Fat Removal (eBook)

Invasive and Non-invasive Body Contouring

Mathew Avram (Herausgeber)

eBook Download: EPUB

2015
John Wiley & Sons (Verlag)
978-1-118-66195-6 (ISBN)

Infos

The perception of an inadequate body shape is a cause of concern to many people, and new techniques for altering body shape are increasingly being developed and offered to patients. Of these, the removal and transfer of fat is fast growing in importance and availability. This practical guide offers a comprehensive overview of this rapidly-evolving field, and thorough coverage of the implementation of fat removal techniques, both invasive and non-invasive, in a cosmetic practice.

It begins with an overview of basic fat anatomy and physiology as an important introduction to this topic. The distinction between the physiology and treatment of cellulite and fat is also discussed. The next section of the book covers invasive treatments of fat such as traditional liposuction, laser-assisted liposuction, fat transfer procedures and mesotherapy. The latter half of the book largely focuses on non-invasive treatments for fat, including radiofrequency, ultrasound, cooling and laser technologies for fat removal. Throughout, potential complications and pitfalls of the various treatments are discussed.

Edited by Matthew Avram, with contributions from a group of clinical stars, this book will appeal to cosmetic dermatologists, plastic surgeons, aesthetic medical practitioners, and obstetricians/gynaecologists

Edited by Mathew Avram, with contributions from a group of clinical stars, this book will appeal to cosmetic dermatologists, plastic surgeons, aesthetic medical practitioners, and obstetricians/gynecologists.

Inhalt

List of contributors vii

Abbreviations ix

1 Introduction 1
Hrak Ray Jalian, Alison Avram, and Mathew M. Avram

2 Facial fat: anatomy and implications for rejuvenation 12
Hrak Ray Jalian and Rebecca Fitzgerald

3 Histology and pathology of subcutaneous tissue 23
Selim M. Nasser and Zeina S. Tannous

4 Injectable treatments for fat and cellulite 37
Adam M. Rotunda

5 The architecture of cellulite 59
Arisa E. Ortiz and Mathew M. Avram

6 Cellulite treatment 68
Neil S. Sadick and Suveena Bhutani

7 Cooling for fat 101
Andrew A. Nelson

8 Laser lipolysis and laser-assisted liposuction 120
Robert A. Weiss

9 Soft tissue augmentation for facial lipoatrophy and volumization 137
Nazanin Saedi and Kenneth Arndt

Index 147

Textauszug

Chapter 2
Facial fat: anatomy and implications for rejuvenation

Hrak Ray Jalian and Rebecca Fitzgerald

David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA

1. Introduction
2. Aging changes in multiple structural tissues
3. Summary
4. Conclusions/future directions
5. References

Key Points

• Aging is a dynamic process involving characteristic changes to the skin, adipose tissue, and craniofacial skeleton.
• Facial adipose tissue exists in discrete, reproducible independent anatomical subunits referred to as fat pads.
• Loss of volume within these fat pads contributes to change in facial topography and is evidenced by “downstream” markers, such as the nasolabial fold.
• Fat pads age independently from each other and variably between individuals.
• Soft tissue augmentation with variable agents, in a targeted approach, can achieve natural restoration of youth.

Introduction

As our understanding of the dynamics of facial aging evolves, a complex paradigm involving structural changes in multiple tissue layers is emerging. What we once predominantly attributed to fragmentation of dermal collagen and mere gravitational influence on the skin and soft tissue has now morphed into a multifaceted collection of changes within the craniofacial scaffolding and its overlying soft tissue envelope. Fat compartments play a key role in these changes.

Advances in anatomic understanding are the basis on which both surgical and nonsurgical rejuvenation techniques are designed, advanced, and refined. Rhytidectomy, for example, since its inception in the early 20th century, has evolved from simple skin excision to subcutaneous, sub-SMAS (superficial muscular aponeurotic system), deep plane, and composite dissection. Each advancement paralleled an increased understanding of the anatomy of facial structures and is a testament to the importance of detailed anatomic knowledge as the fulcrum driving improved techniques.

The last decade has shown a strong and steady movement toward nonsurgical “minimally invasive” techniques with injectables and lasers. Future advancements in facial rejuvenation using these techniques will also be driven by the progress in our understanding of facial anatomy. Without regard for facial anatomy, cosmetic treatments will produce incomplete and unnatural results.

In 2007, a landmark study from Rohrich and Pessa at the University of Texas Southwestern Medical Center revolutionized our understanding of facial fat anatomy by showing that facial fat is highly compartmentalized [1]. Studies to elucidate our understanding of this facial fat anatomy have progressed rapidly since that time and are currently in a state of perpetual evolution and refinement. The value of this work lies in its implications for treatment. A more sophisticated understanding of facial fat anatomy will influence the techniques used for facial rejuvenation by furthering our ability to address site-specific corrections to achieve specific results. The goal of this chapter is to review and outline this emerging literature on facial fat anatomy and will follow a brief summary of recent literature on other structural tissue changes with age. A few clinical examples of treatment utilizing these concepts will be included for illustration.

