Structural fat grafting: more than a permanent filler

Adipose-derived stem cells for soft tissue reconstruction

In soft tissue repair, there are several surgical options such as nondegradable, inert, synthetic, biodegradable implants or autologous tissue transplantation. However, the potential of using autologous adult stem cells derived from fat tissue is quickly becoming a clinical reality. The possibility of using an abundant source of extraneous tissue as a soft tissue implant has significant implications for plastic and reconstructive surgeons. This strategy would be particularly useful after tumor removal or trauma. The ability of adult stem cells derived from adipose tissue (termed adipose-derived stem cell) to proliferate and differentiate in vivo or in vitro is actively being studied owing to the potential implementation in reconstructive surgery. This review describes innovative research strategies and discusses the first clinical studies involving adipose-derived stem cells as a motif for soft tissue reconstruction.

Freezing adipose tissue grafts may damage their ability to integrate into the host

In this study, the effect of freezing on the morphology, viability, and VEGF synthesis of human adipose tissue grafts is examined. Currently, storage of adipose grafts involves freezing in simple saline solutions. However, the effect of freezing on the morphology and function of adipose tissue remains unclear. As a result, this study attempts to determine whether freezing adipose grafts should be considered prior to soft-tissue augmentation. In this study, the freezing of adipose grafts in saline for only 24 hr resulted in morphological changes in vivo and affected their ability to synthesize VEGF. The use of a simple cryopreservation medium containing sucrose appeared to maintain VEGF synthetic levels by the grafts and improved both their morphology and retention in vivo. However, the benefits of this cryopreservation medium were directly linked to storage time as long-term storage did not result in any noticeable benefit to graft retention. Finally, as an alternative to freezing, adipose grafts were combined with human adipose-derived stem cells (ASCs) to determine if their presence could enhance in vivo graft structure. The presence of ASCs did appear to improve graft structure in vivo over the short term and was also capable of improving tissue morphology when combined with grafts frozen in PBS. In conclusion, the successful use of adipose grafts may require a closer examination of the graft's storage conditions and time. Specifically, it now appears that the practice of freezing in saline may not be advisable if graft viability, activity, and structure are to be maintained in vivo.

Human adipose-derived stem cells as future tools in tissue regeneration: osteogenic differentiation and cell-scaffold interaction

Tissue engineering is now contributing to new developments in several clinical fields, and mesenchymal stem cells derived from adipose tissue (hASCs) may provide a novel opportunity to replace, repair and promote the regeneration of diseased or damaged musculoskeletal tissue. Our interest was to characterize and differentiate hASCs isolated from twenty-three donors. Proliferation, CFU-F, cytofluorimetric and histochemistry analyses were performed. HASCs differentiate into osteogenic, chondrogenic, and adipogenic lineages, as assessed by tissue-specific markers such as alkaline phosphatase, osteopontin expression and deposition of calcium matrix, lipid-vacuoles formation and Glycosaminoglycans production. We also compared osteo-differentiated hASCs cultured on monolayer and loaded on biomaterials routinely used in the clinic, such as hydroxyapatite, cancellous human bone fragments, deproteinized bovine bone granules, and titanium. Scaffolds loaded with pre-differentiated hASCs do not affect cell proliferation and no cellular toxicity was observed. HASCs tightly adhere to scaffolds and differentiated-hASCs on human bone fragments and bovine bone granules produced, respectively, 3.4- and 2.1-fold more calcified matrix than osteo-differentiated hASCs on monolayer. Moreover, both human and deproteinized bovine bone is able to induce osteogenic differentiation of CTRL-hASCs. Although our in vitro results need to be confirmed in in vivo bone regeneration models, our data suggest that hASCs may be considered suitable biological tools for the screening of innovative scaffolds that would be useful in tissue engineering.

