboli.
Level of Infiltration
Procerus
muscle
Frontalis
muscle
Aponeurosis
Lateral nasal
cartilage
Greater alar
cartilage
Fat is layered from the periosteum/perichondrium
to the intradermal level.

434
Part III  Nonsurgical Cosmetic Treatments
In particular, a significant layer can be placed into the muscles of the upper nose,
nasion, and glabella. Occasionally, fat can even be placed posterior to the cartilage to
help expand the nasal valve, as a “spreader graft.”
Volume Ranges
The volume placed varies widely, depending on the defect being treated, but can be
as little as 0.4 cc in the alar rim to as much as 9 cc in a saddle nose deformity.
Markings
These drawings are for a patient whose primary goal was to increase the projection
of her nasal tip, but she understood that this was difficult to accomplish with fat
grafting. She also wanted the nasal dorsum straightened more, with placement of
more tissue down the center of the dorsum to obtain a more central light reflection.
She also specifically wanted to have still less alar notching and more columellar show.
“Spreader graft”

On the day of the procedure, the goals reflected in the
blueprints are transferred to her nose using colored
markers. Green marks indicate a planned structural
change in the area. Blue marks indicate planned intra-
dermal placement of fat as well as subcutaneous place-
ment; orange marks are used to delineate the limits of
placement (usually no fat is placed in the areas marked
with orange).
435
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
The dorsum is approached first with a curved Coleman cannula through the fore-
head incision. The fat in this case was layered beginning against the periosteum/
perichondrium and gradually brought through the layers to the immediate subder-
mal layer.
Technique
The key to placement of fat into the nose is meticulous placement in every layer avail-
able: intradermal, subcutaneous, and intramuscular; into fibrous tissues; and above
and even below the perichondrium and periosteum.

436
Part III  Nonsurgical Cosmetic Treatments
Fatty tissue is then layered in a similar fashion into the right lateral nose deficiency
through the same forehead incision.
The tip is approached through the same incision to provide the first direction for lay-
ering into the tip to try to increase tip projection.

437
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
From the alar base, tissue is layered for structural support into the area of alar notch-
ing. This structural approach should start at the alar rim through the middle alae.
From this approach, further augmentation of the nasal tip can be attained to increase
tip projection.
The right lateral nasal deficiency that was approached from the forehead now can
be approached from the alar base. Adding a second direction of placement is always
advised if possible.

438
Part III  Nonsurgical Cosmetic Treatments
Before proceeding with another direction of placement into the nose, the incisions
already made should be closed to prevent leakage of the fat out the incision sites.
An incision is made in the vermilion of the lip to access the tip from another direc-
tion as well as placement into the columella to increase columellar show.

439
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Intradermal injections into the central dorsum can sharpen the straight line of re-
flected light and add extra dorsal and maybe even tip projection.
Further support in the alar rim can be created by supplementing the subcutaneous
placement with intradermal injection from a different direction. The surgeon should
avoid injection into the deeper structures with a sharp needle to avoid intravascular
cannulation of arteries.

440
Part III  Nonsurgical Cosmetic Treatments
Dressings
The appearance of the patient immediately after the procedure is shown. Reston foam
is applied to the glabella and base of the columella and secured with Tegaderm to
prevent migration of fat out of the directions of entry.
Postoperative Care
Dressings vary, depending on the specific procedure performed. The dressings are
used to reduce migration of the fat out of the areas of placement through the place-
ment tunnels. This can involve placing pressure between the incision sites and the
area of infiltration, or providing protection to the nose (with a splint) to prevent ma-
nipulation of the newly transplanted fat. The patient should be told to avoid ag-
gressively touching the nose to prevent fat migration.
Problems and Complications
Probably the most common problem after placement of fat is inadequate correction.
Even if there is a significant improvement, patients usually want to have more. Pa-
tients must be prepared for the potential need for a second or even third treatment.

Intravascular injection is the most feared potential complication from injecting any-
thing into the nose with a sharp needle. Care should be taken to inject epinephrine,
remain at a superficial level, and place the fat in tiny aliquots when using sharp nee-
dles in the nose. Blistering that occurs 3 or 4 days after injection of any particulate
substance into the nose is most likely an intravascular event, not an infection.
Results
441
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
This 56-year-old woman had had four rhinoplasties by plastic surgeons on both
coasts of the United States, and silicone injections to her nose. She also had under-
gone two face lifts, a coronal brow lift, and, at least four times, fat grafting by an-
other surgeon to her lower eyelids and cheeks. Surprisingly, she had undergone no
blepharoplasties or any procedures to her upper eyelids, except for the brow lift.
A photograph of the patient when she was younger reveals a much softer nose and
fuller periorbital region. Closing the open roof was a priority to visually connect the
bony and cartilaginous portions of the nose. I planned reconstruction of the alar rim
with an attempt at medialization of the nasal tip, as well as filling of the lateral os-
teotomy sites.

