Facial Fat Grafting: Why, Where, How, and How Much

Abstract

Although the importance of volume loss in the aging face is now well recognized and fat grafting has increasingly become an integral part of contemporary facelift procedures, general acceptance of the fat grafting technique is a relatively recent occurrence and many surgeons reluctance to adopt the technique can be traced back in part to questions they have as to how loss of volume contributes to how the face ages, how to specifically recognize those changes, and questions they have about how to perform the fat grafting procedure to correct them. In this article we attempt to answer the questions "why perform facial fat grafting during facelift procedures?", "where should fat be placed in the face?", "how should fat be injected?", and "how much should be injected in each area?".

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Incisional Ptosis Correction with Hidden Double Fold in Asian Patients

Abstract

Background

Korean males and a few females desire to have larger eyes; however, they often wish to enlarge their eyes and conceal their double eyelids. This paper attempts to describe how to make the eyes bigger and brighter without showing double-fold eyelids.

Methods

The authors performed cosmetic ptosis correction in 121 cases from April 2013 to December 2017. All patients enrolled in this retrospective study underwent surgical procedures at the author's institutions. Patients were included that had mild-to-moderate degrees of ptosis and levator function greater than 5 mm, ages greater than 16 years, and no prior ptosis surgery.

Results

A successful outcome was achieved with this surgical approach in 113 (93.4%) patients. Complications potentially associated with ptosis surgery were not observed.

Discussion

A refined method of preoperative evaluation for incisional ptosis correction to conceal a double fold with no visible signs of surgery is described. Ptosis correction without the formation of double eyelids will result in skin hooding and visible scarring, and thus, it is recommended to lower the height of the double eyelids. The lower height of double eyelids can cover the incisional scar and make it appear there are no double eyelids.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Modified Double Eyelid Plastic Surgery Method: Continuous Buried Suture Method Accompanied by Simultaneous Correction of Mild Blepharoptosis

Abstract

Background

Double eyelid surgery with a buried suture is a popular plastic surgery procedure in Asia owing to the relatively minor scarring and quick recovery associated with it. In this article, we present a new approach involving a continuous single-loop buried suture method, which expands the operating site to the conjunctiva and the aponeurosis–Müller's muscle complex.

Methods

The medical records of 42 patients (80 eyes) who underwent double-eyelid blepharoplasty were retrospectively reviewed. We performed double-eyelid blepharoplasty with a single-knot continuous buried suture method, along with the resection of a small piece of the orbicularis oculi muscle. The formation of a double eyelid was achieved through traction of the aponeurosis–Müller's muscle complex from the medial conjunctiva and penetration of the upper eyelid.

Results

The majority of patients achieved the expected cosmetic effect of double eyelid formation after the procedure. In the subsequent follow-up period of 2–30 months, no complications, such as loosing or sagging of the double eyelid or granuloma formation, occurred. The mean recovery time ranged between one and 6 weeks. The pre-operative margin reflex distance (MRD1) was 2.36 ± 0.61 mm, and the post-operative MRD1 was 3.72 ± 0.63 mm, (p < 0.001). The Wilcoxon signed rank test was used for nonparametric, paired comparisons.

Conclusions

We proposed a modified technique involving a continuous buried suture method to create a better cosmetic effect through the formation of a double eyelid and simultaneous correction of mild blepharoptosis. This modified procedure is simple, fast, and effective, with limited adverse effects.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of the Scar Prevention Effect Between a Carbon Dioxide Fractional Laser and a Continuous Ablative Carbon Dioxide Laser with a 595-nm Nd:YAG Laser

Abstract

Purpose

A linear surgical scar, when located in the head and neck region, can be a significant cosmetic concern. Laser skin resurfacing with a fractional laser and a pulsed dye laser has been proven to be useful for treating such scars. As alternatives, we used a classic ablative CO₂ laser in continuous mode with a 1-mm spot size and a 595-nm Nd:YAG laser. We investigated the effect of the combination of the continuous CO₂ laser and 595-nm Nd:YAG laser and compared it to the effect of fractional CO₂ laser monotherapy on linear scars.

