The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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VIII Surgical Rejuvenation of the Face and Neck
The retaining ligaments were first described independently by
Furnas and by Stuzin. These authors identified fascial systems
that travel from deep fascia to SMAS or from deep fascia to
skin. Stuzin suggested the additional category of osteocuta-
neous ligaments, which traveled directly from bone to skin.
These authors ascribed the function of structural support
to these tissues, hence the name ´retaining.µ A tremendous
body of work involving the fasciae emerged from the work
of dedicated researchers during the 1950s. Holyoke and
Grodinsky noted the close apposition of superficial and deep
fascia at specific regions of the face and named these fusion
zones. Later work related to the fat compartments identified
vascularized membranes as the partitioning membranes (Fig.
43.8, Fig. 43.9).
The terms retaining ligaments, vascularized membranes, and
fusion zones are therefore redundant. It is perhaps best to adopt
the term retaining ligament to avoid un-necessary confusion. The
retaining ligaments may arise either from deep fascia or from
bone and travel to dermis, where they partition fat into discrete
compartments. The zygomaticocutaneous ligament, previously
described as McGregor’s patch, is a type of osteocutaneous retain-
ing ligament.
Retaining ligaments play a role in structural support. Baker
differentiated regions of SMAS based on its ease of mobility,
applying the terms fixed and mobile. The mobile SMAS occurs
where no retaining ligaments travel from deep to superficial
fascia. This anatomic description of ´fixed SMASµ applies to the
observation that retaining ligaments represent highways for
facial anatomy.
This characterization addresses a number of contemporary
problems in aesthetic surgery. Facelift techniques that require
Fig. 43.7 The deep facial fasciae are named according to their
proximity to anatomic structures. The parotid fascia covers and
invests the parotid gland and merges anteroinferiorly with the
masseteric fascia. Superiorly, a thin layer of fat separates the superficial
musculoaponeurotic system (SMAS) from the superficial layer of the
deep temporal fascia, which descends to insert on the outer or lateral
surface of the zygomatic arch. Inferiorly, the parotidomasseteric fascia
merges with the superficial layer of the deep cervical fascia. The buccal
and marginal mandibular branches of the facial nerve travel deep to
the parotidomasseteric fascia. The frontal branch of the facial nerve
travels between the temporoparietal fascia and the superficial layer of
deep temporal fascia.
Fig. 43.8 (a) Retaining ligaments are the highways of the face. The
facial nerve travels deep to the parotidomasseteric fascia in the lateral
cheek. As it nears its target muscle, in this case the zygomaticus major
muscle, it ascends along the retaining ligament between deep fascia
and superficial musculoaponeurotic system (SMAS) at the edge of the
buccal space. A major lymphatic plexus descends from SMAS to deep
fascia along this same retaining ligament. The retaining ligaments
perform several functions, including offering protection from shear
to delicate structures as they transition from deep to superficial (and
superficial to deep). These retaining ligaments are analogous to the
septocutaneous membranes described in reconstructive microsurgery.
(b) Specialized techniques identify lymphatic vessels that travel along
retaining ligaments. The masseteric cutaneous ligament is shown. This
retaining ligament shown in this dissection was described by Stuzin in
his original paper and exists between the deep lateral cheek fat and
the buccal space. This fascial structure must be divided to mobilize
the SMAS. Stuzin described a “picket fence-like arrangement” of fascia
in his description of this retaining ligament. Some of these picketlike,
vertically oriented fibers (not all) are lymphatic vessels (fluorescent
vessels, right). Left shows the dissection viewed under ambient light.
The right dissection was performed after whole mount, in situ (ex vivo)
immunohistochemistry with the lymphatic biomarkers Lhuman D2-40 (which recognizes the human transmembranous lym-
phatic marker podoplanin). Secondary antibody with an FITC-tagged
fluorochrome is imaged using ultraviolet light and identifies the prolific
lymphatic system that travels along this retaining ligament. Such
techniques have the ability to discriminate anatomy at an unparalleled
level of precision. This anatomic description holds true for all retaining
ligaments studied, including the orbicularis retaining ligament (ORL).

43 Clinical Anatomy of the Face and Neck: Visualizing the Face
525
widespread SMAS undermining and division of multiple retain-
ing ligaments lead to prolonged edema. Hamra first described
the retaining ligament between platysma and mandible, later
characterized as an osteocutaneous by Reece. Transection of this
ligament, a major lymphatic pathway for the lower face, may
result in prolonged edema.
:hile the authors provide a reading list, they suggest Stuzin’s
description of the relationship between superficial and deep fas-
cias is a classic and an absolute must-read. The retaining ligament
system of the scalp and forehead is considered analogous to the
facial system and has been well documented by investigators such
as .nize, Mendelson, and 1ahai.
43.9 Danger Zones
Terminology
Danger zones: locations where facial nerve branches are prone
to injury. Anatomic correlation: regions where nerves ascend
along retaining ligaments.
.nowledge of the location and orientation of retaining ligaments
is some of the most important information for the aesthetic
surgeon. Retaining ligaments determine the fat compartments;
the location of perforator blood supply; and the potential sites
of nerve injury during a facelift, referred to as danger zones.
Seckel introduced this concept. Its relationship to the anatomy is
captured by the following illustration and dissection (Fig. 43.10,
Fig. 43.11).
Facial nerve injury is a disastrous complication for the aesthetic
surgeon. Fortunately communication occurs between most buccal
and zygomatic branches. However, even reinnervation may distort
dynamic facial anatomy; the smile-blink reflex (healing between
buccal and zygomatic branches) leads to a dynamic form of tic.
Three concepts help the aesthetic surgeon to avoid iatrogenic
nerve injury. Most important is knowledge of the ligamentous
support of the face, where nerves transition from deep to super-
ficial (Fig. 43.12).
43.10 The Compartmentalization of
Facial Adipose Tissue
Terminology
Fat compartments, anatomic fat compartments: General
location: superficial above SMAS, deep fat compartments
between SMAS and deep fascia. DeÀned by: retaining ligaments.
The characterization of the fat compartments has improved
surgical results by enabling site-specific augmentation. Like any
Fig. 43.9 The appearance of ligaments varies with where we encoun-
ter them on the face. Usually they are broad, thin fascial membranes
like the masseteric cutaneous ligament. However, when two or more
ligaments meet each other, they appear more like what we imagine
ligaments to look like: firm, dense, and cylindrical in nature. The
mandibular ligament was described where the platysmal retaining
ligament (along the mandible) merges with the lateral chin retaining
ligament (boundary between deep cheek and chin fat).
Fig. 43.10 Seckel described specific points where the facial nerve is at
risk during facelift surgery. These are referred to as danger zones. Danger
zones exist where a facial nerve branch ascends from deep to superficial
fascia along a retaining ligament just proximal to its target muscle.
Fig. 43.11 (a) The mandibular ligament occurs where the platysma
cutaneous ligament merges with the lateral chin retaining ligament
(traveling from deep fascia to superficial musculoaponeurotic system).
(b) The marginal mandibular nerve ascends along this retaining
ligament and is prone to injury during rhytidectomy. Another example
of this anatomy is the zygomatic ligament, where a buccal branch
ascends along with a prominent blood vessel. Understanding the
ligamentous structure of the face yields unparalleled knowledge of
soft tissue anatomy.

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VIII Surgical Rejuvenation of the Face and Neck
other concept, this has evolved from the individual observations
of numerous investigators. Hand surgeons were the first to iden-
tify superficial fat compartments. Aiache and Ramirez described
the retro–orbicularis oculi fat (ROOF), a deep compartment of
the upper lid. Pessa described the superficial malar fat pad in
his work on the etiology of periorbital ecchymosis. However, not
until Rohrich and Pessa was this concept applied to the entire
face, forehead, and neck. Like many advances in surgery, this
breakthrough resulted from an out-and-out mistake in the anat-
omy lab³a good story, perhaps, for another time and another
place (Fig. 43.13, Fig. 43.14).
43.11 The Facial Muscles
Terminology
Facial muscles: Characterized by action: elevator vs. depressor
(e.g., frontalis as brow elevator; procerus as brow depressor).
Characterized in relationship to other muscles: agonist vs. antago-
nist (e.g., depressor anguli oris depresses corner of the mouth;
antagonist is levator anguli oris). Relationship to SMAS: SMAS
invests muscles traveling within the same plane (orbicularis,
platysma).
Selective chemodenervation of facial muscles is a powerful tool
for the aesthetic surgeon. The reaction to chemodenervation is
best thought of as increasing the result of resting tone in the target
muscle’s paired antagonist. For example, chemodenervation of
the orbicularis oculi muscle, a brow depressor, results in fore-
head elevation. Chemodenervation of the depressor anguli oris
muscle increases the effectiveness of lip elevation by the levator
anguli oris (Fig. 43.15).
The facial muscles have been described in four layers, with the
buccinator being the deepest layer. Most facial muscles, however,
have a defined bony origin and insert into dermis or into a conflu-
ence of other muscles. There are a few brief points we can make
relate to all facial muscles in general (Fig. 43.16).
1. Facial muscles are innervated on their deep surface. Technically
speaking, even the buccinator muscle is innervated on its deep
surface, which happens to be anterior when viewed from the
frontal position (it would be like saying the trapezius or rhom-
boids are innervated on their superficial surface if one views
them from anteriorly).
2. Facial muscles are innervated proximally. =ygomaticus major
included always reveal two or three facial nerve branches located
just proximal to its origin. This is where nerve injuries occur.
3. Facial muscles insert into either the dermis or a confluence of
other muscles. The corner of the mouth is an excellent example.
4. The SMAS invests muscles traveling within its plane; for exam-
ple, the orbicularis oculi and the platysma.
A cursory review of any anatomic atlas affords ample knowl-
edge to the clinician. However, experience in the cadaver lab lends
an intuitive understanding for the location of specific muscles and
significantly reduces the chance of iatrogenic nerve injury during
submuscular and/or subfascial dissection.
Fig. 43.12 Three concepts help the surgeon avoid iatrogenic nerve
injury. (1) Most, if not all, of the “danger zones” noted by Seckel occur
directly over retaining ligaments, where the facial nerve transitions
from deep to superficial. Transition occurs near each nerve’s anatomic
target, so knowledge of ligamentous and muscular anatomy enables
one to predict these locations. (2) Nerves accompany blood vessels
and lymphatics as they travel along retaining ligaments. As has been
understood since the description of McGregor’s patch, brisk bleeding
encountered during ligamentous release is a warning sign of possible
inadvertent nerve injury. (3) The facial nerve lies deep to the superficial
musculoaponeurotic system (SMAS) and the parotidomasseteric fascia.
Even when a facial nerve branch with a minimal diameter is encoun-
tered, knowledge of anatomic planes ensures safe dissection.
Fig. 43.13 The retaining ligaments determine the presence and
location of the anatomic fat compartments. Just as the presence of
superficial fascia determines a superficial and a deep layer, the course
of retaining ligaments from deep fascia (or from bone) to skin defines
both deep and superficial fat compartments. Initially dye was used to
identify discrete regions of fat, a technique that has been supplanted
by far more precise technologies. Elevation of both zygomaticus major
muscle and superficial musculoaponeurotic system (SMAS) exposes
the sub–orbicularis oculi fat (SOOF). With proper anatomic prepa-
ration, the retaining ligaments can be easily identified. The superior
retaining ligament is the orbicularis retaining ligament (ORL); the
inferior retaining ligament travels horizontally but has not been named
formally. This is a nonwashout/non-latex-injected prep that preserves
lymphatic filling so that the lymphatic plexuses traveling along the
retaining ligaments can be visualized.

43 Clinical Anatomy of the Face and Neck: Visualizing the Face
527
43.12 Anatomic Spaces
Terminology
Anatomic spaces: Spaces are always located beneath the super-
Àcial fascia and contain gliding fat and/or glandular tissue. They
lie between retaining ligaments but in addition are contained
within their own discrete fascia (e.g., capsule of the buccal fat).
Examples: buccal or masticatory space, submandibular space,
premasseteric space.
Mendelson has furthered much of our knowledge of anatomic
spaces and their importance to the aesthetic surgeon. He
described the premasseteric space as the area beneath a line
drawn from the tragus to the corner of the mouth (Fig. 43.17).
The premasseteric space represents a zone of safe dissection
during SMAS elevation. The buccal or masticatory space is located
medial to the premasseteric space and contains the buccal fat
pad of Bichat. Both Stuzin and 1ahai suggest that division of the
lateral fascial border of the buccal space is necessary to reduce the
prominence of jowls. Transection of this fascia with SMAS repair
basically decreases the volume of the buccal space and relocates a
ptotic buccal fat pad (Fig. 43.18).
The submandibular space is shown for illustrative purposes in
Fig. 43.17. Its medial border is represented by the four structures
of the carotid sheath: the carotid artery, the internal jugular vein,
the vagus nerve, and the terminal cerebrospinal drainage of the
entire human brain.
Fig. 43.14 Loss of deep fat may lead to pseudoptosis. Note: the
boundaries of the nasolabial fat compartment, shown above (b)
within the black and red arrows, if defined by cutaneous lymphatic
vessels.(a) Superficial fat compartments are shown. The nasolabial fat
compartment is shown, followed by the cheek compartments: medial,
middle, and lateral temporo-cheek. The periorbital fat compartments
include the superior, inferior, and lateral compartments. (Adapted
with permission from Schaverien MV, Rohrich RJ, Pessa JE. Vascularized
membranes determine the anatomical boundaries of the subcutaneous
fat compartments. Plast Reconstr Surg. 2009; 123:695-700.) (b) Deep
fat compartments may lose volume with aging, which may result in a
form of pseudoptosis. (Note: the boundaries of the nasolabial fat com-
partment, shown above, are within the black and red arrows, if defined
by cutaneous lymphatic vessels.) (Adapted with permission from Rohrich
RJ, Pessa JE. The fat compartments of the face: anatomy and clinical impli-
cations for cosmetic surgery. Plast Reconstr Surg. 2007; 119:2219-2227.)
Fig. 43.15 The facial muscles represent a potential target for facial
rejuvenation through selective chemodenervation. The reaction to
chemodenervation is best understood in terms of enhancing the
resting tone of selected muscles through weakening of their paired
antagonists. For example, the levator anguli oris muscle, which travels
from maxilla to insert into the modiolus, is the antagonist to the
depressor anguli oris. Chemodenervation of the depressor anguli oris
thus increases the effect from the resting tone of the levator anguli
oris muscle. This results in elevation of the corner of the mouth.
Understanding of the paired agonists/antagonists is easily gained by
even a cursory review of any anatomic atlas. Direct experience in the
cadaver lab provides an intuitive understanding of the location of
specific muscles and adds safety to any subfascial dissection.
Fig. 43.16 (a,b) The facial muscles represent targets for potential
chemodenervation. The facial muscles are usually described as four
layers from superficial to deep. Most facial muscles are innervated
from their deep surface.
a
b