442
Part III  Nonsurgical Cosmetic Treatments
Markings delineate the planned procedure: 3.5 cc was placed into the dorsum first
using a Coleman style III cannula, followed by 1 cc with a 22-gauge needle to increase
the light reflection; 3.3 cc was placed into the right alar region and 2 cc into the left;
1 cc was placed into the lateral nose on each side, feathering into the lower eyelids.
The adhesions were so strong that a V-dissection was necessary to release them.
Comparison of these photographs reveals that the remarkable swelling and bruising
present at 6 days postoperatively had resolved completely by the fifth week. The dif-
ference between the 5-week and 1-year follow-up is minimal; primarily there has
been further softening of the osteotomy site corrections. The improvement of the peri -
orbital region in general is evident, with remarkable improvement in the quality of the
skin and lightening of the skin color.
5 weeks postoperatively
1 year postoperatively
Preoperative
6 days postoperatively

Follow-up at 1 year after the fat grafting procedure demonstrates a remarkably normal-
appearing nose. The bony portion of the nose flows more naturally into the cartilag -
inous area, with a more distinct central light reflection and far fewer irregularities.
The augmentation of the central dorsum connects the cartilaginous nose with the
bony nose along the dorsum to allow a line of light to flow continuously from the
nose to the nasion. In addition, structural augmentation of the alar rim pushes the
nasal tip back to a more central, normal-appearing location. Curiously, the increase
in the size of the rest of the nose makes the nasal tip appear much smaller, even
though no tissue was removed.
443
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

This patient had undergone at least 12 previous nasal procedures, including place-
ment and removal of Gore-Tex, numerous ear cartilage grafts, and not only autolo-
gous but also homologous rib cartilage grafts. With all of her procedures, she had
sustained a large septal perforation.
444
Part III  Nonsurgical Cosmetic Treatments
The plan developed during earlier consultations was marked on her immediately
preoperatively. The plan was primarily to create soft tissue coverage to disguise the
many irregularities left from her previous procedures, especially the cartilage grafts.

The green markings indicate changes in shape, and the orange markings show the
limits of placement. In the glabella the focus was on rejuvenation, calling for place-
ment of subtle amounts over the entire area, from orange markings to orange mark-
ings, plus some placement directly into the skin of the frown lines (blue). Incision
sites are marked in red in the forehead, medial eyebrow, anterior malar cheeks, and
vermilion in the middle of the upper lip.
During the procedure, 0.5 cc was placed in each alar region with a Coleman style
III cannula, and 0.5 cc was placed into the dermis of the columella with a 22-gauge
needle. Into the dorsum 3.5 cc was placed with a Coleman style III cannula and
1 cc into the midline with a 22-gauge needle to increase the light reflection; 0.5 cc
was placed diffusely with a Coleman style III cannula and 1.0 cc placed into the
glabellar frown lines and the central vertical wrinkle into the skin with a 22-gauge
needle. At the end of the procedure, a V-dissector was used to free up some of the
scarring present between the skin and the underlying bone or cartilage.
445
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

One year after this procedure, softening of the angular edges from the nasal carti-
lage and bone can be seen, along with an apparent thickening of the skin, especially
over the dorsum. The glabella is slightly fuller, with a diminution of the frown wrin-
kles. However, the wrinkles lateral to the areas of placement are more obvious. The
lateral view shows that the amount of placement was minimal.
446
Part III  Nonsurgical Cosmetic Treatments

Lips
Structural fat grafting to the lips can produce long-lasting enhancement of the up-
per and lower lip with purely autologous material. Structural form is one of the pri-
mary considerations with lip augmentation. Consistently good results are obtained by
placing tissue with careful attention to the effect that injected volume will have on
ultimate lip shape.
Aesthetic and Anatomic Considerations
447
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
An attractive upper lip has a distinctly protuberant and continuous turgid white roll,
which is separate from the skin of the lip. The white roll usually tapers off from peaks
on either side of the Cupid’s bow and becomes less obvious laterally. Cephalad to
the white roll, the skin drops back from the protuberance of the white roll to begin
the slight concave curve of the upper lip. The upper lip has two distinct philtral
columns curving in a similar concave fashion from their origin where the white roll
hits the peaks of the Cupid’s bow to the columella. That curve is dramatically more
concave inferiorly than superiorly. Under the Cupid’s bow, the vermilion of the lip
has a well-centered, distinct tubercle. That tubercle is the most caudal element of an
attractive upper lip. Medial to each commissure is a fullness of the upper lip that is
significantly less protuberant than the central tubercle in the vermilion. Between the
central tubercle and the lateral fullness is a concavity or slight depression.
The lower lip has a slightly protuberant rim like the white roll of the upper lip, but
less distinctive in color and turgidity. An attractive lower lip has elements that com-
plement the upper lip, following the shape, but with the opposite components from
the upper lip. A distinct central depression, essentially a cleft, is bordered on either
side by tubercles significantly larger than the central protuberance of the upper lip.
The alignment of the lower lip tubercles is oblique so that they push the central lip
out into a distinct pout. The most important difference between the upper and lower
lip in a normal, young mouth is that the amount of vermilion visible in the lower lip
is much greater.