Methods

This was a retrospective, case-controlled study designed to compare the efficacy between fractional CO₂ laser therapy and combination therapy with a conventional CO₂ laser in continuous mode and a 595-nm Nd:YAG laser. Treatment efficacy was evaluated by two different scar scales: the Stony Brook Scar Evaluation Scale (SBSES) and the modified Vancouver Scar Scale (mVSS). Laser treatments were performed every month until the 6th month after surgery.

Results

The SBSES and mVSS scores improved over time in both the monotherapy and the combination therapy (P < 0.001). No significant differences were found between the therapies for all the subcategories of the SBSES. However, among all the subcategories of the mVSS, pigmentation showed a better prognosis with combination therapy (P = 0.04).

Conclusion

Monotherapy and combination therapy can provide similar positive effects on linear scar improvement after repeated treatment, whereas combination therapy exerts more favorable anti-pigmentation effects than monotherapy. The combination of a continuous ablative CO₂ laser with a 595-nm Nd:YAG laser can be used as a favorable alternative to a fractional CO₂ laser. The 1-mm spot size of the CO₂ laser beam may mimic the fractional laser form and offer more effective results for linear incision scars.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Fat Necrosis After Autologous Fat Transfer (AFT) to Breast: Comparison of Low-Speed Centrifugation with Sedimentation

Abstract

Background

Despite the advantages of autologous fat transfer to the breast, there are many complications after the surgery, such as oil cysts, calcification and palpable breast nodules. The fat purification process is a key step to reduce those complications, but there is currently no standard processing method. This study was designed to compare the incidence of fat necrosis after autologous fat grafting to the breast with low-speed centrifugation and sedimentation.

Methods

This study analyzed 100 patients (167 breasts) who underwent autologous fat grafts to the breasts from January, 2015 to March, 2017. Patients were divided into two groups randomly, low-speed centrifugation (800 r/min) and sedimentation (15 min). Postoperative fat necrosis such as oil cysts and palpable breast nodules was measured using physical examination and breast ultrasound 3 months after the surgery. The number and the diameter of the fat necroses were detected.

Results

A total of 100 patients (167 breasts) were included this research. There were 21 breasts with clinically palpable nodules (12.57%); fifteen (19.48%) were in the low-speed centrifugation group and six (6.67%) were in the sedimentation group (p < 0.05). According to postoperative breast ultrasounds, there were 83 breasts with hypoechoic cyst formations (49.7%); forty-five (58.44%) in the low-speed centrifugation group and 38 (42.22%) in the sedimentation group (p < 0.05). A positive correlation between the number of operative sessions and fat necrosis was found out.

Conclusion

Although low-speed centrifugation could achieve higher fat purification efficacy when compared with sedimentation, it causes more fat necrosis than sedimentation, such as clinically palpable nodules and subclinical nodules, especially in patients who had a history of breast surgery and those who needed more than one fat grafting session.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Use of a Retromammary Adipofascial Flap in Breast Augmentation for Patients with Thin Soft Tissue

Abstract

Background

In patients with a thin soft tissue breast envelope, lower pole implant palpability is a postoperative sequela that concerns patients. Anatomically, the lower aspect of the breast near the inframammary fold lacks sufficient soft tissue to cover the breast implant after augmentation.

Methods

A transareolar incision was made, and subcutaneous dissection was performed. The dissection first proceeded caudally to the lower aspect to the breast parenchyma. The dissection then changed direction and moved cephalad to the mid breast or nipple region. The fatty tissue and pectoralis muscle fascia were cut transversely at this level, and the dissection was reversed caudally in a subfascial plane to the new inframammary fold region. This maneuver created a retromammary adipofascial flap.

Results

A total of 368 breast augmentations were performed in 184 patients. Breast implants were inserted in the subfascial plane in 40 patients (21.7%) and in the subpectoral–subfascial plane in 144 patients (78.3%). A total of 368 breast implants were inserted, including 140 smooth cohesive silicone implants (38.0%), 2 textured round implants (0.5%), and 226 anatomic-type implants (61.5%). A cadaveric dissection revealed that a retromammary adipofascial flap measuring 3–4 mm in thickness can be acquired. Capsular contracture occurred in six breasts (1.7%).