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VIII Surgical Rejuvenation of the Face and Neck
43.13 Concluding Thoughts
by Foad Nahai
My fascination with anatomy first began in medical school, when
I recognized the beauty and complexity of the body’s anatomic
structures. I well remember one of my professors telling me that
I would learn anatomy three times and forget it four times. Little
did I know how true that statement was. Over the span of my
career I have not only learned and relearned my anatomy, but
also have grown to recognize that this is a topic that requires
frequent revisiting if one is to gain familiarity with anatomic
structures, their relationships, and the intricacies of their vas-
culature and innervation. Perhaps it was this fascination with
anatomy that led me into a career as a surgeon. Regardless, it is
knowledge of anatomy that is the foundation of all of the surgical
procedures that I perform today.
Suggested Reading
[1] Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: an anatomic and
clinical study. Plast Reconstr Surg 1995;95(1):37–42
>2@ Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and
clinical applications. Aesthet Surg J 2013;33(6):769–782
>3@ -acono AA, Malone MH. Characterization of the cervical retaining ligaments
during subplatysmal facelift dissection and its implications. Aesthet Surg J
2017;37(5):495–501
>4@ Huettner F, Rueda S, Ozturk C1, et al. The relationship of the marginal mandibu-
lar nerve to the mandibular osseocutaneous ligament and lesser ligaments of the
lower face. Aesthet Surg J 2015;35(2):111–120
>5@ Ozturk C1, Ozturk C, Huettner F, Drake RL, =ins -E. A failsafe method to avoid
injury to the great auricular nerve. Aesthet Surg J 2014;34(1):16–21
>6@ Owsley -4. Rejuvenation of the midface. Plast Reconstr Surg 2001;108(1):262–
264
[7] Pessa -E. SMAS fusion zones determine the subfascial and subcutaneous anat-
omy of the human face: fascial spaces, fat compartments, and models of facial
aging. Aesthet Surg J 2016;36(5):515–526
[8] Pessa -E, Garza -R. The malar septum: the anatomic basis of malar mounds and
malar edema. Aesthet Surg J 1997;17(1):11–17
[9] Pessa -E, 1guyen H, -ohn GB, Scherer PE. The anatomical basis for wrinkles.
Aesthet Surg J 2014;34(2):227–234
>10@ Rohrich R-, Pessa -E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
[11] Rohrich R-, Pessa -E. The retaining system of the face: histologic evaluation of the
septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg
2008;121(5):1804–1809
Fig. 43.18 The floor of the premasseter space is made up of the mas-
seter fascia. This space is devoid of facial nerve branches, enabling safe
dissection during rhytidectomy. The roof consists of the superficial
musculoaponeurotic system (SMAS) as it invests platysma muscle. At
the medial (toward the midline) aspect, this space is bordered by the
masseteric cutaneous ligament. There are no nerves within the roof of
this space.
Fig. 43.17 Anatomic spaces are defined as having a circumferential
fascial boundary, within which either fat or glandular tissue is further
enclosed by a well-defined capsule. The submandibular space is
shown in this dissection. The surrounding fascia has been freed to
show the submandibular gland within its capsule. The overlying
sternocleidomastoid muscle has been transected to show the medial
boundary of this space, the carotid sheath with its four structures:
the carotid artery, the internal jugular vein, the vagus nerve, and the
terminal drainage of the entire cerebrospinal fluid (CSF) circulation of
the human brain.

44 Clinical Decision Making in Facelift and Neck Lift
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44 Clinical Decision Making in Facelift and Neck Lift
Foad Nahai
Abstract
:ith a variety of surgical and nonsurgical options for facial
rejuvenation, evaluation of the aging face and patients’ wishes
should guide the surgeon in making the appropriate recom-
mendations to each individual. Location and length of scars, flap
elevation, and superficial musculoponeurotic system (SMAS)
and volume management are customized to address specific
changes.
Keywords
short-scar facelift, pretragal and intratragal incisions, high
SMAS, low SMAS, platysma, fat grafts
44.1 Introduction
As noninvasive treatments, especially injectables such as
toxins and fillers, have been proven safe and effective and have
gained in popularity, facial rejuvenation has ceased to be only
in the surgical domain. Aesthetic surgeons are familiar and
experienced with surgical and nonsurgical options. The choice
between the two is based on assessment of the aging face and
the patient’s desires. Generally noninvasive options are better
suited to those with only early signs of aging. For all others, I
believe the results of surgery are better, last longer, and in the
long run are far more cost-effective.
44.2 Evaluation
1ot all faces age in the same way, nor do they require the same
procedures for rejuvenation. The degree of volume loss, tissue
descent, and skin changes will vary. Each face ages individually,
with some areas remaining more youthful than others. I evaluate
the entire face, assessing skin quality, volume, and descent. I do
not believe in a ´facelift for all seasonsµ; rather, I feel we should
customize or tailor the procedure to each individual patient³a
´freestyle faceliftµ where the length and location of the incisions,
extent of undermining, superficial musculoaponeurotic system
(SMAS) management, volume management, and ancillary proce-
dures are all individualized based on the patient’s aging changes,
facial morphology, and desires. During the initial evaluation of a
patient for facial rejuvenation I specifically ask, ´:hat concerns
you most or what would you most like improved"µ Answers vary
from ´my neck,µ ´my jowls,µ or ´my eyesµ to ´I want to see improve-
ment of all of it.µ Occasionally a patient responds, ´I am here for
your recommendations.” The patient’s wish and my assessment
will then guide me in selecting the appropriate procedure.
For descriptive purposes, I think of the face in terms of three
zones: periorbital, perioral, and neck.
The forehead, brow, and upper midface make up the periorbital
zone; the lower part of the face³nasolabial folds, lips, jowls, and
chin³is called the perioral area; and the jawline, submental area,
and neck are referred to as the neck zone. I also think of these three
zones as dividing the face and neck into upper, middle, and lower
thirds (Fig. 44.1).
Fig. 44.1 Evaluation of the face is organized by thirds.

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VIII Surgical Rejuvenation of the Face and Neck
Ideally, I prefer to rejuvenate all three zones simultaneously so
as to restore a youthful appearance with a harmonious transition
from zone to zone. Most of the time, however, patients request
improvement in one zone or only one component of a given zone.
Many patients who would be excellent candidates for full facial
rejuvenation say, ´I just want my eyes or my neck done.µ Another
typical request is, ´I know I could use a facelift, but I just want to
get rid of my baggy eyelids.µ These patients require an explanation
of the aging process so that they will understand that it is best to
address an entire zone rather than individual components of a
zone. It is even better to address all three face and neck zones rather
than only one. Nevertheless, some patients truly need rejuvenation
of only one zone rather than of the full face. In these patients, the
aging process has advanced more rapidly in one zone than in the
others.
In the 56-year-old patient shown in Fig. 44.2, aging affected
all three of the facial zones. She underwent an endoscopic brow
lift, upper and lower blepharoplasty, and face- and neck lift. Her
postoperative result demonstrates harmonious rejuvenation of all
three facial zones.
The signs of aging are not as far-reaching in the 48-year-old patient
shown in Fig. 44.3. Her facial aging was confined mostly to the upper
third, or periorbital zone. She underwent an endoscopic brow lift and
upper lid blepharoplasty with transpalpebral midfacial rejuvenation.
Her postoperative result also demonstrates harmonious facial reju-
venation, even though the surgical correction was far more limited.
:hen a patient expresses interest in a procedure involving only
one zone, I advise her or him about how the overall result could be
enhanced by adding procedures involving adjacent zones. Doing so
avoids a patchwork effect in which a rejuvenated periorbital area
leads into an aging lower face and neck. The patient’s motivation for
Fig. 44.2 (a,c) Preop and (b,d) postop photos of patient who underwent endoscopic brow lift, upper and lower blepharoplasty, and face and neck
lift. An optimal result required rejuvenation of all three facial zones.
a
c
b
d

44 Clinical Decision Making in Facelift and Neck Lift
531
seeking less rather than more may be financial or could be related to
a fear of surgery and anesthesia, or the patient may have a genuine
lack of concern about the rest of the face compared with the area
in question. The surgeon should initiate an open discussion of the
patient’s wishes, concerns, and fears so that the patient will be
pleased rather than disappointed with the results. :hen examining
a candidate for facelift surgery, I first determine which zones require
intervention and whether the aging process has affected the face
equally. For example, is the most striking feature of this aging face
the neck, the midface, or the brow" Or are they all equally involved"
Facial aging involves more than sagging, wrinkling skin with
shifting soft tissue; most of these patients have also lost volume. An
aging face in a thin patient looks much older than an equally aged
full face in an overweight patient. This is obviously related to loss of
volume. After my initial impression, I evaluate the skin, each zone,
and the components of each zone according to my mental checklist.
44.2.1 Facial Skin
The evaluation includes an assessment of skin quality and skin
excess, along with the presence of rhytids at rest and on animation. I
look for signs of photoaging and sun-related dyschromia. I assess the
skin’s thickness and elasticity and make a mental note of where the
excess skin is and whether the excess is real or apparent (Table 44.1).
The 50-year-old woman shown in Fig. 44.4 has facial aging in
all three zones. Her skin quality is rather poor, showing real and
apparent excess skin, significant photoaging, and deep rhytids at
rest and on animation.
The 51-year-old patient shown in Fig. 44.5 also demonstrates
facial aging in all three zones but has better skin quality. Her
full, heavy face has more apparent than real excess skin, normal
elasticity, and minimal photoaging. 1o rhytids are visible at rest.
44.2.2 Upper Third of the Face:
The Periorbital Zone
Evaluation of the periorbital zone begins with an analysis of
the medial and lateral brow position and the relationship of the
brow to the upper eyelid. I look at the glabella for lines as well
as active and passive rhytids. The temporal–brow junction, with
the upper cheek-zygomatic area, is evaluated for the presence of
deep rhytids (crow’s–feet) and excess skin. I evaluate the upper
and lower lids, assessing the skin, muscle, and fat in the lids.
After noting the relationship of the upper lid to the brow, I move
to the lower lid, noting the relationship of the lower lid to the
cheek and the transition from the periorbital to the perioral zone
and the nasolabial fold. Lower lid tone is assessed. The volume of
the cheek and midface area is also noted.
Checklist for Evaluating the Upper Third of the
Face/Periorbital Zone
Brow position
• Lateral
• Medial
Glabella
• Depth of rhytids
• Muscle activity
Upper eyelid
• Skin
• Muscle
• Fat
• Relationship to brow
Lower eyelid
• Skin
• Muscle
• Fat
• Lid–cheek junction
• Lid tone
Nasolabial folds
Transition to perioral zone
Soft tissue volume
44.2.3 Middle Third of the Face:
The Perioral Zone
The perioral area, or middle third, is evaluated next. The naso-
labial folds and marionette grooves are categorized by noting
their depth at rest and when smiling. The angle of the mouth is
noted. The lips are evaluated for volume and length of the upper
lip. :ith aging, the lips lose a significant amount of volume, and
the distance from the nose to the upper lip vermilion lengthens,
Fig. 44.3 (a) Preop and (b) postop photos of patient who underwent
endoscopic brow lift and upper lid blepharoplasty with transpalpebral
midfacial rejuvenation. As her facial aging was confined mostly to
the periorbital zone, a more limited surgical correction achieved a
harmonious result.
Table 44.1 Checklist for evaluating the aging face—facial skin
Quantity
Quality
Rhytids
¥ Visible skin excess
¥ Thickness
¥ At rest
¥ Elasticity
¥ On animation
¥ Photoaging
Texture
a
b

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VIII Surgical Rejuvenation of the Face and Neck
leading to a loss of definition of the philtral columns. Lip lines
are noted. I specifically look at the depth of the chin crease for
chin ptosis and evaluate the jowls. I also evaluate the role of the
mandibular ligament in the aging appearance in this area. The
nose, especially the tip, often becomes ptotic with aging.
Checklist for Evaluating the Middle Third of
the Face/Perioral Zone
• Nasolabial folds and marionette grooves
• Angle of the mouth
̑ Downward
̑ Neutral
̑ Upward
• Upper lip
̑ Volume
̑ Length
̑ Philtral columns
̑ Lip lines
• Lower lip
̑ Volume
̑ Lip lines
• Chin
̑ Chin crease
̑ Chin ptosis
• Jowls
• Nose
̑ Tip ptosis
44.2.4 Lower Third of the Face:
The Neck Zone
In assessing the quality and quantity of the neck skin, I look
for excess skin below the thyroid cartilage and over the
sternocleidomastoid muscle. I look also for transverse neck
lines or creases, noting how many and how deep they are. A
judgment is made as to whether the submental skin excess is
real or apparent. I then look at the jawline, submental area,
and neck–jaw angle and their relationship to each other.
Assessment of the submental and neck fat includes the subcu-
taneous fat and the subplatysmal fat. I differentiate between
subcutaneous and subplatysmal fat by pinching the submental
area at rest and then after contraction of the platysma muscles.
Checklist for Evaluating the Lower Third of the
Face/Neck Zone
Skin
• Quality
̑ Elasticity
̑ Transverse creases or lines
• Quantity
̑ Real excess
̑ Apparent excess
Fat
• Subcutaneous/preplatysmal
• Subplatysmal
• Platysma bands
• Jawline
• Neck/jaw angle
• Digastric muscles
• Submandibular gland
The platysma bands are evaluated. I like to note not only
central platysma bands but also lateral bands usually seen only
on animation. The submandibular gland and digastric muscles
are assessed by looking for a bulge below the mandibular rim
within the submandibular triangle, especially on neck flexion
(Fig. 44.6).
Fig. 44.4 Assessment of this patient’s skin quality reveals real and
apparent excess skin, significant photoaging, and deep rhytids (a) at
rest and (b) on animation.
Fig. 44.5 (a) This patient has a full, heavy face with more apparent
than real excess skin, normal elasticity, minimal photoaging, and (b) no
rhytids visible at rest.
a
a
b
b

