206 Clinical procedures in laser skin rejuvenation Fig.18.1 Preoperative (a) and postoperative (b) photographs of a patient who underwent a deep plane facelift,lower lid transconjunctival blepharoplasty,and upper lid blepharoplasty,combined with fat transfer to superior and inferior orbital rim, midface,and prejowl sulcus. Fig.18.2 (a) This patient has a prominent-appearing eye following an aggressive isolated lower lid transconjunctival blepharoplasty.(b) An attractively framed eye following periobital and midface fat transfer.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:Complementary Fat Grafting.Philadelphia:Lippincott Williams & Wilkins;2007. ab a b 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 206 PREOPERATIVE CONSIDERATIONS Anatomy Periorbital volume restoration is of primary importance in creating an appropriately full frame around the eye. The most important component of the ‘frame’ is the inferior orbital rim. Reviewing photographs of models allows us to understand this aesthetic ideal.Variations in the upper periorbital frame exist, with the most com- mon appearance being a full brow with a few millime- ters of the upper lid skin visible (Fig. 18.3). Some very attractive individuals have relatively sculpted and hol- lowed brow/upper eyelid complexes, but uniformly every young beautiful face has a full lower eyelid that blends seamlessly with a full cheek. Again, review of an individual’s old photographs will help determine what is a natural appearance for the specific patient.As already mentioned, significant pseudoherniation of lower orbital fat will benefit from selective reduction via a transconjunctival blepharoplasty combined with con- current filling of the inferior orbital rim by autologous fat transfer. Similarly,a truly deflated and hanging upper eyelid would be best approached with conservative removal of redundant skin, with some degree of fat transfer into the brow (Fig. 18.4). The cheek is an extension of the lower frame of the eye and is a vital component of a youthul heart- shaped face.The cheek can be divided into anterior and lateral components. With advancing age, the anterior cheek, which develops the most significant volume loss along the malar septum, is a primary target for fat transfer. The lateral cheek, when restored, should reveal the lustrous highlight that is associated with a convex youthful shape (Fig. 18.5). Often, the buccal region must be volume-enhanced, as it becomes relatively hollow after augmentation of the malar region. However, care must be taken to avoid overfilling this area if the patient desires the more sculpted look that manifests in one’s 30s as opposed to the fuller oval shape of someone in their early 20s. Placement of fat into the precanine fossa and nasolabial fold is not so much intended to efface the linear depression but rather to provide an improved contour from the newly augmented cheek to the upper lip.We believe that any one of a number of avail- able dermal fillers is more useful for elimination of the nasolabial and labiomandibular folds. Similarly, lip augmentation with fat grafting only yields subtle results after considerable and protracted postoperative edema. Complementary fat grafting 207 Fig.18.3 A youthful face with an attractive periorbital frame.This young woman (who has not had surgery) demonstrates a full upper eyelid with only several millimeters of lid skin visible and a lower eyelid that transitions seamlessly into a full cheek. Reprinted with permission from Lam SM,Glasgold MJ, Glasgold RA.:Complementary Fat Grafting. Philadelphia:Lippincott Williams & Wilkins;2007. 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 207 Facial fat grafting of the lower face is centered on finishing the lower point of the triangle of a youthful countenance.Therefore, the focus of fat grafting along the lower face is concentrated in the prejowl sulcus, anterior chin, labiomental sulcus, and labiomandibular depression.Augmentation of the lateral mandible can- not be undertaken concurrently with a facelift due to undermining of the skin in this portion of the face. Patients with mild jowling or prejowl volume loss can achieve a very good restoration of the jawline with fat grafting alone. In contrast, we have found that it is dif- ficult to truly attain a straightened jawline with facial fat grafting alone in patients who have a heavy jowl and