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Fat Grafting to the Forehead/Glabella/Radix Complex and Pyriform Aperture: Aesthetic and Anti-Aging Implications

Fat Grafting to the Forehead/Glabella/Radix Complex and Pyriform Aperture: Aesthetic and... Downloaded from http://journals.lww.com/prsgo by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/08/2021 D. Mythili Original artiCle Original Article Cosmetic xxx Fat Grafting to the Forehead/Glabella/Radix xxx Complex and Pyriform Aperture: Aesthetic and 2015 Anti-Aging Implications Plastic & Reconstructive Surgery-Global Open Andrew N. Kornstein, MD*† Background: Optimal aesthetic outcomes from rhinoplasty are heavily influ- Jeremy S. Nikfarjam, MD‡ enced by structures adjacent to the nose. Although the importance of the chin has been emphasized since the inception of rhinoplasty, little attention has been given to the forehead. The forehead/glabella/radix complex repre- sents a vital triad in rhinoplasty, from which the nasofrontal angle is derived. In the present study, the authors sought to determine whether fat grafting Facial Fat Grafting: Aesthetic and Anti-Aging Implications to the forehead/glabella/radix complex and pyriform aperture can favor- ably impact the nasofrontal and nasolabial angles, respectively. Methods: The authors reviewed pre- and postoperative images (obtained Kornstein and Nikfarjam by an independent professional photographer) of patients who underwent autologous fat grafting to the forehead/glabella/radix region and the pyri- form aperture, with or without concurrent rhinoplasty. Nasofrontal and nasolabial angles were measured on lateral images. Mean pre- and post- operative values were calculated and compared. A Wilcoxon rank-sum test was used for statistical analysis. Results: Twenty-six patients underwent fat grafting alone (FG group; mean follow-up, 3.3 years), and 19 had fat grafting plus rhinoplasty (FG + R group; mean follow-up, 5.2 years). The mean nasofrontal angle in the FG group de- creased by 2.0° (P = 0.005), and the mean nasolabial angle increased by 2.3° (P = 0.006). The mean nasofrontal angle in the FG + R group decreased by 2.0° (P = 0.011), and the mean nasolabial angle increased by 6.0° (P = 0.026). Conclusions: Autologous fat grafting to the forehead/glabella/radix com- plex and pyriform aperture is a reliable method to favorably influence the nasofrontal and nasolabial angles, respectively. Such treatment optimizes the interplay between the nose and the adjacent facial features, enhancing overall aesthetics. (Plast Reconstr Surg Glob Open 2015;3:e500; doi: 10.1097/ GOX.0000000000000470; Published online 27 August 2015.) hinoplasty began as an operation of the cent to the nose, particularly the interplay between nasal profile, with particular emphasis on the nose and the chin. He described nasal hump 1 2 R nasal reduction and reshaping. Aufricht reduction and “transplantation” of the osteocar- was one of the first rhinoplasty surgeons to tilaginous segment to the chin as a treatment for describe the significance of facial features adja- microgenia. From the *Museum Mile Surgery Center, New York, N.Y.; Copyright © 2015 The Authors. Published by Wolters †Split Rock Surgical Associates, Wilton, Conn.; and ‡the Divi- Kluwer Health, Inc. on behalf of The American Society of sion of Plastic and Reconstructive Surgery, Montefiore Medical Plastic Surgeons. All rights reserved. This is an open-access Center / Albert Einstein College of Medicine, New York, N.Y. article distributed under the terms of the Creative Commons Received for publication November 4, 2014; accepted July Attribution-Non Commercial-No Derivatives License 4.0 1, 2015. (CCBY-NC-ND), where it is permissible to download and This research was awarded First Prize, R.K. Daniel Resident share the work provided it is properly cited. The work cannot be © 2015 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American changed in any way or used commercially. Award, at the 19th Annual Meeting of The Rhinoplasty Society of Plastic Surgeons. All rights reserved. DOI: 10.1097/GOX.0000000000000470 Society, April 24, 2014, San Francisco, Calif. 10.1097/GOX.0000000000000470 www.PRSGlobalOpen.com 1 Downloaded from http://journals.lww.com/prsgo by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/08/2021 PRS Global Open • 2015 Unlike the chin, the forehead has received little In the present study, the authors examined whether or no attention in relation to the nose. According fat grafting to the forehead, glabella, and radix com- to Ousterhout, the forehead functions to convey plex can provide control of the nasofrontal angle and, beauty, strength, feelings of intelligence, and various similarly, if fat grafting to the pyriform aperture can emotions. Methods to alter its contour include bony favorably influence the nasolabial angle. The study advancement, bone grafts, Silastic implants (Dow population included patients who underwent fat graft- Corning, Midland, Mich.), and methyl methacrylate, ing alone (FG group) and patients who underwent it in his method of choice (at the time of publication). An conjunction with rhinoplasty (FG + R group). In all cas- internet search of “forehead augmentation” yielded es, the procedures were performed to address aesthetic only a few results for forehead augmentation with concerns that included the appearance of the nose. fat or methyl methacrylate, all of which were Asian 4–6 cosmetic sites, and none of them mentioned the PATIENTS AND METHODS influence of the forehead on the nose. Only recently (September 2014), in a review of forehead rejuve- Study Design nation, was forehead contour mentioned along with A level III retrospective review was performed of more standard techniques. independently obtained professional photographs of Anatomically, the forehead comprises 2 compo- consecutive patients who underwent fat grafting to the nents, the upper forehead and the supraorbital bar, forehead/glabella/radix complex and the pyriform which contribute to the nasofrontal angle (Fig. 1). aperture, with or without concomitant rhinoplasty. The forehead, glabella, and radix represent a critical All procedures were performed by the senior author triad in aesthetic rhinoplasty, forming the nasofron- (A.N.K.). Eligible participants were required to have tal angle. This relationship is similar to the interplay both pre- and postoperative professional clinical pho- between the upper lip, the columella, and the nasal tographs. Patients who had undergone rhinoplasty tip, reflecting the nasolabial angle. previously or had received prior injections of dermal Autologous fat grafting to the face is growing fillers or botulinum toxin A were excluded from the in popularity and is currently regarded as a reli- analysis. Written informed consent was provided by all 8,9 able and efficacious procedure. It is being used study patients after the risks and benefits of the proce- increasingly to revolumize the aging face, as a dures had been discussed thoroughly with them. stand-alone treatment or in conjunction with sur- gical procedures such as facelifts and rhinoplasties Review of Photographs performed by the senior author (A.N.K.). Facial All photographs originated from a prospectively atrophy, including soft tissues and skeletal remod- maintained database owned by the senior author eling, directly influence both the nasofrontal and (A.N.K.). Pre- and posttreatment frontal and lateral 10–12 nasolabial angles. From the senior author’s 20- images of eligible patients were evaluated. Data col- year experience with this procedure, he believes (as lected during the review included patient age, gen- do many of his patients) that successful fat graft- der, follow-up interval, quantity of grafted fat, and ing may help control ongoing facial atrophy in ad- measurements of nasofrontal and nasolabial