Mark J. Glasgold

Autologous Fat Grafting: Long-term Evidence of Its Efficacy in Midfacial Rejuvenation

OBJECTIVE To provide quantitative objective data demonstrating the longevity and amount of volume augmentation in the midface obtained with autologous fat grafting. METHODS A prospective analysis of all patients who underwent autologous fat transfer to the midface region at our private practice and were followed up for at least 1 year. Three-dimensional imaging was performed with a Canfield Scientific Vectra camera and software, with quantitative volume measurements evaluating the amount of postoperative volume change. RESULTS Thirty-three patients (66 hemiface-midface regions) were included in the study. The mean follow-up time was 16 months. The mean amount of autologous fat injected into each midface region was 10.1 mL. Overall, the mean absolute volume augmentation measured at their last postoperative visit was 3.3 mL (31.8% take). There was variability between patients in the volume amount and percentage that remained. Touch-up procedures were performed in 8 patients. CONCLUSIONS To our knowledge, this study is the first clinical quantification of autologous fat transfer and/or grafting in the literature that provides definitive evidence on the amount as well as the resultant longevity in the midface. Autologous fat transfer to the midface has definite long-term volume augmentation results. On average, approximately 32% of the injected volume remains at 16 months. However, some variability exists in the percentage of volume that remains that may require a touch-up procedure.

Volume loss versus gravity: new concepts in facial aging.

Purpose of reviewThe earliest techniques of facial rejuvenation have been continuously adapted to reflect changes in the understanding of the aging face. Significant, paradigm-shifting advances in this understanding have been made in recent years which have allowed application of specific therapeutic modalities, resulting in dramatically improved results over those achieved with traditional facial rejuvenation. Recent findingsPioneering work by several authors has shown that gravity is not the sole determinant of the aging face. These authors have demonstrated that volume loss, including that of soft tissue and bone, is at least equally important in the pathogenesis of the stigmata of aging. Rejuvenative techniques developed to reverse these atrophic changes have exhibited outstanding results. The consequence is an increasing emphasis on the use of volume restoration procedures to address the aging face. SummaryRecent improvements in the understanding of the facial aging process have brought about newly refined techniques for facial rejuvenation, ushering in a new era of plastic surgery for the aging face which is being manifested by increasingly natural results.

Quantitative evaluation of volume augmentation in the tear trough with a hyaluronic Acid-based filler: a three-dimensional analysis.

BACKGROUND Despite the prevalent use of hyaluronic acid-based filling materials for facial soft-tissue augmentation and favorable reports of durability in the infraorbital region, no quantitative data exist on the long-term durability of these products following injection. This study represents the first attempt to use three-dimensional imaging to quantify augmentation achieved and duration of effect with one hyaluronic acid product in the tear trough. METHODS The authors conducted a prospective, blinded case series in a clinical setting. One non-animal stabilized hyaluronic acid material was used to augment 20 tear troughs to address cosmetic deficiency in this region. Patients were followed long term with three-dimensional imaging. Posttreatment and pretreatment images were compared, volume change was calculated at each time point, and percentage change between immediate and long-term posttreatment was evaluated. All measurements and calculations were performed independent of the injector. RESULTS Residual effect from the hyaluronic acid product was demonstrable on three-dimensional imaging in 100 percent of tear troughs augmented in this study at the final follow-up visit. Average follow-up was 14.4 months (range, 8.5 to 22.75 months). Average initial augmentation measured by three-dimensional imaging was 0.21 cc per site. Average maintenance of effect for patients at the final follow-up visit was 85 percent. CONCLUSIONS The long-term durability of a small gel particle-based hyaluronic acid in the tear trough is substantiated for the first time in an objective, quantitative fashion using three-dimensional imaging for evaluation of volumetric facial rejuvenation. Three-dimensional photographic imaging offers clinicians a precise and expeditious method for quantitatively evaluating volumetric changes in the face, and represents a significant advance in technology for studying the effects of facial aging.