Engineered adipose tissue of predefined shape and dimensions from human adipose-derived mesenchymal stem cells

Human adipose-derived mesenchymal stem cells (hAD-MSCs) were cultured in growth medium of low calcium concentration to which antioxidants had been added. Large numbers of hAD-MSCs could be obtained within 2 weeks. Scaffolding was made with 3 commonly used biomaterials. Gelatin sponges and polyglycolic acid meshes were cut into small pieces and put into the scaffold pocket, which was made of polypropylene mesh and measured 1.5 x 1.0 x 0.5 cm3. Immune-deficient mice were divided into 3 groups. In Group I, only hAD-MSCs were injected. In Group II, the scaffold alone was implanted and harvested after 2 months in vivo. In Group III, scaffolds were cultured with hAD-MSCs in adipogenic medium for 2 weeks before implantation, and 2 implanted scaffolds were harvested after 2, 4, and 6 months in vivo. All of the successfully harvested scaffolds were filled with newly formed adipose tissue and had retained their predefined shape and dimensions. New blood vessels had also grown into the newly formed adipose tissue. Adipose tissue of specific shape and 3 dimensions was regenerated in vivo using tissue engineering of hAD-MSCs and scaffolding made with 3 common biomaterials.

Advances in minimally invasive facial rejuvenation

PURPOSE OF REVIEW

Current cosmetic surgical practice for facial rejuvenation has undergone a significant change due to the introduction of technologies to improve the age-associated changes of the face. The most widely adopted methods of minimally invasive facial rejuvenation include the use of neuromuscular blocking agents and injectable fillers. The topic of minimally invasive procedures might include a variety of subjects including nutritional and hormonal modulation, light-based and laser-based therapies, minimal incision surgical procedures, as well as the use of botulinum toxin and fillers. The focus of this study will be on the minimally invasive facial rejuvenation efforts achieved by injection techniques.

RECENT FINDINGS

Botulinum A neurotoxin has been shown to be effective in the reduction of hyperfunctional lines in the upper and lower face. Anatomic areas that have been found to benefit include the glabella, the forehead, the periorbital area, lips, and the platysma muscle. The more recently introduced hyaluronic acid and other injectable fillers are receiving increasing usage. These temporary fillers have been found to improve creases and wrinkles, augment deep nasolabial folds, augment thin lips, and improve hollowing in the periorbital and other depressions and deformities.

SUMMARY

There has been a significant paradigm shift in the field of rejuvenation surgery. Injectable minimally invasive methods have been offered to remedy age-related and other acquired deformities of the head and neck region. These methods have provided temporary correction of undesirable characteristic that were traditionally approached with more invasive surgically oriented modalities.

Autologous fat grafts harvested and refined by the Coleman technique: a comparative study

BACKGROUND

The viability of fat grafts obtained by even a well-established technique remains poorly studied and unknown. This study was designed to determine the viability of fat grafts harvested and refined by the Coleman technique.

METHODS

Sixteen adult white women were enrolled in this study. In group 1 (n = 8), fat grafts were harvested and processed with the Coleman technique by a single surgeon from the abdomen of each patient according to his standardized method. In group 2 (n = 8), fat grafts were harvested with the conventional liposuction by another surgeon. After centrifugation, the resulting middle layer of tissue was collected. All fat graft samples were analyzed for the following studies: trypan blue vital staining for viable adipocyte counts, glycerol-3-phophatase dehydrogenase assay, and routine histologic examination.

RESULTS

The higher viable adipocyte counts were found in group 1 compared with group 2 (4.11 +/- 1.11 versus 2.57 +/- 0.56 x 10 cells/ml; p < 0.004). The level of glycerol-3-phophatase dehydrogenase activity was significantly higher in group 1 compared with group 2 (0.66 +/- 0.09 versus 0.34 +/- 0.13 U/ml; p < 0.0001). Histologic examination showed normal structure of fragmented fatty tissues in both groups.

CONCLUSIONS

Although fat grafts obtained by both methods maintain normal histologic structure, the Coleman technique yields a greater number of viable adipocytes and sustains a more optimal level of cellular function within fat grafts and should be considered superior to conventional liposuction as a preferred method of choice for fat graft harvesting.

Calf augmentation with autologous tissue injection

BACKGROUND

Lean or asymmetric calves may cause body image problems. These deformities can be corrected by inserting a silicone calf prosthesis or silicone injection, and also through the use of an autologous fat or tissue cocktail.

METHODS

Thin and asymmetric parts of the leg are marked while the patient is standing. Depressed areas are observed at the anteromedial part of the tibia from the knee to the ankle. Fat tissue harvested under general anesthesia, using a syringe and a 4-mm cannula, is centrifuged to eliminate blood and lipids, antibiotic is added, and small amounts of fat grafts are injected into different layers using a cannula 15 or 26 cm in length and 3 mm in diameter. For the preparation of the tissue cocktail, tissue (dermis, fascia, fat) was cut into very small pieces measuring 0.5 mm to be passed through 16-gauge needles. The amount injected depends on the severity of deformity and the size of the legs. Rather than overcorrecting, injections are repeated if necessary, two to four times at 3-month intervals.