angles dition to remedying the contour issues associated (obtained from the photographs). Measurements 13,14 with aging. With respect to age-related bone at- were expressed in degrees. rophy, the senior author posits that it results from progressive diminution of blood supply. Vascular Measurement of Nasofrontal Angles growth factors in successfully grafted fat cells are The radix was marked on right-sided lateral pho- able to retard ongoing bone loss. tographs. Lines were drawn using a digital protrac- tor to the junction of the forehead and the nasal dorsum. If a deep radix was present, the protracted Disclosure: Dr. Kornstein is in private practice in New lines were set to a point just anterior to the radix to York City, N.Y., where he is the Director of the Museum facilitate accurate measurement of the angle. Angles Mile Surgery Center. He is also a member of Split Rock were measured using Adobe Photoshop 7.0 (San Surgical Associates in Wilton, Conn. Dr. Nikfarjam Jose, Calif.) and documented. is a fellow in plastic and reconstructive surgery at the Montefiore Medical Center / Albert Einstein College of Measurement of Nasolabial Angles Medicine, New York, N.Y. The authors have no finan- The junction of the upper lip and the columella cial interest to declare in relation to the content of this was marked on right-sided lateral photographs. article. The Article Processing Charge was paid for by Lines were drawn using a digital protractor to the the authors. upper lip and columellar-lobule junction. If this Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 1. t he upper forehead and the supraorbital bar contribute to the nasofrontal angle. r eprinted with permission from Ousterhout DK, ed. Aesthetic Contouring of the Cranio- facial Skeleton. 1st ed. San Francisco, Calif.: little, Brown and Co; 1991. junction was curvilinear, a point was made on the patient was assessed before injection. Less fibrous fat midpoint of the curve. Angle measurements were has better flow characteristics, permitting smoother documented. infiltration. It is important to be cognizant of the flow characteristics of the fat being injected to pre- Surgical Techniques vent irregularities and to ensure that specimens of Fat Harvesting and Injection similar quality are used symmetrically. Donor sites were infiltrated with tumescent solu- Attention was then focused on the recipient 3 3 tion (1 cm to 1 cm for expected volume of fat har- sites of the face. No incisions were made; instead, a vested), and fat was harvested using a 3-mm Luer-lock 16-gauge needle was used to provide cannula access. cannula under low pressure in 10-cm syringes. Fat was Then, small aliquots of fat were injected through a then collected in 10-cm syringes, and oil and serum 17-gauge side port bullet-tip cannula (Grams Medi- were decanted before centrifugation. The harvested cal, Costa Mesa, Calif.). The tip of the cannula was fat samples were centrifuged at 3000 rpm for 2–4 min- placed to a depth until bone was palpated. Fat was utes, depending on the tissue turgor of the specimens. injected in tiny aliquots to maintain intimate contact The goal was to obtain a homogeneous “paste” that with adequate vascular supply, similar to skin graft- could be easily and predictably injected. The oil and ing. Digital control of aliquot dispersion and mini- serum were again fractionated and decanted. mizing side-to-side sweeping of the cannula (which Viable fat cells were placed in 1-cm syringes can produce local tissue trauma) are important for achieving optimal results. in preparation for injection. The fat type of each 3 PRS Global Open • 2015 The initial injections were administered in the Table 1. Descriptive Data for Patients Who deep compartments, preperiosteally, with careful at- Underwent Fat Grafting Alone (FG Group) tention to local skin turgor. If skin laxity and contour Nasal Mean were not addressed sufficiently, the injection pro- Angle Preoperative Postoperative Difference P ceeded superficially. It is imperative to constantly re- Nasofrontal 136.7° 134.7° 2.0° 0.005 evaluate the global aesthetics of the face during the Nasolabial 93.6° 95.9° 2.3° 0.006 injection process to ensure blending of the forehead Preoperative and postoperative angles are mean values. and the nose and of the upper lip and nasal base. Any lumps that might have remained after injection Table 2. Descriptive Data for Patients Who were aspirated with the 19-gauge injection cannula. Underwent Fat Grafting + Rhinoplasty (FG + R Group) The amount of fat injected varies according to Nasal Mean the site itself and the goals of the patient and sur- Angle Preoperative Postoperative Difference P geon. Approximately 20 cm of fat was injected into Nasofrontal 136.4° 134.4° 2.0° 0.011 the lower forehead and nasofrontal region until the Nasolabial 94.5° 100.5° 6.0° 0.026 aesthetic endpoint of a lateral-to-lateral and cranial- Preoperative and postoperative angles are mean values. to-caudal gentle convexity was achieved. The mean nasofrontal angle was 136.7° before treat- Rhinoplasty ment and 134.7° after treatment (Table 1). The differ- Standard rhinoplasty techniques were performed ence between the mean values was 2.0° (P = 0.005). as dictated by preoperative and intraoperative evalu- The mean nasolabial angle in this group was 93.6° ation and until the senior author was satisfied with before treatment and 95.9° after treatment. The dif- the result in the operating room. ference between the mean values was 2.3° (P = 0.006). Comparisons and Statistical Analysis FG + R Group (n = 19) Pre- and postoperative nasofrontal and nasola- The average volumes of injected fat were 13.94 bial angles were compared within the FG and FG + 3 3 cm to the nasofrontal region and 12.36 cm to the R groups. A Wilcoxon rank-sum test and SPSS Sta- pyriform region. tistics software (version 21 for Mac; IBM, Armonk, The mean nasofrontal angle was 136.4° pre- N.Y.) were used to compare pre- and posttreatment operatively and 134.4° postoperatively (Table 2). measurements. Statistical significance was defined as The difference between the mean values was 2.0° P < 0.05. (P = 0.011). The mean nasolabial angle was 94.5° preopera- RESULTS tively and 100.5° postoperatively. The difference be- Each study group was analyzed separately. As not- tween the mean values was 6.0° (P = 0.026). ed earlier, the FG group underwent fat grafting to the No complications occurred in either group. nasofrontal and pyriform regions alone, and the FG Long-term fat retention throughout the follow-up + R group received fat grafting to the same regions period was ≥80% in all patients. Visual and digital in conjunction with rhinoplasty. The FG group com- examination revealed smooth forehead contour in prised 24 women and 2 men, with a mean age of 44.15 all cases. Representative before-and-after clinical years (range, 23–60 years) and mean follow-up period photographs are shown in Figures 2–5. of 3.3 years (range, 0.64–9.1 years). The FG + R group consisted of 17 women and 2 men, with a mean age of DISCUSSION 39.10 years (range, 27–63 years) and mean follow-up Rhinoplasty modifies the central feature of the time of 5.2 years (range, 0.28–11.4 years). face, and outcomes are judged from both frontal Postoperative measurements of both angles were and lateral views. Thus, the rhinoplastic operation is collected during follow-up visits. Data from the most inherently influenced by adjacent facial structures. recent follow-up visit are presented herein. Through- A truly comprehensive approach requires consider- out the follow-up period, no patient in either study ation and, when necessary, alteration of the struc- group received additional fat grafting to these regions. tures required to optimize “global” nasal aesthetics. Postoperative Measurements Findings of the present study suggest that the nose FG Group (n = 26) can be reliably influenced by altering the contour The average volumes of injected fat were 19.60 and dimension of the forehead, glabella, and ra- 3 3 cm to the nasofrontal region and 11.61 cm to the dix complex, and therefore the nasofrontal angle, as well as by stabilizing the nasal “foundation”—the pyriform region. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 2. Fat grafting and rhinoplasty. Preoperative lateral (a ), postoperative lateral (B), preoperative frontal (C), and postoperative frontal (D) images of a 27-year-old white woman who underwent autologous fat grafting to the nasofrontal and pyriform regions in combination with open rhinoplasty. t he preoperative photographs demonstrate a “premature” forehead, at- rophy of the glabella and radix, and an acute nasolabial angle. t he post- operative photographs, obtained 6.5 years after the procedures, show improved contour of the lower forehead after transplantation of 19 cm of fat to the nasofrontal region and 16.5 cm to the pyriform region. note reduction of the nasofrontal angle (from 133.4° preoperatively to 124.6° postoperatively) and greater tip rotation, with significant change in the nasolabial angle (from 51.3° preoperatively to 85.8° postoperatively). pyriform aperture (known to enlarge with age)—via prominence and its exacerbation of perceived na- long-lasting autologous fat grafts. sal projection” (Fig. 6). Historically, the structures most commonly Aesthetic facial analysis begins with dividing the addressed in relation to the nasal profile are face into anatomic zones. Four imaginary horizon- the radix, chin, and neck. However, Greer et al tal lines are drawn: (1) at the anterior hairline, (2) commented that “although rarely altered, sur - at the eyebrows, (3) at the columellar-labial junction, geons frequently point out the lack of forehead and (4) at the edge of the chin. Ideally, the vertical 5 PRS Global Open • 2015 Fig. 3. Fat grafting and rhinoplasty. Preoperative (a ) and postoperative (B) lateral views of a 37-year-old white woman who underwent autologous fat grafting and rhinoplasty. t his patient did not require any change in tip rota- tion. Preoperatively, the patient had a retrusive upper facial third (forehead/ glabella/radix complex) and an open nasofrontal angle, contributing to the appearance of an over-projected nose. t he postoperative photograph, ob- tained 6.3 years after the procedure, shows improvement in facial balance and contour. t he patient received 12 cm of fat in the nasofrontal region and 18 cm in the pyriform region (including a posttraumatic nasolabial scar). note reduction of the nasofrontal angle (from 141.5° preoperatively to 137.6° postoperatively), with no change in tip rotation. Fig. 4. Fat grafting alone. Preoperative (a ) and postoperative (B) lateral views of a 33-year-old white woman who underwent autologous fat graft- ing of the face. t he preoperative photograph demonstrates flattening of the lower forehead with an open nasofrontal angle and an appropriately rotated nasal tip. t he postoperative photograph, obtained 1.6 years fol- lowing the procedure, shows improvement in forehead contour. t he pa- of fat in the nasofrontal region only. note reduction tient received 3 cm in the nasofrontal angle (from 134.3° preoperatively to 130.5° postopera- tively) and no change in tip rotation. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 5. Fat grafting alone. Preoperative lateral (a ), postoperative lateral (B), preoperative frontal (C), and postoperative frontal (D) images of a 51-year- old white woman who underwent autologous fat grafting of the face. t he preoperative photographs demonstrate loss of forehead volume and contour, with an obtuse nasofrontal angle and an appropriately rotated nasal tip. t he postoperative photographs, obtained 5.8 years after the procedure, show greater fullness and contour of the forehead. t he patient received 19 cm of fat in the nasofrontal region. note improvement in the nasofrontal angle (from 137.4° preoperatively to 130.3° postoperatively) and the slight change in the nasal tip (from 94.5° preoperatively to 96.3° postoperatively) presumably due to malar, nasolabial, and upper white lip autologous fat augmentation. measurements between lines 1 and 2, lines 2 and 3, and Modifications to date have focused predominantly on lines 3 and 4 should be equal to one another; this is the muscle and skin layers (eg, neurotoxin injections, commonly termed “the rule of thirds.” Therefore, the resurfacing, and foreheadplasty). Greater attention to forehead represents the majority of the upper third of the bone and fat pads is critical if we are to harmonize the face. Yet in terms of aesthetic enhancement and/or and optimize facial anatomy and aesthetics as well as ac- antiaging therapies, it receives surprisingly little atten- count for the changes that accompany aging. Although tion. The forehead is composed of 4 lamellar compo- bone is difficult to replace and sculpt, autologous fat nents: (1) bone, (2) muscle, (3) fat pads, and (4) skin. grafting (and/or temporary dermal fillers) may treat 7 PRS Global Open • 2015 to Sheen and Sheen, the “radix” denotes the origin or root of the nose. However, the nasion is the most depressed part of the nose, lying 4 mm to 6 mm deep to the glabella, at the level of the upper lid margin. Fat grafting is also a uniquely customizable means of altering the forehead and the glabella. The naso- frontal angle represents the transition between the forehead and the nose, where a soft concave curve connects the brow and the dorsum of the nose. This angle can vary from 128° to 140°, with ideal values being 134° in women and 130° in men. Furthermore, fat grafting to the radix may mini- mize complications associated with other means of radix augmentation, such as visibility, resorption, and donor-site issues, while providing a readily available solution to the thick nasal base. According to McKinney and Sweis, modifying (increasing) nasal radix height lessens the amount of hump or tip modification re- quired. This is especially important in patients whose skin is thick. A cranial radix position creates a lon- ger nasal dorsum with reduced anterior projection, whereas a caudal position delineates a shorter nasal dorsum and increased anterior projection. A deep radix reduces the nasofrontal angle, whereas a high radix opens or enlarges the nasofron- tal angle. Changes associated with aging, including those affecting bone, muscle, fat, and skin, are active Fig. 6. Young woman with enhanced nasal prominence due determinants of the nasofrontal angle. The glabella to a retrusive forehead/glabella/radix complex. image of Bar- bra Streisand, reprinted with permission from Steve Schapiro. and nasion are known to retrude with advancing age. Bossing of the forehead may be present due to hyperaeration of the frontal sinus. Depression or congenital deformities and sequelae of aging, restor- flatness in the lower forehead may result from soft- ing more normal anatomy, as evidenced by their direct tissue atrophy or bony remodeling that accompany influence on the position and contour of the brow, gla- 21 22 the aging process. Pessa and Chen and other in- bella, radix, and other structures. vestigators have noted that the orbital aperture wid- Fat grafting provides a safe and long-lasting means ening that occurs with aging may significantly affect of controlling the position of the radix. According Fig. 7. Pan facial fat grafting. Preoperative (a ) and postoperative (B) frontal views of a 49-year- old white woman who underwent autologous fat grafting to bilateral malar regions in 2002 3 3 3 ; left, 4 cm ) and in 2011 (pan facial, 57 cm ). t he postoperative image, obtained (right, 7 cm more than 3 years after the pan facial procedure, demonstrates apparent reduction in nasal size (width) due to restoration of facial volume. a lso note the reduction in dyschromia (pres- ent preoperatively), presumably due to adipose growth factors. (no other treatments have been rendered to her face since the fat grafting.) Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 8. Chin augmentation with fat grafting. Preoperative (a ) and postop- erative (B) lateral views of a 58-year-old white woman who had a retrusive and vertical deficient chin as well as a deep labiomental crease and dis- harmony of the upper and lower lips. She received autologous fat grafting to the lower lip, labiomental groove, parasymphyseal region, and mentalis 3 3 (left, 8 cm ; right, 14 cm ). note the overall improvement in contour, which would not have been achievable by genioplasty or prosthetic augmenta- tion alone. Fig. 9. Chin augmentation with fat grafting. Preoperative (a ) and postoperative (B) lateral views of a 46-year-old white woman with a retrusive chin who underwent autologous fat 3 3 grafting (13 cm bilaterally to the labiomental grooves, 4 cm to the submental crease, and 6 cm to the mentalis). t he postoperative image was obtained 4.1 years after augmentation. note the reduction in mentalis strain. the overlying soft-tissue envelope and the appear- fat pad, immediately and dramatically reduces the ance of the aged forehead. apparent size of the nose and improves harmony Changes in forehead and glabellar musculature among facial features (Fig. 7). are also dynamic, with either hypertrophy or atro- With respect to chin augmentation, the most phy (often due to regular neurotoxin use), enhanc- common procedures are prosthetic implants and ing or diminishing the overlying soft-tissue volume, osseous genioplasty. Both typically address only a respectively. Taken together, these factors directly small segment of the chin, usually the caudal por- impact the nasofrontal angle and thereby directly tion. If one considers the many anatomic changes influence apparent nasal length and anterior pro- that occur with aging, fat grafting is an ideal choice jection. However, attempts to reduce a high radix because of its versatility. Aging shortens the lower by resecting bone and/or soft tissue are not as suc- third of the face secondary to atrophy of fat, weak- cessful. According to Sheen and Sheen and Daniel ening of the orbicularis oris, and maxillary alveolar 24 25 et al, the response rate is 25%: 1 mm of deepening hypoplasia. Fat grafting alone, or in combination for every 4 mm of resection. This is presumably due with autogenous and alloplastic augmentation, al- to poor redraping of the glabellar skin, which makes lows for greater control of chin vertical height and deepening the radix difficult at best. a more harmonious transition to adjacent structures Fat grafting is also effective for influencing nasal such as the jowl, buccal, and lower lip regions, as well aesthetics in frontal views. Restoring facial volume, as ameliorating asymmetry with their contralateral especially in the malar region and the lateral facial counterparts (Fig. 8). Finally, restoring support for 9 PRS Global Open • 2015 Fig. 10. illustration of the plunging tip deformity secondary to skeletal aging. note derotation of the nasal tip with an acute nasolabial angle due, in part, to posterior and superior atrophy of the pyriform aperture. Cor- rection of the plunging tip includes tip rotation through alteration of the nasal base/pyriform aperture and the tip complex. r eprinted with permis- sion from Pessa Je, Peterson Ml, t hompson JW, et al. Pyriform augmenta- tion as an ancillary procedure in facial rejuvenationsurgery. Plast Reconstr Surg. 1999;103:683–686. the mentalis muscle can positively affect strain and iting loss of skeletal support with long-term fat graft- lower lip position (Fig. 9). An elevated lower lip can ing may reduce age-related nasal changes. reflexly shorten an elongated upper lip. Augmentation of the pyriform aperture restores Aging is typically accompanied by midface retru- nasal support, permits tip rotation, and may limit na- sion. This includes the pyriform aperture, which sal aging by stabilizing bone resorption via adipose remodels posteriorly relative to the upper face, result- cell–derived vascular growth factor revascularization ing in loss of bony support for the alar base. The an- in and around the nasal foundation. Therefore, it terior-posterior position of the alar base is important is likely that some nasal revisions could be avoided in determining the nasolabial angle, which changes by reconstitution of the nasal foundation. Long- as we age. Augmenting the facial skeleton by placing term follow-up of patients who undergo fat grafting hydroxylapatite beneath the alar base results in an- plus rhinoplasty may demonstrate a reduction in the terior reprojection and tip rotation. In the present number of revisions needed, owing to minimization study, fat grafting was shown to successfully rotate the 11 of these skeletally induced changes. tip in a manner similar to that of hydroxylapatite and may provide a more durable result. Furthermore, our CONCLUSIONS results indicate that fat grafting and rhinoplasty are Autologous fat grafting to the forehead/glabel- additive in their effects on rotating the nasal tip. Fat lar/radix complex and pyriform aperture may be grafting alone rotated the tip 2.3°, whereas fat graft- used consistently and reliably to modify the naso- ing plus rhinoplasty achieved rotation of 6°. frontal angle and the nasolabial angle, respectively. Although a patient’s soft-tissue response to the Although the interplay between the nose and the amount of injected fat is not linear, our results chin has been a major focus of aesthetic evaluation showed that all patients experienced improvement of the nose since the inception of rhinoplasty, its in forehead projection and narrowing of the naso- facial counterpart—the forehead—has been un- frontal angle. derappreciated, perhaps because a safe and reliable The pyriform aperture also remodels superiorly, means to alter the forehead had been lacking. Au- pulling the alar base with it. This action leads to a tologous fat grafting brings the aesthetic evaluation plunging or caudal inclination of the nasal tip (Fig. 10). Finally, loss of skeletal support for the alar of the nasal profile full circle and optimizes aesthet- base can affect the medial foot plates, and splaying ic balance from the frontal view. Controlling facial of the medial crura reduces columellar height and aging in and around the pyriform aperture poten- tip widening. Stabilization of the nasal base by lim- tially may reduce the number of late nasal revisions. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications 11. Pessa JE, Desvigne LD, Zadoo VP. The effect of skel- Andrew N. Kornstein, MD etal remodeling on the nasal profile: considerations 1050 Fifth Avenue for rhinoplasty in the older patient. Aesthetic Plast Surg. New York, NY 10028 1999;23:239–242. E-mail: info@kornstein.com 12. Pessa JE, Peterson ML, Thompson JW, et al. Pyriform aug- mentation as an ancillary procedure in facial rejuvena- tion surgery. Plast Reconstr Surg. 1999;103:683–686. ACKNOWLEDGMENT 13. Kornstein A, Nikfarjam JS. Facial rejuvenation with fat We thank Lynda Seminara of ClearView Medical cells. In: Herman CK, Strauch B, eds. Encyclopedia of Communications, LLC, for editorial assistance. Aesthetic Rejuvenation through Volume Enhancement. 1st ed. New York, N.Y.: Thieme; 2014:52–59. 14. McArdle A, Senarath-Yapa K, Walmsley GG, et al. The PATIENT CONSENT role of stem cells in aesthetic surgery: fact or fiction? Plast Patients provided written consent for the use of their Reconstr Surg. 2014;134:193–200. 15. Greer SE, Matarasso A, Wallach SG, et al. Importance of images. the nasal-to-cervical relationship to the profile in rhino- plasty surgery. Plast Reconstr Surg. 2001;108:522–531; dis- REFERENCES cussion 532–535. 1. Joseph J. Operative Reduction of the Size of the Nose 16. Guyuron B. Patient assessment. In: Guyuron B, Eriksson (Rhinomiosis). 1898. E, Persing JA, et al, eds. Plastic Surgery: Indications and 2. Aufricht G. Combined plastic surgery of the nose and Practice. 1st ed. 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Fat Grafting to the Forehead/Glabella/Radix Complex and Pyriform Aperture: Aesthetic and Anti-Aging Implications

