Applications of the classic dermal fat graft in primary and secondary facial rejuvenation

Volumetric facial aging occurs primarily as a descent of facial soft tissues, followed by their secondary atrophy. Proper volumetric facial rejuvenation, therefore, demands effective superior redistribution of fallen soft tissues, for which the author prefers malar imbrication. Only then do augmentative adjustments become appropriate, including solid facial protheses, "soft-tissue" fillers, dermal fat grafts, free-fat micrografts, and Erol's "tissue-cocktail." Of these, the author prefers the time-honored dermal fat graft for all primary volumetric augmentations within the surgical field, reserving free-fat micrografts for adjustments outside the field and those performed secondarily. Dermal fat grafts are added to the face in three categories: "camouflage" grafts from the anterior face lift discard specimen to correct contour irregularities in the sculpted subcutaneous cheek in half of patients; "transition" grafts from the suprapubic abdomen to the zone between the midface and lower face in 5 percent of patients with an emaciated quality to their aging; and "secondary" grafts from the abdomen in occasional patients with volumetric deformities following inexpert face lift and other forms of trauma. All grafts were harvested, prepared, and placed according to 10 straightforward technical principles. The grafts were highly effective and predictable in their ability to augment contour; none of 283 total grafts were regarded as a treatment failure. The use of such grafts was extremely safe, with complications limited to cyst formation in 1.5 percent of grafts, all of which were treated nonoperatively. The use of the dermal fat graft is seen as safe, effective, and convenient when the subcutaneous plane of the face is exposed during facial rejuvenation. The majority of grafts were derived from the face lift discard specimen. Although those that came from outside the head and neck presented extra inconvenience and operative time, their use was limited to occasional and challenging circumstances that justified extra investment.     

The anatomy and clinical applications of the buccal fat pad

The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.     

The behavior of fat grafts in recipient areas with enhanced vascularity

Fat grafts are used for soft-tissue augmentation of various anatomic regions, most frequently for the improvement of facial contours. Resorption of the graft is the main problem, and several different procedures have been described to minimize this phenomenon. Using 25 New Zealand rabbits, the behavior of fat grafts in a highly vascularized recipient site was studied. The recipient sites prepared on the backs of the rabbits were divided into four regions. A capsule formation with silicone sheet application was accomplished in two of these recipient areas before the transplantation of the fat grafts. Fat grafts were placed in the other two recipient areas without any prior preparation. We prepared two types of fat tissue; in one the lobular structure was preserved and in the other it was manually crushed and rinsed with lactated Ringer's solution. The fat tissues with preserved lobular structure were placed in area I and area III. Manually crushed and rinsed fat tissues were placed in area II and area IV. In areas III and IV, a capsule formation with silicone sheet had been accomplished 3 weeks before grafting. Biopsy samples were obtained from these sites at the end of the first, third, sixth, and tenth months. Our aim was to observe the histologic fate of fat tissue in different recipient areas. The macroscopic and microscopic evaluation of the fat grafts in areas with silicone sheet indicated significant differences in the resorption time of the fat grafts; however, it was concluded that the significant resorption of the transplanted autologous fat tissue grafts at the end of the first year was an inevitable consequence of fat grafting.     

Treatment of human immunodeficiency virus-associated lipodystrophy with dermafat graft transfer to the malar area

Acquired immunodeficiency syndrome, a death sentence two decades ago, has been transformed into a chronic disease with a life expectancy of many years, due to the advent of highly active antiretroviral therapy. Despite virologic success, nearly 50 percent of patients on highly active antiretroviral therapy develop lipodystrophy with central and visceral fat accumulation and/or facial and limb fat atrophy. The changes are referred to as the human immunodeficiency virus lipodystrophy syndrome. The authors describe a series of five patients with antiretroviral therapy-induced lipodystrophy of the face who benefited from surgical correction of their typical stigmatizing malar atrophy. Dermafat grafts were transferred from the abdominal wall to malar pockets through a transoral approach. The aesthetic results were dramatic and stable, lasting the duration of the 1- to 2-year follow-up period.     