Conclusions

During breast augmentation, an inferiorly based retromammary adipofascial flap can be created to help cover the lower pole of the breast from implant palpability. This is helpful especially in patients with thin skin, hypoplastic breasts, or constricted breasts.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Measurement of Warping Angle in Human Rib Graft; Experimental Study

No abstract available

Reply to: “The addition of Platelet-rich Plasma to facial lipofilling A Double-Blind, Placebo-Controlled, Randomized Trial.”

No abstract available

“Impact of Chronic Steroid Use on Plastic Surgery Outcomes: Analysis of 94,140 Cases”

Background: Steroids, commonly used to treat many chronic conditions, have been proven to suppress inflammation, edema, autoimmunity, and delay wound healing. Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), this study aims to characterize the risk of perioperative chronic steroid use for complications in plastic surgery cases. Methods: A retrospective study was performed on 94,140 plastic surgery cases from the ACS NSQIP database for the years 2006-2015. Current procedural terminology codes were used to categorize the operations. Patients were separated into two cohorts based on chronic steroid use status. Univariate analysis was performed using χ2, Fisher's exact tests, or Wilcoxon rank sum tests. Logistic regression models were fitted to evaluate the association between chronic steroid use and postoperative complications. Total hospital length of stay was compared for cohorts. Odds ratios were computed at the 95% confidence interval. Results: Chronic steroid users were more likely to develop surgical complications (OR 1.3; p=0.0452) and medical complications (OR 1.8; p=0.0002) compared to non-steroid users. Among the ten most frequent procedures performed on chronic steroid users, steroid use was a significant risk factor for postoperative complications after reduction mammoplasty (OR 2.2; p=0.001); delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction (OR 2.2; p=0.049); and in trunk muscle, myocutaneous or fasciocutaneus flap (7.2; p=0.0029). Conclusion: With this information in hand, plastic surgeons will be better equipped to counsel patients and adequately design perioperative protocols for chronic steroid users. Financial Disclosure: Nothing to disclose. Presented at: None applicable Acknowledgement: We would like to thank Dr. Ari Rubenfeld and Julie Moore for their assistance and guidance with access to the ACS NSQIP database and their guidance with this project. DISCLAIMER: American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Corresponding Author: Matthew J Ranzer, MD, Assistant Professor of Surgery, University of Illinois at Chicago, Division of Plastic, Reconstructive, and Cosmetic Surgery, 820 S Wood St, Suite 515 CSN, Chicago, IL 60612 USA. Office: 312-996-9313 Fax: 312-413-0495, E-mail: ranzerm@uic.edu ©2018American Society of Plastic Surgeons

Preclinical experience using a new robotic system created for microsurgery

Background: Completing microsurgical anastomosis requires great technical skills. Robotic assistance in microsurgery can exceed the maximum human level of precision and manual dexterity to improve clinical outcomes. Since no robotic device has been designed primarily for microsurgery the authors developed a dedicated microsurgical robotic system (MSR). This preclinical study investigates whether microsurgical anastomosis can be successfully completed on silicone vessels using a prototype of this newly developed robotic system, and compares outcomes of robotic-assisted versus conventional anastomotic microsurgery. Methods: Three participants at different levels of microsurgical training completed ten anastomoses by hand and ten anastomoses with robotic assistance. Four blinded experienced microsurgeons evaluated the quality of the microsurgical skills using a modified version of the Structured Assessment of Microsurgical Skills (SAMS). Time to perform the anastomosis and adverse events were recorded. Results: The total time to perform the anastomoses with and without robotic assistance decreased to 35.1 minutes and 12.5 minutes respectively during the study. The overall performance and indicative skill of the SAMS improved during the conventional method (from respectively 2.8 to 3.6 and 2.6 to 3.7) and the robotic-assisted method (from respectively 2.3 to 3.0 and 2.3 to 3.1). Conclusions: It is feasible to complete anastomotic microsurgery on silicone vessels using the MSR. In comparison to the conventional method, time to perform the anastomosis was longer and quality of the microsurgical skills were lower in the robotic-assisted group. However, the robotic-assisted performance showed steeper learning curves (faster improvement) compared to the conventional performance for both surgical time and domains of microsurgical skills. The encouraging results indicate further development of the MSR and additional preclinical trials as step up towards clinical validation. FINANCIAL DISCLOSURE STATEMENT: Tom van Mulken has a financial disclosure, as he is Chief Medical Officer of the spin off company MicroSure: costs of travel and share in company. Rene van der Hulst has a financial disclosure as shareholder of MicroSure. Raimondo Cau has a financial disclosure, as he is Chief Technical Officer and shareholder of MicroSure. Ferry Schoenmakers is a software developer for MicroSure. The other authors have no financial disclosures. ACKNOWLEDGEMENTS: The four microsurgeons, forming the assessment panel, are gratefully acknowledged for their efforts. CORRESPONDING AUTHOR: Tom J.M. van Mulken, MD, Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands, Tel: (+31) 043-3875474; Fax: (+31) 043-3875473, Email: tom.van.mulken@mumc.nl ©2018American Society of Plastic Surgeons