that, for optimal patient and surgeon satisfaction, a facelift should be incorporated for these patients. However, augmentation of the prejowl with fat graft- ing can enhance the result of any facelift, and is incor- porated into most of our rhytidectomies (Fig. 18.6). Consultation As with any cosmetic consultation, the ultimate goal is to establish aesthetic objectives for surgical and/or nonsurgical intervention mutually agreed between the surgeon and the prospective patient. Besides the stan- dard psychological, emotional, and aesthetic consider- ations that are part of every initial patient encounter, the surgeon must establish aesthetic goals, realistic expectations, and an understanding of the potential recovery period that relate specifically to fat grafting. These unique considerations will be elaborated in this section, and can be incorporated into the framework of a standard consultation. Often during the consultation, the patient must be refocused on what truly gives them an aging appear- ance.Women, in particular, focus on fine lines that typically achieve disproportionate importance when 208 Clinical procedures in laser skin rejuvenation Fig.18.4 Preoperative (a) and postoperative (b) photographs of a patient who underwent upper lid skin-only blepharoplasty, lower lid transconjunctival blepharoplasty,and periorbital and midface fat transfer. ab 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 208 Complementary fat grafting 209 Fig.18.5 Preoperative (a) and postoperative (b) photographs of a patient who underwent transconjunctival lower lid blepharoplasty and periorbital and midface fat transfer.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.: Complementary Fat Grafting.Philadelphia:Lippincott Williams & Wilkins;2007. Fig.18.6 (a) Patient following a facelift,with the appearance of persistent jowling.(b)Volume augmentation of the prejowl sulcus creates a straight jawline.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:Complementary Fat Grafting.Philadelphia:Lippincott Williams & Wilkins;2007. a b a b 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 209 viewed with a magnifying mirror and bright illumi- nation during makeup application.The consultation aims to recalibrate their thinking to evaluate their face the way other people see them from conversa- tional distances.Additionally, we point out that they primarily see themselves only in frontal view in a mirror, whereas in the real world they are usually seen at an oblique angle.To help the patient appreci- ate this, we will often take digital images of the patient and review these with them. Volume and shape are emphasized over fine wrinkles and minor cutaneous blemishes, which, to reiterate, are not truly ameliorated with facial fat grafting. Digital imaging of possible results plays a very limited role in the discussion of facial fat grafting. It is almost impossible to demonstrate the benefits of fat grafting with digital morphing analysis, since the technology is two-dimensional and the operative intervention is three-dimensional. Instead, use of a catalog of before-and-after photographs of patients whom the surgeon has taken care of is perhaps the most effec- tive way of demonstrating to the patient the benefits of fat grafting. Showing patients how they may look at 1 week, 2 weeks, 1 month, etc. after surgery provides the most useful information about potential recovery time. Most often, when an individual views other patients during this early recovery period, he or she may not perceive that they look very swollen, just better. However, it is important to emphasize that most of these patients were uncomfortable with the way they looked during the first 2–3 weeks following surgery. These psychological details are helpful to discuss with each patient in the preoperative setting. Use of old photographs can also be very enlightening both for the patient and for the surgeon.The patient should readily grasp the volume changes associated with aging, and the surgeon can better discuss with the patient what aesthetic changes will be most beneficial toward reestablishing a youthful appearance.As already stated, many women do not like the fullness, often referred to as ‘baby fat’, that is prevalent in their teens and early 20s, but prefer the relative sculpted (but not yet hollow) appearance of themselves in their late 20s to early 30s. OPERATIVE TECHNIQUE