INTRODUCTION
By superimposing photographs of patients in their youth and senility, Lambros observed
no inferior displacement of the position of several reference points of the face,
concluding that ptosis is not a preponderant factor of aging. Consequently, he postulated
that volume loss is a primary factor in aging the upper midface region1.
Tonnard & Verpaele agreed with Lambros regarding the central portion of the face,
while true ptosis occurs in the periphery. Thus, they combined the antigravity facelift
procedures with volumization by fat grafting2.
In the wake of the perception that aging is linked to volume loss, the demand for
filling materials that are safe, long-lasting and biocompatible has grown, increasing
the emphasis on fat grafting3.
Although Gir et al.4 cite the lack of reliability and consistency in the final clinical result of fat
grafts as major concerns, this seems to be being overcome since Kling et al.5 found that 80% of the 456 surgeons who responded to the survey of their study, used
the method. Thus, fat has been the material of choice for facial fillers, in the opinion
of many plastic surgeons, because it is abundant, cheap and easily available4.
However, the literature does not provide clear data on how much injected fat actually
remains on the face, making it difficult to decide how much to inject6.
Shue et al.7 performed a review, focusing on the description of injected volumes. Correlating
the injected volumes with the results obtained in several cases may be a solution
to the difficulty caused by the fact that we do not know the percentage of graft loss.
In other words, it would be more important to know how much it is necessary to inject
each type of deformity than to quantify the volume retained.
In their review, Shue et al.7 show no consensus on how much to inject in each area. They also demonstrate that
only 19 of the 81 articles eligible for their review cited volumes and applied areas,
with n varying between 1 and 83 patients per article. They also stated that the amount
of fat injected into each facial compartment is typically based more on the surgeon’s
experience than scientific information. Accordingly, a recent article by us describes
the application areas with their respective standardized volumes in 151 consecutive
cases, also based on our clinical experience, without solid science behind it8.
In 2017, more than 85,000 facial fat fillers were performed in the United States,
more than three times the number of otoplasties in the same period9. Even though it is considered a significant number for a surgical procedure, it is
very small compared to the 2.7 million fillings with synthetic materials in the same
year9.
On the other hand, although non-surgical procedures are more frequent, there are more
articles on facial fat grafting. Therefore, it would be interesting to find a way
to take advantage of the practical experience accumulated with these numerous non-surgical
procedures in the exercise of fat grafting and take advantage of the effervescent
scientific production of fat grafting to improve fillings with synthetic materials.
The present study deepens the systematization made in a previous publication, updates
small changes in the volume distribution and initiates a semantic correlation with
the methodology of facial fillings with synthetic materials.
The systematization follows the technique described by Coleman10, with the adaptations described by Lam et al. in the book Complementary Fat Grafting11. The injection receiving areas’ descriptions are represented with the same symbols
used in the MD Codes®12 facial filling methodology.
OBJECTIVE
To analyze the results of the case series and systematize the volumes to be applied,
correlating the language used in facial fat grafting with the language used in the
Md Codes®12 methodology.
METHODS
This is a retrospective clinical trial based on a review of the medical records of
all patients operated on in the Plastic Surgery Service of the Clínica Eduardo Furlani
between 08/15/2017, when we started to correlate the descriptive language of facial
fat grafting with the descriptive language of the methodology Md Codes®, and 02/25/2019, in Fortaleza-CE, Brazil. All patients undergoing facial fat grafting
were included. The main author operated all. Patients undergoing fat grafting for
the exclusive treatment of acne scars were not included. All determinations of the
Helsinki agreement were followed, and all patients signed a free consent form after
clarification. The Research Ethics Committee approved the study under opinion number:
3,922,266.
Description of the technique used
Fat collection
Donor area
The choice of removal area followed the criteria of convenience due to the ease of
positioning, the abundance of material and the patient’s body contour. Thus, the most
frequent locations were the flanks and trochanteric regions. Patients undergoing abdominoplasty
had the region excised in the hypogastrium as the donor area of choice.
Withdrawal method
Patients undergoing regional blocks for simultaneous body procedures had the donor
area infiltrated with a 0.9% NaCl solution and 1:200,000 adrenaline. In cases without
an anesthetic block, the solution was added with 0.4% lidocaine and 0.01% levobupivacaine.
