Effects of Hyperbaric Oxygen at 1.25 Atmospheres Absolute with Normal Air on Macrophage Number and Infiltration during Rat Skeletal Muscle Regeneration

Use of mild hyperbaric oxygen less than 2 atmospheres absolute (2026.54 hPa) with normal air is emerging as a common complementary treatment for severe muscle injury. Although hyperbaric oxygen at over 2 atmospheres absolute with 100% O₂ promotes healing of skeletal muscle injury, it is not clear whether mild hyperbaric oxygen is equally effective. The purpose of the present study was to investigate the impact of hyperbaric oxygen at 1.25 atmospheres absolute (1266.59 hPa) with normal air on muscle regeneration. The tibialis anterior muscle of male Wistar rats was injured by injection of bupivacaine hydrochloride, and rats were randomly assigned to a hyperbaric oxygen experimental group or to a non-hyperbaric oxygen control group. Immediately after the injection, rats were exposed to hyperbaric oxygen, and the treatment was continued for 28 days. The cross-sectional area of centrally nucleated muscle fibers was significantly larger in rats exposed to hyperbaric oxygen than in controls 5 and 7 days after injury. The number of CD68- or CD68- and CD206-positive cells was significantly higher in rats exposed to hyperbaric oxygen than in controls 24 h after injury. Additionally, tumor necrosis factor-α and interleukin-10 mRNA expression levels were significantly higher in rats exposed to hyperbaric oxygen than in controls 24 h after injury. The number of Pax7- and MyoD- or MyoD- and myogenin-positive nuclei per mm² and the expression levels of these proteins were significantly higher in rats exposed to hyperbaric oxygen than in controls 5 days after injury. These results suggest that mild hyperbaric oxygen promotes skeletal muscle regeneration in the early phase after injury, possibly due to reduced hypoxic conditions leading to accelerated macrophage infiltration and phenotype transition. In conclusion, mild hyperbaric oxygen less than 2 atmospheres absolute with normal air is an appropriate support therapy for severe muscle injuries.     

The effect of interleukin-8 on the viability of injected adipose tissue in nude mice

Adipose tissue injection as a free graft for the correction of soft-tissue defects is a widespread procedure in plastic surgery. The main problem in achieving long-term soft-tissue augmentation is partial absorption of the injected fat and hence the need for overcorrection and re-injection. The purpose of this study was to improve the viability of the injected fat by the use of interleukin-8. The rationale for the use of interleukin-8 was its abilities to accelerate angiogenesis and attract inflammatory cells and fibroblasts, providing the injected adipocytes more feeding vessels and a well-established graft bed to enhance their viability. Human adipose tissue, obtained by suction-assisted lipectomy, was re-injected into the subcutis in the scalp of nude mice. Interleukin-8 (0.25 ng) was injected subcutaneously to the scalp as a preparation of the recipient site 24 hours before the fat injection and was added to the fat graft itself (25 ng per 1 cc of injected fat). In the control group, pure fat without interleukin-8 was injected and no interleukin-8 was added for the preparation of the recipient site. One cubic centimeter of fat was injected in each animal in both the study and control groups. There were 10 animals in each group. The animals were euthanized 15 weeks after the procedure. Graft weight and volume were measured and histologic evaluation was performed. In addition, triglyceride content and adipose cell sizes were measured as parameters for fat cells viability. Histologic analysis demonstrated significantly less cyst formation in the group treated with interleukin-8. No significant differences were found between the groups with regard to graft weight and volume or the other histologic parameters investigated. No significant differences were demonstrated in adipose cell sizes and their triglyceride content. In conclusion, less cyst formation, indicating improved quality of the injected fat, can be obtained by the addition of interleukin-8. Further studies of various dosages of interleukin-8 and their long-term effect are required before these encouraging results could be applied clinically.     

