ORLANDO One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.
"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.
"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missingfat.
Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.
For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.
Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.
Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.
Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.
Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.
The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.
For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 15 cc for the upper lid/brow, 36 cc for the lower lid/cheek, 46 cc for the perioral area, up to 2 cc for the lips, and 35 cc for the mandible. "The round contour is really the key to a youthful eye," he said.
He advises physicians to think globally, not focally. Don't think about filling just one or two linesfill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.
Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.
Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman