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© 2015 American Society of Plastic Surgeons
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10.1097/GOX.0000000000000470
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Downloaded from http://journals.lww.com/prsgo by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/08/2021 D. Mythili Original artiCle Original Article Cosmetic xxx Fat Grafting to the Forehead/Glabella/Radix xxx Complex and Pyriform Aperture: Aesthetic and 2015 Anti-Aging Implications Plastic & Reconstructive Surgery-Global Open Andrew N. Kornstein, MD*† Background: Optimal aesthetic outcomes from rhinoplasty are heavily influ- Jeremy S. Nikfarjam, MD‡ enced by structures adjacent to the nose. Although the importance of the chin has been emphasized since the inception of rhinoplasty, little attention has been given to the forehead. The forehead/glabella/radix complex repre- sents a vital triad in rhinoplasty, from which the nasofrontal angle is derived. In the present study, the authors sought to determine whether fat grafting Facial Fat Grafting: Aesthetic and Anti-Aging Implications to the forehead/glabella/radix complex and pyriform aperture can favor- ably impact the nasofrontal and nasolabial angles, respectively. Methods: The authors reviewed pre- and postoperative images (obtained Kornstein and Nikfarjam by an independent professional photographer) of patients who underwent autologous fat grafting to the forehead/glabella/radix region and the pyri- form aperture, with or without concurrent rhinoplasty. Nasofrontal and nasolabial angles were measured on lateral images. Mean pre- and post- operative values were calculated and compared. A Wilcoxon rank-sum test was used for statistical analysis. Results: Twenty-six patients underwent fat grafting alone (FG group; mean follow-up, 3.3 years), and 19 had fat grafting plus rhinoplasty (FG + R group; mean follow-up, 5.2 years). The mean nasofrontal angle in the FG group de- creased by 2.0° (P = 0.005), and the mean nasolabial angle increased by 2.3° (P = 0.006). The mean nasofrontal angle in the FG + R group decreased by 2.0° (P = 0.011), and the mean nasolabial angle increased by 6.0° (P = 0.026). Conclusions: Autologous fat grafting to the forehead/glabella/radix com- plex and pyriform aperture is a reliable method to favorably influence the nasofrontal and nasolabial angles, respectively. Such treatment optimizes the interplay between the nose and the adjacent facial features, enhancing overall aesthetics. (Plast Reconstr Surg Glob Open 2015;3:e500; doi: 10.1097/ GOX.0000000000000470; Published online 27 August 2015.) hinoplasty began as an operation of the cent to the nose, particularly the interplay between nasal profile, with particular emphasis on the nose and the chin. He described nasal hump 1 2 R nasal reduction and reshaping. Aufricht reduction and “transplantation” of the osteocar- was one of the first rhinoplasty surgeons to tilaginous segment to the chin as a treatment for describe the significance of facial features adja- microgenia. From the *Museum Mile Surgery Center, New York, N.Y.; Copyright © 2015 The Authors. Published by Wolters †Split Rock Surgical Associates, Wilton, Conn.; and ‡the Divi- Kluwer Health, Inc. on behalf of The American Society of sion of Plastic and Reconstructive Surgery, Montefiore Medical Plastic Surgeons. All rights reserved. This is an open-access Center / Albert Einstein College of Medicine, New York, N.Y. article distributed under the terms of the Creative Commons Received for publication November 4, 2014; accepted July Attribution-Non Commercial-No Derivatives License 4.0 1, 2015. (CCBY-NC-ND), where it is permissible to download and This research was awarded First Prize, R.K. Daniel Resident share the work provided it is properly cited. The work cannot be © 2015 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American changed in any way or used commercially. Award, at the 19th Annual Meeting of The Rhinoplasty Society of Plastic Surgeons. All rights reserved. DOI: 10.1097/GOX.0000000000000470 Society, April 24, 2014, San Francisco, Calif. 10.1097/GOX.0000000000000470 www.PRSGlobalOpen.com 1 Downloaded from http://journals.lww.com/prsgo by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/08/2021 PRS Global Open • 2015 Unlike the chin, the forehead has received little In the present study, the authors examined whether or no attention in relation to the nose. According fat grafting to the forehead, glabella, and radix com- to Ousterhout, the forehead functions to convey plex can provide control of the nasofrontal angle and, beauty, strength, feelings of intelligence, and various similarly, if fat grafting to the pyriform aperture can emotions. Methods to alter its contour include bony favorably influence the nasolabial angle. The study advancement, bone grafts, Silastic implants (Dow population included patients who underwent fat graft- Corning, Midland, Mich.), and methyl methacrylate, ing alone (FG group) and patients who underwent it in his method of choice (at the time of publication). An conjunction with rhinoplasty (FG + R group). In all cas- internet search of “forehead augmentation” yielded es, the procedures were performed to address aesthetic only a few results for forehead augmentation with concerns that included the appearance of the nose. fat or methyl methacrylate, all of which were Asian 4–6 cosmetic sites, and none of them mentioned the PATIENTS AND METHODS influence of the forehead on the nose. Only recently (September 2014), in a review of forehead rejuve- Study Design nation, was forehead contour mentioned along with A level III retrospective review was performed of more standard techniques. independently obtained professional photographs of Anatomically, the forehead comprises 2 compo- consecutive patients who underwent fat grafting to the nents, the upper forehead and the supraorbital bar, forehead/glabella/radix complex and the pyriform which contribute to the nasofrontal angle (Fig. 1). aperture, with or without concomitant rhinoplasty. The forehead, glabella, and radix represent a critical All procedures were performed by the senior author triad in aesthetic rhinoplasty, forming the nasofron- (A.N.K.). Eligible participants were required to have tal angle. This relationship is similar to the interplay both pre- and postoperative professional clinical pho- between the upper lip, the columella, and the nasal tographs. Patients who had undergone rhinoplasty tip, reflecting the nasolabial angle. previously or had received prior injections of dermal Autologous fat grafting to the face is growing fillers or botulinum toxin A were excluded from the in popularity and is currently regarded as a reli- analysis. Written informed consent was provided by all 8,9 able and efficacious procedure. It is being used study patients after the risks and benefits of the proce- increasingly to revolumize the aging face, as a dures had been discussed thoroughly with them. stand-alone treatment or in conjunction with sur- gical procedures such as facelifts and rhinoplasties Review of Photographs performed by the senior author (A.N.K.). Facial All photographs originated from a prospectively atrophy, including soft tissues and skeletal remod- maintained database owned by the senior author eling, directly influence both the nasofrontal and (A.N.K.). Pre- and