RESULTS

Between 1992 and 2003, 77 patients underwent calf augmentations with autologous fat and tissue cocktail injections, with follow-up from 1 to 8 years. Outcome was satisfactory in most patients, with moderate improvement in 10 patients (13 percent) and good improvement in 67 (87 percent). In 12 patients, small irregularities or asymmetries were seen after the first injection and were corrected with a second injection. No infection was reported in any case.

CONCLUSION

Autologous augmentation and shaping offers scar-free, long-lasting results, with no late complications, and with the possibility of touchup.

FGF-2 enhances vascularization for adipose tissue engineering

BACKGROUND

Current therapies for soft-tissue reconstruction include autologous tissue flaps and alloplastic implants. Although autologous fat transplantation using a minimally invasive cannula harvest has less donor-site morbidity than tissue flaps, there is a variable degree of fat resorption over time. Preadipocytes isolated from harvested fat are better able to withstand the mechanical trauma from the suction cannula and subsequently may result in improved cell survival and generation of new fat tissue after transfer to another anatomic site. The authors hypothesized that particulate small intestinal submucosa could be useful as injectable cell delivery vehicles for preadipocytes, and that the release of fibroblast growth factor (FGF)-2 would enhance vascularization.

METHODS

Preadipocytes were isolated from discarded human adipose tissue and cultured on small intestinal submucosa particles in a stirred bioreactor (spinner flask). Preadipocytes attached and proliferated on small intestinal submucosa microparticles and maintained high viability over several weeks of culture. FGF-2 was encapsulated in poly(lactic-co-glycolic acid) microspheres and injected in conjunction with the preadipocyte/small intestinal submucosa particles into a mouse subcutaneous model.

RESULTS

Preadipocytes attached and proliferated on small intestinal submucosa particles in vitro. In vivo, vascularization was significantly enhanced with the incorporation of FGF-2-loaded poly(lactic-co-glycolic acid) microspheres. In addition, cell survival during the 14-day in vivo observation period was confirmed by fluorescent dye labeling.

CONCLUSIONS

Small intestinal submucosa particles are a favorable scaffold for preadipocytes, allowing ex vivo proliferation on particles small enough to be injected. Delivery of FGF-2 from poly(lactic-co-glycolic acid) microspheres resulted in cell survival and enhanced vascularization.

Preserved proliferative capacity and multipotency of human adipose-derived stem cells after long-term cryopreservation

BACKGROUND

Human adipose-derived stem (stromal) cells are promising as a regenerative therapy tool for defective tissues of mesenchymal lineage, including fat, bone, and cartilage, and blood vessels. In potential future clinical applications, adipose-derived stem cell cryopreservation could be an indispensable fundamental technology, as has occurred in other fields involving cell-based therapies using hematopoietic stem cells and umbilical cord blood cells.

METHODS

The authors examined the proliferative capacity and multipotency of human adipose-derived stem cells isolated from lipoaspirates of 18 patients in total before and after a 6-month cryopreservation following their defined protocol. Proliferative capacity was quantified by measuring doubling time in cell culture, and multipotency was examined with differentiation assays for chondrogenic, osteogenic, and adipogenic lineages. In addition, expression profiles of cell surface markers were determined by flow cytometry and compared between fresh and cryopreserved adipose-derived stem cells.

RESULTS

Cryopreserved adipose-derived stem cells fully retained the potential for differentiation into adipocytes, osteoblasts, and chondrocytes and for proliferative capacity. Flow cytometric analyses revealed that surface marker expression profiles remained constant before and after storage.

CONCLUSIONS

Adipose-derived stem cells can be cryopreserved at least for up to 6 months under the present protocol without any loss of proliferative or differentiation potential. These results ensure the availability of autologous banked adipose-derived stem cells for clinical applications in the future.

Autologous fat grafting to the breast for cosmetic enhancement: experience in 66 patients with long-term follow up

BACKGROUND

Autologous fat grafting to the breast for cosmetic enhancement remains controversial because the efficacy and fate of fat grafting to the breast are primarily unknown. In this report, we present our retrospective study in 66 patients who underwent autologous fat grafting to the breast for various cosmetic reasons and who were followed with sonography, mammography, or magnetic resonance imaging (MRI).

