Clinical Procedures in Laser Skin Rejuvenation - part 10 docx

18.1 Preoperative a and postoperative b photographs of a patient who underwent a deep plane facelift, lower lid transconjunctival blepharoplasty, and upper lid blepharoplasty, combined w

Fig 18.1 Preoperative (a) and postoperative (b) photographs of a patient who underwent a deep plane facelift, lower lid transconjunctival blepharoplasty, and upper lid blepharoplasty, combined with fat transfer to superior and inferior orbital rim, midface, and prejowl sulcus

Fig 18.2 (a) This patient has a prominent-appearing eye following an aggressive isolated lower lid transconjunctival blepharoplasty (b) An attractively framed eye following periobital and midface fat transfer Reprinted with permission from Lam

SM, Glasgold MJ, Glasgold RA.: Complementary Fat Grafting Philadelphia: Lippincott Williams & Wilkins; 2007

PREOPERATIVE CONSIDERATIONS

Anatomy

Periorbital volume restoration is of primary importance

in creating an appropriately full frame around the eye

The most important component of the ‘frame’ is the

inferior orbital rim Reviewing photographs of models

allows us to understand this aesthetic ideal.Variations in

the upper periorbital frame exist, with the most

com-mon appearance being a full brow with a few

millime-ters of the upper lid skin visible (Fig 18.3) Some very

attractive individuals have relatively sculpted and

hol-lowed brow/upper eyelid complexes, but uniformly

every young beautiful face has a full lower eyelid that

blends seamlessly with a full cheek Again, review of an

individual’s old photographs will help determine what is

a natural appearance for the specific patient As already

mentioned, significant pseudoherniation of lower

orbital fat will benefit from selective reduction via a

transconjunctival blepharoplasty combined with

con-current filling of the inferior orbital rim by autologous

fat transfer Similarly, a truly deflated and hanging upper

eyelid would be best approached with conservative

removal of redundant skin, with some degree of fat

transfer into the brow (Fig 18.4)

The cheek is an extension of the lower frame of the eye and is a vital component of a youthul heart-shaped face The cheek can be divided into anterior and lateral components With advancing age, the anterior cheek, which develops the most significant volume loss along the malar septum, is a primary target for fat transfer The lateral cheek, when restored, should reveal the lustrous highlight that is associated with a convex youthful shape (Fig 18.5) Often, the buccal region must be volume-enhanced,

as it becomes relatively hollow after augmentation of the malar region However, care must be taken to avoid overfilling this area if the patient desires the more sculpted look that manifests in one’s 30s as opposed to the fuller oval shape of someone in their early 20s

Placement of fat into the precanine fossa and nasolabial fold is not so much intended to efface the linear depression but rather to provide an improved contour from the newly augmented cheek to the upper lip.We believe that any one of a number of avail-able dermal fillers is more useful for elimination of the nasolabial and labiomandibular folds Similarly, lip augmentation with fat grafting only yields subtle results after considerable and protracted postoperative edema

Fig 18.3 A youthful face with an attractive periorbital frame.This young woman (who has not had surgery) demonstrates a full upper eyelid with only several millimeters

of lid skin visible and a lower eyelid that transitions seamlessly into a full cheek

Reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA.: Complementary Fat Grafting

Philadelphia: Lippincott Williams & Wilkins; 2007

Facial fat grafting of the lower face is centered on

finishing the lower point of the triangle of a youthful

countenance.Therefore, the focus of fat grafting along

the lower face is concentrated in the prejowl sulcus,

anterior chin, labiomental sulcus, and labiomandibular

depression Augmentation of the lateral mandible

can-not be undertaken concurrently with a facelift due to

undermining of the skin in this portion of the face

Patients with mild jowling or prejowl volume loss can

achieve a very good restoration of the jawline with fat

grafting alone In contrast, we have found that it is

dif-ficult to truly attain a straightened jawline with facial

fat grafting alone in patients who have a heavy jowl and

that, for optimal patient and surgeon satisfaction, a

facelift should be incorporated for these patients

However, augmentation of the prejowl with fat

graft-ing can enhance the result of any facelift, and is

incor-porated into most of our rhytidectomies (Fig 18.6)