Placement of fat into different parts of the lip leads to different results. Particular at-
tention should be paid to the level and anatomic areas into which the fat is placed.
The goal of lip augmentation is to flip out the vermilion of the lips enough to create
attractive, pouty lips with the least volume possible. This is accomplished by super-
ficial layering of structural fat, primarily immediately under the mucosa and ver-
milion to increase the exposed surface area of the lip.
Because the goal is eversion of the vermilion of the lip, care should be taken not to
place any support into an area that might oppose eversion. For instance, placement
of fatty tissue deep to the cutaneous element of the lips will increase the structural
support of the skin. This may soften some of the vertical wrinkles cephalic to the
white roll or caudal to the rim of the lower lip. However, increasing the structural
support of the skin will invert the vermilion of the lips, making them appear smaller.
Indications and Patient Selection
The primary indications for lip augmentation are aging and the patient’s desire for ad-
justment of facial proportion. Often these two indications are present in the same
patient. As a person ages, the lips lose subvermilion and subcutaneous fullness. This
results in an inversion of the lower lip and deflation of the upper lip. As a person
ages, the upper and lower lips usually become more similar in size on frontal view.
The best candidates for lip augmentation are persons who had full lips when they
were young. Restoring fullness to their lips will return them to their youthful state.
The most challenging patient is the one who never had full, attractive lips. In these
patients, to create a full, attractive lip, the fatty tissue must be placed so that the vec-
tors of placement overwhelm the patient’s natural anatomic tendencies.
One of the most difficult patients is the one who has had placement of a noninte-
grated, permanent soft tissue filler such as Gore-Tex, solid silicone, dermal fat grafts,
fascia grafts, or other similar fillers. If these nonintegrated substances can be removed
from the lip, I usually recommend doing so. In patients in whom I have left the sub-
stances in place, there remains an unnatural feel to the lip. Patients who have had in-
jections into their lips of permanent fillers such as silicone, Artecoll, DermAlive, and
polyacrylamide gel represent a different challenge. Because it is impossible to remove
these substances, the surgeon who chooses to operate on these patients must devise
a careful plan that will avoid making the lips look worse.
Anesthesia
Sedation is usually used in combination with local infiltration. In addition, 1% li-
docaine with 1:100,000 epinephrine can be used for infraorbital and mental nerve
blocks to further facilitate anesthesia; 0.5% lidocaine with 1:200,000 epinephrine
448
Part III  Nonsurgical Cosmetic Treatments

is infiltrated into the dermis at the incision sites before the incisions are made. Next,
0.5% lidocaine with 1:200,0000 epinephrine is infiltrated into the superficial mus-
cle and submucosal planes using a style III cannula, with placement of approximately
3 or 4 ml into each lip.
Incisions
449
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
The incisions for placement into both the upper and lower lip are most commonly
made near the commissures of the lip entirely on the cutaneous lip. I will place the
incision in a wrinkle line radiating from the lip. Occasionally I use the midmalar in-
cision or mandibular incisions for placement of some of the tissue, especially to ap-
proach the cutaneous lips.
Infiltration Cannulas
The sharpest of the blunt cannulas, a style III infiltration cannula, is used almost ex-
clusively for placement into the entire lip. This cannula allows me to place the re-
fined fat with the greatest accuracy into the plane immediately deep to the mucosa
or vermilion.
For an aging lip with wrinkling, I will often place 0.5 to 1 cc of fat using a 22-gauge
needle injecting into the deep dermis and immediate subdermal space.
Midmalar
Commissure
Lateral chin
Style III