METHODS

Sixty-six patients who desired cosmetic enhancement of the breast for various reasons underwent autologous fat transplantation between August 2000 and March 2005 in our institution. The cosmetic outcome was assessed by the plastic surgeons as well as the patients. The imaging features of fat necrosis, cyst formation, and calcification in these patients were carefully studied and biopsies of palpable lumps were evaluated histologically.

RESULTS

All patients were followed from 13 to 61 months with an average of 37 months. Breast cosmetic contour was significantly improved in 28 patients (42.4%), improved in 24 patients (36.4%), and not improved in 14 patients (21.2%) as judged by the plastic surgeons. Twenty-seven patients (40.9%) were very satisfied, 26 patients (39.4%) were satisfied, and 13 patients (19.7%) were unsatisfied. Eleven patients (16.7%) developed liponecrotic cysts but only two patients elected to have the breast lump surgically removed.

CONCLUSION

Autologous fat grafting to the breast can be a useful procedure for cosmetic enhancement in many patients who desire such a procedure. Patients with breast contour deformities after removal of silicon implants were found to be the best candidates for fat grafting. The primary long-term complication is the formation of liponecrotic cysts which have characteristically benign appearances in sonography, mammography or MRI.

Bicompartmental breast lipostructuring

The techniques of additive mastoplasty described over the years require the use of alloplastic materials (silicon), which often are poorly tolerated by the body and need access paths that could leave visible, unaesthetic residual scars. Furthermore, the controversy over silicone gel-filled breast implants, which in the early 1990s restricted their clinical use for primary cosmetic breast augmentation, still raises concerns in some patients. The authors therefore felt encouraged to search for alternatives to breast implants and reconsider fat transfer. In fact, for almost a century, autologous adipose tissue has been used safely and with success in many other surgical fields for the correction of volumetric soft tissue defects. Its natural, soft consistency, the absence of rejection, and the versatility of use in many surgical techniques have always made autologous adipose tissue an ideal filling material. In the past, the authors used this technique, as originally described by Fournier (intraparenchymal, en bloc injection), for 41 patients. However, disappointed by a very high rate of complications and the almost complete reabsorption of the grafted fat, they quit using the procedure. An extensive literature review indicated that the complications observed were related only to technical errors and to the anatomic site of harvesting and implantation. The authors therefore developed a new method incorporating recent contributions in functional anatomy and fat transfer. Fat is harvested in a rigorously closed system, minimally manipulated, and reimplanted strictly in two planes only: into the retroglandular and prefascial space and into the superficial subcutaneous plane of the upper pole of the breast (bicompartmental grafting). Any intraparenchymal placement is carefully avoided. Since 1998, 181 patients (300 breasts) have undergone this procedure. Grafted fat volume has ranged from 160 to 685 ml (average, 325 ml) per breast. Complications have been minimal and temporary. All patients have been carefully monitored with preoperative and serial postoperative mammograms and ultrasonograms. This strict follow-up assessment allowed the authors to clarify the controversial aspect of microcalcifications, the main point of criticism for this procedure over the years. Microcalcifications can occur in response to any trauma or surgery of the breast, but are very different in appearance and location. Thus, they can be discriminated easily from those appearing in the context of a neoplastic focus. Probably the most important point is that the fat survival ranged from 40% to 70% at 1 year. The volume is maintained because when the authors transplant living fat tissue, they also transfer a consistent amount of adult mesenchymal stem cells that spontaneously differentiate into preadipocytes and then into adipocytes, compensating for the partial loss of mature adipocytes reabsorbed through time. This theory has been well demonstrated via advanced research performed by the authors and by many other prominent medical institutes worldwide. The findings show that adipose tissue has the same potential for growth of adult mesenchymal totipotential stem cells of bone marrow and can eventually be differentiated easily by the use of specific growing factors and according to the needs and applications in other cellular lines (osteogenic, chondrogenic, myogenic, epithelial). In summary, the authors wish to highlight a formerly controversial procedure that, thanks to recent technical and clinical progress, has become a safe and viable alternative to the use of alloplastic materials for breast augmentation for all cases in which additive mastoplasty with implants is either unsuitable or unacceptable by the patient herself. However this method cannot be considered yet as a complete substitute for augmentation with implants because the degree of augmentation and projection still is limited.