Facial attractiveness is related to women's cortisol and body fat,but not with immune responsiveness

Recent studies suggest that facial attractiveness indicates immune responsiveness in men and that this relationship is moderated by stress hormones which interact with testosterone levels. However, studies testing whether facial attractiveness in women signals their immune responsiveness are lacking. Here, we photographed young Latvian women, vaccinated them against hepatitis B and measured the amount of specific antibodies produced, cortisol levels and percentage body fat. Latvian men rated the attractiveness of the women''s faces. Interestingly, in women, immune responsiveness (amount of antibodies produced) did not predict facial attractiveness. Instead, plasma cortisol level was negatively associated with attractiveness, indicating that stressed women look less attractive. Fat percentage was curvilinearly associated with facial attractiveness, indicating that being too thin or too fat reduces attractiveness. Our study suggests that in contrast to men, facial attractiveness in women does not indicate immune responsiveness against hepatitis B, but is associated with two other aspects of long-term health and fertility: circulating levels of the stress hormone cortisol and percentage body fat.     

The lumbrical fat graft: a replacement for lost upper eyelid fat

Human eyelids seem to age earlier and more rapidly than do other regions of the face, making blepharoplasty (either age or familially indicated) an operation often performed earlier than other remedial procedures for facial aging. The traditional and more doctrinaire approach to upper blepharoplasty in which fat and orbicularis muscle are excised has led to a type of iatrogenia that often leaves the upper (and lower) eyelids hollowed and vacant, before their time. The notion of upper blepharoplasty as a simple operation is, therefore, to be questioned. The idea of normal and obligatory asymmetry as a key to recognizability is brought into relief when contemplating blepharoplasty. In questioning the judgments by which upper palpebral fat (and orbicularis muscle) is excised, the author suggests both a remedy-the lumbrical fat graft-and the need for a heightened awareness of the synergy such excisions make with the age-related palpebral fat atrophies. This is a report of 35 cases (70 eyelids), over a 24-month period, during which the current technique was used. The technique is relatively simple, the anatomy well known, the learning slope shallow, the results gratifying, and the complications and problems few and benign.     

Free-fat injections for the correction of hemifacial atrophy

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.     

Facial contour restoration in Barraquer-Simons syndrome using two free anterolateral thigh flaps

Barraquer-Simons syndrome, or cephalothoracic lipodystrophy, is characterized by fat atrophy of an obscure pathogenesis involving the face and, eventually, the thoracic region. Simultaneously, fat hypertrophy of the lower extremities, a nephropathy, and complement anomalies may be observed. We presented two patients with the typical features of this disease, as well as a previously undescribed vascular and perivascular inflammation of the facial arteries and veins that caused problems with microvascular anastomosis. Both patients were treated with a bilateral transfer of the anterolateral thigh flap, which has not been reported previously. In contrast to other transfers previously reported, the fat tissue of this flap is never affected by the disease and is redundantly present. Placing the fascia of the flaps toward the skin allows for strong fixation to the temporal region and guarantees a stable result with a smooth facial contour.     

Importance of neural input and thyroid hormones in the control of brown fat atrophy in mice

In euthyroid mice, a 48-h fast caused brown fat (BAT) atrophy characterized by loss of tissue proteins, succinate dehydrogenase (SDH), and a significant reduction in mitochondrial uncoupling protein (UCP) content. Chemical sympathectomy and surgical denervation failed to mimic the changes in BAT protein and SDH contents observed after food deprivation. However, suppression of sympathetic activity could account for the loss of UCP from the mitochondria. In mice made hyperthyroid by repeated triiodothyronine injections, losses of tissue SDH and proteins caused by food deprivation or surgical denervation were markedly suppressed, while the loss of UCP from the mitochondria remained unchanged. These results suggest that reduced sympathetic activity to BAT in fasted mice is not the exclusive cause of the tissue atrophy and that thyroid hormones may play a role in the control of brown fat atrophy in mice.     

