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

Injection Technique
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Part III  Nonsurgical Cosmetic Treatments
Epidermis
Dermis
Subcutaneous
tissue
ArteFill has been injected in all of the soft tissues of the face as well as other parts
of the body. It is injected in similar fashion to other soft tissue fillers. The recom-
mended needle is 26-gauge , and it is supplied in a 0.5 cc syringe. ArteFill is placed
as the needle inserted into the deep dermal plane is withdrawn. Once the ArteFill
has been placed in a region, it must be massaged to make sure that there is unifor-
mity of placement and that there are no lumps or bumps. Immediately after injec-
tion, mobile areas (nasolabial folds and lips) should have tape placed over them to
limit the amount of movement and facilitate the formation of scar tissue around
the beads. Tapes should be in place for the first 4 to 5 days. With lip augmentation,
Botox should be injected around the lips in small doses (1 to 2 units in four points
above and below the lips) in addition to taping the treated areas to prevent too
much motion.
The technique for acne scars involves placing the ArteFill on the deep dermal plane
with either simultaneous or subsequent release of the scar if necessary. As in other
soft tissues, serial injections every 8 weeks may be required for complete correction
of the scar. The material should be stored at 4° C and warmed to room temperature
before use.
Level of Placement and Volumes
ArteFill is placed in the deep dermal plane. A nerve block is generally required for
its administration. Initially, the average volume of ArteFill used in the lips is 0.5 cc
per lip with patient follow-up 6 to 8 weeks after the injection. Varying amounts

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
can be used in other areas; nasolabial folds may require anywhere from 0.5 to 1.5 cc
of ArteFill per side for correction. It is important to note that with initial injection
the aim is to undercorrect the area.
Longevity
ArteFill is considered a permanent filling substance. As the patient ages, more vol-
ume may be required after about 11⁄2 years.
Ease of Injection
Technically, Artecoll is the most difficult filler to inject. It is more viscous than any
other filler and the syringes can contain air (due to the evaporation of collagen),
which may cause irregularity in pressure and delivery.
Combined Treatments
Other fillers such as Restylane may be used in the same areas as ArteFill. A nonper-
manent filler is often placed first; then a permanent augmentation with ArteFill is
done 4 to 6 months later. Botox is very useful to help reduce the movement in areas
such as the lips and glabellar region. The Botox treatment should be done 2 weeks
before the ArteFill treatment to reduce the movement of the tissues in the first 3 to
5 days after the injection. Restylane Fine Lines/Touch should be used for the super-
ficial lines rather than ArteFill. Care should be taken in patients undergoing treat-
ments with radiofrequency as Artecoll may cause the tissues locally to receive more
energy if the probe is placed right over the ArteFill. The PMMA is stable when sub-
jected to very high temperatures.
Postinjection Care
The patient should be scheduled for a postoperative visit 6 to 8 weeks after the ini-
tial injection. They should also be informed that they will not see initial results for
the first 6 to 8 weeks. In comparison to other fillers, there is only a mild to moder-
ate increase in soft tissue augmentation in the first weeks as three fourths of the vol-
ume of the syringe is collagen, which is rapidly absorbed after the initial injection.
Collagen is the vehicle for placement of the bead. Volume change occurs when the
tissue grows into the bead. Cool packs and medications recommended for Restylane
(such as antihistamines) will also help with reduction of postinjection morbidity.
Adverse Effects, Reactions, and Complications
One of the disadvantages of ArteFill is that irregularity will result if too much ma-
terial is placed in one spot. If this is discovered soon after injection, it should be
treated with massage followed by injection with a dilute dose of steroid (0.2 mg/ml

triamcinolone [Kenalog]) to soften the irregularity. Subsequent excision of the ir-
regularity may be required if there is a persistent lump or bump. The incidence of
granuloma formation is very low when ArteFill is injected with proper technique. It
is highly recommended that a new user undergo supervised training before injecting
ArteFill. With careful planning and placement of ArteFill, one can achieve excellent
results for long-term to permanent soft tissue contouring.
Results
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Part III  Nonsurgical Cosmetic Treatments
This 33-year-old woman requested lip augmentation. She had a good lip shape to
start with and was the ideal candidate for lip augmentation with ArteFill or any other
filler. The injection was done under a nerve block with local anesthetic with adren-
aline. ArteFill 1 cc was injected into the upper lip; 1 cc was also injected into the
lower lip. It was placed in the vermilion border to increase border definition, pro-
jection, and size; the dry lip to increase size and projection; and the wet-dry junc-
tion to increase size and projection. She is shown 1 year after injection. No lumps,
bumps, or irregularities are evident. The patient is very satisfied with the result and
shows good long-term results and normal appearance of the lips when animating.
The injections were done in two steps with 0.5 cc per lip per session 2 months apart.
With ArteFill the injections should be planned 11⁄2 to 2 months apart to allow max-
imal change with tissue formation around the beads. For the lips some patients may
require a total of 3 to 4 cc. Patients with thin lips should be warned of the minimal
to moderate change in size and shape. If too much volume is placed, there is an in-
creased chance of lumps, bumps, or irregularities.
1, ArteFill is placed at the vermilion border first. 2, Augmentation of the dry lip must be done with care.
3, Augmentation of the wet-dry junction and the lateral lip (this can be turned out by injecting from the
vermilion to the wet-dry mucosal junction).

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A total of 1.5 cc of ArteFill (0.75 cc per side) was placed in this 38-year-old woman,
who requested amelioration of nasolabial folds and marionette lines. ArteFill was
injected into the deep dermis of her nasolabial folds, lip-vermilion border, and mar-
ionette lines. Restylane Fine Lines/Touch was placed at the dermal-epidermal junction,
overlying the area in which ArteFill was placed in the marionette grooves (a total of
0.4 cc: 0.2 cc per side).
This 47-year-old man demonstrates the effectiveness of ArteFill for correction of cys-
tic acne scarring (arrows indicate acne scars). A total of 3 cc of ArteFill was injected
into the deep dermis on each side of his face. Two sessions of injections were per-
formed under local anesthetic 2 months apart to achieve the desired result. He also
had 0.7 cc of Restylane injected into his upper and lower lip vermilion.
Center: 1, Areas where ArteFill has been placed in the deep dermis. 2, Areas where ArteFill has been
placed in the deep dermis, and Restylane Fine Lines/Touch has been placed at the dermal-epidermal
junction.

Autologous Fat Grafting
Features and Applications
The relatively recent development of effective methods of structural fat grafting have
been revolutionary in contouring the face and body. Autologous fat enhances the
subcutaneous volume and intramuscular size but does not act as a dermal filler. Ba-
sic indications are facial (cheek, malar hollow, jawline shape, chin projection, supra-
orbital hollow, nose shaping), body contouring (buttock augmentation, correction
of liposuction deformity, chest contouring, correction of scars), and more recently,
the breast. With respect to the breast, fat grafting is very promising for primary aug-
mentation, secondary corrections, and breast reconstruction, yet its use remains con-
troversial. Proper training is required, and a long learning curve can be expected to
achieve top-quality results.
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Part III  Nonsurgical Cosmetic Treatments
In this 48-year-old man (left), fat was placed at 1, the deepest level of the infraor-
bital hollow, just below the orbital rim. The inferior extent of fat placement is indi-
cated at 2. The fat is first placed to the deep layer at the inferiormost aspect, then
added stepwise superiorly to the orbital rim; 3 indicates the malar high point. In the
38-year-old woman (right), Restylane treatment and fat grafting were combined to
good effect to fill the infraorbital hollow.
Preoperative and 1-year postoperative results after microfat grafting to the hand are
shown in a 58-year-old woman.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Preoperative and 1-year postoperative results are shown after microfat grafting to the
temples, cheeks, and jawline and bilateral upper blepharoplasty in a 50-year-old man.
Common areas in which fat is placed for effective correction are the infraorbital hol-
low, malar region, the angle of the mandible, anterior/posterior jawline, chin, na-
solabial folds, and the supraorbital/temporal region (1 and 2). Indications may vary
from facial aging to lipoatrophy to congenital aesthetic deformities. Structural fat
grafting is also extremely effective in the periorbital region in combination with lower
and upper lid blepharoplasty, as well as in facial rejuvenation in combination with
a SMAS technique to fill the periorbital hollow. The supraorbital region, the na-
solabial fold, the jawline anterior to the jowl, and the nasal base may be augmented
with microfat grafting in combination with face lifting.
In comparison to the injectable soft tissue fillers, autologous fat is an excellent tool for
deep soft tissue filling and augmentation. Fat grafting is also effective in scar subcision
when the scars are soft and fat filling is carried out underneath. Fat is also used to
contour deformities of the nose, after either traumatic or aesthetic surgery. In com-
parison to the injectable fillers, results are variable when fat is used to contour the
lips and perioral region. Fat can be used for deep soft tissue augmentation when it