Donor harvesting For very thin individuals, it may be advisable to evalu- ate potential donor sites during a preoperative visit. Generally speaking, most patients will be able to inform the surgeon where they have abundant fat. For instance, men are predominately truncal-dominant, whereas women can either be truncal (abdomen/ waist) or extremity (inner or outer thigh) dominant. For very thin individuals or those who have undergone extensive prior body liposuctioning, the lower back and triceps may be ideal reserves that remain for har- vesting. Most commonly, the lower abdomen and inner thigh serve as excellent donor sites for fat harvesting if intraoperative patient repositioning is problematic. Before lower abdomen harvesting is undertaken, it is imperative to inquire what abdominal procedures the patient has had in the past and to evaluate the dis- tribution of abdominal scars. In order to ensure that the patient does not have an occult ventral or umbilical hernia, the surgeon should ask the patient to Valsalva in a supine position with his or her head elevated for optimal evaluation. Obviously, a hernia in the field of harvesting would preclude harvesting in that area. Many aesthetic surgeons who are uncomfortable with body harvesting express trepidation about uninten- tional violation of the visceral cavity during harvesting. This outcome is very unlikely, especially under con- scious sedation, given the thickness of the muscular fascia as well as the exquisite discomfort elicited when the fascia is even abraded with the harvesting cannula. For the inner thigh, the surgeon must ensure that the cannula passes through a superficial fascial layer before fat harvesting can commence. Superficial passage of the cannula is evident by the visibility of the cannula through the skin, which should be immediately cor- rected to avoid a potential contour deformity in the donor area. Although fat grafting can be undertaken with any level of anesthesia, we have found that intravenous sedation provides excellent pain control and patient compliance.After the patient is adequately sedated, 210 Clinical procedures in laser skin rejuvenation 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 210 the donor area is infiltrated with 0.25% lidocaine with 1:400000 epinephrine using a 20 cm 3 syringe outfit- ted with a 22-gauge spinal needle. (The mixture is attained by combining 5cm 3 of 1% lidocaine and 1:100000 epinephrine with 15 cm 3 of normal saline.) If the patient is under oral sedation, then a higher per- centage of lidocaine (0.5% lidocaine with 1:200000 epinephrine) should be used to improve patient com- fort. (The mixture is attained by combining 10cm 3 of 1% lidocaine and 1:100000 epinephrine with 10 cm 3 of normal saline.) When allocating the 20cm 3 of local anesthesia, the surgeon should aim to place 10 cm 3 in the deep aspect of the fat pad (immediately above the muscle/fascia) and 10cm 3 into the immediate subcutaneous plane, leaving the bulk of the fat pad untouched with anesthetic. After the patient has been sterilely prepped and draped, a 16-gauge Nokor needle (or No.11 Bard–Parker blade) is used to make a stab incision for entry of the harvesting cannula. For lower abdominal harvesting, the incision can be made inside the lower aspect of the umbilicus or suprapubically, and for the inner thigh, it can be made along the inguinal crease. Many different types of harvesting cannulas can be used.We prefer a 3 mm bullet-tipped cannula for har- vesting (Fig. 18.7). All harvesting is undertaken with a 10cm 3 syringe manually, i.e., without machine assis- tance, using only 1–2cm 3 of negative pressure on the plunger.A few technical pearls that can help the novice surgeon undertake harvesting easily and effectively should be enumerated. First, the surgeon should attempt to remain within the middle substance of the fat pad. Rippling of the skin with passage of the cannula indicates that the cannula is too superficial.The surgeon should always be cognizant of where the cannula tip resides, as the tip is the active end where fat enters. If the cannula tip abrades the deep fascia or goes beyond the anesthetized area, the patient can experience undue and unnecessary discomfort. As the surgeon continues harvesting, the cannula should be retracted almost back to the entry site before redirecting to the adjacent site. If the cannula tip is not