Correction of hemifacial atrophy with autologous fat transplantation

BACKGROUND

Autologous fat transplantation has frequently been used by many surgeons for facial recontouring in esthetic patients, with good long-term results. However, this technique has not been used primarily in treating patients with hemifacial atrophy, and its efficacy and long-term outcome remain unknown.

METHODS

In a 7-year period, 31 patients with hemifacial atrophy were treated with autologous fat transplantation in our institution. All patients had been in their stable phase of the disease for at least 1 year. Autologous fat grafts were harvested from the lower abdomen or thigh with our preferred low-pressure syringe technique and then spun at the lower speed. The fat grafts were injected into multiple areas in multiple tissue planes and tunnels to the diseased side of the face. The same procedure was repeated once or twice as necessary after each injection in at least 3 months. All patients were followed up to 5 years, and their outcomes were evaluated by the patients, plastic surgeons, and laypersons separately.

RESULTS

Obviously improved facial contour was evident in most patients after autologous fat transplantations. More than 65% of the patients in this series were assessed as satisfactory by all 3 groups. Between 10% and 30% of the patients were mostly satisfactory. Only less than 7% of the patients were unsatisfactory. No complications were seen in either donor sites or recipient sites in this series.

CONCLUSIONS

Autologous fat transplantation can be a good treatment of choice for patients with hemifacial atrophy.

Autologous platelet-rich plasma as an adipocyte in vivo delivery system: case report

Tissue engineering has emerged as a promising alternative to current clinical treatments for restoration of soft tissue defects. A key element in the process of tissue engineering is an ideal implant that provides structural support and a favorable environment for growing cells. The authors hypothesized that autologous platelet-rich plasma (APRP) could be used as an in vivo adipocyte delivery system to favor cell survival and to stimulate early recruitment of microcapillaries to the site of implantation. Autologous fat was included in APRP and injected as a gel into a subcutaneous pocket created to correct a painful, adherent scar at the shoulder level in a 75-year-old woman. The surgical outcome was evaluated by histologic and immunohistochemical analysis as well as by ecography before and after surgery. The results were satisfactory, showing fat survival 1 year after surgery. The characteristics of this new material should stimulate research into future clinical applications for such cell constructs in plastic and reconstructive surgery.

The vertical midface lift. An improved procedure

We describe a novel procedure for an anatomically-based face lift to correct vertical vectors in the ageing face. It has the advantage of surgical simplicity, minimal tissue removal and minimal risk. It provides an effective readjustment of cheek volume and correction of periorbital hollowness. Natural facial expression is preserved largely because there is no change in the position of the lateral canthus. The cheek is mobilised subperiosteally through a blepharoplasty incision. A second dissection is made via a short temporal incision, to join the infraorbital dissection. A Hagedorn needle is then inserted through a point inferior to the lateral canthus and in line horizontally with the nasal ala. It is passed to the orbital incision, charged with a loop of suture material, and pulled down again to the cheek incision, from where it is pushed back to the orbit to suspend the cheek. The upper border of orbicularis oculi is fixed firmly to the temporalis aponeurosis at the level of the temporal incision. We now frequently use an Endotine Midface device for fixation. Of the first 150 patients, results were excellent or good in 145. This represents a revival of the subperiosteal mask lift, and abandons the use of endoscopic techniques. In spite of its simplicity, the operation involves subperiosteal dissection as well as delicate eyelid surgery that necessitate plastic surgical skill.

Volume loss versus gravity: new concepts in facial aging

PURPOSE OF REVIEW

The earliest techniques of facial rejuvenation have been continuously adapted to reflect changes in the understanding of the aging face. Significant, paradigm-shifting advances in this understanding have been made in recent years which have allowed application of specific therapeutic modalities, resulting in dramatically improved results over those achieved with traditional facial rejuvenation.

RECENT FINDINGS

Pioneering work by several authors has shown that gravity is not the sole determinant of the aging face. These authors have demonstrated that volume loss, including that of soft tissue and bone, is at least equally important in the pathogenesis of the stigmata of aging. Rejuvenative techniques developed to reverse these atrophic changes have exhibited outstanding results. The consequence is an increasing emphasis on the use of volume restoration procedures to address the aging face.