450
Part III  Nonsurgical Cosmetic Treatments
Level of Infiltration
Successful enhancement of the lip is not just a matter of placing a specific volume of
fat into the lip. The level of fat placement is of paramount importance to consistently
realize any planned changes.
Almost all of the grafted fat should be infiltrated into the most superficial level, im-
mediately deep to the vermilion and mucosa.
Volume Ranges
The suggested volumes of placement are as follows:
 More than 0.75 cc but rarely more than 1.25 cc for restructuring the white roll
 More than 0.75 cc and less than 1.25 cc in the lower lip rim
 A minimum of 1.5 cc but rarely more than 4 cc into the body of the upper lip
 Slightly more than twice the amount placed in the upper lip is placed in the
lower lip body for the average patient
Technique
This 38-year-old woman presented for treatment of acne scarring. During her initial
consultation, she noted that an attempt to augment her lips had been made in the
distant past with intradermal collagen injections and requested a modest lip aug-
Correct superficial fat placement

mentation to soften her lips and make them look less severe. She desired more ver-
milion show to her upper lip but wanted to avoid having too much of a flip in the
upper lip because she did not want her lips to have an overly augmented, puffy look.
Markings
451
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
The green pen markings outline the plan for lip augmentation. The green line below
the white roll shows the plan for placement into the vermilion below the white roll,
not into the white roll. The placement caudal to the white roll will extend out almost
to the commissure but will end approximately 4 mm before the oral commissures.
The markings show that placement into the body of the lip will be emphasized cen-
trally and laterally to create a distinct concavity of the area not marked in green.
The beginnings of the philtral columns are marked as a reminder that placement of
the fat should be extended slightly into the base of the philtral columns to slightly
increase their turgor. The lateral oblique “balls” of the lower lip are also marked.
The lower lip placement is in the vermilion next to the cutaneous lip, with no place-
ment at all deep to the cutaneous element of the lower lip. Slight depressions in the
lateral cutaneous lip were identified in this patient and marked on the skin. This is
the only place that structure will be placed under the lower lip cutaneous portion.
White Roll
I usually begin simple aesthetic augmentation of the lip by placing tissue into the
area of the white roll. This area is the most difficult and requires the most precise
placement. Although I commonly use the style III cannula for placement into the
white roll, I occasionally will use a sharp needle to place a small amount into the
deep dermis.

452
Part III  Nonsurgical Cosmetic Treatments
Access for the white roll placement is from the incisions near the lip commissures
on either side.
After advancing the tip almost to the opposite commissure through the upper lip,
the cannula is withdrawn slowly across the cephaladmost vermilion as gradual pres-
sure is placed onto the plunger of the 1 cc syringe. The objective is to lay down a
small (but sometimes as much as 1⁄5 cc) increment of refined fat. In many lips, such as
those shown above, the metallic tip can be seen shining through the vermilion cau-
dal to the white roll as the cannula is withdrawn across the lip.

453
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
I usually approach the placement into the white roll from both lateral incisions. To
add structure to the philtral columns, I divert the cannula up from the vermilion into
the columns. This placement is also extremely superficial, and the tissue is placed
immediately under the skin, avoiding insertion of fat directly into the orbicularis oris
muscle when possible. I placed 0.8 cc of tissue into this patient’s upper lip white roll.
Lower Lip
Although the lower lip does not have an actual white roll, the placement in the lower
lip begins with an approach almost identical to that of the upper lip white roll. The
graft is placed in the vermilion just cephalic to the cutaneous border using a style III
cannula. Again the fat in the lip should be placed in the immediate subdermal layer.
Although I advance the tip of the cannula all the way to the opposite commissure,
I place most of the tissue along the lower lip rim into the central two thirds of the
lip. An attractive lip is not excessively full all the way to the commissure. Care is taken
to place this tissue extremely superficially and in the vermilion only.

454
Part III  Nonsurgical Cosmetic Treatments
The next consideration in infiltrating the lower lip is maintenance of a youthful shape.
My first approach to the lower lip after establishing a turgid rim is to create oblong
“balls” or protuberances on each side, just lateral to the center of the lip. In this pa-
tient an ipsilateral incision is used to place the left ball into the lower lip. As in most
areas of the lip, the depth of placement is immediately under the mucosa and ver-
milion with a style III cannula. The key to this placement is central eversion of the
lower lip while leaving a distinct deficiency, almost a cleft centrally. As always, the
fat must be placed in miniscule amounts.
After an initial volume from one side is placed, a similar amount is placed into the
opposite side through its ipsilateral incision.

At this point, 1 cc has been placed into each ball and another 1 cc into the lower
lip rim.
455
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
As I continue to place tissue into the balls of the lower lip, I switch to the contralat-
eral incision for placement of another volume on either side. This approach allows
me to feather back into the mucosal lip with a structural layer.

456
Part III  Nonsurgical Cosmetic Treatments
The focus of vermilion augmentation of the lower lip is the formation of lateral ob-
long balls with a central deficiency or cleft. The focus of placement into the mucosa
is to encourage a central pout or eversion of the lower lip. After establishing the shape
of the lateral oblong balls in the vermilion, some central lip placement is feathered
between the lateral balls. The objective of this maneuver is to force out a central
prominent pout from the lower lip while creating the lateral oblong balls. A thin
layer of tissue is placed all the way to the frenulum of the lower lip to encourage
eversion of the lower lip.
After placement of 2 cc into each lower lip ball and 1 cc into the lower lip rim, the
lower lip has a distinct central pout with lateral protuberances and a central defi-
ciency.