is injected below the periosteum of the malar bone in the upper one third of the na-
solabial fold. Fat may have decreased longevity when placed in the subcutaneous
layer to soften the nasolabial fold if the patient has a dynamic smile with compression
of the fold.
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Part III  Nonsurgical Cosmetic Treatments
The use of Perlane on the deep layer of tissue can achieve similar results to fat graft-
ing in certain areas of the face as can be seen in this woman whose periorbital hol-
lows and malar bone were augmented with this filler.
Injection Technique
The basic technique for microfat grafting consists of the harvesting of fat from a
donor site and transplantation to a recipient site where it acquires a new blood sup-
ply, which enables it to survive. Technically, small packets of fat are placed in indi-
vidual spaces to increase the volume of the tissue. These small packets acquire a new
blood supply through angiogenesis. The cells that are transplanted may increase or
decrease in size depending on weight gain or weight loss. Fat survival is technique
dependent, and some cases may require secondary injections that may be done at
varying lengths of time after the initial surgery. Fat storage after harvesting, for fur-
ther or late grafting, is controversial, because fat cells have been shown to lose via-
bility when frozen.
1, Primary depth of hollow in which Perlane is first placed, on the bone. 2, Area augmented with Perlane to
contour the malar region and correct the “polar bear” feature.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
The technique for harvesting may be done with either a Coleman 14-gauge harvest-
ing cannula or a Lambros 3 mm cannula (Grams Medical, Costa Mesa, CA). Aspi-
ration is done with a 10 or 20 cc syringe held at 1 to 2 cc negative pressures to min-
imize trauma to the fat. The site of harvesting has no consequence with regard to
results and longevity. Fat may be harvested from any location where there is excess.
The fat is then spun for 1 minute at 1500 rpm to separate the blood, oil, and local
anesthetic. The remaining fat is then transferred into syringes for injection using a
variety of techniques, depending on the region, density, and thickness of the tissues.
A 1 cc syringe is used in the facial region, with less than 0.1 cc of fat being placed
with each pass. Varying degrees of correction are carried out when placing the fat.
The harvesting cannula may also be used for injection of the fat in truncal areas.
Volumes
The volumes of fat required vary. In general, 3 to 7 cc may be used per side in the
periorbital region and 2 to 5 cc for the nasolabial fold, 1 to 3 cc for the anterior jaw-
line, and 6 to 15 cc for the posterior jawline. The surgeon should harvest two to four
times the volume required for transfer, depending on the site and harvest technique.
Longevity
If fat survives transfer, it becomes permanent. It gains or loses volume if there is an
increase or decrease in total body fat. It is sensitive to direct trauma, including for-
ceps injury, and it is also sensitive to injury with radiofrequency devices (Thermage,
Inc., Hayward, CA). Radiofrequency devices should not be used in areas that have
been grafted. If a physician is contemplating fat transfer in combination with ra-
diofrequency, the radiofrequency treatment should be completed before the fat trans-
fer; this may be done immediately before the grafting procedure.
Adverse Effects, Reactions, and Complications
Complications of fat transfer are similar to those of any other injection or surgical
technique. Care should be taken to deposit small amounts (0.1 cc) per each injection
pass in the face to avoid fat emboli to the eye or brain. Technique-related complica-
tions include placing the fat too superficially in the thin skin of the upper and lower
eyelids. Care should be taken not to inject the fat into the intramuscular or direct
subcutaneous layer between the muscle and the skin. Fat placed in these areas will
manifest as an irregularity, either static or dynamic. To address this complication,
the surgeon may remove fat either through a blepharoplasty incision or a direct in-
cision followed by pinching the fat with forceps. Other rare complications include
infection/abscess, chronic inflammation, change in skin texture (peau d’orange), and
fat graft survival, either too much or too little.

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Part III  Nonsurgical Cosmetic Treatments
Results
This 48-year-old man is shown 1 year after microfat grafting to the malar region
combined with transconjunctival blepharoplasty and canthopexy. A total of 6 cc of
fat was placed per side in the subperiosteal region on the periosteum to augment the
malar soft tissues and eliminate the periorbital hollow. The eyelid was not incised.
Postoperatively the nasojugal groove and periorbital hollow were eliminated, and
good lid position is exhibited.
This 38-year-old woman complained of fullness below her lower eyelid. This full-
ness was due to the orbicularis oculi muscle (1). Microfat grafts (4 cc) were placed
on the deep layer below and up to the edge of the muscle bulge (2). She required only
one grafting session and no eyelid surgery. She is shown 11⁄2 years after injection.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
This 60-year-old woman underwent a face lift, open brow lift, upper blepharoplasty,
and lower eyelid transconjunctival blepharoplasty. Left: 1 indicates the superolateral
extent for fat grafting. A total of 4 cc of fat was injected to the malar bone and naso -
jugal groove to increase cheek projection (2). She is seen 1 year after microfat grafting.
This 36-year-old woman underwent microfat grafting to the malar region and na-
sojugal groove (1) to correct her tear trough and periorbital hollowing. The oil from
the harvested fat was injected between the skin and the orbicularis oculi muscle (2)
to induce inflammation and scar tissue, which lightens the color of the skin. She did
not require a blepharoplasty incision. She is seen 1 year after fat grafting.

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This 34-year-old woman underwent transconjunctival blepharoplasty, canthopexy,
and malar fat grafting to improve facial contouring (1 indicates an old scar). The fat
was used to increase cheek projection, augment the malar high point, and decrease
the nasojugal groove and periorbital hollow (2). She is seen 1 year after treatment.
Technical Guidelines for Filler Combinations
To achieve optimal benefit, tissue fillers may be used in combination. In particular,
the hyaluronic acids, which come in three different sizes, produce excellent results
when used in combination. The larger-molecule fillers, Perlane, Puragen, and Juvé-
derm Ultra Plus, should be placed in the deep layer followed by the addition of Resty-
lane, Hylaform, Juvéderm Ultra, Elevess, or Prevelle Silk in a more superficial plane.
This layering can be done in both the nasolabial folds and the lips depending on the
depth and severity of rhytids. Restylane Fine Lines/Touch is an excellent choice to
use on top of either Perlane or Restylane at the most superficial level, the dermal-
epidermal junction. Quite often the depth of a fold is associated with a fine line at
its very deepest portion. The Fine Lines products are able to soften this line. Addi-
tionally, Restylane Fine Lines/Touch is quite useful in combination with Restylane,
Hylaform, Juvéderm Ultra, Prevelle, or Elevess for the glabellar region in which the
fold may have a degree of depth and breadth of 1 to 2 mm with a very fine line run-
ning down the central deep portion. Again, to avoid tissue necrosis, caution should
be used when injecting in the glabellar region.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
For the lips, combinations of fillers may include ArteFill combined with Resty-
lane/Hylaform/Juvéderm Ultra/Elevess or Restylane Fine Lines/Touch to achieve long-
term correction and enhancement as is seen in this patient (also seen on p. 377).
Combining Perlane and Restylane Fine Lines/Touch can achieve very similar results
after repeat injections over a longer period of time. In some cases the combination of
the two fillers produces results that may last from 8 months to 1.5 years. In areas such
as the hollowing anterior to the jawline and jowl, Pelane/Puragen/Juvéderm Ultra
Plus can be placed on the bone to give a deep-layer enhancement followed by sub-
cutaneous or intermediate dermal placement of Restylane/Hylaform/Prevelle Silk/
Elevess/Juvéderm Ultra to complete the correction of the deformity at the ante-
rior jawline.
The combining of the larger molecules of Perlane/Puragen/Juvéderm Ultra Plus along
with Restylane Fine Lines/Touch is quite useful in the treatment of acne scarring
whose acne scarring was significantly improved with this approach. ArteFill is also
a great choice for filling acne scars for permanent results.
Some individuals prefer to combine Restylane injection in the deep layer of the lip
with Zyderm/CosmoDerm for the superficial augmentation. These individuals would
inject the Zyderm/CosmoDerm before Restylane/Hylaform/Juvéderm Ultra to take
advantage of the lidocaine anesthetic effect.