44 Clinical Decision Making in Facelift and Neck Lift
533
44.2.5 Facial Adhesions and Retaining
Ligaments
Determining whether the facial ligaments and adhesions should
be released is an important step in planning surgical rejuvena-
tion of the face.
Proper elevation and rejuvenation of the periorbital area
depends on the appropriate release of a number of temporal
adhesions and attachments, regardless of the degree of brow
ptosis or facial aging. In contrast to the face, these temporal
adhesions and attachments are not visible and cannot be assessed
clinically.
Retaining ligaments of the midlateral face can be assessed
clinically. These ligaments maintain the facial skin in its
normal anatomic position. Stuzin et al described two types of
retaining ligaments: a true osteocutaneous ligament, running
Fig. 44.6 Evaluation of the neck. (a) Evaluation of excess skin of the neck and platysma bands with the patient at rest. (b) Evaluation of platysma
bands on animation. (c) Evaluation of the location of submental fat by pinching the submental area at rest. (d) Subcutaneous versus platysma fat is
assessed by pinching the submental area during contraction.
a
b
c
d

534
VIII Surgical Rejuvenation of the Face and Neck
from a fixed bony origin to the dermis (such as zygomatic and
mandibular), and a second system made up of a coalescence
of superficial and deep facial fascia fixing the fascial layers to
the underlying structures, such as the parotid and masseter,
and then attaching superficially to the skin (the parotid cuta-
neous and masseteric cutaneous ligaments). These ligaments
are essentially fixed structures, so facial tissue, especially fat
pads, can pivot around them, producing creases such as the
marionette lines of the lower face. :ith age, the ligaments
attenuate and relax. This relaxation, along with loss of skin
elasticity and soft tissue, causes some of the stigmata of aging.
The zygomatic ligaments suspend the malar soft tissues and
fat pad over the zygomatic prominence. As this support weak-
ens, the malar soft tissues gradually migrate downward, and
redundant skin hangs over the fixed nasolabial sulcus. Rather
than deepening with age, it is the downward migration of the
soft tissues against the fixed nasolabial sulcus and volume
depletion that accounts for the observed changes. Similarly,
attenuation and weakness of the masseteric cutaneous liga-
ments allow a downward shift of the cheek tissues below the
mandibular margin. Tethering by the mandibular ligament
forms the jowls (Fig. 44.7).
Clinical evaluation of the face should take note of these
ligaments and the role they play in the aging face. Ligaments
extending from bone to dermis must be released during a facelift
to achieve the desired results. Leaving the masseteric ligaments
intact limits lateral mobility. An evaluation of the relevance of
these ligaments to the observed aging changes enables the sur-
geon to plan appropriately for ligament release. Although release
of these ligaments is required in most older individuals, it is not
always necessary to divide them in younger individuals and in
those who are undergoing limited rejuvenation procedures.
44.3 Treatment Options
44.3.1 The Face
I have already mentioned that I do not believe that there is a
facelift for all seasons. However, all described facelift techniques
have five things in common:
1. An incision
2. Flap elevation
3. SMAS management
4. Volume management
5. Ancillary procedures
Evaluation of the face leads to selection of the procedure,
including length and location of scars; level and extent of dis-
section or flap elevation; management of the SMAS, including
vectors; volume management; and ancillary procedures. These
decisions are based on analysis of the patient’s degree of aging,
morphology, skin quality and quantity, and, most important, the
patient’s expectations and my understanding of the result antici-
pated. Video imaging has proven a be a useful tool in this regard.
The options include a variety of incisions, different levels of dis-
section, varying extent of skin and SMAS undermining, different
vectors, and repositioning of the subcutaneous tissues through a
number of suspension or plication techniques.
Fig. 44.7 (a) Facial adhesions and (b) retaining ligaments.
a
b

44 Clinical Decision Making in Facelift and Neck Lift
535
Treatment Options for the Face
Incisions
• Length
• Location
Levels of dissection and extent of undermining
• Subcutaneous
• Subfascial sub-SMAS
• Subperiosteal
• Combination
SMAS management
• Plication
• Mobilization and plication
• Resection and plication
• Mobilization, resection, and plication
Sub-SMAS work
• Buccal fat pad
• Parotid
Vectors
• Vertical
• Diagonal
Suspension sutures
Incisions
The length of the incisions varies from minimal incisions for
liposuction and endoscopic to the classic full-length facelift
incision. The purpose of skin incisions is to gain access to deeper
tissues or to resect excess or inelastic skin or both.
If the purpose of the skin incision is to allow access to the
deeper tissues and the deep tissue rearrangement renders the
desired result without skin excision, these access incisions
can be kept to a minimum, as in liposuction and endoscopic
procedures. If the desired result cannot be attained through the
rearrangement of the deeper tissue without skin excision, a
longer skin incision is necessary, and the length of that skin inci-
sion will reflect the location of the excess skin to be removed. For
example, endoscopic facelifting is achieved without removing
any facial skin, whereas short-scar facelift techniques eliminate
the postauricular scar in patients who have no excess skin below
the level of the cricoid and posterior to the sternocleidomastoid.
However, the success of endoscopic and short-scar procedures
depends not only on the location of excess skin but also on
the quality and elasticity of the skin. These procedures rely on
redraping and redistribution of the skin, especially in the neck.
Stretched, inelastic skin, regardless of location³face, breast, or
abdomen³will not redrape, redistribute, or retract and must be
excised.
The short-scar techniques have increased in popularity as
patients demand minimally invasive procedures, with less
downtime and reduced morbidity. Patient selection is the key,
because unless a less invasive procedure with a shorter scar
produces a result comparable to that of standard procedures, it
is not in the best interest of the patient and may result in loss of
the surgeon’s credibility. I believe the quality of the result and
not the length of the incision should be foremost. In selecting
patients for the short-scar technique, I assess the quality of the
neck skin and then evaluate the patient with what I call the
´vertical simulationµ test. I place my hand on the side of the
patient’s face in front of the tragus and pull vertically upward,
simulating the vertical vectors of the short-scar facelift. :hile
my hand is elevating this tissue, I observe the junction of the
earlobe and neck skin. If there are no folds of excess skin extend-
ing posteriorly beyond that area, the patient is an excellent
candidate for a short-scar facelift. If there is excess skin or if a
fold develops there, the patient is best suited for a full-scar pro-
cedure. Additionally, this one of the tests that also enables me to
evaluate the neck and submental area and determine whether
I will make a submental incision or not by observing the neck
during the vertical simulation test.
For example, the images in Fig. 44.8 depict an ideal candidate
for a short-scar facelift. The vertical vector, as demonstrated by
the examiner’s hand, does not result in any folds of excess skin
behind the earlobe, and the improvement seen in the submental
area obviates the need for a submental incision.
In contrast, the images in Fig. 44.9 show an individual who
would not be a candidate for a short-scar facelift, because the
vertical vector demonstrated by the examining hand results
in folding of excess skin beyond the earlobe, and the lack of
improvement in the submental area and jawline indicates the
need for a submental incision and a central approach to neck
recontouring.
Location
The scar location depends on the patient’s facial structure,
including the hairline, sideburns, skin color, and ear topography.
Temple Incision
The options include placement of the incision 2 to 3 cm behind
the temporal hairline or right at the temporal hairline. This
decision is based on the distance between the lateral canthus
and the anterior part of the temporal hairline, which ideally
should be 3 to 5 cm. To maintain this ideal distance, the excess
skin over the upper cheek is assessed. This excess skin will be
recruited and rotated upward when the facelift flap is elevated.
If resection of excess cheek skin through the incision behind
the temporal hairline would widen the distance between the
hairline and lateral canthus, I prefer a prehairline incision to
maintain a natural 3- to 5-cm distance. :idening beyond 5
cm results in an unnatural or ´operated-onµ appearance. :hen
resection of the excess cheek skin would not shift the temporal
hairline posteriorly or widen the distance between the hairline
and lateral canthus, the incision can safely be placed behind the
hairline. This placement is of more significance in men than in
women (Fig. 44.10).
In patients with short sideburns, I prefer the prehairline inci-
sion to avoid elevation or elimination of the sideburns through
the vertical shift of facial skin. In secondary facelifts I make a
prehairline incision, because most of these patients already have
shortened sideburns (Fig. 44.11).

536
VIII Surgical Rejuvenation of the Face and Neck
Fig. 44.8 (a) The “vertical simulation” maneuever facilitates selection of patients for the short-scar facelift technique. Observe the junction of the
earlobe and neck skin. (b) If there are no folds posterior to this area, as in this case, the patient is an excellent candidate for a short-scar approach.
a
b

44 Clinical Decision Making in Facelift and Neck Lift
537
Fig. 44.9 (a) In this patient, a vertical simulation test demonstrates folding of excess skin beyond the earlobe. (b) The submental area and jawline do
not improve with a vertical lift alone, so a central approach to recontour the neck is necessary as in a full scar approach.
a
b

538
VIII Surgical Rejuvenation of the Face and Neck
Fig. 44.10 The temple incision can be placed to 2 to 3 cm behind the temporal hairline (top) or right at the hairline (bottom).
Fig. 44.11 (a) As the incision approaches the ear, it can be continued behind the hairline or (b) anterior to the hairline, as is preferred in patients with
short sideburns.
a
a
b
b
Prehairline incision
Prehairline incision
Incision behind the temporal hairline
Incision behind the temporal hairline

44 Clinical Decision Making in Facelift and Neck Lift
539
Preauricular Incision
The incision in the preauricular area is made in the anatomic
margin between the ear and the face rather than in front of
it. 1ot only the color but also the texture and thickness of the
ear skin, including the tragus, vary from that of facial skin (Fig.
44.12). To mask this difference, a curved incision along the curve
of the anterior border of the helix is made to the upper border of
the tragus. At this juncture, the incision may be curved in front
of the tragus or along the posterior border of the tragus; then it
follows the sulcus between the earlobe and the cheek. My pref-
erence is for the intratragal incision along its posterior border
but not behind the tragus. A well-executed intratragal incision
is imperceptible compared with a pretragal incision. In the rare
patient who has little color difference between the facial and
tragal skin, the pretragal incision may serve as well. For a tragal
incision to be imperceptible, the tragus has to have a beginning
and an end (Fig. 44.13, Fig. 44.14, Fig. 44.15) and not blend into
the cheek at the lower border. The inferior tragal border must
be preserved. The entire closure must be without tension. The
prominence of the tragus plays a role in selecting the intratragal
incision. The more prominent the tragus, the better the result will
be. A flat tragus may retract forward and lead to enlargement of
the external auditory meatus. Special attention must be paid in
men whose facial skin may be ruddier than the ear skin. In these
patients a pretragal incision is preferred (Fig. 44.16, Fig. 44.17,
Fig. 44.18). These factors are summarized in Table 44.2.
The Earlobe
Distortions of the tragus and earlobe are clearly visible signs of
a facelift, a poorly executed facelift I do not suture the earlobe
down but instead anchor the facial flap to the deep tissues at the
level of the lower conchal border, with the earlobe hanging free
over the flap. This avoids the ´pixie earlobe.µ
The two main procedures I undertake to rejuvenate and
enhance the appearance of the earlobe are fat grafting to replace
lost volume and reduction of the elongated earlobe to remove the
deflated excess skin.
Retroauricular Incision
I used to make retroauricular incisions only in patients with inelas-
tic or stretched neck skin with excess skin below the cricoid and
posterior to the sternocleidomastoid, but now I rely on the vertical
simulation test to determine the need for a retroauricular incision.
This incision is best placed just above the retroauricular sulcus so
that once it has healed, the resultant scar will be in the sulcus.
Fig. 44.12 The preauricular incision is made in the anatomic margin
between the ear and the face, and it may be intra or pre-tragal.
Fig. 44.13 The tragus must have a beginning and an end.
Fig. 44.14 (a–c) Tragus. Beginning but no end. Incision closed under no tension with 6.0 suture.

540
VIII Surgical Rejuvenation of the Face and Neck
Fig. 44.16 Pretragal or intratragal. Avoid undesirable scars and tragal
distortion such as this when planning incisions. The tragus must be
distinct and must have a beginning and an end. There is a beginning
and no end with distortion secondary to tension.
Fig. 44.17 Pretragal or intratragal. Avoid tension such as this with
the closure where there is a beginning and no end with distortion
secondary to tension.
Fig. 44.18 Result of intratragal incision resulting n a natural tragus and
earlobe. Tragus has a beginning and end but no color or texture match.
Fig. 44.15 (a, b, c) Tragus. Pre , early (middle), and late post op demonstrating a normal tragus and earlobe following an intra tragal incision.

