TABLE 3.

6 Master Table for Systematic Fat Infiltration

ORDERSITE ENTRY VOLUME AMOUNT LEVEL TISSUE CANNULA SITE (CC) PER PASS a BARRIER PHASE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Medial inferior straight orbital rim Lateral inferior straight orbital rim Nasojugal straight groove Lateral cheek straight Buccal straight

A A A A A B

1 1 1 2 2 3 1 0.5 3

3 to 5 per D 1/10 cc 3 to 5 per D 1/10 cc 1/10 cc D 1/10 cc 1/10 cc 1/10 cc

None None None

D, I, S None I None

Anterior cheek straight

Superior straight or B orbital rim Amar #7 (SOR) Lateral canthal 0.9-mm B area straight Prejowl sulcus straight C Tear trough

D, I, S Malar septum 3 to 5 per D None 1/10 cc 3 to 5 per D Fibrous 1/10 cc adhesions 1/10 cc D, I, S Fibrous adhesions 3 to 5 per I None 1/10 cc D, I, S None Refinements 1/10 cc D, I, S Malar septum 1/10 cc I None 3 to 5 per D None 1/10 cc 3 to 5 per S None 1/10 cc 1/10 cc D, I, S None 1/10 cc S None D, I, S None D D S None None None

Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Volumetric foundation Refinements Refinements Refinements Refinements Refinements Refinements Refinements Refinements Advanced Advanced Advanced

0.9-mm A 1 straight Lateral cheek straight A 14 1/10 cc Anterior cheek straight A & B 12 Buccal straight Precanine straight fossa Nasolabial foldstraight A & B 15 A 12 A 12

Lateral jawline straight C 1 Marionette linestraight or D 12 Amar #7 18 Labiomental straight or D 12 1/10 cc sulcus Amar #7 19 Inferior margin straight or B 0.50.75 3 to 5 per of SOR Amar #7 1/10 cc 20 Central upper straight or B 0.30.5 3 to 5 per eyelid Amar #7 1/10 cc 21 Temple straight or B 2 3 to 5 per Amar #7 1/10 cc a D, Deep; I, Intermediate; S, Superficial tissue planes.

Technical Pearls Tips

Selection of donor site prior to the day of surgery may be beneficial in select patients. For example, gaunt patients with sparse donor fat, patients who have undergone extensive body lipocontouring in the past, or patients who have had prior abdominal surgery when the lower abdomen is an area favored for harvesting. For patients who have undergone extensive body liposuctioning, an area often overlooked that can provide an excellent donor source for harvesting is the waistroll, the roll of adipose that extends superomedially to inferolaterally along the lower lateral back. Asking the patient where he or she thinks that he or she has the most fat or where fat is the most difficult to lose is very helpful to guide the surgeon's search for the ideal donor site. Infiltration of local anesthesia into the donor site is carried out into the more superficial and deeper portions of the fat pad, with the central portion left relatively untouched for fat harvesting. A different local anesthetic mixture is used for patients under oral sedation versus deeper sedation (Table 3-4). During fat harvesting, avoid tenting or tethering the skin with the cannula, which implies too superficial a passage. During fat harvesting, the cannula should be almost entirely withdrawn to the skin entry site after three to four passes to redirect the cannula into another area. Simply turning the angle of the cannula without withdrawal does not actually move the cannula tip to a new harvesting site, which can lead to overharvesting in one area. When calculating the total fat that should be harvested, the surgeon should recall that typically 50% of the filled syringe would be comprised of nonviable contents (blood, lidocaine, albumin, and lysed fat cells). A greater amount should be harvested in cases in which more blood is encountered in the syringe, which can raise the nonviable portion of the collected syringe upwards of 70% to 80%. If a patient needs fat harvested from an area that requires repositioning (Table 3-3), consider a lighter sedation to permit patient cooperation with repositioning. During fat processing, remember to always remove the supranatant first before the infranatant. If the infiltration cannula becomes clogged, the cannula should be completely withdrawn and then cleared before reinsertion. Doing so will minimize the chance of inadvertently administrating an oversized bolus of fat into a particular area. Bony landmarks are a key guide to placement of fat, for example, the inferior orbital rim, the zygoma, and the mandible. The nondominant hand provides tactile feedback to ensure that the cannula is passed in the desired area for enhancement. The surgeon should complete the standard volumetric foundation first before deciding whether the additional fat refinement would be justified. Additional placement of fat during the refinement phase can raise the degree of morbidity and should be undertaken with surgical experience and with proper patient preoperative counseling. Advanced techniques should be undertaken only in experienced hands. Only skin is removed in an upper blepharoplasty, with occasional removal of a protuberant medial fat pad as needed. A conservative transconjunctival lower blepharoplasty should be performed, removing an appropriate amount of medial and middle fat pad. The lateral fat pad should be addressed if there is a sizable protuberance of fat in that area. Consider using a malar implant in combination with fat transfer in thin patients who lack sufficient fat reserves for harvesting. The lateral mandible cannot be addressed if a concurrent facelift is performed. Care should be taken to avoid undermining skin in areas of transplanted fat.