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Results
This 47-year-old woman requested restoration of her lips, chin fold, jowls, and naso-
labial folds. Note the herpetic outbreak on her left upper lip. She underwent injec-
tions of 0.35 to 0.7 cc of Perlane/Restylane into her nasolabial folds and 0.2 cc of
Restylane with 0.2 cc Restylane Fine Lines/Touch into her extended nasolabial folds.
She also had 0.2 cc Restylane placed into her marionette lines. Her mental fold was
treated with 0.3 cc of Perlane/Restylane and 0.3 cc Restylane Fine Lines/Touch. Then
0.35 to 0.7 cc Perlane was injected on bone or into deep dermis to correct her jowls.
She is shown 4 months after injection.
General Considerations and Technical Pearls
Technical Nuances
All fillers result in dramatic improvements if used correctly and precisely. It is im-
portant to note that the results achieved with each filler are dependent on a learn-
ing curve, and some fillers are more forgiving than others. When learning to inject
fillers, it may be easier to use the collagen fillers because their viscosity is low and
placement into the tissue is done with relative ease. Additionally, these fillers do not
last as long as the hyaluronic acids. There are special adjustable needles provided
with the syringes that make injecting for novices even easier. Collagen is formulated
with lidocaine so a patient is more comfortable as the injection process proceeds.
Perlane/Juvéderm Ultra Plus/Puragen and Restylane/Juvéderm Ultra/Elevess/Prevelle
Silk are less forgiving when injected improperly. These must be placed precisely at
the level of the deep dermis and mid-dermis, respectively. The amounts placed on
each pass should be limited to less than 0.1 cc so that no lumps or bumps are cre-
ated. If an irregularity is noted, then this may be massaged gently to reduce its promi-
nence. If a large amount of material is placed at one site, then a possible sterile ab-
scess may occur resulting in loss of volume in the region along with inflammation
and swelling.
ArteFill can be used as baseline filler for the nasolabial folds and lips. Subsequently
injections can be performed with Perlane, Restylane, or Restylane Fine Lines/Touch
with excellent results. It must be noted that ArteFill, despite its permanence in the
tissue, provides correction of a deformity only for a period of 11⁄2 to 2 years. Age-

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
related changes and atrophy may give rise to the need for additional soft tissue aug-
mentation.
Of these fillers, ArteFill is the most difficult to inject. It is highly viscous and must
be warmed to room temperature to allow ease of injection. If there is loss of the col-
lagen suspension, there may be air present in the syringe, which can make the injec-
tion quite irregular. Careful massage of the tissue must be done after placement so
that no lumps or bumps remain. The larger 26-gauge needle causes more tissue
trauma and bruising compared with the smaller 27- to 31-gauge hyaluronic acid nee-
dles. Perlane and Restylane are easier to inject than ArteFill.
Perlane/Juvéderm Ultra Plus is injected with a 27-gauge needle, and Restylane/
Juvéderm Ultra/Prevelle Silk/Elevess is injected with a 30-gauge needle. They can be
placed with precision. Fantastic results can be achieved with proper training and a
good aesthetic eye Restylane Fine Lines/Touch is less viscous than Perlane and Resty-
lane. It is placed at a very superficial level and may be placed in a serial injection
technique by spot placement or by linear threading at a very superficial level. If an
irregularity is noted, then gentle massage of the tissue will correct the deformity. It is
supplied with a 31-gauge needle and tissue trauma and bruising are minimal.
Sculptra can be used in conjunction with most fillers other than ArteFill. Generally it
is more of a panfacial filler; to add volume to the whole face and improve the tex-
ture and quality of the skin. More focused contouring may be done with the hyal -
uronic acids, Radiesse, or the collagens. Radiesse can be used in a similar fashion
to Sculptra (panfacial volume restoration), but it does not have the same longevity.
A patient may decide that he or she wants an immediate change instead of waiting 3
to 4 months for the results of Sculptra to be evident. But some patients like the
longevity of Sculptra (11⁄2 to 2 years versus Radiesse’s 1 year).
Adverse Effects, Reactions, and Complications
All of the fillers have possible adverse effects. Perlane, Restylane, and Restylane Fine
Lines/Touch have an incidence of reaction of approximately 1 in 3000. Reactions
may occur such as local erythema, swelling, and deformity, which may be undulat-
ing and recurrent. This is rarely seen. Other reactions to the hyaluronic acids may in-
clude frank allergy, cellulitis, sterile abscess, local noncellulitic erythema, and telan -
giectasia. If the patient has preexisting telangiectasia, this should be noted before
injection. Additionally, the patient should be informed that there is a possible risk
of telangiectasia formation and that preexisting telangiectasias may become more
severe and require treatment after injection. Soft tissue necrosis and embolic phe-
nomenon have been reported but are rare. The area most implicated is the glabella,
rarely on injection with Restylane and more commonly with collagen. An algorithm
for treatment of blanching postinjection that includes warm compresses, nitroglyc-
erine, epinephrine, hyaluronidase, and heparin has been proposed to reverse or min-
imize such ischemic events.

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ArteFill can result in local granulomatous reactions (as with any soft tissue filler).
The instances reported to date in North America are low (0.02% to 1%). There have
been more extensive reports of granulomas in Europe (perhaps because of the ear-
lier generations of the product). These may present as localized bumps or nodules
that are tender to the touch. On histologic examination of the tissue, giant cells and
multinuclear giant cells are present in the nodules, with an accompanying inflam-
matory response. If the product is placed too superficially in the dermis, the resultant
tissue formation may lead to a white coloring of the skin. This is similar to the bluish
discoloration (Tyndall effect) that may occur with any of the hyaluronic acid fillers
when placed in the superficial layer of the dermis. If ArteFill is not placed in small
amounts with each pass, deformities may result that can be difficult to treat. These
nodules may be treated with local excision, massage, or injection of dilute steroid
(0.2 mg/ml of triamcinolone [Kenalog]). A stronger Kenalog concentration (up to
40 mg/ml) may be needed to control the inflammation. If granuloma occurs, treat-
ment options include direct steroid injection, excision, systemic treatment with
oral steroids, or a combination of these treatments depending on the severity of the
granuloma.
Bovine collagen (Zyplast and Zyderm) has been associated with severe local or re-
gional allergic reactions that can become chronic and difficult to treat. Again, if these
reactions are unresponsive or minimally responsive to local steroid injection, they
may require oral steroid treatment. Allergic reactions can result in long-term scar-
ring. Localized infection may occur after injections. No such hypersensitivity reac-
tions are seen with human-derived CosmoDerm/CosmoPlast.
The injection of all filling substances may result in a herpetic outbreak if the patient
has a predisposition. It must be noted that patients with a previous history of her-
pes simplex outbreak should receive prophylactic treatment with an appropriate an-
tiviral medication.
Concluding Thoughts
The ideal filler has not yet been defined or created. There are a large number of fillers
available in the international market; however, there are fewer available for use in
the United States and Canada. The ideal filler may not be a single product. At the
present time, a combination of available fillers provides correction of soft tissue
rhytids and soft tissue augmentation and enhancement, and in some cases a non-
surgical lift. A truly permanent filler may not be desirable as the facial soft tissues
change with age. For example, certain patients who received silicone many years ago
have resultant permanent deformities that cannot be corrected because silicone can-
not be removed from the tissue. For this reason we do not inject silicone. The com-