withdrawn prior to directing it to an adjacent site to continue harvesting, the surgeon will effectively be harvesting in the same passage site, not in a new area.While harvesting, the nondominant hand should stabilize the fat pad,not squeeze or deform the donor area, to prevent uneven harvesting and potential donor-site contour deformity.When harvest- ing, the surgeon should recall that usable fat will be about one half the harvest volume, e.g., each 10 cm 3 syringe will yield approximately 5cm 3 of viable fat. Processing the fat The next step is processing the fat.The 10cm 3 syringes are placed in the centrifuge and spun for approximately 2–3 minutes at 2000 to 3000 rpm.This will sufficiently separate the unwanted blood, lidocaine, and lysed fat cells from viable fat cells. Before centrifugation, each 10cm 3 syringe must be outfitted with customized caps and plugs to ensure that the contents do not spill out during the centrifugation process. It is imperative not to use the prepackaged plastic caps that fit onto the Luer- Lok side, as they will invariably become detached dur- ing centrifugation. It should also be emphasized that the centrifuge should be able to accommodate either sterile individual sleeves that hold each syringe or, alterna- tively, an entire central rotary element that holds all of the syringes, which can be removed and sterilized. After the fat has been centrifuged, the supranatant (from the plunger side), consisting of lysed fat cells, is poured off. Only after removing the supranatant is the Luer-Lok cap removed and the infranatant drained. A noncut 4×4 gauze (or cotton neuropaddy) is placed into the plunger side, making contact with the column of fat in order to wick the remaining supranatant away. After 5–10 minutes, the column of fat is then poured from the open plunger side of the 10cm 3 syringes into the open plunger side of a 20cm 3 Luer-Lok syringe. The 20cm 3 syringe should not be filled beyond the 15cm 3 mark.When pouring the fat into the 20cm 3 syringe, the surgeon should attempt to keep any resid- ual bloody infranatant in the original 10 cm 3 syringe.A Luer-Lok transfer hub allows transfer of fat from the 20cm 3 syringe into 1cm 3 Luer-Lok syringes used for fat injection.The plunger on the 1cm 3 syringe should be drawn all the way until it is actually removed from the syringe while filling the syringe with fat, so as to eliminate the air bubble that typically resides between Complementary fat grafting 211 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 211 the plunger and the end of the fat column.The plunger is then returned to the 1.0cm 3 mark to maintain accurate volume counts. Fat infiltration The following general principles of technique will help to optimize results and minimize problems.The pri- mary principle behind safe fat grafting, particularly when learning the technique, is to ‘hit doubles’ rather than strive for a ‘home run’. Placing too much fat into any area, especially in the periorbital region, is very difficult to correct, whereas placement of additional fat can be easily and quickly undertaken in a second session (see ‘Management of complications’ below). Placement of fat is done only in small parcels (0.03–0.05cm 3 per pass for sensitive areas and 0.1cm 3 per pass in more forgiving zones) in order to attain optimal fat cell survival by allowing maximal contact of each particle with the surrounding tissue and neighboring blood supply.The use of blunt cannu- las (Fig. 18.7) (Tulip Medical Inc., San Diego, CA; Byron Medical Inc.,Tucson,AZ; Miller Medical Inc., Mesa, AZ) allows for less traumatic insertion of fat, resulting in less bruising and swelling.While injecting fat, the nondominant hand is used to palpate the underlying bony landmarks (to be discussed below) in order to guide the passage of the cannula in the correct depth and location. Finally, as the cannula tip cannot be visualized, the surgeon must mentally envision the depth of the tip during the procedure. We have divided the injection planes into three basic levels, which will be referred to throughout this section on infiltration technique, as deep (corresponding to the supraperiosteal level), medium (the musculofascial or deep subcutaneous level), and superficial (the superficial subcutaneous depth). Recipient site anesthesia The three skin entry sites (A: midcheek; B: lateral can- thal; and C: posterior to