Consultation

As with any cosmetic consultation, the ultimate goal is

to establish aesthetic objectives for surgical and/or nonsurgical intervention mutually agreed between the surgeon and the prospective patient Besides the stan-dard psychological, emotional, and aesthetic consider-ations that are part of every initial patient encounter, the surgeon must establish aesthetic goals, realistic expectations, and an understanding of the potential recovery period that relate specifically to fat grafting These unique considerations will be elaborated in this section, and can be incorporated into the framework

of a standard consultation

Often during the consultation, the patient must be refocused on what truly gives them an aging appear-ance Women, in particular, focus on fine lines that typically achieve disproportionate importance when

Fig 18.4 Preoperative (a) and postoperative (b) photographs of a patient who underwent upper lid skin-only blepharoplasty, lower lid transconjunctival blepharoplasty, and periorbital and midface fat transfer

Fig 18.5 Preoperative (a) and postoperative (b) photographs of a patient who underwent transconjunctival lower lid

blepharoplasty and periorbital and midface fat transfer Reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA.: Complementary Fat Grafting Philadelphia: Lippincott Williams & Wilkins; 2007

Fig 18.6 (a) Patient following a facelift, with the appearance of persistent jowling (b) Volume augmentation of the prejowl sulcus creates a straight jawline Reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA.: Complementary Fat Grafting Philadelphia: Lippincott Williams & Wilkins; 2007

viewed with a magnifying mirror and bright

illumi-nation during makeup application The consultation

aims to recalibrate their thinking to evaluate their

face the way other people see them from

conversa-tional distances Addiconversa-tionally, we point out that they

primarily see themselves only in frontal view in a

mirror, whereas in the real world they are usually

seen at an oblique angle.To help the patient

appreci-ate this, we will often take digital images of the

patient and review these with them Volume and

shape are emphasized over fine wrinkles and minor

cutaneous blemishes, which, to reiterate, are not

truly ameliorated with facial fat grafting Digital

imaging of possible results plays a very limited role

in the discussion of facial fat grafting It is almost

impossible to demonstrate the benefits of fat grafting

with digital morphing analysis, since the technology

is two-dimensional and the operative intervention

is three-dimensional Instead, use of a catalog of

before-and-after photographs of patients whom the

surgeon has taken care of is perhaps the most

effec-tive way of demonstrating to the patient the benefits

of fat grafting

Showing patients how they may look at 1 week, 2

weeks, 1 month, etc after surgery provides the most

useful information about potential recovery time

Most often, when an individual views other patients

during this early recovery period, he or she may not

perceive that they look very swollen, just better

However, it is important to emphasize that most of

these patients were uncomfortable with the way they

looked during the first 2–3 weeks following surgery

These psychological details are helpful to discuss with

each patient in the preoperative setting Use of old

photographs can also be very enlightening both for the

patient and for the surgeon.The patient should readily

grasp the volume changes associated with aging, and

the surgeon can better discuss with the patient what

aesthetic changes will be most beneficial toward

reestablishing a youthful appearance.As already stated,

many women do not like the fullness, often referred to

as ‘baby fat’, that is prevalent in their teens and early

20s, but prefer the relative sculpted (but not yet

hollow) appearance of themselves in their late 20s to

early 30s

OPERATIVE TECHNIQUE Donor harvesting

For very thin individuals, it may be advisable to evalu-ate potential donor sites during a preoperative visit Generally speaking, most patients will be able to inform the surgeon where they have abundant fat For instance, men are predominately truncal-dominant, whereas women can either be truncal (abdomen/ waist) or extremity (inner or outer thigh) dominant For very thin individuals or those who have undergone extensive prior body liposuctioning, the lower back and triceps may be ideal reserves that remain for har-vesting Most commonly, the lower abdomen and inner thigh serve as excellent donor sites for fat harvesting if intraoperative patient repositioning is problematic

Before lower abdomen harvesting is undertaken, it

is imperative to inquire what abdominal procedures the patient has had in the past and to evaluate the dis-tribution of abdominal scars In order to ensure that the patient does not have an occult ventral or umbilical hernia, the surgeon should ask the patient to Valsalva in

a supine position with his or her head elevated for optimal evaluation Obviously, a hernia in the field of harvesting would preclude harvesting in that area Many aesthetic surgeons who are uncomfortable with body harvesting express trepidation about uninten-tional violation of the visceral cavity during harvesting This outcome is very unlikely, especially under con-scious sedation, given the thickness of the muscular fascia as well as the exquisite discomfort elicited when the fascia is even abraded with the harvesting cannula For the inner thigh, the surgeon must ensure that the cannula passes through a superficial fascial layer before fat harvesting can commence Superficial passage of the cannula is evident by the visibility of the cannula through the skin, which should be immediately cor-rected to avoid a potential contour deformity in the donor area