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
ponents of an ideal filler include excellent safety profile, biocompatibility, longevity,
ease of use, reproducibility, ease of storage, affordable cost, ability to combine with
other fillers, and stability to give the most ideal result. It is important for physicians
to have proper training and to understand the injection techniques that apply to each
category of fillers. With precision placement and a good eye for aesthetics, tremen-
dous results can be achieved. The combination of injectable fillers with surgical and
nonsurgical techniques including botulinum toxin will continue to evolve as cosmetic
surgeons continue to develop an understanding of the aging face and what is required
to reverse this process. In particular, surgeons have moved to using a combination
of tissue adjustment and volume restoration. Companies are eager to bring new fillers
to the market. Each new tissue filler will have to be evaluated for its best applica-
tion, technique of injection, amount used for quantifiable effect, ease of use, ability
to combine with other fillers, longevity, and possible adverse effects.
Clinical Caveats
 Off-label use of synthetic materials is technically possible but does carry some risk.
The plastic surgeon is vulnerable from a liability standpoint, and discretion should
used when using products in an off-label manner. The patient must be informed
of off-label use.
 When treating deep folds and tear troughs, it is important to undercorrect these
deformities. This results in a more natural appearance and leaves room for further
correction in the future if that is desirable. Overcorrection of these areas can re-
sult in visible abnormalities and stigmata of filler use, particularly when the pa-
tient shows animation.
 Inexperienced injectors should always opt for rapidly resorbable fillers such as
bovine collagen (if available) and hyaluronic acids. This allows for faster resolu-
tion of any technical errors that may occur. Alternatively, in the case of hyaluronic
acid fillers, hyaluronidase can be used to dissolve the filler.
 Often in cases in which a slight correction is required, the patient forgets his or
her preoperative appearance. It is imperative to use photography and point out
any asymmetries before treatment to establish the patient’s expectations and for
comparison after injection.
 Complications of dermal fillers can be avoided by the use of proper technique
(small aliquots, appropriate level and quantity of injection, undercorrection, and
massaging with some fillers). This is especially important with the longer-lasting
fillers.

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Annotated Bibliography
Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004.
Fat grafting is rapidly becoming one of the most requested procedures for a new gener-
ation. It offers a valuable tool to address patient demands for less invasive cosmetic pro-
cedures that produce natural, long-lasting results. The author provides surgeons with
the expert guidance needed to master this technique for a wide variety of applications,
including facial and hand rejuvenation, adjustment of facial proportions, and correc-
tion of liposuction deformities.
Kinney BM, Hughes CE. Soft tissue fillers: an overview. Aesthetic Surg J 21:469-471, 2001.
The worldwide search for the ideal soft tissue filler material continues. We focus on the
stringent safety and efficacy requirements for soft tissue fillers and provide an overview
of the current natural and synthetic materials.
Nahai FN, McGrath M. Tissue Fillers. Roundtables in Plastic Surgery, vol 1, no 2. St Louis:
Quality Medical Publishing, 2004.
In recent years a variety of products have been brought to market that possess many of
the properties necessary for improving facial appearance. Almost all of these innovative
materials are effective for restoring youthful contours and fortifying aging skin; how-
ever, many of them work only in defined sites and planes of the soft tissue layers of the
face. Additionally, all of them have short-term and long-term adverse consequences with
various levels of severity. In this monograph an assembled panel of experts collect and
organize the marketing information and clinical reports, present the regulatory status,
and discuss what new products are in the pipeline. They also discuss the characteristics
of each filler and debate their efficacy and clinical applications in a spirited roundtable
discussion. Numerous pretreatment and posttreatment cases are presented.
Saylan Z. Facial fillers and their complications. Aesthet Surg J 23:221-224, 2003.
A number of facial filler materials that have not yet been approved by the FDA for use
in the United States have been employed by physicians in Europe for several years. Al-
though these products have proved efficacious, some complications events have been
associated with their injection or inappropriate application. Moreover, the long-term
effects of injecting into the face materials that cannot be removed without surgical in-
tervention is an issue that deserves serious consideration by both physicians and pa-
tients.

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Allevato MA, Pastorale EP, Zamboni M, et al. Complications following industrial liquid
silicone injection. Int J Dermatol 35:193-195, 1996.
Alster TS, West TB. Human-derived and new synthetic injectable materials for soft-tissue
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Bergerte-Galley C. Comparison of resorbable soft tissue fillers. Aesthet Surg J 24:33-46, 2004.
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Cassuto D. The use of Dermicol-P35 dermal filler for nonsurgical rhinoplasty. Aesthet Surg
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Chajchir A. Fat injection: long term follow-up. Aesthetic Plast Surg 20:291-296, 1996.
Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic
Plast Surg 19:421-425, 1995.
Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 28:111-119, 2001.
De Boulle K, Swinberghe S, Engman M, et al. Lip augmentation and contour correction with
a ribose cross-linked collagen dermal filler. J Drugs Dermatol 8(3 Suppl):S1-S8, 2009.
Dorne L, Alikacem N, Guidoin R, et al. High resolution solid-state 29SiNMR spectroscopy
of silicone gel used to fill breast prosthesis. Magn Reson Med 34:548-554, 1995.
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Fagien S. Facial soft-tissue augmentation with injectable autologous and allogeneic human
tissue collagen matrix (autologen and dermalogen). Plast Reconstr Surg 105:362-373,
2000.
Ford CN. Autologous collagen vocal fold injection: a preliminary clinical study. Laryngo-
scope 105:944-948, 1995.
Friedman PM, Mafong EA, Kauvar AN, et al. Safety data of injectable nonanimal stabilized
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Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for preven-
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remedy for treatment of vocal fold insufficiency—an animal study. Acta Otolaryngol
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Hamilton TK. Skin augmentation and correction: the new generation of dermal fillers: a der-
matologist’s experience. Clin Dermatol 27(Suppl):S13-S22, 2009.
Hanke CW, Higley HR, Jolivette DM, et al. Abscess formation and local necrosis after treat-
ment with Zyderm or Zyplast collagen implant. J Am Acad Dermatol 25:319-326, 1991.
Hevia O. A retrospective review of calcium hydroxylapatite for correction of volume loss in
the infraorbital region. Dermatol Surg 35:1487-1494, 2009.
Hisako M, et al. Creation of an acellular dermal matrix from frozen skin. Aesthetic Plast
Surg 23:316-322, 1999.
Hoffmann C, Schuller-Petrovic S, Soyer HP, et al. Adverse reactions after cosmetic lip aug-
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40:100-102, 1999.
Hotta T. Dermal fillers: the next generation. Plast Surg Nurs 24:14-19, 2004.
Hulterstrom AK, Ruyter IE. Changes in appearance of silicone elastomers for maxillofacial
prosthesis as a result of aging. Int J Prosthodont 12:498-504, 1999.
Inglefield C. Nonsurgical hand rejuvenation with Dermicol-P35 30G. Aesthet Surg J 29
(3 Suppl):S19-S21, 2009.
Jones FR, Schwartz BM, Silverstein P. Use of a nonimmunogenic acellular dermal allograft
for soft tissue augmentation: preliminary report. Aesthetic Surg Q 16:196-201, 1996.
Kim KJ, Lee HW, Lee MW, et al. Artecoll granuloma: a rare adverse reaction induced by mi-
croimplant in the treatment of neck wrinkles. Dermatol Surg 30(4 Pt 1):545-547, 2004.
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part 2. Treatment options. Plast Reconstr Surg 123:1864-1873, 2009.
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lasting correction of wrinkles: refinements and statistical results. Aesthetic Plast Surg
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342, 2000.