Hyperbaric oxygen induces apoptosis via a mitochondrial mechanism

During therapeutic hyperbaric oxygenation lymphocytes are exposed to high partial pressures of oxygen. This study aimed to analyze the mechanism of apoptosis induction by hyperbaric oxygen. For intervals of 0.5–4 h Jurkat-T-cells were exposed to ambient air or oxygen atmospheres at 1–3 absolute atmospheres. Apoptosis was analyzed by phosphatidylserine externalization, caspase-3 activation and DNA-fragmentation using flow cytometry. Apoptosis was already induced after 30 min of hyperbaric oxygenation (HBO, P < 0.05). The death receptor Fas was downregulated. Inhibition of caspase-9 but not caspase-8 blocked apoptosis induction by HBO. Hyperbaric oxygen caused a loss of mitochondrial membrane potential and caspase-9 induction. The mitochondrial pro-survival protein Bcl-2 was upregulated, and antagonizing Bcl-2 function potentiated apoptosis induction by HBO. In conclusion, a single exposure to hyperbaric oxygenation induces lymphocyte apoptosis by a mitochondrial and not a Fas-related mechanism. Regulation of Fas and Bcl-2 may be regarded as protective measures of the cell in response to hyperbaric oxygen.     

Prolongation of skin allograft survival after neonatal injection of donor bone marrow and epidermal cells

Composite-tissue (e.g., hand allograft) allotransplantation is currently limited by the need for immunosuppression to prevent graft rejection. Inducing a state of tolerance in the recipient could potentially eliminate the need for immunosuppression but requires reprogramming of the immunological repertoire of the recipient. Skin is the most antigenic tissue in the body and is consistently refractory to tolerance induction regimens using bone marrow transplantation alone. It was hypothesized that tolerance to skin allografts could be induced in rats by injecting epidermal cells with bone marrow cells during the first 24 hours of life of the recipients. Brown Norway rats (RT1n) served as donors for the epidermal cells, bone marrow cells, and skin grafts. Epidermal cells were injected intraperitoneally and bone marrow cells were injected intravenously into Lewis (RT1l) newborn recipient rats. In control groups, recipients received saline solution with no cells (group I, n = 12), bone marrow cells only (group II, n = 15), or epidermal cells only (group III, n = 15). In the experimental group (group IV, n = 18), recipients received epidermal and bone marrow cells simultaneously. Skin grafts were transplanted from Brown Norway (RT1n) rats to the Lewis (RT1l) rats 8 weeks after cell injections. Skin grafts survived an average of 8.5 days in group I (10 grafts), 9.2 days in group II (12 grafts), and 12 days in group III (14 grafts). Grafts survived 15.5 days (8 to 26 days) in group IV (15 grafts). The difference was statistically significant (p < 0.05). Hair growth was observed in some accepted grafts in group IV but never in the control groups. This is the first report of prolonged survival of skin allografts in a rat model after epidermal and bone marrow cell injections. Survival prolongation was achieved across a major immunological barrier, without irradiation, myeloablation, or immunosuppression. It is concluded that the presentation of skin-specific antigens generated a temporary state of tolerance to the skin in the recipients that could have delayed the rejection of skin allografts.     

高压氧暴露大鼠肺组织内PPAR通路分子变化规律

目的:研究高压氧暴露大鼠肺组织内过氧化物酶体增殖因子活化受体(PPAR)通路分子表达变化规律。方法:27只雄性SD大鼠随机分为高压常氧对照组(0.23 MPa空气)、高压氧时间序列处理组(0.23 MPa纯氧,分别暴露2 h、4 h、6 h和8 h),持续小流量通风,维持舱内O2浓度>99%。应用HE染色观察各组大鼠肺组织形态学变化;应用oligo芯片检测各个时间表达谱;应用RT-PCR验证发生改变的部分PPAR通路基因。结果:与高压常氧对照组相比,高压氧时间序列处理组造成的肺损伤逐渐加重;表达谱芯片的基因本体论(Go)富集分析结果中有一类PPAR通路类,包含有多个PPAR通路分子;RT-PCR结果提示PPARδ-和PPARγ-均在较长时间高压氧暴露的肺组织中上调。结论:高压氧长时间暴露造成的肺型氧中毒可引起PPAR通路的激活。     