Mechanical Properties of Septai Cartilage Homografts

The compressive mechanical properties of untreated and chemically and physically treated nasal septum homografts were determined. Mechanical properties of control, saline-, thimerosal (Merthiolate)- and Alcide-treated specimens were similar. At high strains, the stiffness of treated cartilage ranged from 12.8 to 22.5 MPa and was unaffected by storage time. In comparison, irradiated and freeze-dried nasal septum exhibited stiffnesses of 35 and 37.5 MPa, respectively, after approximately 1 month of storage. These values of stiffness were significantly different from controls at a 0.95 confidence level. On the basis of these results, it was concluded that Alcide and Merthiolate treatment did not alter the compressive mechanical properties of cartilage and that a combination of these treatments may adequately sterilize and preserve nasal septum homografts.

Periorbital Fat Grafting

Contemporary esthetic facial rejuvenation has undergone a paradigm shift from what was once a primarily excision-based approach to one with an emphasis on volume preservation and augmentation. Nowhere on the face is this more evident than in the periorbital region. Fat grafting has become an accepted and pivotal component of volume augmentation strategies. Over the last decade, fat grafting has become not only a critical surgical adjunct, but also a primary stand-alone procedure to restore the youthful lower lid and its interface with the cheek. While this transition has been slower in regard to the upper lids, we are now seeing a similar progression in this area. Successful outcomes are dependent on a critical knowledge of periorbtial aging, establishing appropriate patient expectations, and on implementing a conservative approach as one gains increasing experience with the technique.

Fat harvesting techniques for facial fat transfer.

Fat grafting has become popular as a stand-alone technique or as part of a combined procedure for facial rejuvenation, as volume restoration has increasingly become recognized as an important component in overall facial aging. Many facial plastic surgeons who are experienced in operating only in the head and neck region are unaccustomed to working elsewhere in the body. Accordingly, this article sets out to detail the specific technique for safe and effective lipoharvesting for facial fat transfer. In addition, site-specific considerations for the lower abdomen, inner/anterior/outer thighs, triceps, inner knee, buttock, and lower back are also discussed.

Analysis of Facial Aesthetics as Applied to Injectables

Summary: Understanding the role of volume loss in the aging face has resulted in a paradigm shift in facial rejuvenation techniques. Injectable materials for volume restoration are among the most widespread cosmetic procedures performed. A new approach to the aesthetics of facial aging is necessary to allow the greatest improvement from volumetric techniques while maintaining natural appearing results. Examining the face in terms of facial frames and facial shadows provides the fundamental basis for our injectable analysis.

Introduction to volumetric facial rejuvenation.

The volumetric techniques of injectable fillers and autologous fat transfer are an important tool in the treatment of facial aging. Rapid widespread adoption has outpaced a sophisticated understanding of the goals of volume rejuvenation. The development of shadows and shadow patterns are the fundamental changes that occur with volumetric facial aging. A detailed examination of these shadows will lead to an understanding of how to apply volumetric techniques to create natural appearing results.

Upper Eyelid Volumization with Hyaluronic Acid

In the periorbital region, the growing appreciation for the role of volume in rejuvenation has been primarily focused on the lower eyelid. We believe the importance of volume in the appearance of a youthful upper eyelid is dramatically underappreciated and routinely incorporate volume-restoring techniques in our approach to the aging upper eye. Traditional treatment of the upper eyelid and brow focuses on a sculpted aesthetic that relies heavily on skin, muscle, and fat resection and surgical brow elevation. The result of this approach is a skeletonized appearance rather than a restored natural youthful look.

Midface sculpting with autologous fat.

There is currently a major paradigm shift from excision-based surgery to strictly volume enhancement. Because there is still no perfect facial filler, development of synthetic facial injectables continue to advance at a remarkable pace. Each type of filler carries a specific characteristic that makes it more suitable for a certain clinical application. The continuing change in facial fillers offers the possibility for volume augmentation procedures with less downtime and without the need for harvesting fat. We predict that volume enhancement will continue to play an increasing role as both a complementary and as a stand-alone procedure in facial rejuvenation.