44 Clinical Decision Making in Facelift and Neck Lift
541
The upward length is not only a matter of personal preference but
of practical importance. I vary it according to my estimate of the
amount of skin to be removed. The less skin that is being removed,
the longer I make this retroauricular incision before taking it
transversely across into the occipital hairline. In patients with an
excessive amount of redundant skin, I take this incision across to
the occipital hairline and then follow it downward. I discuss these
options with patients so that they understand that the incisions
are being altered to achieve a better result (Fig. 44.19; Table 44.3).
Levels of Dissection
Subcutaneous
I do not perform a subcutaneous facelift, and I believe that few
surgeons do. The subcutaneous dissection serves two purposes:
access to deeper tissues (SMAS) and skin resection. All modern
facelift techniques include various degrees of skin undermining.
Extensive skin undermining to release the nasolabial fold and
mandibular retaining ligaments, although effective, can increase
the risk of vascular compromise and hematoma and may not be
necessary for all faces (Fig. 44.20).
Subfascial
Most modern facelifts include some form of subfascial or sub-
SMAS dissection. The extent of this dissection varies from
technique to technique. The vectors and methods of plication
also vary from surgeon to surgeon. I rely heavily on SMAS mobi-
lization and a vertical vector for improvement of the perioral
area, jowls, and jawline.
Low dissections of the SMAS have a limited effect on the upper
midface and periorbital area. High SMAS dissections dramatically
improve the upper midface and periorbital area.
In thin faces, I try to preserve the SMAS; in heavy faces, I resect
it. I plicate the SMAS or undermine and plicate as necessary. My
preference is to incise the SMAS not immediately preauricularly,
as in some described techniques, but rather at the junction of the
mobile and fixed SMAS. This avoids dissecting the very thin SMAS
in the preauricular area. My decision to plicate or to mobilize and
plicate the SMAS depends on its mobility. I pick the SMAS up at
the junction of the fixed and mobile SMAS and pull it superiorly
while observing the effect on the jawline and perioral area. If the
pull provides the desired effect, I simply plicate (in thin faces) or
resect and plicate (in heavy faces). However, if pulling without
mobilization does not produce the desired effect, I incise and
mobilize the SMAS until the desired effect is observed; in thin
faces I plicate with no resection, but in heavier faces I resect then
plicate. If I plan sub-SMAS procedures such as buccal fat pad
management or parotid gland reduction, then SMAS elevation and
mobilization are mandatory (Fig. 44.21, Fig. 44.22).
Table 44.2 Selecting a pretragal or intratragal incision
Pretragal
Intratragal
Color
No match
Match
Thickness
Thicker
Match
Texture
Textured
Smooth
Tragal prominence
Flat
Prominent
Primary/secondary
Secondary
Primary
Fig. 44.19 The retroauricular incision. (a) High retroauricular incision. (b) Lower retroauricular incision. (c) Occipital hairline incision.
a
c
b

542
VIII Surgical Rejuvenation of the Face and Neck
Subperiosteal
The advantage of the subperiosteal approach to the midface is
its relative ease, speed, and safety. The facial nerve branches are
less at risk with this approach; however, it is limited in its effects
on the lower face, jawline, and jowls. The subperiosteal approach
depends on suspension sutures to maintain the result (Fig. 44.23).
Combinations
The subperiosteal and subfascial or subperiosteal and subcuta-
neous levels of dissection can be combined in a variety of ways.
Examples include a subperiosteal approach to the periorbital
area and midface and a sub-SMAS approach to the perioral area
and jawline.
Table 44.3 Choosing the incision in a facelift
Facelift: Incision options
Features
Prehairline
Prehairline
with
discontinuous
temporal
incision
Temporal
continuous
with
preauricular
incision
Sideburns
High or short
¥
¥
Low or long
¥
Hairline
Anterior: Lateral
canthus to hairline
distance 3 to 5 cm
¥
¥
Posterior: Lateral
canthus to hairline
distance > 5 cm
¥
¥
Secondary facelift
¥
¥
Fig. 44.20 Subcutaneous dissection plane in facelift.
Fig. 44.22 Sub SMAS dissection following elevation of the skin.
Plication suture is shown.
Fig. 44.21 Superficial musculoaponeurotic system is elevated and
buccal fat pad is delivered into the field.

44 Clinical Decision Making in Facelift and Neck Lift
543
Vectors
Most modern facelifts include separate vectors for the skin and
deeper tissues. The deeper tissues are elevated in a more vertical
or diagonally vertical vector and the skin in a more posterior and
vertical direction. The vertical vector on the SMAS improves the
jawline, the perioral area, and, with the high SMAS technique,
the midface. The more diagonal vector on the platysma improves
on the neck and submental area. :ith a short-scar facelift, the
skin vector is vertical, but the vector on the SMAS and platysma
can be varied (Fig. 44.24; Table 44.4).
Suspension Sutures
Most endoscopic and subperiosteal midface techniques require
suspension sutures or other devices to elevate and hold the soft
tissues in the desired position. Although usually effective, these
sutures are not risk-free; a disadvantage is that the fixation point
is far removed from the tissue being fixed (Fig. 44.25).
Volume Management
:ith the clear understanding that deflation as an important and
integral part of facial aging, adding volume, usually in the form
of fat, has become an integral part of facial rejuvenation with and
without facelifts (Fig. 44.26). I do not routinely fat-graft every
facelift. The patients and areas of grafting are selected based on the
degree of deflation, most commonly the cheeks, temple, and peri-
oral areas followed by lips, earlobes, and submalar areas. The areas
to graft and the amount of fat are individualized for each patient.
Although volume management usually includes augmentation
of tissues, in selected patients I also remove excess volume, espe-
cially in the neck and jowls. Alloplastic implants, autologous fat,
and fillers are available for volume enhancement. By far the most
popular material of choice for volume enhancement is autologous
fat. In some patients, volume enhancement with fat transfer has
become routine. Alloplastic materials such as chin and cheek and
submalar implants may be preferable to fillers or autologous fat
in selected patients. Fillers are also an acceptable alternative to
autologous fat for volume enhancement.
The buccal fat pad is very prominent in some heavy faces and
must be addressed to recontour the perioral area and jawline.
The buccal fat pad can be approached either through the facelift
Fig. 44.23 Endoscopic subperiosteal dissection of the mid face.
Fig. 44.24 The skin and superficial musculoaponeurotic system (SMAS) are fixed with different vectors.

544
VIII Surgical Rejuvenation of the Face and Neck
incision deep to the platysma or through an intraoral incision. I
have resected the buccal fat pad as an isolated procedure in heavy,
youthful faces (those that present a cherubic appearance) and in
primary as well as secondary facelifts for recontouring. Despite
the intimate relationship of the superficial portions of the buccal
fat pad with the facial nerve, I have found this procedure to be both
safe and effective. Although I do not routinely modify the buccal
fat pad, in the right patient it has a dramatic effect in recontouring
the lower face and managing volume.
It is rarely and only in a heavy face that I resect fatty tissue.
:hen I do so, it is limited to the jowls. However, in all but the
thinnest of necks I resect some fat below the skin, between the
platysma muscles, or deep to the platysma, depending on the
volume of the neck and distribution of the fat in these three layers,
as described in the section on the neck.
Ancillary Procedures
Ancillary procedures include may include resurfacing, earlobe
reductions, or augmentation and lip lifts. One or more of these are
performed almost routinely in all of my facial rejuvenation proce-
dures to enhance the overall result. Although in the past the actual
facelift was the end result, today many of us feel that the facelift
lays the foundation while volume management and the ancillary
procedures that are performed concomitantly represent the finish-
ing touches that result in true rejuvenation rather than simply the
rearrangement of soft tissues and removal of excess skin.
Resurfacing
Rearranging the deep tissues and resecting excess skin does
not always result in improvement of the quality of the skin.
Fig. 44.25 Endoscopic and subperiosteal midface techniques require suture suspension to a usually distant fixation point, typically the temporal fascia.
Table 44.4 Choosing the dissection level and vector in a facelift
Facelift: levels of dissection
Subcutaneous
Subfascial
Subperiosteal
Suspension
sutures and
devices
5egiRnDO e̥eFWV
Low or standard
SMAS
High SMAS
Extended SMAS
SMASectomy
Periorbital
+
+
+ + + +
+ +
+ +
+ + + +
+ + + +
Cheek and
nasolabial folds
+ +
+ +
+ + + +
+ + + +
+ + + +
+ + + +
+ + + +
Jowls and jawline
+ +
+ + + +
+ + + +
+ + + +
+ + + +
+
+
Neck
+ +
+ + +
+ + +
+ + +
+ + +
Vectors
Diagonal
Vertical
Vertical
Vertical
Vertical
Vertical
Diagonal
Diagonal
Diagonal
Diagonal
Diagonal
Diagonal
Risks
Skin flap viability
+ + + +
+ +
+
+
+
Facial nerve
+
+ +
+ + + +
+ + + +
+ +

44 Clinical Decision Making in Facelift and Neck Lift
545
Sun-damaged, inelastic, wrinkled skin is usually dealt with
through resurfacing, concomitant with the facelift. This
includes dermabrasion, peels (croton oil or trichloroacetic acid
>TCA@), and lasers. These procedures, when combined with a
facelift, are not only effective but also safe if limited to the
areas where there has been no skin undermining. The under-
mined skin may also be treated with dermabrasion, peel, or
laser, but cautiously and very superficially. -udgment must be
exercised on an individual basis when resurfacing over facelift
flaps (Fig. 44.26).
44.3.2 The Neck
Treatment Options for the Neck
Incisions
• Length
• Location
Levels of dissection
• Subcutaneous
• Subplatysmal
Extent of skin undermining
Vectors
• Vertical
• Diagonal
Suspension sutures
Plication sutures
Incisions
Length
Incisions for rejuvenation and recontouring of the neck range
from liposuction access incisions to submental incisions and
preauricular and retroauricular incisions. Incision length is
dictated by the anatomic and morphologic findings as well as the
planned procedure. The submental incision allows access to the
medial platysma and subplatysmal structures. The retroauricu-
lar incision allows access to the lateral platysma and affords the
opportunity for skin resection.
Location
My preference for the submental incision, varying in length
from 3 to 5 cm, is to place it just caudal to the submental crease.
Others prefer to place the incision within the crease. I believe
placement within the crease further deepens the crease and
attracts attention to the scar. Caudal placement affords better
access to the submental area and allows dissection cranially
to eliminate or render the submental crease less shallow. This
incision also allows access to the chin for correction of the ptotic
or ´witch’sµ chin (Fig. 44.27).
In the isolated neck lift without a facelift, it is sometimes
necessary to start the incision at or below the level of the tragus,
continuing around the earlobe and into the retroauricular area
to prevent earlobe distortions and improve access to the jawline
and neck. In the past I typically reserved retroauricular incisions
for patients with inelastic or stretched neck skin with excess
skin below the cricoid and posterior to the sternocleidomastoid,
but now I rely much more on the vertical simulation test. The
Fig. 44.26 Woman aged 64 (a) before and (b) after face- and neck lift, fat grafting of cheeks, upper and lower eyelids.
a
b

546
VIII Surgical Rejuvenation of the Face and Neck
best placement is just above the retroauricular sulcus. Upward
length should be varied according to the amount of skin removal
required. The less skin to be removed, the longer I make this
vertical component before crossing to the hairline. If neck skin
is excessive, I place the incision along the occipital hairline in a
downward and backward direction rather than extending it into
the hair. These incisions are all planned preoperatively, and their
location and alternatives are fully discussed with the patient. I
emphasize the benefits of a lower incision in terms of tightening
the lower neck skin (Fig. 44.28; Table 44.5).
Levels of Dissection
Planes of the Neck
• Superficial plane
• Intermediate plane
• Deep plane
I think of the neck as having three planes: superficial (skin and
subcutaneous fat), intermediate (platysma and interplatysmal
fat), and deep (subplatysmal structures).
SuSerÀFiDO 3ODne
The superficial plane includes the skin and subcutaneous fat;
each neck and submental lift includes varying degrees of dissec-
tion and undermining in this plane. It is important to leave at
least a 3- to 5-mm thickness of fat on the deep surface of the skin,
whether the defatting is performed directly or through liposuc-
tion. Leaving this layer of fat with a suitable thickness renders a
smooth contour to the neck and eliminates the skin irregulari-
ties that are seen with aggressive removal of subcutaneous fat.
Aggressive removal of fat leads to adherence of the skin onto the
platysma. Intervention in this plane is usually combined with
interventions in the other two planes, except in individuals who
are candidates for liposuction only (Fig. 44.29).
Intermediate Plane
The platysma and the small amount of fat between the medial
border of each platysma muscle make up this plane. Plication of
Fig. 44.27 The submental incision in neck lift is placed just posterior
to the submental crease.
Fig. 44.28 Options for the retroauricular incision in neck lift.

44 Clinical Decision Making in Facelift and Neck Lift
547
the platysma in the midline is the most common procedure at
this level. In a patient with a heavy submental area, the interven-
ing fat between these medial borders is resected as necessary.
If fat is resected from between the platysma muscles and deep
to the platysma, it is important that sufficient fat be left deep
to the skin. Removing fat aggressively below the skin, between
the platysma muscles, and deep to them, leads to an unnatural
hollowing of the submental area. Very rarely do I remove fat from
all three layers. The more deep fat I remove, the more superficial
fat I leave behind (Fig. 44.30).
Deep Plane
The subplatysmal fat, digastric muscles, and submandibular
gland make up the structures of the deep plane. Resection of the
subplatysmal fat, the anterior belly of the digastric muscle, and
the superficial lobe of the submandibular gland are the proce-
dures performed in this plane. If needed, a suprahyoid fascial
release is also performed in the deep plane (Fig. 44.31).
To distinguish between excessive preplatysmal (subcutaneous)
fat and subplatysmal fat, a useful maneuver is to grasp the sub-
mental fold between the thumb and index finger and then ask the
patient to grimace, thus contracting the platysma muscles. If the
Fig. 44.30 Intermediate plane in neck lift.
Fig. 44.29 Superficial plane in neck lift.
Table 44.5 Choosing the incision in a neck lift
Features
Neck lift: incision options
Preauricular
Submental
Short in
retroauricular
sulcus only
Longer above level
of tragus, crossing
into hair
Long to level of
tragus, crossing
into hair
Long to just below
level of tragus,
then crossing down
along occipital
hairline
Skin quality
Normal
elasticity
¥
¥
Inelastic,
stretched,
sun-damaged
¥
¥
¥
¥
¥
¥
Skin quantity
No skin excess
¥
¥
¥
Apparent skin
excess
¥
¥
¥
Real skin excess
¥
¥
¥
¥
¥
Planes of
intervention
Superficial
¥
¥
Deep to
platysma
¥
¥
¥
¥
¥

548
VIII Surgical Rejuvenation of the Face and Neck
fold between the examiner’s thumb and index finger is unchanged,
the bulk of the fat is subcutaneous; if it diminishes, then the bulk
of the fat is deep to the platysma and must be removed in that
plane to recontour the submental area (Fig. 44.32).
Once the subplatysmal fat has been dissected, the anterior belly
of the digastric muscle is easily viewed. If it appears as a bulge when
the patient’s neck is flexed, a tangential excision of the anterior
belly would further improve the submental contour (Fig. 44.33).
A large submandibular gland is often visible preoperatively.
Once the digastric muscle has been identified, the superficial lobe
of an enlarged submandibular gland is readily visible. If it bulges
further on neck flexion, the superficial lobe can be resected to
further enhance neck contour and improve on the visible bulge.
Extent of Skin Undermining
:ith the exception of liposuction only, extensive neck undermin-
ing is the rule to facilitate the redraping of the apparent excess
skin of the neck, especially in the submental area. The under-
mining usually extends from the sternocleidomastoid muscle on
each side, across the midline, and down to the level of the thyroid
cartilage. More extensive lateral and inferior dissection and
undermining may be necessary in some individuals who have an
excessive amount of neck skin or inelastic skin. Undermining of
the neck deep to the transverse creases will significantly improve
the appearance of the neck and the creases. Direct excision of the
deep creases has also been described (Table 44.6).
Fig. 44.31 The deep plane, including the subplatysmal structures.
Fig. 44.32 Maneuver to distinguish subcutaneous from subplatysmal fat. The submental fold is grasped and the patient asked to grimace. If the fold
is unchanged, the excess is likely subcutaneous. If it diminishes, it is mostly deep to the platysma.