Upper Lip
457
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
In the upper lip, placement starts in the central fourth of the lip with a style III can-
nula. The level is against the vermilion and mucosa centrally. The placement in the
upper lip is in the same depth as the lower lip, but the areas into which the fat is
placed are opposite of those used in the lower lip. The placement here continues
where I left off with the white roll. In the central fourth of the upper lip, I infiltrate
under the vermilion by repeated linear injections into a level immediately under the
vermilion to create a layer of tissue extending from the white roll back into the mu-
cosal lip almost to the frenulum. Everting the lip with the opposite hand allows more
predictable immediate subcutaneous placement. Note the blanching of the mucosa
of the right upper lip. Finally, the contralateral tubercle is approached in a similar
fashion.

The following volumes were used in the lips of this patient. Into the cutaneous por-
tion of the upper lateral lip, 0.3 cc was placed on each side. Into the white roll of the
upper lip, 0.8 cc was placed with a 22-gauge needle, and 2 cc was placed into the
lip itself. Into the lower lip, 0.75 cc was placed with a 22-gauge needle, and 6.5 cc
more was placed using a style III cannula. The patient is shown at 4 days,
7 days, and 44 days after treatment.
458
Part III  Nonsurgical Cosmetic Treatments
Preoperative
44 days postoperatively
7 days postoperatively
4 days postoperatively

The patient returned at 4 months, extremely pleased with her result and appreciating
that she had a better pout and fuller upper lips. To evaluate the lips on any patient,
the mouth must be relaxed and the lips not touching each other. I find that having
the patient purse the lips allows a different evaluation of the volume of the lips.
459
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

Posttreatment Care
No dressings are used on the lips. Patients are told that the wet mucosa will undergo
keratinization and become dry mucosa or vermilion. During this process, the lips
may peel like a snake shedding its skin. Moisturizers or ointments are helpful during
this process. The patient is asked not to massage the lips in the first weeks; however,
the patient is encouraged to move the orbicularis oris in an attempt to promote lym-
phatic drainage. There are no further restrictions on lip motion after the procedure.
Recovery from fat grafting in the lips is usually the most difficult, in terms of the de-
gree and duration of swelling, until it resolves sufficiently for the patient to return
to daily activities. Cold or iced dressings (frozen peas or crushed ice in Baggies) are
therefore of the utmost importance on the lips and should be actively encouraged.
Problems and Complications
In my experience rupture of the skin of the lower lip has occurred several times. This
is a situation in which tension placed on the lower lip creates enough internal pres-
sure to cause spontaneous lacerations that split open the lip in several locations. Such
lacerations are closed with simple interrupted sutures. Because this lip splitting has oc-
curred only in the lower lip, when it does occur it has become the volume-limiting
factor in that case. For that reason, I usually start placement into the body of the
lower lip before the body of the upper lip. Other possible but unusual complications
include scarring, pyogenic granulomas, infection, and lip necrosis.
The mouth is one of the most likely sources of contamination. Therefore I am espe-
cially concerned about transporting bacteria, fungus, virus, or mycobacteria from
the mouth to other sites and delay placement of tissue into the lip until the last step
of any facial procedure. Any time I make an incision near the lip, I give prophylac-
tic antibiotics (usually intraoperative cephalosporin). Eight years ago I started hav-
ing patients gargle with Peridex preoperatively. Since that time, I have seen only one
minor perioral infection.
460
Part III  Nonsurgical Cosmetic Treatments

461
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Results
This 50-year-old patient presented with lips that were already aesthetically appeal-
ing but no longer as everted as when she was young. The lower lip was no longer the
dominant larger lip, and the upper lip was not as full as when she was young.
As always, more attention was directed to planning the shape than in considering
the volume. The markings made on the patient’s lip reflect the plan. The approach
to the lower lip emphasizes the dramatic eversion of the central lip while minimiz-
ing placement into the central lip. This is accomplished by primary placement into
the previously described oblong balls of the lower lip. The alignment of these oblong
structures is such that their axes converge above the most protuberant point of the
pouty lower lip. On this patient, the upper lip markings were drawn to emphasize
eversion of the central tubercle of the upper lip. However, some eversion of the lateral
upper lip is desirable. It is this eversion of the lateral upper lip vermilion show that es-
tablishes the apparent width of a lip.