The infiltrated volume corresponds approximately to the volume scheduled for withdrawal.
Fat removal was performed by aspiration with a 3mm cannula with 16 1mm holes, cutting
edges (Fagha Medical), and a 10ml Luer lock syringe (BD Medical), with manually controlled
plunger traction, seeking to maintain negative pressure generated by pulling the syringe
1cc.
The technique differs from Lam et al.11 by not using albumin solution and cannulas from another manufacturer.
Preparation
Filled syringes are decanted while others are withdrawn. As a rule, the former quickly
decant a clear infranatant, which is discarded, and the syringe returns to be filled
by the surgeon.
The syringes are closed and taken to the centrifuge (Cirúrgica Monserrat®, R=100mm), with a rotation of 2000rpm (448 G), for 4 minutes. Then the infranatant
and supernatant are discarded. Gauze is placed in contact with the top of the fat
to absorb the residual oil.
The remaining fat in the syringe is transferred to another syringe to complete the
volume of 10ml. The fat is slightly homogenized, mixed between two syringes, using
an adapter that connects the two syringes. It is then transferred again to 1ml syringes
for application.
Preparation of the receiving area
Patients undergoing body procedures, rhytidoplasty and other simultaneous facial procedures
are sedated, and those undergoing rhinoplasty receive general anesthesia. Cases of
isolated fat grafting are performed only with local anesthesia.
In all cases, infraorbital, mental and zygomaticofacial branches of the trigeminal
nerve are blocked. The recipient areas are infiltrated with 0.9% NaCl solution, 1:200.00
adrenaline, and 0.4% lidocaine with the same cannulas used to inject the fat. In cases
of rhytidectomy, the solution has an adrenaline concentration of 1:400,000.
Fat infiltration
The cannulas have a lumen of 1.2 mm and a length of 3 to 7 cm (Rhosse Instruments®).
We only used straight cannulas coupled to 1ml syringes (BD Medical®).
The cannula entry points are routinely punctured with a 25x7 cutting needle at locations
A, B, C and D, as shown in Figure 1. Other perforations are performed as needed in each case. There is no need to close
the incisions.
Figure 1 - Image taken from the article Facial rejuvenation with fat grafting: systematization
and study of 151 consecutive cases
8.
Figure 1 - Image taken from the article Facial rejuvenation with fat grafting: systematization
and study of 151 consecutive cases
8.
Application areas
The preparation and application methodology followed that described by Lam et al.11. The injection is performed antegrade and retrograde, with the injection of approximately
0.1 ml for every 1 cm displacement of the cannula. The application areas are represented
in Figure 2.
Figure 2 - Image taken from the article MD Codes™: A Methodological Approach to Facial Aesthetic
Treatment with Injectable Hyaluronic Acid Fillers
12.
Figure 2 - Image taken from the article MD Codes™: A Methodological Approach to Facial Aesthetic
Treatment with Injectable Hyaluronic Acid Fillers
12.
Description of application areas
In order to establish a parallel between the knowledge acquired with facial fat grafting
and synthetic material fillings, the nomenclature that has been disseminated as Md
Codes®12 was used.
Table 1 presents the equivalence as understood by the authors. It also presents a correlation
with the nomenclature previously used and with the findings of the review by Shue
et al.7,8.
Table 1 - Correlation between Md Codes® and the nomenclature previously used, distribution of
volumes in their respective regions, average injected and frequency with which the
area was treated.
