Keywords

Introduction

Endoforehead lift is one of the most common endoscopic procedures among the techniques in endoscopic plastic surgery. The endoscopic “browlift” or “forehead lift” is similar to the open procedures where unidimensional or bidimensional stretching of the brow and forehead soft tissues is performed. Since Dr. Ramirez’s early pioneering work on the procedure, we have been gradually introducing several modifications to improve the outcome of the typical endoforehead. One of these modifications is the tridimensional or volumetric restoration of the upper face. Among the several modalities to obtain tridimensionality, we will deal in this chapter with tridimensional enhancement of the brow, glabella, and temple with microfat injection.

Surgical Technique

The brow glabella and temple augmentation by microfat injection is done at the completion of the endoforehead and after the fixation of the temporal and frontal flaps have been performed. The fat is obtained from the upper abdomen using 10-cc syringes and 2.1-mm harvesting cannula of the “Cell Friendly” system of Tulip Biomedical Company (San Diego, CA). The fat is spun on the electric centrifuge at about 3,000 rpm/m × 3 min. The water as well as the oily elements are decanted, and the fat is mixed with triamcinolone acetonide (Kenalog) in a ratio of 10 mg per each 30 cc of injectable fat. This mixture is then transferred to 1-cc Luer-Lock syringes for injection.

The injection is done using 0.9- and 1.2-mm diameter Ramirez type of microcannula of the Tulip “Cell Friendly” system. These cannulaes are atraumatic to the fat cell as well as to the recipient tissues.

The micro stab wound incisions are done using an 18-gauge Nokor needle. The pearls of fat are injected in different parallel layers in the brow area, from the infrabrow to the suprabrow areas in the vertical plane, from the head to the tail of the brow in the horizontal plane, and from the subdermal to the galeal layer in the anteroposterior plane (Fig. 97.1). An average of 2 cc (1–4 cc) of fat is injected to each brow. In the glabellar area, the creases are injected first using the 0.9-mm cannula; then, using the 1.2-mm cannula, fat is injected to the entire glabellar area including the area toward the medial infrabrow and under the head of the brow.

Fig. 97.1
figure 1

Fat is injected into the brow using the Ramirez “Cell Friendly” cannula of Tulip

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The fat is crisscrossed in different directions and different planes from the subdermal to the subcutaneous layer (Fig. 97.2). An average of 4 cc of fat is injected in the whole glabellar area. If the glabellar augmentation creates a deep nasoglabellar angle or if the patient has a preexistent deep angle, additional fat is injected to fill in this area. Fat also can be extended to the proximal nasal dorsum.

Fig. 97.2
figure 2

The crisscrossing technique for fat injection into the glabella

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Fat also can be injected into the temporal areas. The temples become wasted with development of a concavity during aging. Injection can be done through the tail of the brow. The fat is injected in multiple layers starting deep into the temporal fascia proper, then into the intermediate temporal fascia, into the temporalis fascia proper, and then in between the temporoparietalis fascia and subgaleal fascia. I do not recommend the injection into the subcutaneous or subdermal plane because there are large veins in this area that can be easily traumatized and also because contour irregularities can be produced very easily. I recommend 1.2-mm-diameter cannulas or larger for injection in this area to prevent inadvertent injection into three temporal veins with the potential fat emboli problems intracranially. The amount of fat injection will depend on the depth and surface that needs to be augmented. I have injected as little as 3 cc and as much as 15 cc to each temporal area.

Each one of the puncture wounds used for the fat injection is closed with single 6-0 Prolene sutures. This prevents the irritation of the point of entrance by the free oil, which can mimic an acne pimple and also the potential of extravasation of the fat.

Fat harvesting is done by the assistant and preparation by the surgical technicians while the surgeon is performing the endoforehead. So, the actual increase in time for the fat injection part of the procedure is very minimal. It will take as little as 5 min and as much as 15 min depending on the amount fat to be injected.

The aim of the volumetric enhancement of the temple, glabella, and brow areas with microfat injection was to enhance the esthetic results obtained with the typical endoforehead (Figs. 97.3, 97.4, 97.5, 97.6, 97.7, and 97.8). It will not only give you a tridimensional volumetric augmentation but also prevent the skeletonized or depressed look on those areas; this is commonly present after brow-/forehead lift. The procedure does not add on significant morbidity or recovery time to the basic operation. It can be done as an isolated procedure or as a secondary surgery following the standard endoforehead operation. It can also be used as an isolated procedure for patients who do not wish to have the endoscopic brow and forehead lift. However, the muscle action in the glabellar areas will prevent a good take of the fat, and there will be recurrence of the glabellar creases very quickly. The brow may also tend to become too heavy if they are not lifted prior to the fat injection. The temple areas will get the benefit in either of those situations (operated or nonoperated cases).

Fig. 97.3
figure 3

Preoperative frontal view. Observe the early sagging of the brow as well as a deflation process

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Fig. 97.4
figure 4

Postoperative frontal view of same patient. Notice the plump look of the brow and glabella

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Fig. 97.5
figure 5

Preoperative 3/4 view of a middle-aged woman. Notice the thin deflated brow with orbital skeletonization

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Fig. 97.6
figure 6

Postoperative 3/4 view of the same patient. Brow and orbital are full. No skeletonization. Also notice the volumetric augmentation of the glabella

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Fig. 97.7
figure 7

Preoperative 3/4 view in another middle-aged woman. Notice the deflated brow and loose infrabrow skin. Also notice the glabellar crease

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Fig. 97.8
figure 8

Postoperative 3/4 view. Observe the plump and convex glabella as well as the subtle fullness of the brows

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Conclusions

Fat injection techniques provide a tridimensional or volumetric augmentation to the forehead area; this restores the volume lost as a consequence of the aging process. It also prevents some of the undesirable sequelae of the standard brow-/forehead lift. The volumetric enhancement obtained provides to the patient the impression of vitality and youth. This gives a true rejuvenation to the brow and forehead areas. Representative views of patients with brow augmentation with microfat injection are included.