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Structural Fat Grafting:
Basics and Clinical Applications
in the Hand, Face, and Nose

SYDNEY R. COLEMAN
CHAPTER 13

A
utologous fat grafting is a technique that has grown in popularity in recent
years with the increasing demand for injectable tissue fillers and with new dis-
coveries concerning the regenerative capabilities of transplanted fat. Interest in fat
grafting applications has grown exponentially as physicians have recognized fat’s
enormous potential for solving aesthetic and reconstructive problems. As one of the
most biocompatible of soft tissue fillers, autologous fat has broad applications in
aesthetic surgery. Placement by separating the parcels one from the other encourages
longevity, promotes stability, and effectively integrates the fatty tissue into the host
tissues so that they are minimally detectable. Fat grafted in this manner is a safe, long-
lasting, and natural-appearing tissue filler. It is also an effective means of changing
facial and nasal contours, revising scars, and rejuvenating the hands and face. This
chapter focuses on the basic principles of structural fat grafting and the most common
applications for rejuvenation of the hands, nose, lips, and nasolabial folds.
Evolution of Technique
Physicians have been experimenting with injections of substances to alter surface
contours of the face since the nineteenth century. In 1899 Gersuny first reported the
injection of paraffin to replace resected testicles. He later reported on the use of paraf-
fin to correct facial contour deformities. Additional reports on the use of paraffin for
correcting facial defects were later made by Miller and Kolle. As paraffin use fell into
disfavor because of the many complications associated with it, aesthetic surgeons
continued to use injection techniques with other substances such as rubber and pu-
rified latex in search of the ideal filler material. In 1908 Eugene Holländer of Berlin
first published his experiences with injecting fat into the face. In 1912 Holländer pub-
lished before-and-after photographs of the use of injectable fat for correction of fa-
cial atrophy and breast scarring. In 1926 Charles Conrad Miller in the United States
described his experiences injecting fatty tissues through cannulas.
The introduction of liposuction in the 1980s helped to popularize this idea of using
autologous fatty tissue for implantation. A byproduct of liposuction, the suctioned
semiliquid fat could be reinjected through cannulas and needles. The ready avail-
ability of semiliquid fat after liposuction helped to renew surgeons’ interest in graft-
ing autologous fat through a cannula, and myriad techniques for grafting have been
introduced since that time, with mixed results.
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In 1987, after initial success with grafting fat into iatrogenic liposuction deformities,
I began to place fat in the face for aesthetic reasons. These early efforts yielded long-
term structural changes that have demonstrated permanence. Since that time the
technique has been refined, altered, and improved to ensure better integration and
stability of the grafted fat and to provide an alternative method, outside of tradi-
tional surgical techniques, for altering facial contours and contributing to overall fa-
cial rejuvenation. It has also been used successfully for hand rejuvenation and for
treating iatrogenic deformities resulting from liposuction. (See Chapter 87 for more
information on fat grafting for iatrogenic deformities.)
Pretreatment Assessment
Determining the specific amount of fat and the levels of placement necessary to ex-
ecute subtle contour changes in the face requires a well-developed strategy. Before a
plan can be established, the surgeon must evaluate the patient’s appearance and ac-
quire information on the patient’s lifestyle, expectations, prior aesthetic procedures,
and medical history.
The surgeon should carefully review past aesthetic procedures to make certain noth-
ing has been overlooked. In my experience, injections of silicone and even fat are the
procedures that patients most often neglect to mention. Even if patients disclaim any
injections on the intake form, it is advisable to ask whether they have had silicone,
collagen, or fat injections. Because the presence of scars on the skin can influence
the approach for placement of fat grafts, the history should include skin biopsies,
punch biopsies, and so forth.
Because structural fat grafting is invariably an elective procedure, the treatment of
candidates in poor general health should be approached with caution. Problems with
bleeding, bruising, and unusual swelling after prior procedures should be addressed
to prepare the patient and surgeon for similar problems. A history of any outbreaks
of fever blisters on the lips is solicited to determine whether herpes simplex prophy-
laxis is indicated. A neurologic history is essential. Fat infiltrated into the muscles of
a patient who has recovered from a facial nerve injury or Bell’s palsy may act as a
stent, inhibiting movement in the affected areas of the face. Any history of psychi-
atric problems and their current status, along with their possible impact on the sur-
gical patient, should be carefully considered before a patient is accepted.
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Chapter 13  Structural Fat Grafting: Basics and Clinical Applications

I schedule several consultations with a patient before surgery. For patients interested in
rejuvenation procedures, I ask them to bring photographs of themselves when they were
young to help determine the degree of augmentation needed. These photographs pro-
vide a better gauge of the patients’ aesthetic preferences. Patients need to understand
the details of the planned procedure, the expected outcome and postoperative course,
their responsibilities during recovery, and possible sequelae and complications.
Informed Consent
In my experience, the most important part of the informed consent process is the
time spent with the patient in preparing for the procedure. In addition to a verbal
explanation of the procedure and the perioperative course by the surgeon and nurses,
the patient is given printed material for referral. It is important to prepare the pa-
tient for the postoperative swelling and bruising and the potential for complications.
Although this procedure is associated with a high rate of long-term patient satisfac-
tion, patients who are not prepared for the expected or unexpected postoperative se-
quelae can pose major problems.
Physical Examination
Physical examination of the face supplements the photographic documentation. Be-
cause photographs cannot capture the relationship of the underlying structures to
the skin, palpation is used to determine landmark relationships, such as the height
of the infraorbital rim compared with the eyelid and the relationship of the angle of
the mandible to the actual shadow of the jawline.
Pretreatment Planning
Photographs
Detailed photographic documentation is essential to successful structural fat graft-
ing. Photographs record the patient’s preoperative appearance and serve as a basis
for three-dimensional analysis. For example, in the face I take photographs of the
patient from a variety of angles and views. In all of these views, the patient’s hair
should be pulled back from the face and ears, even for male patients, and collars
should be pushed down or clothing covering the neck should be removed. At least
one set of pretreatment photographs is taken with the patient wearing no makeup
so that the color and texture of the skin can be documented.
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Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
Tracings and Blueprints
Summary of Perceived Problems
When grafting fat in the face, tracings of the patient’s face are used to evaluate per-
ceived problems and document patient complaints. They are used when I plan the
procedure and in discussions with the patient. I use them to predict the volumes re-
quired, the level of placement, and the structural support required to achieve the
desired changes. These tracings also serve as a form of informed consent to docu-
ment the planned changes during the consultation, detailing areas of fatty tissue
placement and removal as well as incision sites. What is most important, they serve
as a reference for making the markings immediately before treatment and during the
procedure.

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Part III  Nonsurgical Cosmetic Treatments
On a separate tracing I summarize the operations
over the facial features involved. I also ask pa-
tients to describe all botulinum toxins, hyal -
uronic acid, calcium hydroxylapatite, collagen,
silicone, or other substances injected into their
faces and map this information on the tracing,
along with the time of these injections.
Markings
On the day of the procedure, colored marks are drawn on the patient’s face using
the blueprints created at the second consultation as guides. The markings outline ar-
eas to be augmented and amounts of tissue to be infiltrated. These markings also
serve as reminders of the specific levels of placement against the skin, against bone,
or in intermediate levels. I photograph these markings with a digital camera and print
them out for a quick record; they are also stored at a higher resolution for a higher
quality record. These digital images and printouts of the markings serve as a useful
reference during the procedure, especially because the markings may become oblit-
erated during placement of the fatty tissue.