44 Clinical Decision Making in Facelift and Neck Lift
549
Vectors
The vectors that influence the appearance of the neck and jaw-
line include the vertical vector applied to the jawline through the
platysma plication of a facelift. A more diagonal and posterior
vector involving the lateral border of the platysma combined
with a medial plication of the two platysma muscles defines the
submental area and the neck–jaw angle (Fig. 44.34).
Sutures
Suspension Sutures
Suspension sutures running over the platysma and below the
mandibular border, designed to define the neck–jaw angle, were
described by Guerrerosantos and later popularized by Giampapa.
In carefully selected patients, suspension sutures can be effec-
tive, but I have found them to be of limited value in individuals
with large submandibular glands. In my experience, a more
direct approach in the deep plane produces longer-lasting results
(Fig. 44.35).
Table 44.6 Choosing the incision in a neck lift
Neck lift: incisions and anatomic features
Incisions
Fat distribution
Structures
Planes or layers
of the neck
Liposuction
access
Submental
Subcutaneous
Interplatysmal
Deep or
subplatysmal
Platysma
Digastric
muscles
Submandibular
gland
Hyoid fascia
Superficial
¥
¥
Intermediate
¥
¥
¥
¥
Deep
¥
¥
¥
¥
¥
¥
¥
¥
Fig. 44.34 Platysma vectors.
Fig. 44.35 Suspension sutures from the platysma to below the
mandibular border
Fig. 44.33 The anterior belly of the digastric muscle is encountered after dissection of the subplatysmal fat.

550
VIII Surgical Rejuvenation of the Face and Neck
Plication Sutures
Plication of the platysma in the midline, as advocated by Feldman
(the corset platysmaplasty), is highly effective in recontouring
the submental area. :hen combined with a lateral plication,
platysmal plication defines the jawline and neck–jaw angle. This
step is an integral part of almost all the neck lifts I perform.
Ancillary Procedures
Although volume management in the neck almost always means
removal of fat or partial resection of the digastric or subman-
dibular gland, volume addition in the form of autologous fat or
acellular dermal matrix has been advocated for correction of the
contour irregularities associated with aggressive oversuction
superficial to the platysma. Resurfacing either with laser or (my
preference) TCA peels is an acceptable adjunct to neck lift. The
energy levels on the laser are set below those for a facelift. I apply
20, 30, or even 50 TCA to the face, but I limit neck peeling to
20 TCA, and even then the endpoint is a mottled frosting rather
than the uniform frosting that I look for on the face. For the very
deep transverse creases, fillers or fat are effective.
Suggested Reading
[1] Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and
clinical applications. Aesthet Surg J 2013;33(6):769–782
>2@ Baker DC, Nahai F, Massiha H, Tonnard P. Short scar face lift. Aesthet Surg J
2005;25(6):607–617
>3@ Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMA-
Sectomy: evolution and application. Aesthet Surg J 2001;21(1):14–26
>4@ Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMA-
Sectomy. Aesthet Surg J 2001;21(1):68–79
>5@ Barton FE Jr. Aesthetic surgery of the face and neck. Aesthet Surg J
2009;29(6):449–463, quiz 464–466
>6@ Hashem AM, Couto RA, Duraes EFR, et al. Facelift part I: history, anatomy, and
clinical assessment. Aesthet Surg J 2019;sjy326; >Epub ahead of print@ doi:
10.1093/asj/sjy326
[7] Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J
2007;27(2):188–198

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
551
45 Structural Fat Grafting: Basics and Clinical Applications in
the Hand and Face
Michael J. Cammarata and Sydney R. Coleman
Abstract
This chapter reviews the essential steps of harvesting, refining,
and placing autologous fat using the Coleman technique and
applies these methods in the hand, lips, nasolabial folds, and
marionette grooves. The Coleman technique was introduced in
the 1990s and has proven to be a reliable method of achieving
hand and facial rejuvenation, hence its adoption by plastic sur-
geons throughout the world. Meanwhile, the clinical applications
of fat grafting continue to expand, owing to the unique properties
of autologous fat, which provides a safe, predictable, and long-
lasting soft tissue filler that not only restores youth and subcuta-
neous fullness but also improves skin quality by way of growth
factors and adipose-derived stem cells within the harvested
lipoaspirate. This chapter takes the reader step by step through
the basics of the Coleman technique and applies them across
several clinical regions, specifying appropriate sites of incision
and correct levels of infiltration to achieve the ideal postoperative
result. After each technical explanation of proper fat placement,
the chapter also features postoperative images and cases with
extended long-term follow-up, highlighting the stability of struc-
tural fat grafting performed with the Coleman technique.
Keywords
fat grafting, structural fat grafting, Coleman technique, lipo-
structure, facial augmentation, autologous fat, fat, lipoaspirate,
soft tissue augmentation
45.1 Structural Fat Grafting Basics:
The Coleman Technique
45.1.1 Evolution of the Technique
For over 100 years, surgeons have been in search of the ideal soft
tissue filler. From paraffin, a hydrocarbon injected into the face
and body beginning in the late 19th century, to the modern-day
dermal filler hyaluronic acid, each has its respective drawbacks,
such as risk of foreign body reaction and gradual resorption.
Adipose tissue has long offered a natural and readily accessible
solution to soft tissue augmentation, but the techniques and
clinical applications of autologous fat grafting have undergone
considerable evolution since first reported by Gustav 1euber
in 1893. In 1910, Eugene Hollander described the transfer of
autologous fat into the face, and by 1919, Erich Lexer published
on the harvesting and transplantation of fat en bloc to perform
reconstructions of the breast, face, and hand. The first account
in U.S. literature, however, was by Charles C. Miller in 1926, who
described subcutaneous fat injections using injection cannulas
for aesthetic restoration of the face. Despite the achievements of
these pioneers, the process of fat resorption was poorly under-
stood, and the technique failed to be widely adopted.
It was not until the advent of liposuction in the 1980s that inter-
est revived in the harvest and transfer of fat, now in a semiliquid
form amenable to reinjection through cannulas and needles;
however, attempts at fat grafting continued to yield mixed results
owing to graft resorption over time. High negative pressure during
tissue harvesting subjected fat cells to considerable stress, not
unlike the harmful manipulations such as straining, whisking, and
filtering utilized during the processing of fat in years past. Seeing
promise in the potential applications of fat grafting, particularly in
restoring iatrogenic liposuction deformities, one of us (Coleman)
applied the principles of tissue transplantation to fat harvest
and transfer. In 1994, he refined his technique and established
Lipostructure for hand and facial rejuvenation, which emphasized
low-trauma harvest via syringe liposuction combined with the
delicate and meticulous layering of autologous tissue. His impres-
sive results and reproducible technique helped repopularize fat
grafting and made it one of the techniques most widely adopted
by practicing surgeons.
45.1.2 Overview of Harvesting,
5eÀnemenW Dnd 7rDnVIer
and Placement
The three cardinal steps of structural fat grafting via the Coleman
technique are the following:
1. Harvesting of autologous fat with a blunt cannula attached to
a low-suction syringe
2. 5HÀQHPHQW RI WKH OLSRDVSLUDWH with brief centrifugation
to facilitate removal of nonliving components, with refined
lipoaspirate then transferred to low-volume syringes for
placement
3. CDUHIXO SODFHPHQW RI DXWRORJRXV IDW into recipient tissues in
small aliquots
:hile progressing through the aforementioned steps, consider
the following corresponding principles:
A. Fat is a delicate structure with its own supporting architecture,
and it is susceptible to mechanical, chemical, temperature, and
barometric insults and thus requires careful handling.
B. Accurate estimation of the volume of harvested fat is facilitated
by centrifugation to separate viable fat from blood, lidocaine,
and the oil expelled from lysed adipocytes. Failure to isolate and
discard nonfatty components will yield unpredictable results.
C. Fatty parcels are composed of adipocytes, which require oxygen
and nutrients from the surrounding host tissue for aerobic res-
piration and survival. Overzealous placement of large volumes
can compromise access to nutrients, leading to cell death and
poor graft retention.

552
VIII Surgical Rejuvenation of the Face and Neck
45.1.3 Harvesting
Incisions and Donor Site Access
The choice of donor site for fat harvesting is largely dependent on
patient preference and the quantity of fat needed. Harvest sites
typically include the abdomen; the flank; the ´love handlesµ; the
medial, lateral, and anterior thighs; the suprapubic region; and
above the knees (Fig. 45.1). :hen accessing these areas, an effort
should be made to hide incisions in previous scars, natural creases,
stretch marks, or hirsute regions. The pubic region is often used
as an incision site given the ease of access to the inner thighs,
flank, and abdomen. This is especially convenient during facial
rejuvenation, when the patient is already in the supine position.
In thin patients or men with limited abdominal or medial thigh
fat, consider harvesting from the suprapubic region, anterior
thighs, or above the knees. Additional incision sites include the
midback and lateral sacrum to access the love handles and flanks,
as well as the umbilicus and upper abdomen to access fat from the
flanks and upper abdomen. Occasionally, an incision at the lateral
hip can be used to access the thigh or lower love handle.
Previous research has found no significant difference in the
volume or weight of fat harvested from various donor sites;
however, a higher concentration of adipose-derived stem cells
(ADSCs) has been found in the fat of the lower abdomen and inner
thighs. The author preferentially utilizes the densest fat from
these regions to infiltrate recipient sites that require functional
rejuvenation of the overlying skin. :hen harvesting, be mindful
of the volume removed from a donor site, as large-quantity har-
vests may leave the patient with a liposuction deformity and thus
a new cosmetic concern; in fact, the harvesting process should
offer an opportunity to simultaneously improve contour.
Sterile Technique
Although postoperative infections are uncommon after struc-
tural fat grafting, they can compromise aesthetic outcomes and
patient satisfaction by leading to resorption. Hence, strict adher-
ence to sterile technique is essential during harvesting, refining,
and placement.
Anesthesia
To begin harvesting, infiltrate lidocaine solution with a 25-gauge
needle into the planned incision site. Proceed with a 2-mm
incision using a no. 11 blade. Anesthetic solution should be
infiltrated into the projected sites of fatty removal using a nine-
hole Coleman harvesting cannula attached to a 10-mL Luer lock
syringe. For smaller procedures, a purely local approach can be
used. In this case, 0.5 lidocaine with 1:200,000 epinephrine
buffered with sodium bicarbonate can be infiltrated into the
donor site. For larger procedures, IV sedation using propofol and
local infiltration is the preferred method. The author uses lac-
tated Ringer’s solution with lidocaine and 1:400,000 epinephrine
to ensure hemostasis. Avoid excessive tumescent techniques, as
these may disrupt adipocyte structure. Note that exposure to
epinephrine and lidocaine during harvest has not been shown
to result in functional or histological damage to adipocytes once
grafted, nor has it been shown to interrupt the process of micro-
angiogenesis at the recipient site.
Basic Harvesting Instruments
Harvesting instruments should be efficient and minimally trau-
matic to the grafted tissue, which must be harvested in intact
parcels small enough to pass through the lumen of a narrow
cannula but large enough to maintain tissue architecture.
Smaller-bore cannulas paired with 10-mL syringes have been
previously shown to result in greater fat viability and facilitate
the eventual passage of fat through the much smaller placement
cannulas without clogging (Fig. 45.2). For small harvests when
fat grafting to the face, use a 14-gauge nine-hole cannula. For
larger-volume harvests, the author recommends either a 15- or a
26-cm 12-gauge nine-hole cannula. Each cannula should be con-
nected to a 10-mL Luer lock syringe, with the plunger held at 1 to
2 mm of negative pressure to encourage a gentle, nontraumatic
harvest. It is recommended, however, that surgeons with little
exposure to fat grafting use shorter cannulas given the greater
torque placed on the Luer lock aperture by longer cannulas. This
torque may break the syringe tip, and the surgeon should prog-
ress to using 26-cm cannulas only after becoming familiar with
the instruments and comfortable with the harvesting process.
Similarly, a curved cannula may be a useful tool to harvest from
regions such as the flanks, thorax, or thighs once the surgeon
is more confident in his or her handling of the harvesting
instruments.
Proper instrumentation during the Coleman technique ensures
greater adipocyte viability and long-term graft retention as
compared with suction-assisted lipectomy. Previous studies have
shown that the high negative pressure generated during conven-
tional liposuction may be more traumatic to adipocytes and that
cells harvested via the Coleman technique have a statistically sig-
nificant increase in viability and cellular functioning as measured
by glyceraldehyde 3-phosphate dehydrogenase (G3PD) levels.
The gentle, constant pressure offered by syringe liposuctioning
Fig. 45.1 Common incisions for donor site access when fat harvesting
from (a) anterior and (b) posterior. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
553
preserves the architectural integrity of the grafted fat and fosters
long-term graft retention.
Harvesting may result in frictional trauma due to the repetitive
motion of the cannula against the incision sites. To prevent irrita-
tion and friction burn, use oil acquired from centrifugation and
separation to lubricate the harvest incisions. Incisions are then
closed with simple interrupted nylon sutures.
45.1.4 5eÀnemenW Dnd 7rDnVIer
Centrifugation
Once the fat has been harvested into the 10-mL Luer lock syringe,
remove the cannula and replace it with a dual-function Luer lock
plug to cap the syringe. Do not use the caps that come with the
syringes, as these are less reliable and may leak aqueous fluid
during centrifugation (Fig. 45.3). After removing the plunger, the
author then performs centrifugation at 1,286g for 2 minutes. Be
sure to sterilize the rotor and syringe sleeves after each proce-
dure. Sterilization should be performed with steam instead of
liquid solutions to prevent rusting and corrosion of the centrifuge
parts. The author also recommends that the central rotor be held
in place by gravity, given that bolted rotors can rust over time.
Separation of Components
Centrifugation separates the lipoaspirate into three layers: the
uppermost layer (least dense), consisting of oil released from
lysed adipocytes; a middle layer of potentially viable fatty par-
cels; and a lower layer (most dense), consisting of blood, water,
and lidocaine (Fig. 45.4). Isolated growth factors will not be lost
in the oil or aqueous components; hence, the top and bottom
layers can safely be removed from the central layer without jeop-
ardizing successful results. After decanting the excess oil from
the top (which should be saved for use in lubricating the incision
sites), wick away the remaining oil using Codman neuropads or
Fig. 45.2 (a) Nine-hole harvesting cannulas. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New and (d) back view are shown.
Fig. 45.3 Demonstration of proper syringe plugging. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration. 2nd ed. New Do not use the plugs that accompany the syringes. These may allow
spillage of aqueous contents. (b) Use a dual-function Luer lock plug for
capping.