Microscopic fat cell size measurements on frozen-cut adipose tissue in comparison with automatic determinations of osmium-fixed fat cells

Diameters of fat cells in adipose tissue slices, floating in an isoosmolar solution, were measured under a microscope. The slices were obtained from percutaneous biopsies by freeze-cutting after brief formaldehyde fixation. All cells in a given part of the slice were measured, thus avoiding selection. A normal distribution of fat cell diameters could be demonstrated with this method, as has been found with previously described methods. The error of the method was 2.6% for diameter and 8.0% for weight determinations. Storage of adipose tissue at 4 degrees C for 48 hr had no effects on cell size determinations. Results with this microscopic method were compared with those obtained from a previously described method for automatic determinations of osmium-fixed fat cells. The latter method was slightly modified by using a viscous electrolyte, which prevented sedimentation of large fat cells, and by using sonication to complete cell separation. The methods agreed closely. A method for calculating mean fat cell weight using osmium-fixed fat cells is described, which makes determinations of sample wet weight and ratio of lipid to wet weight unnecessary.     

Subcutaneous fat modulates insulin sensitivity in mice by regulating TNF-alpha expression in visceral fat.

The distribution of fat in obese persons is related to the risk of developing various metabolic disorders, such as glucose intolerance, dyslipidemia and hypertension, and the combination of these conditions is known as the metabolic syndrome. The aim of this study was to investigate the role of subcutaneous fat in regulating insulin resistance and its influence on TNF-alpha expression in visceral fat, by using mice that were subjected to subcutaneous lipectomy with or without subsequent fat transplantation. After partial subcutaneous lipectomy, mice showed significantly greater accumulation of visceral fat compared with sham-operated control mice. Lipectomy led to higher plasma insulin and lower plasma glucose levels after loading with glucose and insulin, respectively, compared with the levels in control mice. Insulin-induced phosphorylation of IRS-1 was decreased in the skeletal muscles of lipectomized mice. Subcutaneous transplantation of fat pads into lipectomized mice reversed the above-mentioned changes indicating insulin resistance in these animals. The fat storage area of adipocytes and TNF- alpha expression by adipocytes in visceral fat were significantly higher in the lipectomized mice than in controls, while subcutaneous transplantation of fat reduced both the fat storage area and TNF-alpha expression. The insulin resistance of lipectomized mice was also ameliorated by systemic neutralization of TNF-alpha activity using a specific antibody. These findings obtained in mice subjected to subcutaneous lipectomy with/without subsequent fat transplantation indicate that subcutaneous fat regulates systemic insulin sensitivity, possibly through altering fat storage and the expression of TNF-alpha by adipocytes in visceral fat. The balance between accumulation of subcutaneous fat and visceral fat may be important with respect to the occurrence of systemic insulin resistance in the metabolic syndrome.     

Substituting dietary polyunsaturated fat with monounsaturated fat increases insulin sensitivity in cultured rat hepatocytes

Increased dietary fat intake generally, and saturated fat specifically, will lead to impairment of insulin action and to development of metabolic syndrome. The aim of this study was to find out changing of hepatic glucose output in dependence of high monounsaturated and high polyunsaturated fat diet and possible direct action of insulin in hepatocytes. Hepatocytes were isolated by a collagenase perfusion technique and cultured for 24 h in M 199 serum-free medium. The glucose production in hepatocytes isolated from rats on high polyunsaturated fat diet, as well as those isolated from rats on high monounsaturated fat diet was significantly higher than in standard controls. Insulin significantly decreased glucose production but only in hepatocytes obtained from rats on high monounsaturated fat diet. On the other side energy expenditure was significantly higher in rats on high monounsaturated fat diet and significantly lower in rats on high polyunsaturated fat diet comparable with animals on standard diet. Monounsaturated fat in Mediterranean diet could have beneficial effect on the development of the metabolic syndrome by increasing insulin sensitivity and energy expenditure.     

Glucose metabolism by isolated fat cells from sloth.

Glucose metabolism by sloth fat cells with and without addition of insulin was investigated. The data were compared to the results obtained with rat fat cells incubated under the same experimental conditions. Sloth fat cells showed a very low glucose oxidation to 14CO2 and incorporation into total lipids. The glucose incorporated into lipids is mainly in the glyceride-glycerol moiety. Addition of insulin did not produce an increase on glucose oxidation and a slight increase in the incorporation into total lipids was observed. Since it has been reported that sloths have a very low rate on thyroxine secretion, the results are discussed in relation to data in the literature on carbohydrate and lipid metabolism in hypothyroid animals.     