462
Part III  Nonsurgical Cosmetic Treatments
A total of 6 cc was placed into the lower lip. Into the upper lip, first 1.1 cc was placed
caudal to the white roll, then 2.5 cc was placed into the upper lip, emphasizing the
central and lateral tubercles, but with some fat placed in the concavity between them.
Finally, 1.4 cc was placed to emphasize the philtral columns.
Swelling at 4 days and 17 days after surgery is alarming to the patient. I always warn
them that they will not look recognizably human but more like a monster for at least
a week. Recovery from fat grafting in the lips is the most difficult. because it can be
up to 4 weeks before the patient feels somewhat comfortable. Although visible
swelling in this patient had completely resolved by 3 months, she claimed to feel
changes in the texture as well as the size of her lips for up to 8 months.
4 days postoperatively
17 days postoperatively
1 year postoperatively

The patient returned after 8 years with little if any change from her first year follow-
up. She had had no procedures performed on her lips and had no fillers placed. She
maintained obvious eversion of the lips in good form. If anything, her lips are slightly
more everted than I would want. In the last few years I have tended to place less fatty
tissue, trying to emphasize eversion over volume. If I were to augment the lips on
this patient now, I would place less than half of the 1.4 cc placed into the philtral
column and I would place less than 1 cc into the area of the white roll.
463
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Preoperative
1 year postoperatively
8 years postoperatively

The ring flash oblique views allow a different analysis of the augmentation. One can
see that despite the sizable volume added to the upper lip, there appears to be more
incisor show as the lip is everted. In addition, the length of the upper lip is short-
ened both by the eversion and by the relative increase in the vermilion of the upper
lip, which makes the cutaneous portion less of the overall lip.
Nasolabial Folds and Marionette Grooves
Fat grafting is also an effective method for treating nasolabial folds and marionette
grooves. The key to fatty placement in these folds is infiltration of areas rather than
individual lines. The focus is on placement over a general area to add support to the
facial structures and improve the quality of skin.
Indications and Patient Selection
The primary indication for correction of the nasolabial folds and marionette grooves
is aging. Older patients object to the expressions that age seems to have painted in
the folds and lines on their faces; these appear more prominent and objectionable
with each passing year. Younger patients who have deep nasolabial folds have a sim-
ilar reaction when they perceive that their deeper-than-usual folds make them ap-
464
Part III  Nonsurgical Cosmetic Treatments

pear older than they are. The most important consideration with nasolabial folds is
to be certain that the patient understands that the folds in the marionette area will
not disappear. Improvement in the texture of the marionette grooves is frequently
the best improvement possible with subcutaneous placement of fatty tissue. Colla-
gen or hyaluronic acid may be indicated for additional blunting of the fold.
Anesthesia
One percent lidocaine with 1:100,000 epinephrine can be used for infraorbital and
mental nerve blocks to facilitate anesthesia; 0.5% lidocaine with 1:200,000 epi-
nephrine is infiltrated into the dermis at the incision sites before the incisions are
made. Next, 0.5% lidocaine with 1:200,0000 epinephrine is infiltrated into the na-
solabial and marionette regions using a style II cannula.
Incisions
Lower midmalar incisions provide access for the perpendicular placement of tissue,
and an incision in the lateral chin or mandibular border provides access for the lon-
gitudinal placement of tissue. Frequently an incision near the commissure is used for
a different angle of placement.
Infiltration Cannulas
465
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
In the nasolabial fold there is little possibility of damage to any underlying struc-
tures, so Coleman style II is the most common cannula used in this area; a Coleman
style III cannula may be used in areas of very fibrous adhesions, especially against
the skin.
Level of Infiltration
The primary level of placement is immediately subcutaneous to deliver structural in-
tegrity to the cutaneous element of the fold. However, for deeper folds and premax-
illary deficiencies, placement in the deeper planes may be indicated, especially in the
nasolabial folds.
Style II

466
Part III  Nonsurgical Cosmetic Treatments
Volume Ranges
Volume ranges vary:
 For correcting a minimal line in the nasolabial fold, as little as 1 cc is some-
times needed.
 For deep nasolabial folds that have a significant premaxillary deficiency, infil-
tration with as much as 10 or 11 cc is required.
 Marionette grooves can be corrected with as little as 0.5 cc, and rarely more
than 3 cc is needed.
 Care should be taken to avoid overfilling of the nasolabial or marionette re-
gions. In the quest to eliminate folds, unnatural fullness can be created.
Technique
The markings are made with arrows pointing to the depth of the nasolabial fold
crease, indicating the need for filling either on both sides of the crease or in the pre-
maxillary region. In the premaxilla and marionette region, I usually fill from the me-
dial area to the crease.
The syringe plunger is pressed minimally with each retreat of the cannula to express
a small line of fatty tissue into the area of the nasolabial fold. Approximately 1⁄10 to
1⁄30 cc is expressed with each retreat of the cannula in this area.