Aging changes in multiple structural tissues

Skin

During the last decade, substantial progress has been made toward understanding the underlying mechanisms of skin aging. A major feature of aged skin is fragmentation of the dermal collagen matrix. Collagen fragmentation is responsible for loss of structural integrity and impairment of fibroblast function in senescent skin [2]. Fragmentation results from actions of specific enzymes, matrix metalloproteinases, that is observed in both intrinsic and extrinsic aging (although extrinsic aging from ultraviolet light accounts for the majority). Fibroblasts that produce and organize the collagen matrix cannot attach to fragmented collagen and they subsequently collapse. The collapsed fibroblasts produce low levels of collagen, and high levels of collagen-degrading enzymes. Once a critical amount of collagen has been lost, this imbalance advances the aging process, in a self-perpetuating, never ending deleterious cycle. The production of new collagen demonstrated by electron microscopy after the injection of hyaluronic acid is felt likely to be due to a mechanical stretch effect, serving to rebalance collagen production and degradation, and thereby slowing its loss [3].

Muscle

The changes to the facial muscles with aging are likely multifactorial. Traditional theory was that muscles had increased laxity overtime. Recent studies suggest that the muscles of facial animation react to shifts in facial volume by increasing their resting tone. Clinically, this may have an impact on the depth at which we choose to place our fillers. If increased volume could decrease facial muscle tone, then there may be an advantage to deeper placement of facial fillers [4, 5].

Bone

Craniofacial bony remodeling is increasingly being recognized as an important contributor to the facial aging process. The landmark 2008 study by Shaw and Kahn [6–8] demonstrated statistically significant changes in the glabellar, orbital, maxillary, and pyriform angles of the facial skeleton. A recently published retrospective review of computed tomography scans of 100 patients consecutively imaged at Duke University Medical Center (including 50 men and 50 women from two age groups) found similar changes [9]. Sharabi et al. [10] and Mendelson et al. [11] have published excellent literature reviews on this topic.

Fat

As noted earlier, recent anatomic studies of the face have led to an increased understanding of the anatomy of the subcutaneous fat. For centuries, it was believed that facial fat on the face existed as one confluent mass, which eventually gets weighed down by gravity, creating sagging skin. Aesthetic facial rejuvenation therefore traditionally focused on surgical procedures, based on a paradigm of removing “excess” tissue and lifting tissues against gravity. The central role of volume loss and deflation in the aging face, rather than ptosis alone, has been compellingly illustrated by Lambros in a longitudinal photographic analysis of more than 100 patients spanning an average period of 25 years [12]. The study matched old photographs brought in by the patients with current photographs taken to match lighting and position, which were then animated using computer graphics software. These animations revealed that many facial landmarks were stable over time, eloquently demonstrating that volume loss visually mimics gravitational descent. While these animations also illustrated a somewhat predictable variability in the pace of aging between individuals, some astute observers noted a variable pace of aging within different areas of individual faces over time, challenging the long-held assumption that the face ages as one homogeneous object and perhaps prompting some of the early studies revealing the compartmentalization of fat.

As mentioned earlier, Rohrich and Pessa's 2007 study was the first observation that superficial facial fat is organized in distinct, reproducible anatomic units. Using fresh cadavers, methylene blue dye was injected into distinct points, and cadavers were later dissected to observe dye migration. These investigators found reproducible migration and sequestration of dye, suggesting that superficial facial fat exists in independent subunits. In this initial study, distinct superficial fat compartments were described in the forehead, periorbital region, and cheek [1], some of which are illustrated in Figure 2.1.

Figure 2.1 (a–d) Superficial fat compartments of the face. Methylene blue injection of facial fat pads. Nasolabial, medial cheek, middle cheek, and the large temporal lateral cheek fat compartments. Abbreviations: ORL, orbital retaining ligament; SOOF, suborbicularis oculi fat; ZM, zygomatic major muscle; SCS, superficial cheek septum.

(Adapted from Rohrich & Pessa, 2007 [11]. Reproduced with permission of Lippincott Williams & Wilkins.)

Subsequent work not only validated the consistent, reproducible nature of these fat compartments, but also confirmed the presence of distinct septal barriers. Histologic evaluation of the borders of the fat compartments demonstrated a fibrous condensation of connective tissue, which forms the diffusion barrier for the dye, and separates adjacent fat compartments. These septal barriers that originated from underlying fascia, were found to be distinct from the SMAS, and inserted into the dermis [13].

There are important functional implications that come from this anatomic observation. The presence of these septal barriers forms a three-dimensional network enveloping the fat pads. This system provides scaffolding, forming a “retaining system” for the face. With these compartments so intimately intertwined, it is no surprise that volume or position change of one compartment has an effect on adjacent subunits. It is this retaining ligament system that determines the shape and location of each compartment. Moreover, in addition to their structural support of the fat pads, these retaining ligaments prevent migration of the overlying skin, a finding that is clearly evident on clinical examination. Additionally, they represent...

Produkt-Details

• Erscheint lt. Verlag: 28.1.2015
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Ästhetische und Plastische Chirurgie
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Dermatologie
• Schlagworte: altering • Body • cause • comprehensive overview • concern • Cosmetic / Esthetic Dermatology • Coverage • dermatologic surgery • Dermatologie • Dermatologische Chirurgie • fat • Field • growing • Guide • importance • inadequate • Kosmetische Chirurgie • Kosmetische u. Ästhetische Dermatologie • Kosmetische u. Ästhetische Dermatologie • many • Medical Science • Medizin • New • patients • People • perception • Practical • rapidlyevolving • removal • removal techniques • Shape • techniques • Transfer
• ISBN-10: 1-118-66195-8 / 1118661958
• ISBN-13: 978-1-118-66195-6 / 9781118661956