the prejowl sulcus) are infil- trated with 1% lidocaine with 1:100000 epinephrine (Fig. 18.8).Then, appropriate facial regional blocks are performed, usually including the infraorbital, zygo- maticotemporal, zygomaticofacial, and supraorbital nerves.An 18-gauge needle is used to create the three entry sites on each side of the face.The same infiltra- tion cannula intended for fat infiltration is used to inject local anesthesia (1% lidocaine with 1:100000 epinephrine) into the planned recipient sites in order to minimize tissue trauma. Inferior orbital rim The inferior orbital rim is the area that requires special attention in terms of both total volume placed and tech- nique. Fat grafting to the inferior orbital rim is done through an entry site on the cheek, which allows the fat to be deposited perpendicular to the bony orbital rim. In our experience, a lateral-based entry point in which the cannula is passed parallel to the orbital rim con- tributes to an unacceptably high incidence of fibrotic fat bulges. Generally speaking, for the beginning surgeon, we advocate placement of 1cm 3 of fat along the medial inferior orbital rim and 1 into the lateral inferior orbital rim.The fat is injected into the deep (supraperiosteal) plane.The nondominant index finger is used to palpate the rim to confirm the appropriate cannula depth and to guard against injury to the globe (Figure 18.9). As the cannula tip is passed perpendicularly across the inferior orbital rim (about 1mm in either direction), 0.05cm 3 of fat is layered per pass of the cannula.Additional fat 212 Clinical procedures in laser skin rejuvenation Fig.18.7 The Glasgold Fat Transfer Set (Tulip Medical Inc.): 0.9 mm ×4 cm blunt spoon-tip infiltration cannula; 1.2 mm ×6 cm blunt spoon-tip infiltration cannula; 2mm× 12 cm multiport harvesting cannula;3 mm× 15cm bullet-tip harvesting cannula.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.: Complementary Fat Grafting.Philadelphia:Lippincott Williams & Wilkins;2007. 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 212 can be placed for more volume-depleted patients at a medium depth. Fat infiltration superficial to the orbicu- laris oculi muscle is not recommended.The supramus- cular plane in this region has no added advantage, and has significant potential for contour irregularity.We rec- ommend being conservative with volumes in this area until the surgeon is comfortable with the technique. Even for the more experienced fat injector, we caution against exceeding 4cm 3 in the infraorbital rim at one setting in order to minimize problems. Superior orbital rim/brow The primary objective in filling the superior orbital rim is to re-establish a youthful appearing lateral brow convexity. Filling a markedly hollow upper eyelid sulcus is an advanced technique, lying beyond the scope of this chapter. Placement of fat along the superior orbital rim can be undertaken easily from a lateral entry point and rapidly filled using 0.1cm 3 per pass without difficulty or significant risk of contour deformity.The passage of the cannula should follow the plane of least resistance.The appearance of this area being overfilled may arise toward the end of augmentation – this should give rise to alarm, as it will settle over time. Generally, 2 cm 3 of fat begins to restore the deflated lateral-brow convexity. Nasojugal groove The nasojugal groove is the triangular depression out- lined superiorly by the medial inferior orbital rim and medially by the nasal sidewall. For the purposes of fat transfer, we make a distinction between the nasojugal groove and the tear trough.The latter is distinguished as the visible depression in the region of the medial orbital rim, which, depending on a patient’s particular anatomy, may or may not directly correlate with the bony nasojugal groove.The nasojugal groove is gener- ally filled with 1cm 3 of fat, which can be placed quickly with 0.1cm 3 per pass of the cannula. Anterior cheek The area of greatest volume loss in the anterior cheek is usually along a linear depression running from superomedial to inferolateral, corresponding to the malar septum.The anterior cheek is infiltrated from the lateral canthal entry point. As the cannula passes through the anterior cheek, it is common to feel resis- tance from the malar septum.The primary areas of fat deposition in the anterior cheek are along the malar septum and