Cephalad, the fat is placed medial to the folds. Only minimal fat is placed lateral to
the fold, because the area lateral to this part of the nasolabial fold is usually already
fuller than the patient desires.
467
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
A good deal of attention is paid to treating creases medial and lateral to the existing
nasolabial folds and crease. Correction of the fold without infiltration of surround-
ing tissues will serve to accentuate preexisting minor creases. Next, the nasolabial
fold is infiltrated from below to complement the structural placement of the trans-
verse elements of fatty tissue. Although the cheek approach is the most important
direction for placement of fatty tissue, placement of fat in a longitudinal direction
allows a more precise volume correction immediately against the crease of the fold
itself and adds structural integrity.
From the same cheek incision site that was used to place the fat perpendicular to the
nasolabial folds, I begin the approach to the marionette region. Again placement is
guided with the opposite hand with attention to avoiding perforation of the oral mu-
cosa. Often infiltration of the marionette groove is continuous with the lateral men-
tal region.

The marionette area is approached from many di-
rections: it can be infiltrated from the chin, oral com-
missure, or the lateral mental region as well as the
cheek. The aim of this multidirectional approach is
to improve the texture of the region and to provide
structural integrity to slightly elevate the corners of
the mouth. The surgeon must avoid overfilling the
marionette region with subcutaneous placement. Of-
ten a small amount of intradermal injection of fillers
or fat can improve the result from subcutaneous
placement.
468
Part III  Nonsurgical Cosmetic Treatments
Posttreatment Care
One layer of 1-inch Microfoam tape is used as a dressing for the nasolabial and mar-
ionette grooves. Recovery from placement into the nasolabial fold and marionette
grooves is usually better tolerated than placement into other areas such as the lips
or periorbital region. Bruising is often minimal, and the swelling usually looks ac-
ceptable within a few days. I do not recommend massage of the nasolabial and mar-
ionette areas.
Complications
The most common complication after ablation of the nasolabial fold is the forma-
tion of folds medial or distal to the old folds. That is why surrounding structures
should be feathered or infiltrated when indicated.
Results
This early patient is shown before and 9 years 3 months after injection of fat using a
16-gauge sharp needle. I injected only 4 cc into each nasolabial fold from one direc-
tion (inferiorly).

Changes in this patient are typical of those commonly seen after nasolabial fold cor-
rection. Although there is a significant improvement, it is not the stereotypical change
often anticipated by most surgeons who perform intradermal injections. The most
consistent change observed after placement of a volume of fat into the subcutaneous
planes of the nasolabial folds is that the fold moves forward on the face to be fur-
ther away from the underlying bone and dentition. The mass effect of the diffuse
placement of fatty tissue blunts the crease of the fold, but a slight fold remains. This
type of fold is usually present in youthful photographs of patients. There is also a
texture change in the area of the fat infiltration with a decrease in fine wrinkles and
pore size. Even with careful feathering, some increase in the wrinkling of the skin
can be seen where the feathering ends, especially in the medial marionette region. If
patients desire a greater change to specific folds or wrinkles, adding additional full-
ness can sometimes help.
469
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

Clinical Caveats
 Fat is living tissue that must be in close proximity to a nutritional and respiratory
source to survive.
 Maximizing the surface area of contact of each parcel of fatty tissue with the sur-
rounding host tissues is essential for successful integration and anchoring of the
newly placed tissue and to structurally manipulate the host tissues.
 Incisions are placed in wrinkle lines, in folds, or in hair-bearing areas such as the
eyebrow, sideburns, or pubic hair when possible. This facilitates placement of the
fatty tissue in at least two directions when indicated.
 To strengthen bony or underlying support, the fat can be layered in the deeper lev-
els against the bone or cartilage. To support the skin, improve texture and color,
and achieve a more aesthetic external appearance, the fat is layered immediately
under the skin. For filling, plumping, or restoring fullness, tissues are placed in the
intermediate layers between skin and the appropriate underlying tissue.
Hands
 Placement of lumps of fat that the surgeon then tries to smooth out is the most
likely technical error encountered in treatment of the hands. With the normal edema
that is present, the surface of the hand may appear smooth, but as the edema re-
solves over the next 12 weeks, the irregularities become visible through the thin skin
of the dorsum of the hand.
 On palpation, fat parcels placed next to skin will feel like thicker skin, not like fat
under skin.
 Placing fat in a structured fashion with many minuscule tunnels of parcels of fat
over the dorsal hand creates underlying support as well as a radial expansion of
the skin.
Nose
 Hydrodissection of the alae is often helpful before placement in that region to pre-
vent perforation of the mucosa. This is especially important in scarred noses.
 Even in the nose, it is important to try to place tissue from two different directions.
 Blistering in the nose after injection of any filler or fat using a sharp needle is likely
to be caused by intravascular injection.
 The corrections with structural fat grafting are so natural (and often subtle) that
the patient has trouble seeing them. Therefore it is essential to document the pa-
tient’s preoperative appearance and postoperative condition so he or she can ap-
preciate the change.
470
Part III  Nonsurgical Cosmetic Treatments