| Region according to publication/volume injected |
Vol. Injected |
Freq |
| Article Shue et al.7 |
Vol. |
V/AS |
Furlani 2018 |
Vol. |
Current |
Average |
SD |
| Infraorbital region |
1.4 |
|
MOIM |
1.03 |
TT3 |
0.7 |
0.2 |
46% |
| MOIL |
1.03 |
TT1
TT2
|
0.7
0.7
|
0.2
0.2
|
46%
44%
|
| Nasolabial sulcus |
2.8 |
|
FPC |
1.67 |
NL1 |
2.9 |
1.3 |
61% |
| S/E |
|
NL2
NL3
|
1.0
0.0
|
-
-
|
2%
0%
|
| Cheeks |
25.7 |
4.7 |
MLAT |
2.1 |
CK1 |
3.1 |
1.2 |
87% |
| CK2 |
2.0 |
0.5 |
76% |
| CK4 |
3.5 |
1.0 |
28% |
| 3.5 |
BUCAL |
2.3 |
CK5 |
2.0 |
- |
2% |
| 2.6 |
MANT |
3.1 |
CK3 |
2.0 |
0.9 |
20% |
|
FNJ |
1 |
|
|
|
|
| Eyebrow |
|
5.5 |
MOS |
1.1 |
E1 |
0.8 |
0.2 |
11% |
| E2 |
0.8 |
0.7 |
11% |
| E3 |
0.4 |
0.1 |
6% |
| No equivalent |
|
|
APL |
0.6 |
O1 |
0.0 |
- |
0% |
| O2 |
0.5 |
0.0 |
4% |
| O3 |
0.5 |
- |
2% |
| Mento |
6.7 |
|
MENT |
5.8 |
C1 |
2.5 |
1.5 |
50% |
| C2 |
4.2 |
2.3 |
69% |
| C3 |
0.0 |
- |
0% |
| C4 |
3.3 |
1.9 |
56% |
| C5 |
1.0 |
0.0 |
4% |
| JW5 |
1.0 |
0.0 |
4% |
| Mandibular Area |
11.5 |
|
MANDL |
4.8 |
JW1 |
5.4 |
1.0 |
22% |
| MANDR |
|
JW2 |
3.0 |
0.0 |
4% |
| MANDC |
|
JW3 |
0.0 |
- |
0% |
| SPB |
2.3 |
JW4 |
2.7 |
0.7 |
39% |
| C6 |
1.8 |
0.3 |
6% |
| Marionette Lines |
1.3 |
|
MNT |
0.6 |
M1 |
1.3 |
0.5 |
6% |
| M2 |
1.0 |
- |
2% |
| Temporal |
5.9 |
|
TEMP |
2.9 |
T1 |
2.1 |
1.1 |
15% |
| No equivalent |
|
|
LIPS |
|
LP6 |
0.9 |
0.4 |
22% |
| Upper lip |
3 |
|
|
|
LP1S |
3.7 |
1.8 |
41% |
| Lower lip |
3.7 |
|
|
|
LP1I |
6.1 |
2.8 |
41% |
| Frontal |
6.5 |
|
FRONTAL |
|
F1 |
0.7 |
0.4 |
9% |
| F2 |
0.9 |
0.2 |
9% |
| F3 |
1.0 |
0.0 |
6% |
| Glabella |
1.4 |
|
GLABELA |
|
G1 |
0.0 |
- |
0% |
| G2 |
1.0 |
- |
2% |
| No equivalent |
|
|
DORSO N |
|
NOSE |
2.6 |
1.3 |
13% |
Table 1 - Correlation between Md Codes® and the nomenclature previously used, distribution of
volumes in their respective regions, average injected and frequency with which the
area was treated.
RESULTS
Sixty facial fat grafting procedures were performed between 08/15/2017 and 02/25/2019.
Six cases were excluded due to data loss. Men represented 11.11% (six cases) and women
88.88% (48 cases) of the total. Age ranged between 20 and 71 years (mean 43.94 years,
standard deviation – SD – 11.21 years). Twenty-nine patients (53.70%) had some associated
body surgery, and 32 patients (59.3%) had some associated facial surgery, whose frequencies
are shown in Table 2.
Table 2 - Frequency of facial procedures by the number of patients and equivalent percentage.
| Procedure |
Quantity |
Percentage |
| Frontoplasty |
10 |
20.8 |
| Upper blepharoplasty |
4 |
8.3 |
| Lower blepharoplasty |
0 |
0.0 |
| Mentoplasty |
0 |
0.0 |
| Bichectomy |
10 |
20.8 |
| Otoplasty |
4 |
8.3 |
| Rhinoplasty |
15 |
31.3 |
| Others |
5 |
10.4 |
Table 2 - Frequency of facial procedures by the number of patients and equivalent percentage.