Effect of hyperbaric oxygen and medicinal leeching on survival of axial skin flaps subjected to total venous occlusion

This study evaluates the effect of hyperbaric oxygen and medicinal leeching on axial skin flaps subjected to total venous occlusion. Axial epigastric skin flaps (3 x 6 cm) were elevated on their vascular pedicles in 40 male Wistar rats. Total venous occlusion was achieved by division of all veins draining the skin flap. Arterial inflow was left intact. Animals were randomly assigned to one of five groups: sham (n = 8); control, total venous occlusion only (n = 8); occlusion with hyperbaric oxygen (n = 8); occlusion with leeching (n = 8); occlusion with leeching and hyperbaric oxygen (n = 8). The hyperbaric oxygen protocol consisted of 90-minute treatments, twice daily, with 100% O2 at 2.5 atmospheres absolute for 4 days. The leeching protocol consisted of placing medicinal leeches on the congested flaps for 15 minutes, once daily, for 4 days. Laser Doppler measurements of flap perfusion were recorded preoperatively, postoperatively, and on postoperative days 1 and 3. The percentage of flap necrosis was evaluated on postoperative day 3. Mean percentage necrosis and mean laser Doppler readings were compared between both groups. The flaps in the sham group demonstrated 99 percent survival, whereas the flaps in the occlusion-only group demonstrated 100 percent necrosis. The flaps in the occlusion with oxygen, the occlusion with leeching, and the occlusion with oxygen and leeching groups demonstrated 1, 25, and 67 percent survival, respectively. Sham laser Doppler readings remained within normal limits. Laser Doppler readings in the occlusion-only and the occlusion with oxygen groups decreased to negligible levels on postoperative day 1, and on postoperative day 3 no perfusion was demonstrated. In both the occlusion with leeching and the occlusion with leeching and oxygen groups, there was also a significant decrease in laser Doppler measurements after surgery, but perfusion remained stable throughout the remainder of the study. This study demonstrates that hyperbaric oxygen alone is not an effective treatment for skin flaps compromised by total venous occlusion. The combination of leeching and hyperbaric oxygen treatment of total venous occlusion results in a significant increase in flap survival above that found with leeching alone. It appears that hyperbaric oxygen is effective because of the venous outflow provided by leeching as demonstrated by laser Doppler flow readings.     

Free radical generation in the brain precedes hyperbaric oxygen-induced convulsions.

We tested the hypothesis that hyperbaric oxygenation (HBO) generates free radicals in the brain before the onset of neurological manifestations of central nervous system (CNS) oxygen poisoning. Chronically cannulated, conscious rats were individually placed in a transparent pressure chamber and exposed to (1) 5 atmospheres absolute (ATA) oxygen for 15 min (n = 4); (2) 5 ATA oxygen for 30 min (n = 5), during which no visible convulsions occurred; (3) 5 ATA oxygen for 30 min with recurrent convulsions (n = 6); (4) 5 ATA oxygen until the appearance of the first visible convulsions (n = 5); (5) 4 ATA oxygen for 60 min during which no convulsions occurred (n = 5); and (6) 5 ATA air for 30 min (n = 5, controls). Immediately before compression, 1 mL of 0.1 M of alpha-phenyl-N-tert-butyl nitrone (PBN) was administered intravenously (iv) for spin trapping. At the termination of each experiment, rats were euthanized by pentobarbital iv and decompressed within 1 min. Brains were rapidly removed for preparation of lipid extracts (Folch). The presence of PBN spin adducts in the lipid extracts was examined by electron spin resonance (ESR) spectroscopy. ESR spectra from unconvulsed rats exposed to 5 ATA oxygen for 30 min revealed both oxygen-centered and carbon-centered PBN spin adducts in three of the five brains. One of the five rats in this group showed an ascorbyl signal in the ESR spectrum.(ABSTRACT TRUNCATED AT 250 WORDS)     

Expanding the limits of composite grafting: a case report of successful nose replantation assisted by hyperbaric oxygen therapy

A successful nose replantation assisted by hyperbaric oxygen therapy is presented, with a brief discussion of the possible mechanisms and a brief literature review of the use of hyperbaric oxygen in tissue preservation and replantation. Although it is not certain that the hyperbaric oxygenation ensured the survival of the replanted nose in this 2-year-old girl, there was documented change in graft appearance during the initial hyperbaric oxygen treatment. A 1-month, 1-year, and 2-year follow-up is included.     