If the patient later says, “Well, I didn’t really understand you were putting fat there.
I thought you were going to put fat into my forehead also!” I can point to the doc-
umented markings on the photographs in that area to gently remind the patient of
the original plan that he or she agreed to.
Harvesting, Refinement, and Transfer
The basic principles of structural fat grafting include the following:
1. Harvesting with a blunt cannula and syringe using low suction
2. Refinement with centrifugation to facilitate removal of nonliving components
3. Purposeful placement into recipient tissues, separating parcels from each other
Fatty tissue is more fragile than most other human tissues and is easily damaged out-
side the body by mechanical, barometric, and chemical insults. To survive harvest-
ing, transport, and implantation with cannulas and syringes, fat must be harvested
in intact parcels small enough to be inserted through a small cannula but large
enough so that the tissue architecture is maintained.
Material harvested by syringe liposuction may contain as little as 10% or as much
as 90% of fatty tissue on centrifugation. The aspirated material separates into three
layers: the top layer is composed primarily of oil, the bottom layer is almost entirely
made up of blood and lidocaine, and the middle layer contains potentially viable
parcels of tissue. If each sample is composed of a different percentage of viable fat,
it is very difficult to accurately estimate the volume for placement. To obtain consis-
tent predictable results, most of the oil, blood, and lidocaine can be gently removed
from the harvested tissue by sedimentation or centrifugation.
Preparation for Harvesting
Because I have observed no clear correlation between donor site location and
longevity of the implanted tissues, I select harvesting sites that enhance body con-
tour and provide maximal access to the patient in the supine position that is used
for almost all facial augmentation procedures. The abdomen and medial thighs are
commonly chosen donor sites. When abdominal or medial thigh fat is limited be-
cause of prior liposuction or low levels of body fat, the suprapubic region, the an-
terior thighs, and the area above the knees are the next choices.
When the patient is placed in the prone position, the posterior medial thighs, lateral
thighs, and the love handles are prime options for donor tissue. In patients with low
body fat, especially men, the abdomen and love handles may consist mostly of fi-
brous tissue with little available fat. Using the thighs as donor sites in these men is
often a viable alternative.
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Part III  Nonsurgical Cosmetic Treatments
Donor Site Access
Whenever possible, harvesting sites are accessed through incisions placed in creases,
previous scars, stretch marks, or hirsute areas. The pubic region is the most useful
incision site because the abdomen, medial thigh, and anterior thigh can be reached
with ease. To harvest fat from the upper abdomen and flanks, additional incisions
can be made in the umbilicus and upper abdomen. With the patient in the supine
position, the knee can be reached through an anterior knee incision. Occasionally
an incision in the lateral hip can also be used for access to the thigh or to the lower
love handle. Incisions in the midback and lateral sacrum provide access to the love
handles and flank.
Sterile Technique
Bacterial contamination of the fatty tissue can result in infection that causes re-
sorption of the grafted material. Therefore meticulous sterile technique is always ob-
served with careful attention to preoperative patient preparation.
A blunt Lamis infiltrator attached to a 10 cc syringe is used to infiltrate the lidocaine
solution into the projected sites of fatty tissue removal. Usually 1 ml of lidocaine is in-
filtrated for every cubic centimeter of fat harvested.
Epidural or general anesthesia is preferred for removal of larger volumes or when
multiple sites are used. To ensure hemostasis, Ringer’s lactate in a concentration of
1:500,000 epinephrine is also infiltrated in a ratio of 1 ml of solution for each cu-
bic centimeter of fat harvested using a blunt Lamis infiltrator. Tumescent techniques
are not used during the harvesting phase.
Basic Harvesting Instruments
Instruments for structural fat grafting should be efficient and minimally traumatic
to the grafted tissue during both the harvesting and placement phases. A two-hole
cannula with a blunt tip and dull distal openings placed extremely close to the end is
used for harvesting.

The distal openings of the harvesting cannula are the appropriate size and shape for
harvesting the largest intact fatty tissue parcels that can readily pass through the lu-
men of the Luer-Lok syringe and will therefore also be able to pass through the much
smaller (17-gauge) lumen of the infiltration cannulas without clogging.
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Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
The length of the harvesting cannula is usually 15 cm. Although a 23 cm cannula
has a greater reach, it can potentially place greater torque on the Luer-Lok aperture
and break the syringe tip during extraction. It is advisable to use the shorter cannu-
las initially, advancing to longer ones once the surgeon is more familiar with the in-
struments. After a surgeon becomes adept at using straight harvesting cannulas, then
he or she should advance to the use of curved cannulas to follow the curvature of
the flanks, thorax, or thighs. The curved cannula can be especially helpful when har-
vesting from the abdominal midline through an umbilical incision to keep the tip of
the cannula from slipping into a deeper plane.
The incisions made for infiltration of anesthetic solutions are also used for harvesting
fatty tissue. These incisions are just large enough (usually 2 to 3 mm) to permit inser-
tion of the tip of the harvesting cannula. The inserted cannula is attached to a 10 cc
Luer-Lok syringe by the Luer-Lok connection. Only 10 cc syringes are used for har-
vesting; these are small enough to be manipulated manually without locking devices.
Lumen
23 cm
15 cm
Dull opening
Dull opening
Dull opening
Blunt tip
Blunt tip
Blunt tip

During 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 1
or 2 cc of negative pressure space in the barrel of the syringe while the cannula is
pushed through the harvest site. Initially excess fluid may be noted in the harvested
material. When substantial fluid is present, the syringe is placed on a table for sev-
eral 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 syringe with
the refined fat is then reconnected to the cannula, and harvesting continues until a
greater quantity of fat has been obtained. All incision sites are closed with nylon in-
terrupted sutures after harvesting is completed.
Refinement
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Part III  Nonsurgical Cosmetic Treatments
After the fat has been harvested, the cannula is removed from the syringe and
replaced with a dual-function Luer-Lok plug for capping; this is available in most
hospitals.
1-2 cc space

Centrifugation
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Chapter 13  Structural Fat Grafting: Basics and Clinical Applications
After the Luer-Lok syringe is sealed, the plunger is removed from the proximal end
of the syringe. The syringe minus the plunger is then placed into a centrifuge to sep-
arate the viable from the nonviable components. The recommended centrifugation
is 1300 G, which translates into 3000 rpm on the most commonly used small labo-
ratory centrifuges. I have found the optimal centrifugation time to be 3 minutes. Each
10 cc syringe is placed in an individual sleeve of the central rotor of the centrifuge.
These sleeves can be changed or emptied in case of spillage of the aqueous portion of
the syringe. Care should be taken to choose 10 cc syringes that fit into the sleeves
easily.
Centrifugation separates the denser components from the less dense components to
create multiple layers. The upper level, or the less dense level, is composed primarily
of oil; the middle portion is composed primarily of potentially viable parcels of tis-
sue and the lowest level is the densest layer and is composed primarily of blood, wa-
ter, and lidocaine. The middle portion has more oil present in the upper portion and
denser tissue present in the lower portion. It has been my observation that the denser
fatty tissue in the lower portion has a greater reparative effect on the tissues into
which it is injected, and appears to have a more predictable survival. Studies are cur-
rently being conducted to verify these observations.
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

