Trillium Cosmetic Surgery

Cosmetic surgeons who begin performing autologous fat transfer for facial volume restoration should be prepared for a steep learning curve and some surprisinging results, said William W. Ehrlich, M.D., at the annual meeting of the American Academy of Cosmetic Surgery.

“The FAMI technique is powerful and versatile and can enhance the outcome of other cosmetic procedures and even be a useful alternative to incisional browlift, allow plastic facial contouring, and some facelift or tightening procedures. However, excellent doctor-patient rapport is critical since facial autologous fat transfer results in an initial postoperative appearance that may be shocking to both the patient and the surgeon, especially after injection of large volumes,” said the assistant clinical professor of surgery, College of Human Medicine, Michigan State University, East Lansing.

Dr. Ehrlich, who has a private practice in Okemos, Mich., specializing in cosmetic and reconstructive surgery, spoke of the surprises he encountered and lessons he learned in his first 20 cases of facial autologous fat transfer. The procedures were performed between July, 2002 and September, 2003 as in-office surgeries. All of the patients were female and their average age was 52 years.

Under full tumescence produced with Klein’s solution, fat was harvested using low vacuum pressure and a 10-cc Coleman cannula. After centrifuging at 3500 rpm for 10 minutes, the fat was transferred into 1-cc blunt-tipped cannulas and implanted along muscle planes using the FAMI technique of French plastic surgeon Roger Amar M.D.

This 57-year-old woman received 44 cc of fat in one tx. Here she is before (left) and two months after the surgery (right).

For the fat transfer, patients received local infiltration anesthesia, nerve blocks, an oral sedative, and in a few cases, IV sedation. The average volume of fat transferred was 57 cc (range, 13 to 103 cc).

Discussing the early postoperative sequelae, Dr. Ehrlich explained that patients need to be forewarned their face will appear moderately to markedly distorted for two to three weeks after the procedure. In addition to evaluating whether patients fully grasp and seem willing to tolerate that consequence, the preoperative patient selection process should also identify candidates with realistic outcome expectations. “For example, I found out after the surgery that one patient who was moderately dissatisfied was hoping the augmentation procedure would improve her acne scars,” Dr. Ehrlich said.

More specifically to autotogous fat transfer, however, patients should be evaluated for features that adversely affect graft viability. Smokers should be strongly discouraged from undergoing the procedure as well as people with eating and body image disorders, who are at risk for being dissatisfied if they insist on dieting to achieve a lower than ideal body weight.

Dr. Ehrlich noted he encountered one postop infection in his series. Based on that experience, he strongly advocated an antimicrobial prophylaxis regimen consisting of an oral drug begun the day before surgery and continuing for one week postop combined with an IV antibacterial agent given perioperatively. The patient who developed an infection was treated only with an oralcephalosporin for prophylaxis, but the infection responded well to treatment with levofioxacin (Levaquin).

Dr. Ehrlich acknowledged that his preferences for using full tumescent anesthesia in the area of fat harvesting and to avoid tumescent anesthesia in the face represent technique differences compared with the approaches used by other surgeons. He does not use tumescent anesthesia at the recipient site because it distorts the architecture, but finds it has several advantages for harvesting as it allows that procedure to be done comfortably in the office and yields a product that contains little blood.

However, surgeons who choose to harvest fat under tumescent anesthesia must realize that about two-thirds of the volume is lost during processing and about onethird of the grafted volume is lost during the first two to three weeks after surgery. In addition, fewer of the swollen fat cells collected under full tumescence are able to fit within the close proximity to the vascular nutrient supply that is necessary for their survival.

Dr. Ehrlich indicated he plans his surgery using a diagram of the facial muscles and a grid marked for volume to be injected at each site. That volume needs to take into account the harvesting technique, regional differences in fat survival (least in the perioral and glabellar areas), and be individualized to the patient’s needs.

However, as a rough guideline for use of fat harvested with full tumescence, Dr. Ehrlich indicated the average total volume injected into the upper one-third of the face ranges from 18 to 28 cc while 50 to 60 cc would be injected into the lower twothirds of the face. For most individual muscles, however, the volume injected does not exceed 5cc. Dr. Ehrlich cautioned against injecting within the bony orbital rims, where there is a potential space into which the fat may be transferred, and not to overcorrect excessively.

“Given the limited capability of the 3-1) matrix of facial muscles to support viable grafts, one likely reaches a volume threshold which if exceeded would result in no benefit. In addition, there is a chance of causing a lasting overcorrection that is difficult to fix,” he said. With that caution in mind, Dr. Ehrlich said two conservative grafts are better than a single aggressive graft, and surgeons may approach the surgery with the idea of dividing it into two sessions spaced about six months apart. Among his first 20 cases, five were undercorrected and three had a second procedure.

In performing his first cases of facial autologous fat transfer, Dr. Ehrlich mentioned he also found the procedure provided some additional benefits. Most of the patients reported significant, persistent improvements in the tone, texture, and appearance of their facial skin, and several patients had a significant positive change in the appearance of the nose that nearly mimicked the results of a septoplasty.

“It is often said that the nose and ears enlarge with age, but in fact those structures only appear larger because the rest of the face shrinks away from them. As a result of fat injections, the face gains volume and the now looks relatively smaller,” he said.