Complementary fat grafting

138 Pages·2007·11.077 MB·English

by  Samuel M. Lam MD, Mark J. Glasgold MD, Robert A. Glasgold MD

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Private Practice
Lam Facial Plastic Surgery Center & Hair Restoration Institute
Willow Bend Wellness Center, Plano, Texas
Clinical Associate Professor of Surgery
Robert Wood Johnson Medical School, University of Medicine &
Dentistry of New Jersey, Piscataway, New Jersey
Private Practice, Glasgold Group Plastic Surgery, Highland Park, New Jersey
Clinical Assistant Professor of Surgery
Robert Wood Johnson Medical School, University of Medicine &
Dentistry of New Jersey, Piscataway, New Jersey
Private Practice, Glasgold Group Plastic Surgery, Highland Park, New Jersey
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© 2007 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any
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without written permission from the copyright owner, except for brief quotations embodied in critical arti-
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U.S. government employees are not covered by the above-mentioned copyright.
All patient photographs (except Case Study 5) are Courtesy of Mark Glasgold, M.D., and Robert
Glasgold, M.D.
All Illustrations: Samuel M. Lam, M.D.
Cover Design: Vina Lam
Cover Photograph: Patty Foppen
DVD Design and Mastering: Samuel M. Lam, M.D.
Printed in the USA
Library of Congress Cataloging-in-Publication Data
Lam, Samuel M.
Complementary fat grafting / Samuel M. Lam, Mark J. Glasgold,
Robert A. Glasgold.
p. ; cm.
Includes index.
ISBN: 978-0-7817-6424-7
ISBN: 0-7817-6424-6
1. Adipose tissues—Transplantation. 2. Face—Surgery. 3. Surgery,
Plastic. 4. Older people—Surgery. I. Glasgold, Mark J.
II. Glasgold, Robert A. III. Title.
[DNLM: 1. Adipose Tissue—transplantation. 2. Face—surgery.
3. Postoperative Care—methods. 4. Preoperative Care—methods.
5. Surgery, Plastic—methods. 6. Transplantation, Autologous—methods.
QS 532.5.A3 L213c 2006]
RD119.5.L55L36 2006
617.5'20592–dc22
2006031499
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions
or for any consequences from application of the information in this book and make no warranty, expressed
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cation of the information in a particular situation remains the professional responsibility of the practitioner.
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In memory of my beloved father, Samuel S.O. Lam, M.D., whose courage in the face
of adversity has inspired me and all who knew him. He will truly be missed.
S.L.
To Alvin Glasgold, M.D., skilled surgeon, compassionate physician, wise mentor, and
loving father.
M.G.
R.G.
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Preface
My adoption of autologous fat transfer has proven to be the most significant advance in my
evolution as a facial plastic surgeon, which accounts for 100% of my practice. I first appre-
ciated the role that volume loss plays in the aging process from one of Dr. Sidney Coleman’s
courses on Lipostructure. Once I made this leap in understanding, it became almost inevitable
for me to pursue autologous fat grafting. I have witnessed this eye-opening moment in other
surgeons at scientific meetings when they perceive for the first time the incredible rejuvena-
tive capacity of fat grafting and embark on their own journey of discovery.
This book arose out of the tremendous interest that my colleagues expressed about
learning fat grafting and my desire to produce an introductory, algorithmic approach to
what I conceive of as a very straightforward procedure. My understanding of fat grafting has
evolved over the past ten years. I began, as many do, with the disappointing experience of
filling nasolabial folds and lips. I was then encouraged by my early success in filling cheeks.
I learned full-face approaches from Drs. Coleman and Amar who espouse their own unique
techniques for fat grafting. The complementary manner in which I combine fat grafting with
traditional incisional-based procedures has yielded the most uniform patient success when
compared with using either modality alone. I now employ fat grafting in over 90% of my
facial rejuvenative cases.
Fat grafting is usually taught with a heavy emphasis on the artistic nature of the proce-
dure. The technical steps of harvesting, processing and injecting fat are relatively easy to
master and the hurdle encountered always concerns where to place the fat and how much
fat to place. The critical question then arises whether placement and volume can be per-
formed empirically rather than purely aesthetically? The answer is yes and no. I believe that
a volumetric foundation can be placed in an empirical manner that is appropriate for almost
every aging face patient because facial aging is fairly consistent. However, an aesthetic touch
is necessary to refine the result. The application of the volumetric foundation will allow the
surgeon to incorporate fat grafting into his or her box of tools comfortably and with few
problems and facilitate the development of an aesthetic eye with time.
I would like to thank my brother Robert’s and my own patients for allowing us to evolve
and to use their photographs to demonstrate the results and techniques shown in this book.
The evolution of this technique belongs as much to Robert as to me. He is a terrific and cre-
ative surgeon and the development of the ideas for this approach stemmed from a completely
collaborative undertaking with him. Mike Nayak, a previous fellow, came up with the term
Complementary Fat Grafting and his thirst for knowledge pushed me harder than anyone
else has. Sam Lam was the force behind this project, completed all the illustrations, did all
of the groundwork and through hard work and an iron will got this project completed faster
than I would have believed possible.
Mark J. Glasgold, M.D.
Highland Park, New Jersey
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Table of Contents
Book
Preface vii
Chapter 1 Aesthetics and Aging: A New Paradigm 1
Introduction 1
Volume and Shape 4
Highlights and Shadows 8
Framing the Eye 10
Concluding Remarks 11
Chapter 2 Preoperative Evaluation 12
Introduction 12
Preoperative Consultation 12
Preoperative Analysis 13
Upper Face 13
Brow 13
Upper Eyelid 16
Temple 16
Midface 16
Inferior Orbital Rim 17
Tear Trough 19
Lateral Cheek 22
Anterior Cheek 23
Buccal 27
Precanine Fossa/Nasolabial Fold 27
Lower Face 29
Prejowl Sulcus 29
Lateral Mandible 29
Labiomental Sulcus 30
Labiomandibular Fold (Marionette Line) 30
Anterior Chin 31
Concluding Remarks 31
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Chapter 3 Operative Technique 32
Introduction 32
Preoperative Assessment 33
Marking the Face 33
Selection of Donor Site 35
Operative Technique 37
General Principles of Anesthesia 37
Donor-site Anesthesia 37
Recipient-site Anesthesia 39
Recipient-site Anesthesia Phase 1: Injection
with a Sharp Needle 39
Recipient-site Anesthesia Phase 2: Injection with
a Blunt Cannula 41
Harvesting the Fat 42
Instrumentation 42
General Considerations 42
Site-specific Technique 47
Processing the Fat 54
Fat Injection 58
General Principles 58
Volumetric Foundation 62
Refinements 72
Advanced Techniques 77
Complementary Fat Grafting:
Combining Fat Grafting with Traditional
Facial Rejuvenation Procedures 78
Timing 79
Technique 80
Immediate Postoperative Care 81
Technical Pearls & Tips 82
Chapter 4 The Postoperative Period and
Management of Complications 83
Introduction 83
The Postoperative Period 83
Postoperative Care 83
Postoperative Course 85
Management of Complications 88
Identification of the Complication 88
Contour Irregularities 88
Persistent Malar Edema 91
Overcorrection 93
Undercorrection 93
Divoting at the Cannula Entry Site 94
Treatment Options for a Complication 95
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