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Part III  Nonsurgical Cosmetic Treatments
Separation of Components
To avoid losing the vacuum that holds the contents in place, the oil layer is decanted
first, before the plug is removed from the Luer-Lok syringe. (The oil can be used for
lubricating both the harvesting and insertion site incisions.) After the oil is poured
out of the syringe, the plug is removed from the syringe and the aqueous portion
flows out through the Luer-Lok aperture.
Wicking the superior portion of harvested fat using neuropads or Telfa strips re-
moves more of the remaining oily component of harvested fat. After 4 minutes, the
wick is replaced with another piece of wicking material. Wicking is performed at
least twice. Fat may stick to the material as the wick is removed, but scraping the fat
off the gauze can irreparably damage the fat. If the surgeon suspects that some of the
fat has been damaged by excessive exposure to air or mechanical trauma, the fat
should be discarded.
The plunger is then replaced after the fatty tissue is allowed to slide down to the edge
of the syringe. A finger 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 ad-

vanced to obliterate the dead space. The fat can be stored in the 10 cc syringe in this
fashion for brief periods of time before being transferred to smaller syringes for in-
filtration. Advancing the plunger of the 10 cc syringe with the Luer-Lok aperture
placed at the base of the smaller syringe transfers the contents. Both syringes should
be kept in a relatively vertical orientation to avoid accidental insertion of air bub-
bles into the column of fat during transfer. I use only 1 cc Luer-Lok syringes for place-
ment of the tissue into the face and hands and 3 cc syringes for the body.
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Decant
less-dense
oil layer
Oil back to
harvest site to
lubricate incision
Centrifuge fat
Harvest
Wick
Release
dense aqueous
component
Transfer to
smaller syringe
OVERVIEW: FAT REFINEMENT AND TRANSFER

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Placement Techniques
Placement of the refined fat into the recipient site is the most challenging part of fat
grafting. Fat parcels should be placed to ensure uniform survival, stability, and inte-
gration into the surrounding recipient tissue. The key to fatty tissue placement is
maximization of the surface area of contact between the harvested fat and the re-
cipient tissues. By placing these small parcels of fat so they are separated from each
other by the host tissue, the larger surface area of contact can be maintained. Be-
cause bacterial contamination may destroy transplanted fat, scrupulous attention is
paid to sterile technique.
Regional blocks using 1% lidocaine with 1:100,000 epinephrine through 25-gauge
needles are used when appropriate and convenient. For all planned incision sites on
the face or body, I place a solution of 0.5% lidocaine with 1:200,000 epinephrine
with a 27-gauge needle. Incisions 1 to 2 mm long are made in the face, neck, body,
and hands; these are also used for placement of the fatty tissue. Small amounts of
the 0.5% lidocaine with 1:200,000 epinephrine are diffusely infiltrated using the
structural fatty tissue cannulas into the areas of planned placement.

The infiltration cannula is inserted through each tiny incision that was used for in-
filtration of the local anesthesia and advanced through the tissues to the appropri-
ate plane. The skin is stabilized with the opposite hand. No fatty tissue should be
ejected during the advancement of the cannula into the recipient tissues.
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Once the cannula is in the desired location, the plunger of the 1 mm syringe is pressed
slightly while the cannula is being withdrawn. A small aliquot of fatty tissue is then
left in the pathway of the retreating blunt cannula, permitting more stable and reg-
ulated placement and minimizing the potential for irregularities or clumps of tissue.
Placement of minuscule amounts of fatty tissue with each pass is critical to success-
ful structural fat grafting. To maximize the surface area of contact, the largest amount
of tissue that should be placed in the face with each withdrawal is 1⁄10 cc. Intact
parcels of fatty tissue should be somewhat separated by the tissues of the recipient
site to maximize the surface area of contact between donor and recipient tissues.

Estimating the volume to be placed in each area can be challenging, and there is lit-
tle room for error. Minimal compensation should be made for resorption in this sit-
uation. The injected material is not pure fat; even after refinement, there will be quan-
tities of blood, lidocaine, or oil present in the refined fatty tissue. Therefore it is best
to use small amounts of infiltrate initially, increasing the amount gradually as expe-
rience is gained. The use of 1 cc syringes initially is particularly important to pre-
vent overzealous augmentation.
Use of Blunt Cannulas
Although I switched from sharp to blunt cannulas in 1992 to avoid injuries to un-
derlying structures, I have also found blunt instruments to be superior for placing
fatty tissue autografts in other regards as well. Unlike the sharp tip of a needle, the
blunt tip does not cut a swath through the tissue. As the blunt tip is advanced, the
natural tissue planes separate in a more physiologic fashion. As the blunt cannula is
withdrawn, the deposited fatty tissue parcels fall into the natural tissue planes as the
host tissues collapse around them. In addition, using blunt cannulas for more stable
placement of fatty tissues allows the surgeon to place much larger volumes of fatty tis-
sue. Finally, placement with a blunt cannula reduces the possibility of intravascular
injection of the fat.
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Stability of Transplanted Fat
Separating the parcels of fat does more than increase the chance of survival. Placing
the fatty parcels with a blunt cannula that causes minimal disruption of the natural
tissue planes facilitates better fat adherence to the recipient sites. Minimal destruc-
tion of the tissues and maximal surface area of contact combine to create a more sta-
ble relationship between the new fat parcels and the surrounding tissues.
After the edema resolves, the texture of the grafted tissues essentially resembles that
of the host tissues rather than retaining the structural qualities of fatty tissue. By
placing fat in small parcels and separating every parcel with the donor site tissues,
the fat becomes integrated with and feels like the tissues into which it is placed.
This three-dimensional technique of placing refined fat into the recipient sites cre-
ates the shape, volume, and structural changes defined in the operative plan. Accu-
racy of the initial placement is imperative, because the infiltrated fatty tissue is dif-
ficult to remold afterward. The fatty tissue should be deposited in the desired location,
shape, and volume with each pass of the infiltrating cannula. If a cyst or clump forms
accidentally, digital manipulation can sometimes flatten such minor irregularities.
However, the tissue should never be placed with the idea that digital pressure can
change the shape after placement.
Structural Manipulation
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The host tissues can be manipulated to change their shape better if the fatty tissue
is placed bluntly in minuscule amounts with each pass. If the tissue adheres to the
recipient tissue after each pass, then multiple passes can change the intrinsic shape
of a site while adding volume. Injections in the nasolabial folds, lips, and lower eye-
lids to relieve scleral show are examples of structural manipulation.

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Instrumentation for Placement
The instruments used for placement of fatty tissue are dramatically different from
those used for harvesting; they are shorter and have a smaller gauge, with only one
hole at the distal end. The fat infiltration cannulas vary in length and shape, but the
most useful lengths are from 5 to 9 cm for use in facial procedures and from 9 to
15 cm for body-contouring procedures. Cannula tips also come in various sizes and
shapes for individualized treatment.
To facilitate structural fat grafting, I have developed three different styles of blunt-
tipped cannulas as well as a V-dissector, each with its own function. I developed these
beginning in 1993 (Byron Medical, Tucson, AZ, a division of Mentor):
 The Coleman style I cannula is completely capped on the tip, with a lip ex-
tending 180 degrees over the distal aperture. It is my workhorse, and its pri-
mary purpose is to minimize traumatic injury to underlying structures.
 The Coleman style II cannula is similar to the style I but is not totally capped.
It has a lip extending over the distal aperture approximately 130 to 150 de-
grees. This cannula is useful in most situations.
 The Coleman style III cannula is flat on the end, permitting dissection of tis-
sues in specific situations; for example, when pushing through scars or fibrous
tissue. It is also helpful when placing tissue in immediately subdermal or sub-
mucosal tissue.
 The Coleman V-dissector is used for release of adhesions.