Although fat grafting can be undertaken with any level of anesthesia, we have found that intravenous sedation provides excellent pain control and patient compliance After the patient is adequately sedated,

the donor area is infiltrated with 0.25% lidocaine with

1:400 000 epinephrine using a 20 cm3syringe

outfit-ted with a 22-gauge spinal needle (The mixture is

attained by combining 5 cm3 of 1% lidocaine and

1:100 000 epinephrine with 15 cm3of normal saline.)

If the patient is under oral sedation, then a higher

per-centage of lidocaine (0.5% lidocaine with 1:200 000

epinephrine) should be used to improve patient

com-fort (The mixture is attained by combining 10 cm3of

1% lidocaine and 1:100 000 epinephrine with 10 cm3

of normal saline.) When allocating the 20 cm3of local

anesthesia, the surgeon should aim to place 10 cm3in

the deep aspect of the fat pad (immediately above

the muscle/fascia) and 10 cm3 into the immediate

subcutaneous plane, leaving the bulk of the fat pad

untouched with anesthetic

After the patient has been sterilely prepped and

draped, a 16-gauge Nokor needle (or No.11

Bard–Parker blade) is used to make a stab incision for

entry of the harvesting cannula For lower abdominal

harvesting, the incision can be made inside the lower

aspect of the umbilicus or suprapubically, and for the

inner thigh, it can be made along the inguinal crease

Many different types of harvesting cannulas can be

used We prefer a 3 mm bullet-tipped cannula for

har-vesting (Fig 18.7) All harhar-vesting is undertaken with a

10 cm3syringe manually, i.e., without machine

assis-tance, using only 1–2 cm3of negative pressure on the

plunger A few technical pearls that can help the novice

surgeon undertake harvesting easily and effectively

should be enumerated First, the surgeon should

attempt to remain within the middle substance of the

fat pad Rippling of the skin with passage of the cannula

indicates that the cannula is too superficial.The surgeon

should always be cognizant of where the cannula tip

resides, as the tip is the active end where fat enters If

the cannula tip abrades the deep fascia or goes beyond

the anesthetized area, the patient can experience undue

and unnecessary discomfort As the surgeon continues

harvesting, the cannula should be retracted almost back

to the entry site before redirecting to the adjacent site

If the cannula tip is not withdrawn prior to directing it

to an adjacent site to continue harvesting, the surgeon

will effectively be harvesting in the same passage site,

not in a new area While harvesting, the nondominant

hand should stabilize the fat pad, not squeeze or deform the donor area, to prevent uneven harvesting and potential donor-site contour deformity.When harvest-ing, the surgeon should recall that usable fat will be about one half the harvest volume, e.g., each 10 cm3

syringe will yield approximately 5 cm3of viable fat

Processing the fat The next step is processing the fat.The 10 cm3syringes are placed in the centrifuge and spun for approximately 2–3 minutes at 2000 to 3000 rpm.This will sufficiently separate the unwanted blood, lidocaine, and lysed fat cells from viable fat cells Before centrifugation, each

10 cm3syringe must be outfitted with customized caps and plugs to ensure that the contents do not spill out during the centrifugation process It is imperative not to use the prepackaged plastic caps that fit onto the Luer-Lok side, as they will invariably become detached dur-ing centrifugation It should also be emphasized that the centrifuge should be able to accommodate either sterile individual sleeves that hold each syringe or, alterna-tively, an entire central rotary element that holds all of the syringes, which can be removed and sterilized After the fat has been centrifuged, the supranatant (from the plunger side), consisting of lysed fat cells, is poured off Only after removing the supranatant is the Luer-Lok cap removed and the infranatant drained A noncut 4×4 gauze (or cotton neuropaddy) is placed into the plunger side, making contact with the column

of fat in order to wick the remaining supranatant away After 5–10 minutes, the column of fat is then poured from the open plunger side of the 10 cm3syringes into the open plunger side of a 20 cm3Luer-Lok syringe The 20 cm3syringe should not be filled beyond the