SUMMARY

Recent improvements in the understanding of the facial aging process have brought about newly refined techniques for facial rejuvenation, ushering in a new era of plastic surgery for the aging face which is being manifested by increasingly natural results.

Comparative study of the integration and viability of autonomised and nonautonomised autologous fat tissue grafts--experimental model in rabbits

BACKGROUND

The free transplant of fatty tissue has gone through several phases of interest over the last 100 years of medical history, having undergone cycles of use and disuse. In the present study we aimed to create, through a delaying process, an improvement in the integration and lower resorption rates of autologous fat grafts. Similar research has not been found in the literature, and this was the motivating factor for the present study.

METHODS

Twenty-three New Zealand male rabbits were used. The study consisted of two different modalities of autologous fatty tissue transplants [autonomised graft (A) vs nonautonomised grafts (NA)]. In order to characterise the histological differences that could contribute to the different macroscopic aspects in the samples of the autonomised and nonautonomised groups, three anatomic-pathological criteria were considered: steatonecrosis, viable adipocytes, and fibrous proliferation. For this analysis, the 'point-counting' technique proposed by Gundersen et al. was used, with a reticulum of 100 points and 50 lines.

RESULTS

Statistically significant differences were found between the autonomised (A) and nonautonomised (NA) groups in both the macroscopic and microscopic aspects after the 6 month study period (P<0.05).

CONCLUSIONS

We conclude that autonomisation of the fatty tissue and its transfer as an autologous implant, in rabbits, is capable of promoting lower rates of resorption and greater integration of the transplanted tissue, characterised by a greater number of viable adipocytes, lower rates of fibrosis and steatonecrosis in comparison with the nonautonomised graft.

Lipoplasty of the face and neck

PURPOSE OF REVIEW

Facial aesthetic surgery has gained wider acceptance and demand for it is increasing. Patients seeking a more youthful facial look often request lipoplasty. This article reviews the recent advances in lipoplasty and related fat contouring for the face and neck.

RECENT FINDINGS

Lipoplasty of the face and neck continues to be popular. There have been improvements in instrumentation, with laser and powered lipoplasty improving the efficiency of fat removal. Lipoplasty indications for neck lipodystrophy have been extended to patients previously only offered neck lifting. Additionally, limited procedures for patients with isolated anterior neck deformities, including direct lipectomy and skin excision, are gaining in popularity. Considerable attention in the lay and professional literature has been paid to mesotherapy for dissolving unwanted fat. Evidence supporting its efficacy is elusive. Finally, there remains enthusiasm for injection fat transfer for facial volume restoration as a component of rejuvenation.

SUMMARY

The treatment of lipodystrophy of the face and neck involves the removal of undesirable fat and the transfer of fat to other areas to produce improved aesthetic results. With the current emphasis on restoring volume, lipoplasty and fat transfer will continue to be important in facial plastic surgery.

Avoiding and treating dermal filler complications

All fillers are associated with the risk of both early and late complications. Early side effects such as swelling, redness, and bruising occur after intradermal or subdermal injections. The patient has to be aware of and accept these risks. Adverse events that last longer than 2 weeks can be attributable to technical shortcomings (e.g., too superficial an implantation of a long-lasting filler substance). Such adverse events can be treated with intradermal 5-fluorouracil, steroid injections, vascular lasers, or intense pulsed light, and later with dermabrasion or shaving. Late adverse events also include immunologic phenomena such as late-onset allergy and nonallergic foreign body granuloma. Both react well to intralesional steroid injections, which often have to be repeated to establish the right dose. Surgical excisions shall remain the last option and are indicated for hard lumps in the lips and visible hard nodules or hard granuloma in the subcutaneous fat.

Facial Augmentation With Structural Fat Grafting

Fat grafting through a blunt cannula has been used by plastic surgeons for altering facial contours for 100 years. Autologous tissue is completely biocompatible and is usually the safest choice for altering facial volume or contours. Fat grafts can be placed in such a fashion that they are long lasting, completely integrated, and natural appearing. Only in the past 20 years have advances in techniques and instrumentation allowed us to obtain predictable results that make fat grafting a viable option for soft tissue augmentation. Our understanding of aging and methods of rejuvenation have developed also. We now approach rejuvenation and adjustment of facial proportion with a better understanding of the need for the restoration or adjustment of facial volume.