554
VIII Surgical Rejuvenation of the Face and Neck
Telfa strips (Medtronic, Minneapolis, M1) for 4 minutes. Repeat
this process at least once, but avoid prolonged exposure to air
to prevent damage to adipocytes. Discard any fat that has likely
been damaged by exposure to barometric or mechanical trauma.
Dispose of the lowermost aqueous layer by removing the Luer
lock cap and draining by gravity into a collecting receptacle.
Replace the plunger and remove the remaining dead space. 1ote
that 10 mL of harvested fat will yield approximately 4 to 6 mL of
refined fat suitable for placement once centrifugation and dis-
posal of the oil and aqueous components have been completed.
At this point, the syringes can be safely stored temporarily before
transfer to smaller syringes.
Transfer to Syringes
:ithin the middle layer of potentially viable fatty parcels,
higher-density fat will be found toward the bottom of the
syringe. This layer has been shown to survive with less fibrosis
and to contain more ADSCs and growth factors. Higher-density
fat will yield more predictable postoperative results, and the
author therefore separates the harvested fat into 1-mL syringes
based on density. This enables a more strategic placement of the
highest-quality fat into prioritized recipient sites.
In preparation for placement, transfer the isolated fat in the
processed 10-mL syringe into either a 1-mL or 3-mL Luer lock
syringe. Use 1-mL syringes for fat grafting in the face and hands
and 3-mL syringes for larger-volume fat grafting in the body.
Maintain both syringes in a relatively vertical orientation to
prevent the introduction of air bubbles during transfer (Fig. 45.5).
The use of larger placement syringes is discouraged, as those
syringes do not facilitate the placement of small fatty aliquots and
thus pose greater risk of clumping, fat necrosis, and fat emboli.
'iVFuVViRn RI 5eÀnemenW
Alternative processing techniques such as washing and straining,
and harvesting by conventional liposuction, disrupt tissue archi-
tecture and may make fatty parcels more susceptible to damage
by centrifugation. Syringe liposuction used in the Coleman tech-
nique facilitates removal of tissue debris and preserves tissue
architecture, allowing it to withstand greater centrifugal forces.
This is supported by findings that centrifuge speed does not
impact graft survival when harvested with syringe liposuction,
suggesting that this method is less traumatic to grafted tissue.
Studies have also shown, however, that excessively long or vig-
orous centrifugation has been shown to damage adipocytes and
ADSCs, leading .urita et al to recommend 1,200g centrifugation.
Hoareu et al recommended a gentler centrifuge speed of 400g for
1 minute after washings; however, washing may break important
Fig. 45.4 Three layers produced by centrifugation during
refining. Viable fat for placement is retained within the middle level.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)
Fig. 45.5 Transfer of fat to smaller placement syringes. Maintain the
syringes in a vertical orientation to prevent the introduction of air
bubbles. (Reproduced with permission from Coleman SR, Mazzola RF,
Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New N<: Thieme; 2018.)

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
555
connective tissue and reticular fibers that provide architectural
support to fatty parcels. :ashing can also remove fibrin, which
plays an important role in promoting fat engraftment. In a recent
review of the literature, Strong et al concluded that results
among animal and human studies on processing methods have
been inconclusive and that no single technique is superior; but
the discrepancies between study protocols make it difficult to
compare published results. :hile further research is warranted,
it has been the author’s experience that centrifugation alone at
1,286g for 2 minutes is the optimal processing method and pro-
motes successful fat grafting without damage to the lipoaspirate.
45.1.5 Placement
Anesthesia
Infiltrate a solution of 0.5 lidocaine with 1:200,000 epinephrine
via a 27-gauge needle into planned incision sites and make an
incision with a no. 11 blade. Regional blocks with 1 lidocaine
and 1:100,000 epinephrine through a 25-gauge needle may be
used when appropriate. If general anesthesia is administered,
small amounts of dilute epinephrine solutions should be infil-
trated into the recipient site to induce vasoconstriction. If the
procedure is performed under local anesthesia or IV sedation
with propofol, the graft sites should be infiltrated with 0.5
lidocaine with epinephrine 1;200,000 using an appropriate can-
nula. This will help prevent intravascular injection and reduce
intra- and postoperative hematomas.
Placement Technique
Proper fat placement will ensure long-term graft viability and
yield more predictable postoperative results. Placement requires
the meticulous deposition of small aliquots of fat such that each
parcel is within a minimum of 1.5 mm of vascularized host tissue
and thereby has access to essential nutrients and integrates
into the recipient site (Fig. 45.6). Large fat injections prevent
the diffusion of host nutrients to adipocytes, resulting in cell
death, manifesting as large areas of resorption, calcification,
necrosis, and sometimes oil cysts (Fig. 45.7). Postoperatively,
this will yield poor aesthetic outcomes, with regions of either no
notable cosmetic improvement or, worse, palpable irregularities.
Maximizing the surface area of contact between fat parcels and
host tissue will promote continued respiration of grafted adipo-
cytes and will lead to a smooth and predictable postoperative
result.
To begin placing fat, insert the infiltration cannula through
the same incision used for injection of local anesthetic. Once the
cannula is within the desired plane, stabilize the skin and protect
vulnerable structures (e.g., the eyeballs) with the opposite hand.
Press down on the plunger of the syringe while simultaneously
withdrawing the cannula, allowing the deposited fatty parcels to
fall into natural tissue planes as the tissue drapes around them
(Fig. 45.8). This will prevent clumping, promote engraftment, and
increase the chance of graft survival. Fat should be placed in very
small quantities³0.1 mL at most and often as little as 0.02–0.033
mL in areas that require finer contouring, such as the periorbital
Fig. 45.6 (a) Placement of fat into the recipient site. Introduce the cannula, (b) pushing down gently on the plunger as the cannula is withdrawn to
(c) create layers of fat with maximal contact with the host tissue. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New a
b
c

556
VIII Surgical Rejuvenation of the Face and Neck
region. The injected material will likely contain remnants of blood,
lidocaine, or oil even postrefinement; therefore, it is best to start
with small quantities of infiltrate and progress to larger volumes
gradually with experience. Although small-quantity grafting
may not have the desired aesthetic affect with one operation, it
is preferable to perform an undercorrection and return to the
operating room at a later time for further augmentation than risk
tissue necrosis due to an overzealous augmentation.
Fat grafting requires the ability to visualize the desired 3D con-
tour and achieve it with multiple passes through specific tissue
planes, a process known as structural manipulation. During this
process, the Coleman technique promotes integration of the fat
into the host tissue such that the recipient site retains its original
structural quality. This may make it difficult to manipulate a graft
once it has been placed, and postoperatively, patients may believe
that the fat disappeared given that there is no palpable change
(hence the importance of pre- and postoperative photographs to
document clinical differences). Placement of fat deep against the
periosteum is used to modify projection; intermediate-level grafts
are used to restore volume and improve proportions; and super-
ficial intradermal or subdermal grafts enhance skin quality and
eliminate wrinkles. Although the Coleman technique promotes
fat integration, areas of greater mobility (e.g., nasolabial folds,
corrugators) may still be susceptible to fat migration as patients
inevitably resume normal facial expressions postoperatively.
Once fat has been placed, it is important to avoid manipulating
the tissue by hand. Hence, the surgeon should never place fat with
plans to manipulate it into shape by digital pressure. If a large-
volume graft has been mistakenly placed, it can be digitally
molded to restore the desired contour, but otherwise, tissue
should be placed in small linear aliquots as just described.
Instrumentation for Placement
To perform fat grafting, the author uses three basic cannulas
as well as V- and :-dissectors, each with its own purpose (Fig.
45.9). In contrast to harvesting cannulas, placement cannulas
have only one distal opening:
• Coleman Style I has a capped lip that extends 180ƒ over the
distal aperture. This is the workhouse of structural fat grafting.
The rounded lip minimizes traumatic injury to surrounding
tissues during placement.
• Coleman Style II is similar to a Style I but has a capped lip that
extends only 130ƒ to 150ƒ over the distal aperture.
• Coleman Style III has a flat tip instead of a capped lip and is
therefore a reliable tool for dissection through fibrotic tissue
or for placement in tougher, immediately subdermal tissue.
• The Coleman V-dissector is used for release of adhesions.
Placement cannulas can range from 14- to 21-gauge, depending
on the clinical application.
Larger-gauge cannulas are used for corporeal fat grafting, while
shorter, smaller-gauge cannulas are used in the more delicate
structures of the face, such as the eyelids.
Fig. 45.7 Placement principle. (a) Placement of large quantities of fat may compromise access to nutrients and (b) lead to fat necrosis and resorp-
tion. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New 2018.)
Fig. 45.8 Placement technique. (a) During placement, the cannula is inserted to the appropriate plane, and (b) withdrawn slowly as fatty parcels fall
into natural tissue planes. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed.
New

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
557
Use of Blunt Cannulas
The author switched from sharp to blunt placement cannulas in
1992 to prevent underlying tissue damage, lower the risk of intra-
vascular injection, and allow placement into more natural tissue
planes. Sharp needles were seen to create unnatural spaces and
cut swaths through the tissue, leading to less stable grafts, while
blunt cannulas separated tissue in a more physiologic manner.
Despite previously discouraging the use of sharp needles out-
right, the author has more recently begun utilizing sharp needles
for intradermal placement of fat grafts. Carraway and Mellow
previously recommended tissue undermining prior to intradermal
placement, which the author does not routinely perform, except
in cases of acne or other scarring. Deep dermal placement has
demonstrated remarkable improvement of acne scars and enables
a more significant softening of deep facial wrinkles. Be sure to
master the basic cannula techniques of fat grafting before proceed-
ing with intradermal placement (Fig. 45.10).
Fig. 45.9 Available instruments. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd
ed. New for release of adhesions.

558
VIII Surgical Rejuvenation of the Face and Neck
45.1.6 Conclusions
The Coleman technique is rooted in the principles of tissue trans-
plantation and provides a reliable foundation for fat grafting.
Long-lasting results in the hand and face are achievable with
proper harvesting, refinement, and placement techniques that
emphasize careful tissue handling and small volume placements.
45.2 Structural Fat Grafting: Clinical
Applications
45.2.1 Hand Rejuvenation
Much like the head and neck, the hands are often unclothed and
exposed. They are also one of the first areas to display signs of
aging and may become a cosmetic concern if their appearance is
incongruous with a more youthful face. In a healthy, attractive
dorsum of the hand, the extensor tendons are visible and become
more pronounced during metacarpophalangeal (MCP) joint
extension. Extensor tendons remain the color of the overlying
skin, while superficial veins are visible but not conspicuous and
display only a mild blue hue. Although fat will be placed in the
dorsum during rejuvenation, this region is not a repository of fat
in younger hands. The goal of adding fat into the dorsum is to
increase the subcutaneous tissue thickness over time, restoring
a subtle fullness over the hand and fingers that obscures dispro-
portionately prominent features. :hen the Coleman technique
is used, the grafted fat will feel like thicker skin upon palpation,
not like additional subcutaneous fat.
Aesthetic and Anatomic Considerations
In an aging dorsum of the hand, the skin is thin and crepelike
and clings to the surface. The contours of the superficial veins are
significantly more prominent, and the hand appears bony with
clearly defined MCP joints and deepened intermetacarpal spaces
(Fig. 45.11). Appropriately conservative placement of fat in the
dorsum of the hand and fingers restores a fullness reminiscent
of youth, softens the skin color, and masks the extensor tendons
and tortuous veins. However, an overzealous augmentation that
completely obscures the superficial structures of the dorsum
will appear unnatural and overfilled. Remember that in fat
JUDfWLQJ WR DQ\ DUHD, ZHLJKW FKDQJHV RYHU WLPH ZLOO D̵HFW UHVXOWV ,W
is important to weigh the patient at the time of consultation, right
before surgery, and at each postoperative visit to evaluate distant
postoperative changes properly.
The appropriate plane of placement is immediately subder-
mal, between the skin and the veins. Use of only the bluntest of
cannulas will prevent damage to any exposed structures. In the
author’s experience, significant bruising is rare when this plane
is respected. The key to successful fat grafting in the hand is the
placement of a smooth, consistent layer just deep to the dermis,
with additional placement in the web spaces and intermetacarpal
regions.
Indications and Patient Selection
Patients who may benefit from structural fat grafting in the hand
display signs of aging at the hands that do not correspond with
their facial appearance or age. The best candidates have a loss of
subcutaneous fullness, leading to prominent veins and tendons.
Patients with enlarged joints and arthritic changes are also can-
didates. Their hands will appear much healthier by decreasing
the relative size of the joints and filling the intermetacarpal
spaces.
Fig. 45.10 Intradermal placement. Deep dermal placement may be accomplished with sharp needles. (Reproduced with permission from Coleman
SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Fig. 45.11 Age-related changes visible at the hands. Note the tortuous
superficial veins, visible extensor tendons, and crepiness of the skin.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
559
Technical Approach
Markings
Orange lines delineate the limits of placement along the perimeter
of the hand and extend to the proximal forearm. Green markings
represent areas of greater fat placement, while blue dots chart
the courses of large, superficial veins (Fig. 45.12). These lines
may be obscured during fat placement; therefore, they should
be photographed before the patient enters the operating room
so that the photograph can serve as an intraoperative reference.
Incisions
Six to nine incision sites should be placed throughout the dorsum
of the hand. The following sites are recommended: ulnar and
radial wrist, central dorsum of the hand, ulnar and radial thumb,
radial index, web space between the third and fourth fingers,
and the fifth finger (ulnar) MCP joint (Fig. 45.13, see blue dots).
Incisions should be made with a no. 11 blade and should be
slightly longer than 1 mm. Obscure incisions by placing them in
the direction of wrinkle lines.
Cannulas
Be sure to use only Style I cannulas to avoid damage to the
underlying structures, especially the veins. Trauma to the veins
may produce a hematoma and complicate visualization of fat
placement. The author prefers 17-gauge cannulas that are either
7 or 9 cm long.
/eYeO RI InÀOWrDWiRn
In addition to use of the blunt cannula, staying in the appropriate
plane immediately deep to the dermis, but superficial to the
veins, will help prevent tissue damage (Fig. 45.14). Filling in this
plane will provide support, thicken the skin, and obscure the
protuberant veins.
Volumes
Placement volumes of at least 20 to 30 mL in each hand is
recommended. Patients with more significant skin atrophy or
who require feathering into the proximal forearm may require
additional volume, but be very cautious about overcorrecting. Do
not place more fat than necessary in anticipation of resorption.
Placement Pattern
The key to placement is the use of a very superficial plane with
very little layering. Fat will be placed over the proximal fingers
and the entire dorsum of the hand and extend to the wrist and
occasionally the forearm. At the intermetacarpal spaces, fat can
be placed in a deeper plane for additional support.
Begin placement through the central dorsum incision, extend-
ing along the phalanges, past the MCP joints, and into the web
spaces. The most common technical error during placement is
undercorrection of the proximal digits, so be sure that each digit
receives about 1 mL of fat.
Fig. 45.12 Skin markings for fat grafting to the hand. Red lines delin-
eate the borders of placement, blue dots trace the course of superficial
veins, and green markings indicate areas of placement. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New Fig. 45.13 Incision sites for placement at the hand. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Filling to Regeneration, 2nd ed. New Fig. 45.14 Proper level of infiltration for placement at the hand. Note
that the cannula tip remains in the immediately subdermal plane
superficial to the veins. (Reproduced with permission from Coleman
SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd
ed. New