一氧化氮合成酶在不同压力氧气导致的肺型氧中毒中的表达变化

目的：临床上过量使用氧气可导致肺型氧中毒的发生,目前有文献认为常压氧和高压氧导致的肺型氧中毒具有不同的发病机制。本实验拟探讨一氧化氮合成酶在不同压力氧气导致的肺型氧中毒中的表达变化。方法：60只雄性SD大鼠,随机分为6组（n=10）,分别暴露于1绝对压（atmosphere absolute,ATA）、1．5ATA、2ATA、2．5ATA、3ATA,100％氧气中56、20、10、8、6h,暴露于空气组作为对照。出舱后测定各组大鼠肺组织湿干比、支气管肺泡灌洗液蛋白含量。收集肺组织,裂解提取蛋白。行Western blot检测内皮一氧化氮合酶（eNOS）、神经型一氧化氮合酶（eNOS）的表达变化。结果：相对于正常对照组,1．0ATA组肺湿干比、支气管肺泡灌洗液蛋白量表达明显增高。随着氧分压的增高,这种改变减弱。和1．0ATA组相比,高压氧组的肺湿干比、肺泡灌洗液蛋白含量显著降低。各个氧气压力暴露组大鼠肺组织中nNOS的含量没有明显改变。而eNOS含量则在氧气压力为2ATA时明显降低（P〈0．05）,氧气压力为2．5ATA及3ATA时明显增高（P〈0．05）。结论：eNOS在肺中的表达量随着氧气压力的变化而改变。     

三七总皂甙和银杏叶提取物预防急性氧中毒的实验研究

目的:研究三七总皂甙和银杏叶提取物对急性氧中毒的预防作用及其可能机制.方法:分别给小鼠连续腹腔注射三七总皂甙和银杏叶提取物5 d后,在500kPa高压氧中暴露60 min,观察惊厥潜伏期、惊厥次数、惊厥间隔时间等指标;另外测定高压氧暴露15 min后脑组织中活性氧单位、脂质过氧化物、一氧化氮、谷胱甘肽的含量和过氧化氢酶、谷胱甘肽过氧化物酶、单胺氧化酶的活性.结果:三七总皂甙和银杏叶提取物可以明显延长氧惊厥潜伏期和惊厥间隔时间,减少惊厥次数;降低高压氧暴露后脑组织中脂质过氧化物、一氧化氮的含量,使活性氧单位、谷胱甘肽含量和谷胱甘肽过氧化物酶活性保持在较高的水平;对过氧化氢酶和单胺氧化酶活性的影响则不显著.结论:三七总皂甙和银杏叶提取物可以有效预防急性氧中毒,其机制可能与它们的抗氧化活性有关.     

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.     

Erythropoietin improves the survival of fat tissue after its transplantation in nude mice

Background

Autologous transplanted fat has a high resorption rate, providing a clinical challenge for the means to reduce it. Erythropoietin (EPO) has non-hematopoietic targets, and we hypothesized that EPO may improve long-term fat graft survival because it has both pro-angiogenic and anti-apoptotic properties. We aimed to determine the effect of EPO on the survival of human fat tissue after its transplantation in nude mice.

Methodology/Principal Findings

Human fat tissue was injected subcutaneously into immunologically-compromised nude mice, and the grafts were then treated with either 20 IU or 100 IU EPO. At the end of the 15-week study period, the extent of angiogenesis, apoptosis, and histology were assessed in the fat grafts. The results were compared to vascular endothelial growth factor (VEGF)-treated and phosphate-buffered saline (PBS)-treated fat grafts. The weight and volume of the EPO-treated grafts were higher than those of the PBS-treated grafts, whose weights and volumes were not different from those of the VEGF-treated grafts. EPO treatment also increased the expression of angiogenic factors and microvascular density, and reduced inflammation and apoptosis in a dose-dependent manner in the fat grafts.