To facilitate use in different areas of the face and body, the cannulas come not only
in a variety of lengths but also in numerous sizes from 20 to 14 gauge. The smallest
gauges are used in the periorbital region and the larger gauges can be used in the
body.
As a result of recent concerns about the sterilization of small-bore cannulas, a line
of high-quality disposable cannulas is now available in the same shapes and sizes.
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Style I
Style II
Style III
Style III
Style I
Style II
V-dissectors
Front view
Front view
Side view

SPECIFIC CLINICAL APPLICATIONS
Hand
The hands are one of the first areas to exhibit visible signs of aging. The simple, re-
liable technique of autologous structural fat grafting can be used to achieve long-
lasting rejuvenation of the dorsum of the hand, restoring a slight fullness to atrophic
subcutaneous tissue, softening the color, defining the exposed extensor tendons and
veins, and supporting the aging skin.
The key to structural fat grafting of the dorsum of the hand is purposeful placement
of a smooth layer of tissue against the undersurface of the dermis, with extra place-
ment into deficient intermetacarpal and web spaces. The goal is to restore a youth-
ful fullness to the back of the hand.
Aesthetic Considerations
The dorsum of an attractive, healthy-appearing hand has a slight subcutaneous full-
ness that obscures veins and tendons but does not hide them. The tendons are more
defined when the metacarpophalangeal (MCP) joints of the wrist are extended than
when they are flexed or in repose. The superficial veins are usually discernible, and
the more slender and athletic a person is, the larger and more distinct these veins ap-
pear. The blue color of the veins can be seen through the skin, but the white tendon
color is not usually discernible. There is a generalized fullness of the skin and sub-
cutaneous tissues that adds volume to the nonbony hand and frames the joints with
a youthful fullness.
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In the dorsum of an aging hand, generalized subcutaneous fullness gradually disap-
pears as the subcutaneous tissues atrophy. With loss of fullness, the veins appear
more prominent, their blue color deepens, and the extensor tendons appear whiter
and more visible through the thin skin of the dorsal hand. The tendons are promi-

nent even at rest or with flexion of the MCP joints. With the loss of supporting full-
ness under the dermis and a gradual diminution of elasticity, the skin’s texture be-
comes more crêpey and wrinkled.
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The intermetacarpal spaces deepen, especially between the thumb and the index fin-
ger, and there is some loss of intrinsic muscle volume. With loss of fullness in the
hand, the fingers and joints may appear enlarged and arthritic.
Anatomic Considerations
Only the bluntest of cannulas, style I, is used at all times in the hand to avoid dam-
aging underlying structures. With careful placement in the subdermal layer between
the veins and skin, few anatomic structures are exposed to trauma. Even the trauma
to the veins is so minimal with this technique that I have rarely seen significant bruis-
ing after structural fat grafting to the dorsum of the hand. The primary potential for
anatomic problems results from manipulation of fat after placement. Strong digital
pressure on a clump of fat can push the newly grafted tissue deep to the tendons or
even deeper into the intrinsic muscles of the hand.
Indications and Patient Selection
Persons with noticeable loss of subcutaneous fullness of the dorsal hand and ap-
parent thinning of the skin are the best candidates for hand rejuvenation with fat
grafts. These patients usually also have prominent underlying veins and tendons along
with an increase in the crêpiness of the skin. Patients with intermetacarpal wasting or
arthritis are also candidates for this procedure because adjustment of the volume
proportions of the hand will create a much healthier appearance by decreasing the
relative size and boniness of the joints.

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Technique
This 57-year-old woman is typical of patients seeking fat grafting for hand rejuve-
nation. She thought that her hands looked much older than her face, with gradual
loss of the fullness that created a “bony” appearance. She especially disliked how
her joints appeared enlarged and arthritic, even though she had no functional prob-
lems. The well-defined tendons glistening through her thin skin also bothered her,
and she believed that her hands were much too “veiny.”
Markings
The patient’s hands are marked with borders of placement delineated by the orange
line running along the fingers and down the ulnar and radial hand, crossing the prox-
imal forearm. Places where more tissue will be placed are marked in green, and larger
veins are marked in blue.

Anesthesia
General anesthesia or heavy sedation and a double-level wrist block are most often
used for anesthesia of the hands, as was done for this patient. The 1% lidocaine with
1:100,000 ml of epinephrine is placed superficially with 25-gauge needles at two lev-
els: one just proximal to the planned area of infiltration and another approximately
2 cm proximal to the first block.
Incisions
Incisions are made with a No. 11 blade in the direction of the wrinkle lines, at six
or seven sites spaced around the periphery of the hand. The incisions are a little longer
than 1 mm.
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The best locations for incision placement are the following (see red circles):
 Ulnar and radial wrist, at the level of the MCP joints at the ulnar little finger
 Central dorsal wrist
 Web space between the ring finger and middle finger
 Radial index finger
 Radial thumb
Infiltration Cannulas
To avoid damage to underlying structures, particularly the veins, a blunt 17-gauge
cannula is used for fat placement in the hand. This blunt infiltration cannula is com-
pletely capped on the tip, with a lip that extends 180 degrees over a solitary distal
aperture. I prefer cannulas that are 7 or 9 cm in length.
Style I

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Level of Infiltration
The level of placement is almost entirely in the immediate subdermal plane superfi-
cial to the veins, where it can provide support to the skin.
Placement Volumes
I generally recommend placing at least 20 cc of fat in each hand. More fat will be
required for patients who want significant feathering onto the forearm or correction
of intermetacarpal wasting. Extreme overcorrection should be avoided; I place only as
much tissue as is needed to achieve a specific result based on my previous experience.
The basic placement technique is the same as for any location on the face. With each
pass of the cannula, less than 1⁄10 cc and sometimes as little as 1⁄50 cc is placed; 1⁄10 cc
is considered the maximum increment of tissue to place in the hands or face. The
small 1 cc syringe provides much greater control over increments placed with each
pass. Accuracy in the initial placement is crucial, because once placed, it is difficult
to reliably change the shape of the fat significantly after placement, especially after
edema is present. As the tissue is incrementally infiltrated with multiple passes of the
cannula, a plane of fat is created by placing minuscule amounts of tissue in close
proximity to each other, but separated by a tiny space. If the surgeon accidentally
allows a lump or irregularity to form, immediate digital manipulation will usually
flatten it to ensure that the newly placed fat looks and feels smooth to the touch.
Sequence of Placement
I start with the phalanges and proceed proximally over the web spaces, dorsum of
the hand, and dorsum of the wrist and forearm, if indicated. Placement is almost all
immediately subdermal, with occasional slightly deeper placement in deep inter-
metacarpal deficiencies.

The proximal phalanges and web spaces are usually approached first. Placement usu-
ally begins with the radial MCP thumb incision into the proximal phalanx of the
thumb. This placement is sometimes difficult because of the adherent nature of the
skin over the thumb MCP joint, so the incision should not be placed on the volar
surface of the thumb, but more in a more dorsal direction.
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Next, the proximal phalanx of the thumb is infiltrated from the ulnar incision at the
level of the thumb MCP joint.

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Then the first web space is approached from both the ulnar thumb incision and the
radial index finger incision. I place tissue into the proximal phalanx of the index fin-
ger across the first web space from the ulnar thumb incision. The first web space re-
quires at least 1 cc of fat in most cases.
Next, the proximal phalanx of the index finger is approached with several passes
made in a radiating pattern through each incision site. Only a minuscule amount of
fat is placed with each pass in this area. By infiltrating fat from multiple directions,
a “weaving” pattern of placement is created, thereby supporting the skin, in some
cases all the way up to the proximal interphalangeal (PIP) joints.

Once fat has been grafted into the thumb and index finger, placement continues in
minuscule increments over the index, middle, and ring fingers from an incision around
the middle MCP joint. Care is taken to avoid placing fat over the joints, because the
desired appearance is a reduction in the size of the joints. To cover the superficial
digital veins and place fullness evenly around the MCP joint, fat should usually be
feathered so it extends slightly past the proximal half of the proximal phalanx.
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The little finger and ring finger are then infiltrated from the ulnar incision at the level
of the MCP joint.

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From the same ulnar incision, further placement can be made across the MCP joints
all the way to the index finger. This allows more perpendicular placement, extend-
ing down along the distal web spaces, which frequently have thin skin and are wrin-
kled. Sometimes the unsupported skin may even fold over.
After fat is placed over the phalanges and into the distal web spaces, the spaces be-
tween the MCP joints are treated. Only a thin layer of tissue is placed over the MCP
or PIP joints to avoid the appearance of enlarged joints.