560
VIII Surgical Rejuvenation of the Face and Neck
Fat can be placed as distally as the proximal interphalangeal
(PIP) joints and across the MCP joints for continuity, but be cau-
tious about placing fat over already enlarged joints, as this may
accentuate their size, particularly if placement is not adequate
in the intermetacarpal spaces. Infiltrate up to 7 mL of fat in the
phalanges and web spaces (Fig. 45.15a,b). Place about 1 mL or
more at the first web space from the ulnar thumb and radial
index incisions. Placement can extend from the dorsal hand to
the palmar aspect (Fig. 45.15c,d). Proceed to the radial thumb
incision, placing another 3 mL or more in a radiating pattern (Fig.
45.15e). Using the middle MCP joint incision, pass over the entire
dorsum toward the distal forearm (Fig. 45.15f). The radial and
ulnar MCP joint incisions, along with the central dorsum incision,
can be used similarly to spread across the dorsum to the wrist
(Fig. 45.15g–i). Place an additional 5 to 10 mL across the wrist
from the dorsal and radial wrist incisions (Fig. 45.15j). This area
requires larger quantities of fat, given that it is the primary site of
wrinkling of the dorsal upper extremity. Incisions can be closed
with Steri-Strips (3M, St. Paul, M1) or nylon sutures.
Postoperative Care
Incisions are generally closed with Steri-Strips only. The author
formerly dressed the hands, wrist, and phalanges in Microfoam
(3M, St. Paul, M1) tape for 3 to 4 days postoperatively to help
combat edema. However, the tape rarely remained more than
24 hours. More recently, he uses ´fingerless glovesµ made from
sterile stockinette to cover the hands. An extra pair of two can be
given to the patient, who is advised to wear them until the first
postoperative visit. Elevation of the hands will certainly help
with swelling; cold compresses are contraindicated. Patients
should refrain from putting pressure on the dorsum of the hands
for at least 1 week, especially during sleep. However, movement
of the fingers, as in typing, is encouraged after the first few days
to help reduce swelling. Most swelling will resolve by 6 to 8
weeks, although some edema may be present for up to 20 weeks
or more.
Results
A 55-year-old woman was concerned that her hands appeared
much older than her face. Her veins were prominent, and the
whites of her extensor tendons were visible. She elected to
undergo structural fat grafting to the dorsum of both hands,
and fat was harvested under epidural anesthesia. Forty mL of fat
were removed from the abdomen, 30 mL from each medial thigh,
and another 15 mL from each medial knee, totaling 130 mL. After
refinement, 60 mL were left for equal distribution between both
hands. Fat grafting was performed from the proximal phalanges
to the distal third of the forearms. Only one procedure was
required, and at 7 years’ follow-up, the patient remained pleased
with the continued ´elegant definitionµ of her hands as well as
the decreased prominence of her veins and tendons (Fig. 45.16).
A 62-year-old woman presented with prominent veins and ten-
dons, as well as crepiness of the skin. Twenty-nine mL of refined
fat was placed into her left hand, and 28 mL were placed into
her right hand. Fat placement extended to the middle phalanges
and almost to the distal interphalangeal (DIP) joint, given her
concern that her PIP and MCP joints were excessively bony. The
patient was enthusiastic about the results, shown at 39 months
postoperatively (Fig. 45.17).
Complications
Prior to 1992, the author primarily used sharp needles for
placement, which led to occasional lumps and irregularities,
presumably due to fat migration. This complication resolved
once the author began using only blunt instruments in the hand.
Blunt instruments also protect against damage to underlying
structures, contributing to the safety profile of this procedure. 1o
postoperative infections have been seen. The author had one case
of scarring of the dorsal skin secondary to a concomitant chemical
peel and thus no longer combines these two procedures.
Conclusions
Fat grafting to the aging dorsum of the hand can restore a subtle
fullness and thicken the skin over time. Attention to the appro-
priate tissue planes combined with the use of blunt cannulas
makes this a safe and predictable procedure.
Fig. 45.15 Placement pattern at the hands. (Reproduced with permis-
sion from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling
to Regeneration, 2nd ed. New at the central dorsum extending toward the wrist and past the MCP
joints. (c–e) Proceed to the first web space. (f–i) The middle, radial,
and ulnar MCP joint incisions, along with the central dorsum incision,
can be used to spread across the dorsum. (j) An additional 5 to 10 mL
can be placed across the wrist.

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
561
45.2.2 Lips
Aesthetic and Anatomic Considerations
Comparative studies have shown that fuller lips are deemed
more youthful and attractive. Although some surgeons prefer
synthetic fillers for lip augmentation, fat provides durability, has
excellent consistency, is easily accessible, and is well tolerated.
Given that the lips are a central aesthetic feature of the face and
also play functional roles in speech and eating and drinking, it
is important that they remain soft, flexible, and mobile after
enhancement with fat.
Another important consideration during fat grafting to the lips
is discussion about lip shape. Before proceeding with augmenta-
tion, it is important to have a clear idea of what constitutes attrac-
tive lips in the mind of the patient and to reach an agreement
on the aesthetic goals of augmentation. Attractive lips generally
have a well-defined and protuberant white roll that tapers from
the peaks of Cupid’s bow and fades laterally. The upper cutaneous
lip has two distinct philtral columns, which become less concave
as they curve up toward the columella. Moving from medial to
lateral, the body of the upper lip has a central tubercle, then a
slight depression, and a fullness adjacent to the lateral commis-
sures. The lower lip has a central depression bordered by right
and left tubercles, which are larger than the central tubercle of
the upper lip. These lower lip tubercles contribute to the char-
acteristic everted pout of the lower lip. Overall, the lower lip has
significantly more vermilion show than the upper lip (Fig. 45.18).
Most surgeons agree that the upper lip should be approximately
two-thirds the size of the lower lip, but many patients want larger
upper lips.
The goal of lip augmentation is to increase fullness and restore a
youthful, sensual appearance with an everted vermilion. This can
be achieved by layering fat immediately under the mucosa and
vermilion to increase the exposed surface area of the lip. If the
patient’s lips do not yet have an aesthetically pleasing form prior
to the procedure, fat grafting without consideration of their shape
may worsen their appearance.
Indications and Patient Selection
The primary indication for fat grafting to the lips is aging, which
results in volume loss, thinning and drooping of the lips, and
perioral rhytids. Both younger and older patients may desire
fuller, more sensual lips to restore facial proportions. These two
indications may also be present in the same patient. The best
candidates are often older patients who had full lips when they
were younger and are seeking a restoration of youth. Fat grafting
to the lips of male patients is becoming increasingly common.
Technical Approach
Incisions and Markings
Markings are made along the vermilion of the upper lip, caudal to
the white roll. Placement along the vermilion should terminate
Fig. 45.16 (a–f) Results of fat grafting to the hands in a 55-year-old
woman. Seven-year postoperative results demonstrate longevity
and continued fullness of the dorsum. No revision procedures were
necessary. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
Fig. 45.17 (a–f) Results of fat grafting to the hands of a 62-year-old
woman. Results at 39 months postoperative continue to provide
a subtle fullness, obscuring once-prominent superficial veins and
extensor tendons. (Reproduced with permission from Coleman SR,
Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed.
New

562
VIII Surgical Rejuvenation of the Face and Neck
about 4 mm medial to the lateral commissures. 1ote the green
circles of the upper lip highlighting areas of concentrated fat
placement to emphasize the medial and lateral tubercles (Fig.
45.19). Between these areas will be purposefully placed concav-
ities. Markings also extend to the base of the philtral columns to
create a slight turgor. On the lower lip, green markings indicate
the right and left tubercles. Markings may occasionally extend to
the cutaneous portion of the lip, as in this patient, where added
fullness was desired at the lateral cutaneous portion of the com-
missures. Otherwise, placement should be focused only at the
vermilion to promote the characteristic everted pout. Placement
in the cutaneous portion will lead to lip projection, but not the
desired eversion.
Incisions can be made at the lateral commissures, though occa-
sionally a midmalar or lateral chin incision is used for additional
access.
Given that incisions are being made near the oral mucosa, the
author prefers to use intraoperative antibiotics (most commonly
an intravenous cephalosporin). Patients are also instructed to
gargle with chlorhexidine gluconate solution preoperatively and
will receive prophylaxis with valacyclovir if they report a history
of cold sores. :hen multiple areas of the face are being grafted,
the lips should be completed last to prevent contamination of
other areas with oral flora.
Cannulas
The author prefers to use a Coleman Style III cannula, the sharpest
of the blunt cannulas. This cannula offers the greatest accuracy
in grafting into the plane just deep to the mucosa or vermilion.
The mini–Style III cannula may also be used.
/eYeO RI InÀOWrDWiRn
Fat should be placed at the most superficial plane possible, just
deep to the vermilion and mucosa (Fig. 45.20). Placement into
the muscle will only increase the distance from the cutaneous lip
to the teeth and lead to forward projection.
Volumes
Small volumes can make a significant difference in the lips. Use
the following volumes as guidance:
• :hite roll restructuring: at least 0.75 mL but rarely more than
1.25 mL
• Lower lip rim: more than 0.75 but less than 1.25 mL
• Upper lip body: at least 1.5 mL and rarely up to 4 mL maximum
• Lower lip body: place slightly more than twice the volume
placed in the body of the upper lip
Placement
Begin by placing fat into the white roll of the upper lip. Placement
into the white roll is the most technically challenging part of the
procedure and requires that fat be placed immediately deep to
the mucosa and vermilion. Using the Coleman Style III cannula,
extend the tip nearly to the opposite commissure and withdraw
the tip slowly while applying gentle pressure on the 1-mL syringe
(Fig. 45.21). Complete this from the opposite commissure. To
augment the base of the philtral columns, orient the cannula tip
up toward the columns from the same lateral incisions, but be
sure to remain superficial and avoid placement into the deeper
orbicularis oris. To assist in placement at the philtrum, an addi-
tional incision can be made centrally in the vermilion, about 0.5
cm inferior to the Cupid’s bow.
Placement into the white roll of the lower lip is nearly identical
to that of the upper lip (Fig. 45.22a–c). Focus on placing into
the central two-thirds of the white roll. :hen placing into the
vermilion of the lower lip, be sure to accentuate the right and
left protuberances (Fig. 45.22d–f). Some feathering should be
performed between the two tubercles to contribute to the cen-
tral pout, but a slight cleft should be left centrally. At the upper
lip, begin by augmenting the central tubercle. Then proceed to
Fig. 45.18 Ideal shape of attractive lips. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New Fig. 45.19 Markings and incision sites for placement at the lips. Red
lines indicate incisions, while green circles indicate areas of intended
placement. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
Fig. 45.20 Level of infiltration at the lips. (a) Incorrect placement into
muscle is shown on the left. (b) Correct technique requires placement
superficial to the muscle and just deep to the mucosa and vermilion.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)
a
b

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
563
placement at the right and left regions of the upper lip, leaving a
slight depression between the lateral regions and central tubercle
(Fig. 45.23). During placement, small lumps are well tolerated, but
large ones are not.
Postoperative Care
1o special dressings are required after fat grafting to the lip. The
lips should be kept moist with Aquaphor (Beiersdorf Inc., :ilton,
CT) while healing. :et mucosa now exposed to ambient air may
undergo keratinization and ultimately become dry mucosa or
vermilion. During this process, peeling may occur, and it will
be helpful to use Aquaphor or similar ointments. There are no
restrictions to lip movement; in fact, movement of the mouth
will promote lymphatic drainage. However, do not massage the
lips in the first few weeks after the procedure. Counsel patients
that recovery may be more difficult compared with fat grafting
in other regions given the degree of swelling typical of the lip
area (Fig. 45.24).
Results
A 50-year-old woman presented with thin lips and a desire to
restore them to the fullness of youth (Fig. 45.25). The lower lip
was no longer dominant, and she generally lacked vermilion
show. After meticulous preoperative planning, emphasis was
placed on everting tissue more than adding volume (Fig. 45.26).
At the lower lip, 6 mL were placed, followed by 1.1 mL caudal to
the white roll, and 2.5 mL in central and lateral regions of the
upper lip, with some fat feathered in between. An additional 1.4
mL was placed at the base of the philtral columns. As expected,
postoperative edema was significant and discernible for several
weeks (Fig. 45.27). The patient stated that she noted changes in
the size and texture of her lips for up to 8 months. The patient’s
results were stable at 1 (Fig. 45.28b,e) and 8 (Fig. 45.28c,f) years
postoperative. The author has since modified his practice and
would currently use less than half of the volume placed in the
philtral columns and less than 1 mL at the white roll.
A 24-year-old woman presented with a desire for fuller
lips. A total of 40 mL of fat was harvested from her lower back.
Refinement yielded 10 mL of fat, which was placed into the lips
as follows: 1 mL into the white roll of the upper lip; 1 mL into the
border of the lower lip; 2.3 mL in the body of the upper lip; and
2 mL into the body of the lower lip. Images are shown at 1 year
postoperatively (Fig. 45.29).
Complications
Postoperative swelling may lead to spontaneous lacerations in
the lip, which can be closed with simple interrupted sutures but
will usually heal without intervention other than the generous
application of a lubricant such as Aquaphor (Fig. 45.30). The
author has witnessed this only in the lower lip. Lacerations limit
the volume of fat that can be grafted, hence the recommendation
to begin fat placement in the lower lip. Pyogenic granulomas
may form after fat grafting to the lip due to the local trauma (Fig.
45.31). These can be excised. Lip necrosis is a possible compli-
cation of fat grafting to the lip, but highly unlikely when using a
blunt Coleman Style III cannula. The author has never personally
seen this complication.
Patients who have previously had lip augmentation with
permanent fillers such as Gore-Tex (:. L. Gore and Associates,
1ewark, DE), silicone, dermal fat graft, or fascia grafts present
additional challenges. If possible, the author prefers to remove
Fig. 45.21 Placement pattern into the white roll of the upper lip.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)
Fig. 45.22 Placement pattern into the lower lips. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Filling to Regeneration, 2nd ed. New technique for the white roll of the lower lip is nearly identical to that of
the upper lip. (d–f) Emphasize the right and left tubercles during lower
lip placement.