Conclusions/Significance

Our data suggest that stimulation of angiogenesis by a cluster of angiogenic factors and decreased fat cell apoptosis account for potential mechanisms that underlie the improved long-term survival of fat transplants following EPO treatment.     

高压氧预处理对急性减压所致的大鼠肺组织细胞凋亡及Bcl-2/Bax表达的影响

目的:探讨高压氧预处理对减压病大鼠肺组织细胞凋亡的影响相关蛋白表达的影响。方法:雄性SD大鼠24只,随机分为3组,正常对照组(NC group)、HBO预处理组(HBOP group)、减压组(DCS group),每组8只。连续进行HBO预处理5天后进行减压病模型制备,取左侧肺组织进行湿干重比值测定,右侧肺组织用于病理实验;HE染色观察肺组织病理学改变,免疫组织化学法标记Bcl-2、Bax、Caspase-3与MMP-9阳性细胞表达,并对bcl-2/bax值进行分析。结果:减压组肺组织Bax、Caspase-3与MMP-9阳性细胞数明显增加(P0.05),而Bcl-2阳性细胞表达减少(P0.05);高压氧预处理组与减压组相比,Bax、Caspase-3与MMP-9阳性细胞数明显减少(P0.05),而Bcl-2阳性细胞表达增加(P0.05);大鼠肺组织减压组与高压氧预处理组Bcl-2/Bax值较对照组明显降低(P0.05);与减压组相比,高压氧预处理组明显升高(P0.05)。结论:HBO预处理可以减轻减压对肺组织的病理损伤,减轻肺泡和支气管上皮细胞的变性坏死,抑制细胞凋亡,从而起到对减压病的保护作用。     

The effect of hyperbaric oxygen treatment on oxidative stress in experimental acute necrotizing pancreatitis

Various protocols may be used for acute pancreatitis treatment. Recently, the benefit of hyperbaric oxygen (HBO) has been demonstrated. To clarify the mechanism of HBO on the process of the acute pancreatitis, we determined the levels of antioxidant enzymes in an acute pancreatitis model. Forty-five Sprague-Dawley rats were randomly divided into three groups: Group I: sham group (n=15), Group II: pancreatitis group (n=15), Group III: pancreatitis group undergoing HBO therapy (n=15). HBO was applied postoperatively for 5 days, two sessions per day at 2.5 fold absolute atmospheric pressure (ATA) for 90 min. Superoxide dismutase (Cu/Zn-SOD), malondialdehyde (MDA), and glutathione peroxidase (GSH Px) activity were measured in pancreatic tissue and erythrocyte lysate. MDA and GSH Px were also determined in plasma. In addition, amylase levels were measured in the serum. While serum amylase levels and MDA values in erythrocyte, plasma and pancreatic tissue were decreased, the levels of GSH Px and SOD were found to be significantly increased in the Group III as compared to those of the Group II. The findings of our study suggest that HBO has beneficial effects on the course of acute pancreatitis and this effect may occur through the antioxidant systems.     

Cerebral blood flow modulates hyperbaric oxygen induced neurotoxicity by neuronal and endothelial nitric oxide

The goal of work was to reveal changes in microcirculation of the rat brain and the role of nitric oxide (NO) in development of seizures at hyperbaric oxygen exposure. The Wistar rats with implanted paired platinum electrodes in left and right striatum were used for experiments. The latency of seizures was defined by the EEG, the cerebral blood flow (CBF) was measured by hydrogen clearance. One group of animals was exposed to a 5-ata oxygen, while the others before oxygen treatment were injected with: Nw-nitro-L-arginine methyl ester (L-NAME), blockator of constitutive NO synthase; 7-nitroindozol (7NI), specific inhibitor of neural NO synthase. The latency of seizures was 41 +/- 1.9 min at 5 ata oxygen exposure. CBF was decreased to 10-14% but before seizures it increased to 23 +/- 9%. L-NAME and 7NI prevented development of hyperoxygen hyperemia and onset of seizures. The results indicate occurrence of hyperbaric oxygen changes of the CBF that modulate neurotoxic effects of NO in neurons as well as in cerebral vessels.     

Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells

Injection of aspirated fat for the correction of tissue defects is a common procedure in plastic surgery. The reported rates of fat cell survival vary greatly in the medical literature, and different techniques of harvesting, processing, and reinjecting the fat cells are claimed to be responsible for these differences. However, there is no agreement concerning the best way to process the harvested fat before reinjection. The present study was initiated to examine and evaluate the effect of a simple method of isolating the fat particles on the outcome of fat graft survival. In this study, the nude mouse model was used to examine the survival and take of the fat graft concentrated before injection by the cumbersome recommended closed centrifugation technique in comparison with the authors' recommended open method, using an operating room cotton towel as a platform for concentrating the fat cells and separating them from fluids, oil, and debris. One milliliter of concentrated human fat cells preprocessed by towel separation was injected into the nuchal subcutis of 11 nude mice in the study group, and the same amount of fat that was preprocessed by centrifugation was injected into 11 control mice. Injected fat survived in both groups. No significant differences were found regarding fat graft weight and volume, although a tendency for better survival was noticed in the experimental group. Histologic evaluation of the grafts revealed significantly less fibrosis within the study group, meaning that the quality of the fat grafts was better. The authors found this method to be simple, cheap, and friendly to the surgeon in comparison with traditional processing using the centrifuge.     

Hyperbaric oxygen therapy in plastic surgery: a review article

The most important effects of hyperbaric oxygen (HBO), for the surgeon, are the stimulation of leukocyte microbial killing, the enhancement of fibroblast replication, and increased collagen formation and neovascularization of ischemic tissue. Preoperative hyperbaric oxygen induces neovascularization in tissue with radionecrosis. Refractory osteomyelitis and necrotizing fasciitis appear to respond to adjunctive hyperbaric oxygen. Crush injury and compartment syndrome appear to benefit through preservation of ATP in cell membranes, which limits edema. Hyperbaric oxygen in burn injury permits shorter hospital stays, a reduced number of surgeries, and less fluid replacement. Skin grafts and flaps are reported to take more completely and more rapidly. The same mechanisms may apply in ischemic problem wounds such as infected diabetic extremities. Contraindications and side effects are described. Hyperbaric oxygen will not heal normal wounds more rapidly but may, under certain circumstances, induce problem wounds to heal more like normal ones.     

Effect of hyperbaric oxygenation on the Na+, K+-ATPase and membrane fluidity of cerebrocortical membranes after experimental subarachnoid hemorrhage

It is reported that CNS hemorrage causes membrane dysfunction and may exacerbate this damage as a result of secondary ischemia or hypoxia. Since hyperbaric oxygenation improves oxygen metabolism, it may reduce this membrane damage. The present study was conducted to reveal whether hyperbaric oxygenation influences membrane alteration after hemorrhage. Thirty minutes after subarachnoid hemorrhage induction, rats were treated with hyperbaric oxygenation 2 ATA for 1 hour. Rats were decapitated 2 hours after subarachnoid hemorrhage induction. Na⁺, K⁺-ATPase activity measurement, and spin-label studies were performed on crude synpatosomal membranes. Subarachnoid hemorrhage decreased Na⁺, K⁺-ATPase activity. Spin label studies showed that hydrophobic portions of near the membrane surface became more rigid and the mobility of the membrane protein labeled sulfhydryl groups decreased after subarachnoid hemorrhage. Hyperbaric oxygenation significantly ameliorated most of the subarachnoid hemorrhage induced alterations. We conclude that hyperbaric oxygenation may be a beneficial treatment for acute subarachnoid hemorrhage.     

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.