Donor Site Morbidity and Functional Status Following Medial Femoral Condyle Flap Harvest

Background: The medial femoral condyle (MFC) free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor site morbidity and functional outcomes after flap harvest have not been fully appreciated. Herein, we report the postoperative outcomes and analyze the impact of increasing the size of the flap on the knee donor site morbidity. Methods: A retrospective chart review of patients who underwent MFC flap between 2001 and 2012 at our institution was done. The size of the flap was stratified, based on the largest dimension, into 3 groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure: the Lower Extremity Functional Scale (LEFS) questionnaire. A univariate logistic regression analysis was done, and results were analyzed. Results: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years (range: 14-72). Average follow-up time was 13 months postoperatively. Overall Complication rate was 18.6%. Donor site paresthesia in the saphenous nerve distribution was the most common complication. Increasing size of the flap did result in a significant elevation in complication risk (p<.05 a total of patients completed the lefs questionnaire. average score was scored points indicating normal level function on average. conclusions: mfc flap has overall acceptable donor site morbidity with good post-operatively. larger flaps are associated greater number complications. meetings at which paper partially presented: none financial disclosures: authors interest in any products devices or drugs mentioned this manuscript. corresponding author: brian t. carlsen md division plastic surgery department mayo clinic first street sw rochester minnesota usa. phone: fax: email: carlsen.brian society surgeons>

Introducing Knowledge Translation to Plastic Surgery: Turning Evidence into Practice

Best evidence has no bearing on quality of life if it is not implemented in clinical practice. We introduce knowledge translation as a theoretical framework for closing the gap between evidence and practice in plastic surgery. The current state of published evidence in plastic surgery is reviewed and evaluated, with the recommendation to utilize the EQUATOR network's guidelines for reporting clinical research findings. Tools and strategies are offered for the reader to understand and integrate evidence at the bedside. Systemic solutions are also proposed for the dissemination of best evidence to facilitate its translation into practice. Financial Disclosure: The authors have no financial conflicts of interest or sources of funding to declare. Correspondence: Dr. Achilleas Thoma, 101-206 James Street South Hamilton, ON, L8P 3A9,, Phone (905) 523-0019, Fax (905) 523-0229, Email: drathoma@cogeco.net ©2018American Society of Plastic Surgeons

“Increasing Diversity in Plastic Surgery”

No abstract available

Reply to “Lymphedema Quality of Life Score (LeQOLiS): A Simple Method for Evaluation of Subjective Symptoms in Extremity Lymphedema Patients”

No abstract available

An Intraoperative 3D Imaging System for Better Image Sharing and Protection of Reconstructive Surgeons’ Neck

No abstract available

Reply: Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap Clinical Experience with 28 Cases.

No abstract available

Commentary to “Targeting Reflux-free Vein Using Indocyanine Green Dye Angiography”

No abstract available

Reply: An Intraoperative 3D Imaging System for Better Image Sharing and Protection of Reconstructive Surgeons' Neck

No abstract available

Reply to the letter of Klinger et al. on our manuscript “Autologous Fat Injection vs. Lundborg´s Resection Arthroplasty for the Treatment of Trapeziometacarpal Joint Osteoarthritis”

No abstract available

Aesthetic Functional Surgery with ulnar artery perforator, an easier alternative to super-thin SCIP.

No abstract available