15 cm3 mark When pouring the fat into the 20 cm3

syringe, the surgeon should attempt to keep any resid-ual bloody infranatant in the original 10 cm3syringe.A Luer-Lok transfer hub allows transfer of fat from the

20 cm3syringe into 1 cm3Luer-Lok syringes used for fat injection The plunger on the 1 cm3syringe should

be drawn all the way until it is actually removed from the syringe while filling the syringe with fat, so as to eliminate the air bubble that typically resides between

the plunger and the end of the fat column.The plunger

is then returned to the 1.0 cm3 mark to maintain

accurate volume counts

Fat infiltration

The following general principles of technique will help

to optimize results and minimize problems The

pri-mary principle behind safe fat grafting, particularly

when learning the technique, is to ‘hit doubles’ rather

than strive for a ‘home run’ Placing too much fat into

any area, especially in the periorbital region, is very

difficult to correct, whereas placement of additional

fat can be easily and quickly undertaken in a second

session (see ‘Management of complications’ below)

Placement of fat is done only in small parcels

(0.03–0.05 cm3 per pass for sensitive areas and

0.1 cm3per pass in more forgiving zones) in order to

attain optimal fat cell survival by allowing maximal

contact of each particle with the surrounding tissue

and neighboring blood supply.The use of blunt

cannu-las (Fig 18.7) (Tulip Medical Inc., San Diego, CA;

Byron Medical Inc., Tucson, AZ; Miller Medical Inc.,

Mesa, AZ) allows for less traumatic insertion of fat,

resulting in less bruising and swelling.While injecting fat, the nondominant hand is used to palpate the underlying bony landmarks (to be discussed below) in order to guide the passage of the cannula in the correct depth and location Finally, as the cannula tip cannot be visualized, the surgeon must mentally envision the depth of the tip during the procedure We have divided the injection planes into three basic levels, which will be referred to throughout this section on infiltration technique, as deep (corresponding to the supraperiosteal level), medium (the musculofascial or deep subcutaneous level), and superficial (the superficial subcutaneous depth)

Recipient site anesthesia The three skin entry sites (A: midcheek; B: lateral can-thal; and C: posterior to the prejowl sulcus) are infil-trated with 1% lidocaine with 1:100 000 epinephrine (Fig 18.8).Then, appropriate facial regional blocks are performed, usually including the infraorbital, zygo-maticotemporal, zygomaticofacial, and supraorbital nerves An 18-gauge needle is used to create the three entry sites on each side of the face The same infiltra-tion cannula intended for fat infiltrainfiltra-tion is used to inject local anesthesia (1% lidocaine with 1:100 000 epinephrine) into the planned recipient sites in order

to minimize tissue trauma

Inferior orbital rim The inferior orbital rim is the area that requires special attention in terms of both total volume placed and tech-nique Fat grafting to the inferior orbital rim is done through an entry site on the cheek, which allows the fat

to be deposited perpendicular to the bony orbital rim

In our experience, a lateral-based entry point in which the cannula is passed parallel to the orbital rim con-tributes to an unacceptably high incidence of fibrotic fat bulges Generally speaking, for the beginning surgeon,

we advocate placement of 1 cm3of fat along the medial inferior orbital rim and 1 into the lateral inferior orbital rim The fat is injected into the deep (supraperiosteal) plane.The nondominant index finger is used to palpate the rim to confirm the appropriate cannula depth and to guard against injury to the globe (Figure 18.9) As the cannula tip is passed perpendicularly across the inferior orbital rim (about 1 mm in either direction), 0.05 cm3

of fat is layered per pass of the cannula Additional fat

Fig 18.7 The Glasgold Fat Transfer Set (Tulip Medical

Inc.): 0.9 mm×4 cm blunt spoon-tip infiltration cannula;

1.2 mm×6 cm blunt spoon-tip infiltration cannula;

2 mm×12 cm multiport harvesting cannula; 3 mm×15 cm

bullet-tip harvesting cannula Reprinted with permission

from Lam SM, Glasgold MJ, Glasgold RA.:

Complementary Fat Grafting Philadelphia: Lippincott

Williams & Wilkins; 2007

can be placed for more volume-depleted patients at a

medium depth Fat infiltration superficial to the

orbicu-laris oculi muscle is not recommended.The

supramus-cular plane in this region has no added advantage, and

has significant potential for contour irregularity.We

rec-ommend being conservative with volumes in this area

until the surgeon is comfortable with the technique

Even for the more experienced fat injector, we caution

against exceeding 4 cm3in the infraorbital rim at one

setting in order to minimize problems

Superior orbital rim/brow

The primary objective in filling the superior orbital

rim is to re-establish a youthful appearing lateral brow

convexity Filling a markedly hollow upper eyelid sulcus

is an advanced technique, lying beyond the scope of this chapter Placement of fat along the superior orbital rim can be undertaken easily from a lateral entry point and rapidly filled using 0.1 cm3per pass without difficulty or significant risk of contour deformity.The passage of the cannula should follow the plane of least resistance.The appearance of this area being overfilled may arise toward the end of augmentation – this should give rise to alarm,

as it will settle over time Generally, 2 cm3of fat begins

to restore the deflated lateral-brow convexity

Nasojugal groove The nasojugal groove is the triangular depression out-lined superiorly by the medial inferior orbital rim and medially by the nasal sidewall For the purposes of fat transfer, we make a distinction between the nasojugal groove and the tear trough The latter is distinguished

as the visible depression in the region of the medial orbital rim, which, depending on a patient’s particular anatomy, may or may not directly correlate with the bony nasojugal groove The nasojugal groove is gener-ally filled with 1 cm3 of fat, which can be placed quickly with 0.1 cm3per pass of the cannula

Anterior cheek The area of greatest volume loss in the anterior cheek

is usually along a linear depression running from superomedial to inferolateral, corresponding to the malar septum The anterior cheek is infiltrated from the lateral canthal entry point As the cannula passes through the anterior cheek, it is common to feel resis-tance from the malar septum.The primary areas of fat deposition in the anterior cheek are along the malar septum and anteromedial to it Caution should be taken to not overfill this region in men, as this may feminize the face In general, 3 cm3of fat are injected, with 0.1 cm3per pass.The surgeon should try to visu-alize the passage of the cannula from a deeper to a pro-gressively more superficial plane to distribute the fat cells more widely and thereby enhance the potential for adipocyte survival The volumes used can be increased as needed for more volume-depleted patients Anterior cheek volumes should be more conservative in males, where a fuller anterior cheek will tend to feminize the face

Fig 18.8 The three red marks correspond to the planned

entry sites for fat injections: midcheek (A), lateral canthus

(B), and posterior to the prejowl sulcus (C).The black marks

indicate the areas for planned fat injections Reprinted with

permission from Lam SM, Glasgold MJ, Glasgold RA.:

Complementary Fat Grafting Philadelphia: Lippincott

Williams & Wilkins; 2007

Lateral cheek

The lateral cheek highlight is a very important youthful

landmark to restore Approached from the midcheek

entry point, the area overlying the lateral zygoma is augmented with 2–3 cm3of fat The injection can be tapered into the submalar region as needed The tech-nique of gradual progression from a deep to a superfi-cial plane and placement of 0.1 cm3per pass is the same

as that described for anterior cheek augmentation

Buccal Many women find the slight hollow of the buccal region that arises in their early 30s to be attractive

by creating a more sculpted appearance Progressive buccal volume loss will lend the appearance of poor health, and in women can also be masculinizing During a fat augmentation procedure, the addition of volume to the cheeks may create a relative buccal hol-lowing, which should be addressed The buccal area can be approached from multiple entry sites, including the midcheek or lateral canthal entry sites; alterna-tively, a separate lateral commissure entry site can be made for buccal access Filling can progress rapidly as above, with 0.1 cm3per pass in every tissue plane.The buccal area can sustain significant volume enhance-ment without deformity, e.g., 3–8 cm3per side

Precanine fossa/nasolabial fold

As mentioned above, the objective of filling the pre-canine fossa (the bony triangular depression deep to the superior limit of the nasolabial fold and adjacent

to the nasal ala) and the nasolabial fold is not to elimi-nate the fold but to provide improved transition from the augmented cheek to the augmented upper lip.The patient should be cognizant of this limitation so that realistic expectations are established preoperatively The precanine fossa is infiltrated in the deep supra-periosteal plane with approximately 2 cm3of fat The nasolabial fold can be augmented with 2–3 cm3of fat along multiple levels using 0.1 cm3per pass without significant risk of deformity.These areas are addressed from the midcheek entry point so the cannula will pass perpendicular to the nasolabial fold