anteromedial to it. Caution should be taken to not overfill this region in men, as this may feminize the face. In general, 3 cm 3 of fat are injected, with 0.1cm 3 per pass.The surgeon should try to visu- alize the passage of the cannula from a deeper to a pro- gressively more superficial plane to distribute the fat cells more widely and thereby enhance the potential for adipocyte survival. The volumes used can be increased as needed for more volume-depleted patients. Anterior cheek volumes should be more conservative in males, where a fuller anterior cheek will tend to feminize the face. Complementary fat grafting 213 Fig.18.8 The three red marks correspond to the planned entry sites for fat injections:midcheek (A),lateral canthus (B),and posterior to the prejowl sulcus (C).The black marks indicate the areas for planned fat injections.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.: Complementary Fat Grafting.Philadelphia:Lippincott Williams & Wilkins;2007. 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 213 Lateral cheek The lateral cheek highlight is a very important youthful landmark to restore. Approached from the midcheek entry point, the area overlying the lateral zygoma is augmented with 2–3cm 3 of fat.The injection can be tapered into the submalar region as needed.The tech- nique of gradual progression from a deep to a superfi- cial plane and placement of 0.1cm 3 per pass is the same as that described for anterior cheek augmentation. Buccal Many women find the slight hollow of the buccal region that arises in their early 30s to be attractive by creating a more sculpted appearance. Progressive buccal volume loss will lend the appearance of poor health, and in women can also be masculinizing. During a fat augmentation procedure, the addition of volume to the cheeks may create a relative buccal hol- lowing, which should be addressed.The buccal area can be approached from multiple entry sites, including the midcheek or lateral canthal entry sites; alterna- tively, a separate lateral commissure entry site can be made for buccal access. Filling can progress rapidly as above, with 0.1cm 3 per pass in every tissue plane.The buccal area can sustain significant volume enhance- ment without deformity, e.g., 3–8cm 3 per side. Precanine fossa/nasolabial fold As mentioned above, the objective of filling the pre- canine fossa (the bony triangular depression deep to the superior limit of the nasolabial fold and adjacent to the nasal ala) and the nasolabial fold is not to elimi- nate the fold but to provide improved transition from the augmented cheek to the augmented upper lip.The patient should be cognizant of this limitation so that realistic expectations are established preoperatively. The precanine fossa is infiltrated in the deep supra- periosteal plane with approximately 2cm 3 of fat.The nasolabial fold can be augmented with 2–3cm 3 of fat along multiple levels using 0.1cm 3 per pass without significant risk of deformity.These areas are addressed from the midcheek entry point so the cannula will pass perpendicular to the nasolabial fold. Prejowl sulcus/anterior chin/labiomental sulcus/labiomandibular fold The prejowl sulcus is perhaps the most important area in the lower face to address with autologous fat trans- fer. Placement of fat along the prejowl sulcus will not 214 Clinical procedures in laser skin rejuvenation Fig.18.9 Fat injection of the inferior orbital rim. (a) Demonstration of how placement of the index finger of the nondominant hand is used to protect the globe and give tactile feedback as to the cannula position.(b) Intraoperative demonstration of the vector for approaching the inferior orbital rim in a perpendicular orientation from the midcheek entry site.