The mean follow-up time was 155.61 days (minimum 7, maximum 543, SD 156.05).
One patient (2%) underwent a second fat grafting procedure, with an interval of 16
months between interventions.
There were no complications related to the method, considering that the presence of
ecchymosis and edema in the first 15 days are no complications but normal consequences
of the procedure. We did not observe the appearance of previously non-existent asymmetries.
We could not retrieve accurate information on injected volumes in six of the 60 cases
(10%). Thus, the injected volume statistics were calculated considering 54 patients.
Table 1 shows the distribution of volumes, in their respective regions, with the average
injected and the frequency with which this area was treated. The average volume injected
was 29.83 ml, ranging from 6 to 53.9 (SD 12.07).
DISCUSSION
Even with the increase in fat grafting, there are few high-quality clinical studies
for any of the technical steps involved, such as selection of the donor area, fat
collection, processing and injection technique13. In addition, studies do not usually show the volumes injected specifically in each
area.
In a previous article, with 151 consecutive cases, we published a standardization
of volumes used in each area, without major variations from case to case, as if it
were a therapeutic dose for each region. Thus, planning was based more on the choice
of areas to correct than on the volume to be injected into each area. This strategy
seemed successful, as it facilitated planning and allowed us to have consistency in
the results8.
In this article, we made minor modifications to the injected volume pattern, but we
kept the concept of the therapeutic dose for each area or, at least, the minimum dose
to have results in each area.
A recent systematic review raised the articles that described the volumes injected
by the facial subunit, with which we compared our volumes7.
In the present series, we intend to bring the language used in publications on fat
grafting closer to the language used in facial filling with synthetic materials to
make the information on the two types of procedures interchangeable. Thus, Figure 2 demonstrates the applied areas, with the nomenclature used by the Md Codes®12 methodology and reproduced in this study, while Figure 3 demonstrates the nomenclature used by us in the previous series.
Figure 3 - Area 1: Inferior medial orbital margin. Area 2: Lateral inferior orbital margin. Area
3: Nasojugal fossa. Area 4: Lateral Malar. Area 5: Oral. Area 6: Anterior Malar. Area
7: Upper orbital margin. Area 8: Eyelid angle. Area 9: Mandibular pre-pouch sulcus.
Area 10: Lateral jaw. Area 11: Precanine fossa. Area 12: Marionette. Area 13: Mento
Area 14: Temporal. Image taken from the article Facial rejuvenation with fat grafting:
systematization and study of 151 consecutive cases
8.
Figure 3 - Area 1: Inferior medial orbital margin. Area 2: Lateral inferior orbital margin. Area
3: Nasojugal fossa. Area 4: Lateral Malar. Area 5: Oral. Area 6: Anterior Malar. Area
7: Upper orbital margin. Area 8: Eyelid angle. Area 9: Mandibular pre-pouch sulcus.
Area 10: Lateral jaw. Area 11: Precanine fossa. Area 12: Marionette. Area 13: Mento
Area 14: Temporal. Image taken from the article Facial rejuvenation with fat grafting:
systematization and study of 151 consecutive cases
8.
Table 1 was created to analyze the equivalence of nomenclatures and injection volumes performed
by the authors of the review by Shue et al.7, by our group in a previous series and by our group in the present study.
What changed from the previous series to this one?
Anterior Malar (Anterior Malar + FNJ) reduced from 4.1 to 2 (CK3). This way, it approached
the literature with an average of 2.6 ml. Lateral malar increased from 2.1ml to 5.1ml
(ck1 3.1ml, ck2 2.0ml), getting closer to the literature (4.7ml, on average)7.
We started to inject in the lip and nasal dorsum.
Nasolabial sulcus increased from 1.7ml to 2.9ml, getting closer to the literature
average (average of 2.8ml)7.
The mean volume applied to the chin was 5.8 ml in the previous series, similar to
the average in the literature (6.7 ml), while we found 13.8 ml in this series. Although
the volume seems to have doubled concerning the literature average, when analyzing
each article in the review by Shue et al.7, we observed that only two groups described volumes injected into the chin: Xie et
al.14, with an average of 2ml, and Coleman & Katzel, with an average of 16ml15.