564
VIII Surgical Rejuvenation of the Face and Neck
Fig. 45.23 Upper lip placement pattern. Highlight the central tubercles and lateral prominences, leaving a slight depression between these two
regions. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)
Fig. 45.24 Postoperative edema. Counsel the patient on the anticipated severity and duration of edema. (Reproduced with permission from
Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
565
Fig. 45.27 Postoperative edema after fat grafting to the lips. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New subsided but is still present. (c) At 1 year postoperative, no residual edema is visible.
Fig. 45.28 (a-f) Results of fat grafting to the lips in a 50-year-old woman. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat
Injection: From Filling to Regeneration, 2nd ed. New Fig. 45.25 Aging lips. Preoperative images obtained for fat grafting
to the lips in a 50-year-old woman. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New Fig. 45.26 Lip markings for fat grafting plan. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Filling to Regeneration, 2nd ed. New

566
VIII Surgical Rejuvenation of the Face and Neck
these substances. If they are left behind, the lip may have an
unnatural feel. Fillers such as Artecoll (Artes Medical, San Diego,
CA), Dermalive (Dermatech, Paris, France), and polyacrylamide
gel cannot be removed. Patients with these fillers require careful
planning to avoid making the lips appear worse.
Conclusions
:ith careful preoperative planning, fat grafting to the lips can
help improve lip eversion and vermilion show. Superficial lay-
ering of fat immediately deep to the mucosa and vermilion will
help achieve this effect.
Fig. 45.29 Fat grafting to the lips in a 24-year-old woman. Results are shown at 1 year postoperative. A total of 6.3 mL of fat was placed throughout
the lips. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Thieme; 2018.)
Fig. 45.30 Postoperative splitting of the lip. These lacerations may
require simple interrupted sutures. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New Fig. 45.31 Pyogenic granuloma of the lip, which can be treated with
excision. (Reproduced with permission from Coleman SR, Mazzola RF,
Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New N<: Thieme; 2018.)

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
567
45.2.3 Nasolabial Folds and
Marionette Grooves
Aesthetic and Anatomic Considerations
The nasolabial folds run from just superolateral to the nasal ala
to the corners of the mouth. Also known as ´smile lines,µ they
can range from superficial creases to deep grooves and are one
of the most prominent signs of facial aging. Marionette, or labio-
mandibular, grooves run from the lateral oral commissures to
the mandible. Nasolabial folds are particularly important in the
expression of a range of emotions, from joy to disgust, depending
on their orientation. As aging occurs, subcutaneous fullness is
lost and these lines may become fixed in place, resulting in the
unintended projection of emotions (Fig. 45.32).
Indications and Patient Selection
The main indication for structural fat grafting to the nasolabial
folds and marionette grooves is aging. However, the mere pres-
ence of these lines is not an indication for the procedure. Older
individuals with deep or prominent folds, which may convey
a fixed expression, would best benefit from the procedure.
Additionally, younger patients with deep folds that make them
Fig. 45.32 Age-related changes at the nasolabial folds and marionette grooves. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New

568
VIII Surgical Rejuvenation of the Face and Neck
appear older would also be appropriate candidates. Fat grafting
will be able to soften these folds but might not eliminate them
altogether, especially in patients who had them at a younger
age. Request younger photos of the patient to help manage
expectations. Also be wary of overcorrection, which may leave
the patient with a balloonlike appearance and exacerbate nearby
lines, such as those in the cheek.
Technical Approach
Incisions and Markings
Arrows in green indicate the depth of the folds and areas of
placement. Incisions can be made midmalar, at the lateral com-
missures, or at the lateral chin/mandibular border. The chin inci-
sion can be used for longitudinal placement along the fold, while
the midmalar incision can be used for perpendicular placement.
An incision near the commissure may be used for an additional
placement angle (Fig. 45.33).
Cannulas
The most commonly used cannulas are the 6- (mini), 7-, and 9-cm
Style II Coleman cannulas. These will facilitate dissection and
prevent intravascular injection. However, if significant fibrous
adhesions are encountered, a Style III cannula or V-dissector may
be used to assist in undermining the tissue. The author generally
recommends use of the Style II cannula when possible, given that
grafts placed with finer cannulas are more poorly integrated and
may be visible as a delineated mound in the superficial skin.
/eYeO RI InÀOWrDWiRn
Fat may be placed from the subcutaneous to intramuscular
planes, but it should primarily be concentrated in the immedi-
ately subdermal plane. This will improve the overall skin quality
and help lessen the severity of the groove. If further softening
of either the nasolabial folds or marionette grooves is required,
fat may also be placed intradermally with sharp needles (Fig.
45.34).
Volumes
Infiltration of the nasolabial fold may require as little as 2 mL
of fat if the crease is minimal. However, if there is significant
premaxillary deficiency, up to 11 mL may be required. Smaller
volumes, such as 1 to 3 mL, will suffice in the marionette grooves,
although they are difficult to eliminate regardless of volume or
technique.
Placement
The key to successful fat grafting in the nasolabial folds and
marionette grooves is the placement into various subcutaneous
planes throughout the fold instead of into a single crease. The
most common mistake in this region is to place into the deepest
part of the fold without feathering into surrounding areas, which
yields an isolated, circumscribed correction that may promote
wrinkles in surrounding areas (Fig. 45.35).
From the midmalar incision, begin placing fat perpendicular
to the nasolabial fold. Longitudinal placement will be utilized
eventually, but it is the perpendicular placement that bolsters
the nasolabial fold and prevents deepening of the crease. Advance
the cannula past the medial border of the fold, using the opposite
hand to guide the tip of the cannula (Fig. 45.36a). Begin cephalad,
placing a majority of the fat medial to the fold. The lateral portion
of the fold will already have more bulk in the cephalad position.
Deposit 0.033 to 0.1 mL with each retreat of the cannula. As place-
ment progresses caudally, begin placing fat both medially and
laterally to the fold (Fig. 45.36b–f). Throughout placement, use a
fanlike approach and progress from deep to superficial in several
layers while remaining perpendicular. If the fold curves inward
as it extends caudally, use the lateral chin incision to maintain
perpendicular access.
Fig. 45.33 Markings and incisions sites for placement at the nasolabial
folds and marionette grooves. Red circles indicate incision sites
(midmalar, commissure, lateral chin). Green lines indicate areas of
placement. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
Fig. 45.34 Levels of infiltration at the nasolabial folds and marionette
grooves. The primary level is immediately subdermal. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
569
1ext, begin placing longitudinally into the nasolabial fold from
inferiorly (Fig. 45.36g,h). Continue to use blunt instruments for
placement, and use the V-dissector when necessary. Passes of
the cannula can extend the length of the fold, depositing 0.05 to
0.2 mL with each pass, moving from deep to superficial. As when
placing perpendicularly, be sure to place lateral to the fold, both
to prevent isolated fatty placement and to promote integration
into the surrounding tissues. Palpate along the fold to check for
integrity during the placement process. Use the pinch test to
determine whether the nasolabial fold can be re-created. If the
fold is recreated by digital manipulation, additional placement
will be required. However, if no fold can be created, the end point
has been reached (Fig. 45.36i).
To place fat into the marionette grooves, begin from the
midmalar region, again guiding the cannula with the opposite
hand and protecting against perforation of the oral mucosa (Fig.
45.36j). Longer cannulas will be required to extend to the more
inferior region of the marionette grooves. Use the same placement
principles to place fat perpendicularly from several directions. Be
careful to not overcorrect, as this region may enlarge in some indi-
viduals. To manage expectations effectively, remember to counsel
the patient that structural fat grafting of the marionette grooves
will likely not eliminate them entirely. Textural improvements
may be more appreciable than structural ones, even with multiple
interventions.
Postoperative Care
1o special postoperative care is required in this region. 1o
special dressing is used, and massage of the area is not recom-
mended. The recovery is often brief and more easily tolerated
than grafting to regions such as the lips and periorbital tissues.
Results
A 51-year-old woman presented for correction of her nasolabial
folds. She had undergone fat grafting 3 years prior by a different
plastic surgeon and was disappointed that the correction did
not last (Fig. 45.37). She had some early wasting of the anterior
buccal region, which would be accentuated by fat grafting to the
nasolabial region; therefore, it was decided to place fat into the
buccal region also. Her nasolabial folds naturally extended into the
marionette grooves. Preoperatively, the patient supplied a photo
of herself at age 16 (Fig. 45.38a) to compare to her present images
(Fig. 45.38b). Even her younger photo demonstrated the presence
of nasolabial folds. This proved useful during the preoperative
consult to explain that the fold might not be fully ablated. Into
each of the nasolabial folds, 5 mL of fat was placed. An additional
2.4 mL was placed into the marionette grooves and lower nasola-
bial folds. The buccal region received 2.6 mL on the right and 3 mL
on the left, while the outer upper lip also received 0.6 mL and 0.5
mL on the right and left, respectively (Fig. 45.39). Postoperatively,
the patient demonstrated significant softening of the nasolabial
folds and a pleasing contour of the buccal region (Fig. 45.40a–d).
1ote that smiling photographs should also be taken to ensure that
the correction permits a normal-appearing smile.
Complications
The most common mistake is undercorrection or failure of the
initial correction. Avoid the impulse to overcorrect, as this could
lead to fat migration, necrosis, or an unnatural or overfilled facial
appearance. It is much preferable to perform multiple smaller
surgeries than to risk the consequences of overcorrection.
Infections due to perforation of the oral mucosa are possible,
but rare. Use the opposite hand to guide the cannula tip during
placement to prevent perforation.
Conclusions
The nasolabial folds and marionette grooves are early visible
signs of aging and can be improved through structural fat
grafting with a complex matrix of support, whereby at least two
layers are placed in different directions. Intradermal placement
may also serve a role in softening deep creases.
Fig. 45.35 Unwanted postoperative outcome. A circumscribed cor-
rection is visible (green arrow) due to excessively superficial placement
without adequate feathering into surrounding areas. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New

570
VIII Surgical Rejuvenation of the Face and Neck
Fig. 45.36 Placement pattern at the nasolabial folds and marionette grooves. (Reproduced with permission from Coleman SR, Mazzola RF, Pu
LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New Approach from the midmalar incision, placing perpendicular to the nasolabial fold, (e,f) progressing caudally. (g,h) The fold can also be approached
longitudinally from the inferior lateral chin incision. (i) Inability to re-create the fold with digital manipulation means that grafting is complete in this
region. (j) Approach the marionette region from the same midmalar incision.
b
e
h
c
f
i
a
d
g
j

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
571
45.3 Concluding Thoughts
Structural fat grafting to the hand and face offers a reliable
solution to restore youth, improve skin quality, and aestheti-
cally enhance aging tissues. Adherence to the principles of the
Coleman technique will ensure long-lasting, visible results and
improved patient outcomes.
Clinical Caveats
• Harvested fat is a living tissue and requires nutrients from
host tissue for survival.
• Conceal incisions in wrinkles, folds, or hirsute regions when
possible.
• Deep fat grafts against bone or cartilage enhance structural
support, intermediate-layer grafts provide projection, and
more superficial fat placement results in improved skin qual-
ity and reduction of lines and folds.
• The goal of fat grafting to the hand is to increase the subcu-
taneous fullness over time. Upon palpation, fat will feel like
thickened skin, not like fat.
• Large weight changes may be reflected in transplanted tissue.
• When performing fat grafting in several locations, place fat
in the lips last to avoid contaminating other areas of the face
or body.
• At the lips, place fat deep to the mucosa in order to increase
vermilion show and eversion. Placement at the cutaneous
portion of the lip will only increase projection.
• Fat grafting to the nasolabial folds and marionette grooves
requires feathering into surrounding tissues to prevent visibly
circumscribed fat. Placement should always begin perpendic-
ular to the fold.
Fig. 45.37 Nasolabial folds. Preoperative image of 51-year-old woman
consulting for correction of prominent nasolabial folds. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New Fig. 45.39 Surgical plan. Markings are shown for fat grafting to the
nasolabial folds and marionette grooves. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New Fig. 45.38 Preoperative reference photos. Using a photo of (a) the
patient at a younger age to compare to (b) the present can help in
counseling a patient on the degree of nasolabial fold correction to
expect. (Reproduced with permission from Coleman SR, Mazzola RF,
Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New N<: Thieme; 2018.)
Fig. 45.40 Preoperative vs. postoperative results. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New c) The nasolabial folds are prominent preoperatively, while (b, d) the
postoperative images show a softer, more relaxed face with gentler
nasolabial folds.

572
VIII Surgical Rejuvenation of the Face and Neck
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