posttreatment frontal and lateral 10–12 nasolabial angles. From the senior author’s 20- images of eligible patients were evaluated. Data col- year experience with this procedure, he believes (as lected during the review included patient age, gen- do many of his patients) that successful fat graft- der, follow-up interval, quantity of grafted fat, and ing may help control ongoing facial atrophy in ad- measurements of nasofrontal and nasolabial angles dition to remedying the contour issues associated (obtained from the photographs). Measurements 13,14 with aging. With respect to age-related bone at- were expressed in degrees. rophy, the senior author posits that it results from progressive diminution of blood supply. Vascular Measurement of Nasofrontal Angles growth factors in successfully grafted fat cells are The radix was marked on right-sided lateral pho- able to retard ongoing bone loss. tographs. Lines were drawn using a digital protrac- tor to the junction of the forehead and the nasal dorsum. If a deep radix was present, the protracted Disclosure: Dr. Kornstein is in private practice in New lines were set to a point just anterior to the radix to York City, N.Y., where he is the Director of the Museum facilitate accurate measurement of the angle. Angles Mile Surgery Center. He is also a member of Split Rock were measured using Adobe Photoshop 7.0 (San Surgical Associates in Wilton, Conn. Dr. Nikfarjam Jose, Calif.) and documented. is a fellow in plastic and reconstructive surgery at the Montefiore Medical Center / Albert Einstein College of Measurement of Nasolabial Angles Medicine, New York, N.Y. The authors have no finan- The junction of the upper lip and the columella cial interest to declare in relation to the content of this was marked on right-sided lateral photographs. article. The Article Processing Charge was paid for by Lines were drawn using a digital protractor to the the authors. upper lip and columellar-lobule junction. If this Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 1. t he upper forehead and the supraorbital bar contribute to the nasofrontal angle. r eprinted with permission from Ousterhout DK, ed. Aesthetic Contouring of the Cranio- facial Skeleton. 1st ed. San Francisco, Calif.: little, Brown and Co; 1991. junction was curvilinear, a point was made on the patient was assessed before injection. Less fibrous fat midpoint of the curve. Angle measurements were has better flow characteristics, permitting smoother documented. infiltration. It is important to be cognizant of the flow characteristics of the fat being injected to pre- Surgical Techniques vent irregularities and to ensure that specimens of Fat Harvesting and Injection similar quality are used symmetrically. Donor sites were infiltrated with tumescent solu- Attention was then focused on the recipient 3 3 tion (1 cm to 1 cm for expected volume of fat har- sites of the face. No incisions were made; instead, a vested), and fat was harvested using a 3-mm Luer-lock 16-gauge needle was used to provide cannula access. cannula under low pressure in 10-cm syringes. Fat was Then, small aliquots of fat were injected through a then collected in 10-cm syringes, and oil and serum 17-gauge side port bullet-tip cannula (Grams Medi- were decanted before centrifugation. The harvested cal, Costa Mesa, Calif.). The tip of the cannula was fat samples were centrifuged at 3000 rpm for 2–4 min- placed to a depth until bone was palpated. Fat was utes, depending on the tissue turgor of the specimens. injected in tiny aliquots to maintain intimate contact The goal was to obtain a homogeneous “paste” that with adequate vascular supply, similar to skin graft- could be easily and predictably injected. The oil and ing. Digital control of aliquot dispersion and mini- serum were again fractionated and decanted. mizing side-to-side sweeping of the cannula (which Viable fat cells were placed in 1-cm syringes can produce local tissue trauma) are important for achieving optimal results. in preparation for injection. The fat type of each 3 PRS Global Open • 2015 The initial injections were administered in the Table 1. Descriptive Data for Patients Who deep compartments, preperiosteally, with careful at- Underwent Fat Grafting Alone (FG Group) tention to local skin turgor. If skin laxity and contour Nasal Mean were not addressed sufficiently, the injection pro- Angle Preoperative Postoperative Difference P ceeded superficially. It is imperative to constantly re- Nasofrontal 136.7° 134.7° 2.0° 0.005 evaluate the global aesthetics of the face during the Nasolabial 93.6° 95.9° 2.3° 0.006 injection process to ensure blending of the forehead Preoperative and postoperative angles are mean values. and the nose and of the upper lip and nasal base. Any lumps that might have remained after injection Table 2. Descriptive Data for Patients Who were aspirated with the 19-gauge injection cannula. Underwent Fat Grafting + Rhinoplasty (FG + R Group) The amount of fat injected varies according to Nasal Mean the site itself and the goals of the patient and sur- Angle Preoperative Postoperative Difference P geon. Approximately 20 cm of fat was injected into Nasofrontal 136.4° 134.4° 2.0° 0.011 the lower forehead and nasofrontal region until the Nasolabial 94.5° 100.5° 6.0° 0.026 aesthetic endpoint of a lateral-to-lateral and cranial- Preoperative and postoperative angles are mean values. to-caudal gentle convexity was achieved. The mean nasofrontal angle was 136.7° before treat- Rhinoplasty ment and 134.7° after treatment (Table 1). The differ- Standard rhinoplasty techniques were performed ence between the mean values was 2.0° (P = 0.005). as dictated by preoperative and intraoperative evalu- The mean nasolabial angle in this group was 93.6° ation and until the senior author was satisfied with before treatment and 95.9° after treatment. The dif- the result in the operating room. ference between the mean values was 2.3° (P = 0.006). Comparisons and Statistical Analysis FG + R Group (n = 19) Pre- and postoperative nasofrontal and nasola- The average volumes of injected fat were 13.94 bial angles were compared within the FG and FG + 3 3 cm to the nasofrontal region and 12.36 cm to the R groups. A Wilcoxon rank-sum test and SPSS Sta- pyriform region. tistics software (version 21 for Mac; IBM, Armonk, The mean nasofrontal angle was 136.4° pre- N.Y.) were used to compare pre- and posttreatment operatively and 134.4° postoperatively (Table 2). measurements. Statistical significance was defined as The difference between the mean values was 2.0° P < 0.05. (P = 0.011). The mean nasolabial angle was 94.5° preopera- RESULTS tively and 100.5° postoperatively. The difference be- Each study group was analyzed separately. As not- tween the mean values was 6.0° (P = 0.026). ed earlier, the FG group underwent fat grafting to the No complications occurred in either group. nasofrontal and pyriform regions alone, and the FG Long-term fat retention throughout the follow-up + R group received fat grafting to the same regions period was ≥80% in all patients. Visual and digital in conjunction with rhinoplasty. The FG group com- examination revealed smooth forehead contour in prised 24 women and 2 men, with a mean age of 44.15 all cases. Representative before-and-after clinical years (range, 23–60 years) and mean follow-up period photographs are shown in Figures 2–5. of 3.3 years (range, 0.64–9.1 years). The FG + R group consisted of 17 women and 2 men, with a mean age of DISCUSSION 39.10 years (range, 27–63 years) and mean follow-up Rhinoplasty modifies the central feature of the time of 5.2 years (range, 0.28–11.4 years). face, and outcomes are judged from both frontal Postoperative measurements of both angles were and lateral views. Thus, the rhinoplastic operation is collected during follow-up visits. Data from the most inherently influenced by adjacent facial structures. recent follow-up visit are presented herein. Through- A truly comprehensive approach requires consider- out the follow-up period, no patient in either study ation and, when necessary, alteration of the struc- group received additional fat grafting to these regions. tures required to optimize “global” nasal aesthetics. Postoperative Measurements Findings of the present study suggest that the nose FG Group (n = 26) can be reliably influenced by altering the contour The average volumes of injected fat were 19.60 and dimension of the forehead, glabella, and ra- 3 3 cm to the nasofrontal region and 11.61 cm to the dix complex, and therefore the nasofrontal angle, as well as by stabilizing the nasal “foundation”—the pyriform region. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 2. Fat grafting and rhinoplasty. Preoperative lateral (a ), postoperative lateral (B), preoperative frontal (C), and postoperative frontal (D) images of a 27-year-old white woman who underwent autologous fat grafting to the nasofrontal and pyriform regions in combination with open rhinoplasty. t he preoperative photographs demonstrate a “premature” forehead, at- rophy of the glabella and radix, and an acute nasolabial angle. t he post- operative photographs, obtained 6.5 years after the procedures, show improved contour of the lower forehead after transplantation of 19 cm of fat to the nasofrontal region and 16.5 cm to the pyriform region. note reduction of the nasofrontal angle (from 133.4° preoperatively to 124.6° postoperatively) and greater tip rotation, with significant change in the nasolabial angle (from 51.3° preoperatively to 85.8° postoperatively). pyriform aperture (known to enlarge with age)—via prominence and its exacerbation of perceived na- long-lasting autologous fat grafts. sal projection” (Fig. 6). Historically, the structures most commonly Aesthetic facial analysis begins with dividing the addressed in relation to the nasal profile are face into anatomic zones. Four imaginary horizon- the radix, chin, and neck. However, Greer et al tal lines are drawn: (1) at the anterior hairline, (2) commented that “although rarely altered, sur - at the eyebrows, (3) at the columellar-labial junction, geons frequently point out the lack of forehead and (4) at the edge of the chin. Ideally, the vertical 5 PRS Global Open • 2015 Fig. 3. Fat grafting and rhinoplasty. Preoperative (a ) and postoperative (B) lateral views of a 37-year-old white woman who underwent autologous fat grafting and rhinoplasty. t his patient did not require any change in tip rota- tion. Preoperatively, the patient had a retrusive upper facial third (forehead/ glabella/radix complex) and an open nasofrontal angle, contributing to the appearance of an over-projected nose. t he postoperative photograph, ob- tained 6.3 years after the procedure, shows improvement in facial balance and contour. t he patient received 12 cm of fat in the nasofrontal region and 18 cm in the pyriform region (including a posttraumatic nasolabial scar). note reduction of the nasofrontal angle (from 141.5° preoperatively to 137.6° postoperatively), with no change in tip rotation. Fig. 4. Fat grafting alone. Preoperative (a ) and postoperative (B) lateral views of a 33-year-old white woman who underwent autologous fat graft- ing of the face. t he preoperative photograph demonstrates flattening of the lower forehead with an open nasofrontal angle and an appropriately rotated nasal tip. t he postoperative photograph, obtained 1.6 years fol- lowing the procedure, shows improvement in forehead contour. t he pa- of fat in the nasofrontal region only. note reduction tient received 3 cm in the nasofrontal angle (from 134.3° preoperatively to 130.5° postopera- tively) and no change in tip rotation. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 5. Fat grafting alone. Preoperative lateral (a ), postoperative lateral (B), preoperative frontal (C), and postoperative frontal (D) images of a 51-year- old white woman who underwent autologous fat grafting of the face. t he preoperative photographs demonstrate loss of forehead volume and contour, with an obtuse nasofrontal angle and an appropriately rotated nasal tip. t he postoperative photographs, obtained 5.8 years after the procedure, show greater fullness and contour of the forehead. t he patient received 19 cm of fat in the nasofrontal region. note improvement in the nasofrontal angle (from 137.4° preoperatively to 130.3° postoperatively) and the slight change in the nasal tip (from 94.5° preoperatively to 96.3° postoperatively) presumably due to malar, nasolabial, and upper white lip autologous fat augmentation. measurements between lines 1 and 2, lines 2 and 3, and Modifications to date have focused predominantly on lines 3 and 4 should be equal to one another; this is the muscle and skin layers (eg, neurotoxin injections, commonly termed “the rule of thirds.” Therefore, the resurfacing, and foreheadplasty). Greater attention to forehead represents the majority of the upper third of the bone and fat pads is critical if we are to harmonize the face. Yet in terms of aesthetic enhancement and/or and optimize facial anatomy and aesthetics as well as ac- antiaging therapies, it receives surprisingly little atten- count for the changes that accompany aging. Although tion. The forehead is composed of 4 lamellar compo- bone is difficult to replace and sculpt, autologous fat nents: (1) bone, (2) muscle, (3) fat pads, and (4) skin. grafting (and/or temporary dermal fillers) may treat 7 PRS Global Open • 2015 to Sheen and Sheen, the “radix” denotes the origin or root of the nose. However, the nasion is the most depressed part of the nose, lying 4 mm to 6 mm deep to the glabella, at the level of the upper lid margin. Fat grafting is also a uniquely customizable means of altering the forehead and the glabella. The naso- frontal angle represents the transition between the forehead and the nose, where a soft concave curve connects the brow and the dorsum of the nose. This angle can vary from 128° to 140°, with ideal values being 134° in women and 130° in men. Furthermore, fat grafting to the radix may mini- mize complications associated with other means of radix augmentation, such as visibility, resorption, and donor-site issues, while providing a readily available solution to the thick nasal base. According to McKinney and Sweis, modifying (increasing) nasal radix height lessens the amount of hump or tip modification re- quired. This is especially important in patients whose skin is thick. A cranial radix position creates a lon- ger nasal dorsum with reduced anterior projection, whereas a caudal position delineates a shorter nasal dorsum and increased anterior projection. A deep radix reduces the nasofrontal angle, whereas a high radix opens or enlarges the nasofron- tal angle. Changes associated with aging, including those affecting bone, muscle, fat, and skin, are active Fig. 6. Young woman with enhanced nasal prominence due determinants of the nasofrontal angle. The glabella to a retrusive forehead/glabella/radix complex. image of Bar- bra Streisand, reprinted with permission from Steve Schapiro. and nasion are known to retrude with advancing age. Bossing of the forehead may be present due to hyperaeration of the frontal sinus. Depression or congenital deformities and sequelae of aging, restor- flatness in the lower forehead may result from soft- ing more normal anatomy, as evidenced by their direct tissue atrophy or bony remodeling that accompany influence on the position and contour of the brow, gla- 21 22 the aging process. Pessa and Chen and other in- bella, radix, and other structures. vestigators have noted that the orbital aperture wid- Fat grafting provides a safe and long-lasting means ening that occurs with aging may significantly affect of controlling the position of the radix. According Fig. 7. Pan facial fat grafting. Preoperative (a ) and postoperative (B) frontal views of a 49-year- old white woman who underwent autologous fat grafting to bilateral malar regions in 2002 3 3 3 ; left, 4 cm ) and in 2011 (pan facial, 57 cm ). t he postoperative image, obtained (right, 7 cm more than 3 years after the pan facial procedure, demonstrates apparent reduction in nasal size (width) due to restoration of facial volume. a lso note the reduction in dyschromia (pres- ent preoperatively), presumably due to adipose growth factors. (no other treatments have been rendered to her face since the fat grafting.) Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications Fig. 8. Chin augmentation with fat grafting. Preoperative (a ) and postop- erative (B) lateral views of a 58-year-old white woman who had a retrusive and vertical deficient chin as well as a deep labiomental crease and dis- harmony of the upper and lower lips. She received autologous fat grafting to the lower lip, labiomental groove, parasymphyseal region, and mentalis 3 3 (left, 8 cm ; right, 14 cm ). note the overall improvement in contour, which would not have been achievable by genioplasty or prosthetic augmenta- tion alone. Fig. 9. Chin augmentation with fat grafting. Preoperative (a ) and postoperative (B) lateral views of a 46-year-old white woman with a retrusive chin who underwent autologous fat 3 3 grafting (13 cm bilaterally to the labiomental grooves, 4 cm to the submental crease, and 6 cm to the mentalis). t he postoperative image was obtained 4.1 years after augmentation. note the reduction in mentalis strain. the overlying soft-tissue envelope and the appear- fat pad, immediately and dramatically reduces the ance of the aged forehead. apparent size of the nose and improves harmony Changes in forehead and glabellar musculature among facial features (Fig. 7). are also dynamic, with either hypertrophy or atro- With respect to chin augmentation, the most phy (often due to regular neurotoxin use), enhanc- common procedures are prosthetic implants and ing or diminishing the overlying soft-tissue volume, osseous genioplasty. Both typically address only a respectively. Taken together, these factors directly small segment of the chin, usually the caudal por- impact the nasofrontal angle and thereby directly tion. If one considers the many anatomic changes influence apparent nasal length and anterior pro- that occur with aging, fat grafting is an ideal choice jection. However, attempts to reduce a high radix because of its versatility. Aging shortens the lower by resecting bone and/or soft tissue are not as suc- third of the face secondary to atrophy of fat, weak- cessful. According to Sheen and Sheen and Daniel ening of the orbicularis oris, and maxillary alveolar 24 25 et al, the response rate is 25%: 1 mm of deepening hypoplasia. Fat grafting alone, or in combination for every 4 mm of resection. This is presumably due with autogenous and alloplastic augmentation, al- to poor redraping of the glabellar skin, which makes lows for greater control of chin vertical height and deepening the radix difficult at best. a more harmonious transition to adjacent structures Fat grafting is also effective for influencing nasal such as the jowl, buccal, and lower lip regions, as well aesthetics in frontal views. Restoring facial volume, as ameliorating asymmetry with their contralateral especially in the malar region and the lateral facial counterparts (Fig. 8). Finally, restoring support for 9 PRS Global Open • 2015 Fig. 10. illustration of the plunging tip deformity secondary to skeletal aging. note derotation of the nasal tip with an acute nasolabial angle due, in part, to posterior and superior atrophy of the pyriform aperture. Cor- rection of the plunging tip includes tip rotation through alteration of the nasal base/pyriform aperture and the tip complex. r eprinted with permis- sion from Pessa Je, Peterson Ml, t hompson JW, et al. Pyriform augmenta- tion as an ancillary procedure in facial rejuvenationsurgery. Plast Reconstr Surg. 1999;103:683–686. the mentalis muscle can positively affect strain and iting loss of skeletal support with long-term fat graft- lower lip position (Fig. 9). An elevated lower lip can ing may reduce age-related nasal changes. reflexly shorten an elongated upper lip. Augmentation of the pyriform aperture restores Aging is typically accompanied by midface retru- nasal support, permits tip rotation, and may limit na- sion. This includes the pyriform aperture, which sal aging by stabilizing bone resorption via adipose remodels posteriorly relative to the upper face, result- cell–derived vascular growth factor revascularization ing in loss of bony support for the alar base. The an- in and around the nasal foundation. Therefore, it terior-posterior position of the alar base is important is likely that some nasal revisions could be avoided in determining the nasolabial angle, which changes by reconstitution of the nasal foundation. Long- as we age. Augmenting the facial skeleton by placing term follow-up of patients who undergo fat grafting hydroxylapatite beneath the alar base results in an- plus rhinoplasty may demonstrate a reduction in the terior reprojection and tip rotation. In the present number of revisions needed, owing to minimization study, fat grafting was shown to successfully rotate the 11 of these skeletally induced changes. tip in a manner similar to that of hydroxylapatite and may provide a more durable result. Furthermore, our CONCLUSIONS results indicate that fat grafting and rhinoplasty are Autologous fat grafting to the forehead/glabel- additive in their effects on rotating the nasal tip. Fat lar/radix complex and pyriform aperture may be grafting alone rotated the tip 2.3°, whereas fat graft- used consistently and reliably to modify the naso- ing plus rhinoplasty achieved rotation of 6°. frontal angle and the nasolabial angle, respectively. Although a patient’s soft-tissue response to the Although the interplay between the nose and the amount of injected fat is not linear, our results chin has been a major focus of aesthetic evaluation showed that all patients experienced improvement of the nose since the inception of rhinoplasty, its in forehead projection and narrowing of the naso- facial counterpart—the forehead—has been un- frontal angle. derappreciated, perhaps because a safe and reliable The pyriform aperture also remodels superiorly, means to alter the forehead had been lacking. Au- pulling the alar base with it. This action leads to a tologous fat grafting brings the aesthetic evaluation plunging or caudal inclination of the nasal tip (Fig. 10). Finally, loss of skeletal support for the alar of the nasal profile full circle and optimizes aesthet- base can affect the medial foot plates, and splaying ic balance from the frontal view. Controlling facial of the medial crura reduces columellar height and aging in and around the pyriform aperture poten- tip widening. Stabilization of the nasal base by lim- tially may reduce the number of late nasal revisions. Kornstein and Nikfarjam • Facial Fat Grafting: Aesthetic and Anti-Aging Implications 11. Pessa JE, Desvigne LD, Zadoo VP. The effect of skel- Andrew N. Kornstein, MD etal remodeling on the nasal profile: considerations 1050 Fifth Avenue for rhinoplasty in the older patient. Aesthetic Plast Surg. New York, NY 10028 1999;23:239–242. E-mail: info@kornstein.com 12. Pessa JE, Peterson ML, Thompson JW, et al. Pyriform aug- mentation as an ancillary procedure in facial rejuvena- tion surgery. Plast Reconstr Surg. 1999;103:683–686. ACKNOWLEDGMENT 13. Kornstein A, Nikfarjam JS. 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Plastic & Reconstructive Surgery Global OpenWolters Kluwer Health

Published: Aug 1, 2015

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