Although Xie et al.14 reported an average of 2ml, they themselves do not seem to be satisfied with this
volume, as they state that there is a higher rate of resorption in this area, which
may require other procedures. Coleman reports, in three articles, the volume of 12,
16 and 20 ml, respectively. Such volume is closer and even superior to that practiced
in our series. We cannot say there is a higher absorption rate in this area, as suggested
by Xie et al., but it seems that the reported volume of 2ml is insufficient to modify
the chin10,14,15,16.
Terminology problem
When examining the review by Shue et al.7, we noticed a huge effort to discover the volumes injected in each area and compare
with other authors, as each used different terminology. For example, Mailey et al.17 use the term “supramental crease,” probably referring to the term “mental lip sulcus,”
which we use in this terminology (represented by the C1 code). However, no other article
used the same term.
Coleman & Katzel15 use the term “mental Groove,” whereas Pessa & Rohrich18 and Boneti et al.19 use the term “mental crease.” None of these explain what they refer to, but they
are believed to refer to a depression in the anterior mid-chin region between the
mental fat compartments.
Some articles use the term “chin,” equivalent to mento, which we used in our previous
series8,10,14,15. However, we consider the term very general, and we started subdividing it into several
sub-areas since it is not only intended to increase but to achieve certain forms.
For example, when filling the region of the mental lip sulcus, there seems to be an
inferior rotation of the mento, while there seems to be superior rotation with the
filling of what we call C4 (middle anterior portion of the mento). Thus, it is necessary
to specify the injected area.
We consider “bochecha” or “cheek” in English one of the vaguest and most confusing
terms. Pessa & Rohrich18 define the “Anatomic region with precise boundaries: the superior boundary is the lower eyelid,
the lateral boundary the periauricular region, inferior boundary the neck, and the
medial boundary is formed by the nose, lips, and chin. These boundary zones occur
at both a superficial and deep level”.
Even so, authors such as Wang et al.20 use the term “cheek” in their income statement and state that they injected, on average,
29.3 ml in each cheek without further specification. The description “cheek” is insufficient
for those who practice facial fat grafting because it is necessary to know exactly
how much and where to inject.
The authors cited use the much more specific concept of facial fat compartments when
describing the application technique, as demonstrated in the description of their
injection sequence: “(1) medial part of the deep medial cheek fat compartment; (2) medial part of the
sub- orbicularis oculi fat compartment; (3) lateral part of the deep medial cheek
fat compartment; (4) lateral part of the nasal base; (5) upper lip in the submucosa
layer; and (6) superior part of the buccal fat pad “20. We did not find other authors who used the concepts of facial fat compartments in
the practice of lipoinjection.
Some descriptions are based on surface anatomy, others on bone structure. Some descriptions
are based on clinical practice, others on anatomical concepts and subdivisions. Some
authors use technical terms, while others incorporate popular denominations, such
as “Marionette lines.” The fact is that the level of development of anatomical terms
is not yet capable of portraying the reality of those who work in this area, leading
to difficulties in exchanging knowledge.
This lack of unity of language proved to be a bigger obstacle than we imagined in
understanding patterns. We believe, therefore, that efforts in language development
can be a preponderant factor in the exchange of ideas. At this moment, it is perhaps
more important to discuss semantic issues than centrifugation techniques, collection
areas, preparation methods, etc.
CONCLUSION
Autologous fat grafting was applied to 60 consecutive patients without complications
related to the method, being a feasible procedure for certain cases of facial rejuvenation.
The MD Codes® language can be used in parallel with the anatomical description of the injected
regions.
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1. Clínica Eduardo Furlani, Fortaleza, CE, Brazil.
Corresponding author: Eduardo Antonio Torres Furlani Rua Barbosa de Freitas, 1990, Aldeota, Fortaleza, CE, Brazil Zip Code: 60170-021
E-mail: eduardo@eduardofurlani.com.br
Article received: July 05, 2021.
Article accepted: December 13, 2021.
Conflicts of interest: none.
Institution: Clínica Eduardo Fulani Cirurgia Plástica, Fortaleza, CE, Brazil.