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:Complementary Fat Grafting. Philadelphia:Lippincott Williams & Wilkins;2007. a b 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 214 completely straighten a jawline that exhibits moderate to marked jowling, but will significantly enhance any facelift result.The prejowl sulcus should be thought of as a three-dimensional cylinder that runs along the anterior and inferior borders of the mandible. Generally, 3 cm 3 of fat are placed using 0.1cm 3 per pass from an entry site just posterior to the prejowl sulcus, typically about midway along the mandibular body.The first 1cm 3 is placed deeply along the anterior madibu- lar border.The second 1cm 3 is placed deeply along the inferior mandibular border, and the third 1cm 3 is placed at a medium-depth to transition between the two. In patients with a deeper sulcus, larger volumes will be needed to obtain the desired result.Additional fat can be feathered into the anterior chin, labiomental sulcus, and labiomandibular fold as needed. It is impor- tant to emphasize that the degree of variable resorption of fat in the anterior chin leads to less predictable results in terms of chin projection than can be achieved with an implant.Therefore, when the primary goal is anterior chin projection, an alloplastic chin implant is our preferred treatment option. Nevertheless, fat transfer to the anterior chin/mental sulcus region can accentuate the beauty of a youthful face by restoring the inferior apex of the ideal heart shape previously discussed. POSTOPERATIVE CONSIDERATIONS Postoperative care At the end of the procedure, the patient does not require any dressings, bandages, drains, or suture clo- sures for the body or for the face. Icing of all recipient sites will help mitigate postoperative edema.After the first 48–72 hours, the patient may ice the recipient areas as they would like. Sleeping with the head elevated for the first several days may also aid in reduc- tion of edema. Reducing dietary for the first several weeks after surgery may also lessen edema.The patient should refrain from strenuous activity so as not to exacerbate and prolong edema unnecessarily. The patient can return to a modified exercise regimen after the first week and should slowly progress toward a full, standard program, verifying all the while that edema does not worsen with that activity.There are no restrictions on activity for harvested areas, except for not submerging the incisions for a week. Postoperatively, patients often complain of a dull ache and soreness in the donor areas that exceeds any dis- comfort felt in their face. However, there may be some degree of tenderness and tightness in the face, particu- larly in the malar region. Occasionally,patients can feel a flush sensation in the malar area during the first post- operative week, which can be ameliorated with icing. Ecchymosis and edema are most pronounced over the first two postoperative weeks. During the first week, the patient may appear grossly disfigured, which will be proportionate to the amount of fat transferred and the number and extent of concurrent rejuvenation procedures. Ongoing changes will be evident postop- eratively for several months, and it should be empha- sized to the patient that what he or she is seeing is normal and expected due to the dissipation of edema. Educating patients preoperatively and reviewing the expected changes postoperatively are helpful for the patient to have the appropriate understanding of the changes they are seeing as swelling subsides. Management of complications The area most susceptible to complications is the peri- orbital region.The conservative policy of fat enhance- ment (‘hitting doubles’) previously outlined should be followed so as to minimize the occurrence of prob- lems. In order to correct a complication, the surgeon must correctly identify the problem.This section will outline the unique types of problems that occur with fat grafting and how to treat each specific entity.The types of complications can be classified as follows: lumps, bulges, overcorrection, and undercorrection. Lumps A lump is a soft discrete contour deformity that arises when too much fat is transplanted to a specific locus or placed in an imprecise fashion.Although steroid injec- tions have been attempted to manage this problem, they are generally not very effective. An incision with direct removal of the offending lump often must be undertaken.Although uncommon, visible lumps are most apt to occur along the inferior orbital rim. If a lump from the region of the lower lid is to be Complementary fat grafting 215 18 Carniol-8028.qxd 8/23/2007 10:36 AM Page 215 [...]... additional uses 106 –7 side-effects and limitations 106 treatment parameters 104 –5, 105 MultiClear system 142, 142 mupricin, nasal 20 Mydon laser 167 Nd:YAG lasers hazards 5 in leg telangiectasia 159–62, 166–7, 170 in lipolysis 147 Q-switched, in solar lentigines 112–13 in skin tightening 150–1 near-infrared skin tightening 107 –9 background 107 –8 clinical effects 108 –9 future directions 109 side-effects and... keloid scarring 41, 99, 187 Kenalog 25 keratosis actinic 17, 42 seborrheic 17, 39, 40, 42 ketorolac 20 krypton laser in solar lentigines 114 KTP lasers 76 hazards 5 in acne scarring 94 in acne vularis 75–6 in leg telangiectasia 159–62 in poikiloderma of civatte 120 in skin tighening 151 laser- assisted skin rejuvenation (LASR) 32, 41 laser- generated electromagnetic interference 5 laser history 45 laser plume... Page 222 Index Q-switched alexandrite laser in solar lentigines 113–14 Q-switched lasers in acne scarring 95 in solar lentigines 112–14 Q-switched Nd:YAG laser (QSNd:YAG laser) in solar lentigines 112–13 Q-switched ruby laser (QSRL) in solar lentigines 112–13 Quantel Medical Multipulse mode 169–70 Radiesse 97, 186, 195, 197, 198, 198, 199 ReFirme in skin tightening 152, 152 regulations 2 Reloxin 181... for acne scarring 97–8 skin cancer 173 skin rejuvenation, modalities 31–2 skin rolling or needling in acne scarring 95 skin tightening 148–52 infrared light-based 65, 65, 151, 152 Nd:YAG laser 150–1 nonablative rejuvenation 62–5, 63, 149 radiofrequency-based 62–5, 63, 64, 149–50, 150 smallpox 31 SmartEpilII laser 167 SmoothBeam 61 soft tissue fillers droplet technique 188 linear threading 188 serial... limitations 109 treatment parameters 108 neck resurfacing 26–7 Nexgen pixel 36 Nlite System pulsed dye laser 61, 76 nominal hazard zone (NHZ) 5 nonablative skin resurfacing 51 vs ablative skin resurfacing 51–2 in acne scarring 91–2, 94–5 long-wavelength lasers and light sources for collagen stimulation 59–62 for photorejuvenation 52–62 skin tightening 62–5, 63, 64, 65 see also photodynamic therapy non-beam-related... gel 25 meperidine 20 mequinol 112 methicillin-resistant Stapylococcus aureus (MRSA) 20 microablative skin resurfacing 51–2 microdermabrasion in acne scarring 94 in striae distensae 140 microlaser peels 116 microscopic treatment zones (MTZs) 143 microthermal zones (MTZs) 52 midazolam 20 milia formation 22 monopolar radiofrequency skin tightening 104 –7, 105 background 104 clinical effects 105 –6 newer applications... and 149–50 Thermage 196, 201, 202 Titan (Cutera) 103 , 107 –8, 109 tobacco smoking 19–20 training in safety 9 tretinoin, topical, preoperative 19 TriActive laser in cellulite 145 in lipolysis 147 trichoepitheliomas 17 trypsin epidermal grafting in acne scarring 97 Tummy by Thermage treatment 107 UltraPulse carbon dioxide laser 17, 20 UltraShape System Ltd in lipolysis 147 Ultrasoft 187, 188 V Beam 25 valacyclovir... (KTP) lasers see KTP lasers pregnancy, striae distensae in 140 Profile laser 167 Propionibacterium acnes 69, 71–7 see also acne scarring; acne vulgaris Pseudomonas aeruginosa 22 psoriasis 18 pulsed-dye laser in acne scarring 94 in acne vulgaris 76–7 in leg telangiectasia 140–1 in photorejuvenation 53–5, 55, 57, 60 in poikiloderma of civatte 120, 121 Putrtox 181 221 Index Carniol-8028.qxd 222 8/23/2007 10: 36... 80–1 infections 22 causative agents 22 informed consent 49 insurance 3–4 intense pulsed light (IPL) systems 23 in acne scarring 94 in acne vulgaris 79 in dermatoheliosis 119 in photorejuvenation 57, 60 in solar lentigines 114 in striae distensae 140–1 interferon therapy 129 Isolagen 186 isotretinon 41–2 Jessner’s peel 23, 26 in acne scarring 93 Joint Commission (Joint Commission on Accreditation of Healthcare... nonsurgical tightening 103 –9 monopolar radiofrequency 104 –7, 105 near-infrared skin tightening 107 –9 NSAIDS 22 Oasis 186 Occupational Safety and Health Administration (OSHA) 2 optical radiation hazard 4 pacemakers 6 PASS mnemonic 8 pathophysiology of aging 12 Pearl fractional laser 27 perifollicular hypopigmentation of acne scars 97 perioral region in aging face 16 periorbital region in aging face 16 Perlane . acne scarring 97–8 skin cancer 173 skin rejuvenation, modalities 31–2 skin rolling or needling in acne scarring 95 skin tightening 148–52 infrared light-based 65, 65, 151, 152 Nd:YAG laser 150–1 nonablative. 221 Q-switched alexandrite laser in solar lentigines 113–14 Q-switched lasers in acne scarring 95 in solar lentigines 112–14 Q-switched Nd:YAG laser (QSNd:YAG laser) in solar lentigines 112–13 Q-switched. vularis 75–6 in leg telangiectasia 159–62 in poikiloderma of civatte 120 in skin tighening 151 laser- assisted skin rejuvenation (LASR) 32, 41 laser- generated electromagnetic interference 5 laser history