Prejowl sulcus/anterior chin/labiomental sulcus/labiomandibular fold

The prejowl sulcus is perhaps the most important area

in the lower face to address with autologous fat trans-fer Placement of fat along the prejowl sulcus will not

Fig 18.9 Fat injection of the inferior orbital rim

(a) Demonstration of how placement of the index finger of the

nondominant hand is used to protect the globe and give

tactile feedback as to the cannula position (b) Intraoperative

demonstration of the vector for approaching the inferior

orbital rim in a perpendicular orientation from the midcheek

entry site Reprinted with permission from Lam SM, Glasgold

MJ, Glasgold RA.: Complementary Fat Grafting

Philadelphia: Lippincott Williams & Wilkins; 2007

a

b

completely straighten a jawline that exhibits moderate

to marked jowling, but will significantly enhance any

facelift result.The prejowl sulcus should be thought of

as a three-dimensional cylinder that runs along the

anterior and inferior borders of the mandible

Generally, 3 cm3of fat are placed using 0.1 cm3per pass

from an entry site just posterior to the prejowl sulcus,

typically about midway along the mandibular body.The

first 1 cm3is placed deeply along the anterior

madibu-lar border.The second 1 cm3is placed deeply along the

inferior mandibular border, and the third 1 cm3 is

placed at a medium-depth to transition between the

two In patients with a deeper sulcus, larger volumes

will be needed to obtain the desired result Additional

fat can be feathered into the anterior chin, labiomental

sulcus, and labiomandibular fold as needed It is

impor-tant to emphasize that the degree of variable resorption

of fat in the anterior chin leads to less predictable

results in terms of chin projection than can be achieved

with an implant Therefore, when the primary goal is

anterior chin projection, an alloplastic chin implant

is our preferred treatment option Nevertheless, fat

transfer to the anterior chin/mental sulcus region can

accentuate the beauty of a youthful face by restoring

the inferior apex of the ideal heart shape previously

discussed

POSTOPERATIVE CONSIDERATIONS

Postoperative care

At the end of the procedure, the patient does not

require any dressings, bandages, drains, or suture

clo-sures for the body or for the face Icing of all recipient

sites will help mitigate postoperative edema After the

first 48–72 hours, the patient may ice the recipient

areas as they would like Sleeping with the head

elevated for the first several days may also aid in

reduc-tion of edema Reducing dietary for the first several

weeks after surgery may also lessen edema.The patient

should refrain from strenuous activity so as not to

exacerbate and prolong edema unnecessarily The

patient can return to a modified exercise regimen after

the first week and should slowly progress toward a

full, standard program, verifying all the while that

edema does not worsen with that activity.There are no

restrictions on activity for harvested areas, except for not submerging the incisions for a week

Postoperatively, patients often complain of a dull ache and soreness in the donor areas that exceeds any dis-comfort felt in their face However, there may be some degree of tenderness and tightness in the face, particu-larly in the malar region Occasionally, patients can feel a flush sensation in the malar area during the first post-operative week, which can be ameliorated with icing Ecchymosis and edema are most pronounced over the first two postoperative weeks During the first week, the patient may appear grossly disfigured, which will be proportionate to the amount of fat transferred and the number and extent of concurrent rejuvenation procedures Ongoing changes will be evident postop-eratively for several months, and it should be empha-sized to the patient that what he or she is seeing is normal and expected due to the dissipation of edema Educating patients preoperatively and reviewing the expected changes postoperatively are helpful for the patient to have the appropriate understanding of the changes they are seeing as swelling subsides

Management of complications The area most susceptible to complications is the peri-orbital region.The conservative policy of fat enhance-ment (‘hitting doubles’) previously outlined should be followed so as to minimize the occurrence of prob-lems In order to correct a complication, the surgeon must correctly identify the problem This section will outline the unique types of problems that occur with fat grafting and how to treat each specific entity The types of complications can be classified as follows: lumps, bulges, overcorrection, and undercorrection

Lumps

A lump is a soft discrete contour deformity that arises when too much fat is transplanted to a specific locus or placed in an imprecise fashion Although steroid injec-tions have been attempted to manage this problem, they are generally not very effective An incision with direct removal of the offending lump often must be undertaken Although uncommon, visible lumps are most apt to occur along the inferior orbital rim If a lump from the region of the lower lid is to be