Overgrowth of fat autotransplanted for correction of localized steroid-induced atrophy

A case is presented in which regional subcutaneous atrophy in the lateral thigh after steroid injection was treated with autologous fat grafting. More than 1 year after treatment, an increase in the volume of the transplanted site necessitated a secondary procedure to debulk the area. We believe that this is a case in which the transplanted adipocytes (or preadipocytes) survived and subsequently (for an unclear reason) increased significantly in volume. This case report supports the cell survival theory of fat autotransplantation. Animal studies using radioisotope-labeled lipocytes might provide further understanding of the mechanisms of fat graft "survival."     

Curette fat sculpture in rhytidectomy: improving the nasolabial and labiomandibular folds

The nasolabial and labiomandibular folds develop with facial aging by an anterior caudal descent of the fat prominences of the same name. Young patients with minimal folding can be corrected by substances inserted in the fold; however, this and other techniques have failed satisfactorily to improve the folds naturally and permanently. Identification of the prominences and removal of the fat superficial to the skin by curettes have proven safe and effective and superior to fat suction. Complications include small hematomas and visible depressions in the sculpted areas. There was no nerve or skin injury. Follow-up of this technique (an improvement of a previous technique) is 3 1/2 years.     

The evolution of the midface lift in aesthetic plastic surgery

The midface lift has recently gained significant popularity with many surgeons. It allows the surgeon an opportunity to achieve greater facial harmony with facial rejuvenation procedures by correcting midfacial atrophy, addressing the tear trough deformity, and correcting the perceived malposition of the malar fat pad. This article examines the history of midfacial procedures. Surgical attempts at improving the aging face have evolved from minimal excisions and skin closure to aggressive dissections at multiple planes. The midface target area is peripheral to classic approaches, and its correction has required further anterior dissection from a distance or direct access centrally. Ultimately, conquering the stigmata of midface aging is entirely related to vectors and volume.     

Of bears, frogs, meat, mice and men: complexity of factors affecting skeletal muscle mass and fat

Extreme loss of skeletal muscle mass (atrophy) occurs in human muscles that are not used. In striking contrast, skeletal muscles do not rapidly waste away in hibernating mammals such as bears, or aestivating frogs, subjected to many months of inactivity and starvation. What factors regulate skeletal muscle mass and what mechanisms protect against muscle atrophy in some species? Severe atrophy also occurs with ageing and there is much clinical interest in reducing such loss of muscle mass and strength (sarcopenia). In the meat industry, a key aim is optimizing the control of skeletal muscle growth and meat quality. The impaired response of muscle to insulin resulting in diabetes, that is a consequence of the metabolic impact of increasing obesity and fat deposition in humans, is also of increasing clinical concern. Intensive research in these fields, combined with mouse models, is reviewed with respect to the molecular control of muscle growth (myogenesis) and atrophy/hypertrophy and fat deposition (adipogenesis) in skeletal muscle, with a focus on IGF‐1/insulin signaling. BioEssays 28: 994–1009, 2006. © 2006 Wiley Periodicals, Inc.     

Rejuvenation of the midface by elevating the malar fat pad: review of technique,cases, and complications

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.     

Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat

The mechanisms of posttraumatic enophthalmos were evaluated to determine the interrelation between fat and ligaments in globe support. Anatomic studies demonstrate that the ligaments form an essential "sling" framework for the globe but are alone insufficient to maintain the globe's full forward position. Removal of extramuscular fat in cadavers and in patients undergoing blepharoplasty did not significantly change globe position. Loss of intramuscular cone fat (atrophy or displacement) in cadavers and patients produced enophthalmos. Fat atrophy is not a prominent feature in most patients with posttraumatic enophthalmos. Some loss of intramuscular cone fat from displacement outside the muscle cone is frequently present. The principal mechanism, however, of posttraumatic enophthalmos involves a displacement and change in the shape of orbital soft tissue. Loss of bone and ligament support permits posterior displacement and a reshaping of orbital soft tissue under the influence of gravity and the remodeling forces of fibrous scar contracture. The shape of the retrobulbar orbital contents changes from a modified cone to a sphere, and the globe sinks backward and downward. Given that the volume of orbital soft tissue is constant following trauma, procedures to restore the shape and position of the orbital soft tissue by mobilization and bone reconstruction will correct or significantly improve enophthalmos.