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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.3 Aging
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D. De Fazio
Fig. 30.4 Surgical instruments
30.1 Surgical Technique
The sampling region is inltrated with 1000 mL of saline
solution mixed with 1 vial of adrenaline and 4 vials of carbocaine (Fig.30.4). A 19G needle is used to access the tissue
and then a 1.5mm diameter inltration cannula with multiple holes is used which is connected to a 10cc Luer-Lock
syringe. The same cannula is then used to remove adipose
tissue connected to the 10cc Luer-Lock syringe. By aspirating adipocytes through 1mm holes, it is possible to harvest
very small droplets of adipose tissue called micro-fat. The
characteristics of this adipose tissue are ideal for carrying out
a volumetric correction of the eyelids or malar region. In particular, the characteristics of adipose tissue ltered through
small holes eliminates the risks of creating visible and evident fat accumulations in the eyelids compartments. Indeed,
the risk to end up with a visible and palpable fat graft, especially at the level of the lower eyelid, is one of the most concrete risk of this method. There are different types of devices
on the market to obtain the micro and nanofat once taken
with standard method connected to a syringe. Already
Tonnard and authors had described a method of connectors
for syringe with decreasing diameters that allows to treat the
adipose tissue with multiple passages from one syringe to
another progressively reducing the diameter of the connector
in order to obtain a more uid graft and reducing cellularity
(Figs.30.5 and 30.6).
By transforming the adipose tissue into a nanofat, we can
obtain a regenerative graft that has lost its volumizing function, proper of the normal adipose tissue, but maintains the
regenerative ones.
Fig. 30.5 Transfer of adipose tissue between syringes with connectors
of different diameters
Fig. 30.6 Particular device enabling partial ltration of brous material in a closed sterile system, in order to obtain micro, nano, or macro
fat
30.2 Types ofFat Grafting Either
forVolumizing or Regenerative
Results
Type of fat grafts Parcel size Injection site
Macrofat <2.4mm Deep fat compartments
Microfat <1.2mm Supercial fat compartments
Nanofat <400–600 ù • Subdermal
• Intradermal
• Microneedling
Preoperative drawing is carried out with the patient
standing in upright position, in order to mark exactly the
sinking above the lower orbital margin (Fig.30.7). Access is
performed with an 18G needle about 2cm from the lateral
margin of the orbit and 1cm below to the lower orbital mar-
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.7 Cross-fat injection
gin. Then, multiple crossings are made in the deep subcutaneous compartment by using a 19 Gauge lipolling cannula
connected to a 1cm Luer-Lock syringe. The correction of
the lower eyelid also includes tear trough deformity and it
extends inferiorly, medially and laterally by grafting
microfat.
Volumes of microfat regularly grafted at the level of the
lower eyelids range from 1 to 4cc on average.
The intervention is performed in sedation and local anesthesia by inltrating the region of interest with carbocaine
plus adrenaline.
The graft is inserted deeply being able to lay the cannula in contact with the inferior orbital bone margin and
gradually it supercializes without, however, risking to
make evident any cutaneous irregularities of the adipose
graft.
The lipolling of the lower eyelids should not be overcorrected to avoid a result with excessive volume of fat. The
graft is then carried out in the lower eyelid under the orbicolaris oculi muscle in the SOOF compartment (Figs. 30.8,
30.9, 30.10, and 30.11).
Fig. 30.8 Access points
Fig. 30.9 Lateral margin access of lower eyelid
Tonnard’s technique involves the transformation of adipose tissue into nanofat which can be injected with needles
of 25 gauge using either and intradermal, subdermal, or needling technique.
This adipose tissue that has lost its volumizing characteristics maintains a regenerative effect for the eyelid skin. On
average, from 0.5 to 2cc of nanofat are used for the lower
eyelid (Fig.30.12).
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Fig. 30.10 Microfat and nanofat technique
Fig. 30.11 Nanofat
Fig. 30.12 Nanofat intradermal implantation technique
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Nanofat has a regenerative effect and it is used with needling technique with accurate device for the skin of the malar
region (Figs.30.13, 30.14, 30.15, 30.16, and 30.17).
Fig. 30.16 Step 2
Fig. 30.13 Nanofat
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Fig. 30.14 Device’s lling with nanofat
Fig. 30.15 Microneedling with nanofat step 1
Fig. 30.17 Step 3
30.3 Clinical Cases
Patient 45years old 21.34 BMI
Lipolling microfat lower eyelid 2.5cc each side nano-
fat 1.5cc each side
Marionette 2.5cc microfat each side
Nasiolabial fold 2.5cc microfat each side (Figs.30.18,
30.19, 30.20, and 30.21)
Patient 55years old 21.23 BMI
Lipolling microfat cheekbone 4cc each side, cheek
30 cc nanofat each side, marionette 2 cc microfat each
side Eyebrow 1.5cc microfat each side and 2cc nanofat
(Figs.30.22, 30.23, 30.24, and 30.25)
Patient 59years old 23.21 BMI
Lipolling microfat lower eyelid 2cc each side nanofat
1.5cc each side
Marionette 1.5cc microfat each side
Nasiolabial fold 4 cc microfat right side and 5 cc
microfat left (Figs.30.26, 30.27, and 30.28)
Patient 66years old 26.18 BMI
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Fig. 30.18 Pre and post 2years
Fig. 30.19 15days later
Lipolling microfat lower eyelid 2.5cc left side nanofat 1.5cc left side, microfat 1cc right side
Marionette 2 cc microfat each side, nasiolabial fold
3cc microfat each side, malar area 5cc (Fig.30.29)
Patient 45years old 21.30 BMI
Superior blepharoplasty lipolling microfat lower
eyelid 1.5cc each side nano fat 1.5cc each side
Marionette 1.5cc microfat each side
Nasiolabial fold 3cc left and 2cc right microfat, superior lip 6cc nanofat (Figs.30.30, 30.31, and 30.32)
Patient 43years old 21.48 BMI
Lipolling malar scar microfat 3cc and nanofat 2.5cc
and “rigottomies” with 18G needle to relax the brosis
(Figs.30.33, 30.34, and 30.35)
Patient 54years old 18.36 BMI
Lipolling microfat lower eyelid 1.5cc each side nanofat 1.5cc each side
Marionette 2.5 cc (Figs.30.36 and 30.37)
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.20 Pre and post 2years
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Fig. 30.21 Pre and post 2years
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D. De Fazio
Fig. 30.22 Pre and post 1year
Fig. 30.23 Pre
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Fig. 30.24 Pre and post 1year
Fig. 30.25 Pre and post 1year
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D. De Fazio
Fig. 30.26 Pre and post 12months
Fig. 30.27 Pre and post 12months
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