Lips
 When performing several procedures, the lips are saved for the very last step to avoid
contaminating the other areas of the face or body.
 To accomplish lip augmentation with increased vermilion show, fat should not be
placed deep to the cutaneous portion of the lip, because it can expand it and ac-
tually decrease the amount of vermilion show.
 Because the white roll of the upper lip does not extend all the way to the commissures,
placement of fat to strengthen or recreate a white roll should not be extended all
the way to either lateral commissure.
 Small lumps are amazingly well tolerated in the lip. Large ones are not.
Nasolabial Folds and Marionette Grooves
 Correction of a fold without infiltration of surrounding tissues will accentuate pre-
existing minor creases.
 The marionette region should not be overfilled, because the grooves can easily be
enlarged in some individuals.
471
Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Annotated Bibliography
Aboudib JH Jr, de Castro CC, Gradel J. Hand rejuvenescence by fat filling. Ann Plast Surg
28:559-564, 1992.
The authors review the advantages of fat filling for hand rejuvenescence. A highly sat-
isfactory rate was obtained (98.62%) with a low complication rate (4.15%).
Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose
autotransplants. Aesthetic Plast Surg 18:17-19, 1994.
This article discusses the spherical and cylindroid models to correlate the volume and
the percentage of graft viability to the initial injected volume in adipose autotransplants.
The authors concluded that the percentage of graft viability depends on the thickness
and the geometrical shape, and is inversely proportional to the graft diameter if grafts
with a diameter greater than 3 mm are considered.
Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aes-
thetic Plast Surg 10:115-117, 1986.
The authors present the idea of correcting soft tissue defects with an injection of fat ob-
tained by liposuction. The technique is described and the results are demonstrated in
several patients treated over a period of one year.

Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 110:1731-
1744; discussion 1745-1747, 2002.
A simple, reliable technique of autologous fat grafting for long-lasting rejuvenation of
the dorsum of the hand is presented.
Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg 28:111-119, 2001.
The author describes the characteristics of fat as an ideal filler and the keys to the tech-
nique behind successful fat grafting.
Guerrerosantos J. Autologous fat grafting for body contouring. Clin Plast Surg 24:619-631,
1996.
In trying to achieve symmetry and better contour of the back torso and middle third of
the body, the combination of liposuction and lipoinjection is rapidly becoming the pro-
cedure of choice. The indications and operative and postoperative techniques are de-
tailed in this article. Fat graft long-term survival is presented.
Niechajev I, Sevcuk O. Long-term results of fat transplantation: clinical and histologic stud-
ies. Plast Reconstr Surg 94:496-506, 1994.
This article discusses nine cases of idiopathic constitutional subcutaneous fat atrophy
in the cheek area during 1988-1992 that were treated by the autologous transplanta-
tion of fat for purely aesthetic reasons. Results and long-term follow-up are presented.
Contrary to the experience of others, only the partial resorption of the transplanted fat
occurred. This result was verified by six biopsy specimens obtained 7 to 36 months af-
ter transplantation.
Roundtables in Plastic Surgery. Tissue Fillers in Plastic Surgery, vol 1, no 2. St Louis: Qual-
ity Medical Publishing, 2004.
A panel of experts discuss the current options in synthetic and biologic tissue fillers as
well as autologous fat grafting, their efficacy, clinical applications, and pitfalls. Case ex-
amples and results are included.
Suggested Readings
Abrams HL, Lauber JS. Hand rejuvenation. State of the art. Dermatol Clin 8:553-561, 1990.
Carraway JH, Mellow CG. Syringe aspirations and fat concentration: a simple technique for
autologous fat injection. Ann Plast Surg 24:293-297, 1990.
Chajchir A, Benzaquen I, Wexler E, et al. Fat injection. Aesthetic Plast Surg 14:127-136, 1990.
Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg 33:567-577,
2006.
Coleman SR. Facial recontouring with LipoStructure. Clin Plast Surg 24:347-367, 1997.
Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic
Plast Surg 19:421-425, 1995.
Coleman SR. My view: structural fat grafting. Aesthetic Surg J 18:386, 1998.
Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg
118(Suppl):108S-120S, 2006.
472
Part III  Nonsurgical Cosmetic Treatments