Structural Fat Grafting. By Sydney R. Coleman, M.D. Pp. 404. Quality Medical Publishing, Inc., St. Louis, Mo., 2004. Price $365.
Dr. Coleman has secured his place in cosmetic surgery history by popularizing the use of the fat injection, which he calls “structural fat grafting.” He has written an extended monograph on the evolution, aesthetics, and method of his technique of modifying the human form by enlarging aspects of it.
This is a coffee table-style book, beautiful to look at and thumb through. It has very high production values, and the organization and layout are well thought out. With its excellent writing and editing, the book flows well and is more readable than most medical texts.
After an introductory section, the basic techniques of fat grafting are discussed. An accompanying CD demonstrates these techniques. I think that the content of the CD could be amplified to better show the technique in more relevant areas.
Each clinical section outlines the treatment of a specific body area and has subheadings on patient selection, technique (with exhaustive photographs illustrating needle placement), postoperative care, complications, potential problems, and technical pearls. In combination with the CD, someone with no experience with injected fat would have a reasonable understanding of how to perform the procedure.
Problems for which the author uses injected fat include postsurgical deformities of the body as well as most aspects of the face. The face is covered most thoroughly, with discussions of the hollow upper lid, the tear trough and cheek, as well as the nasolabial fold and lips. Results are sometimes hard to see, and some are not visible even when they are well photographed, but some are excellent. More interesting is the ability to actually change the proportions of the face, for example, by enlarging a narrow jawline. Changes like this can be very powerful and deal with problems not well suited to correction with standard plastic surgical techniques. The difficulty here is not so much technical but visualizing what would look good and convincing the patient.
The photographs are well matched for the most part and consistently illuminated by on-camera flash. This method of lighting is excellent for throwing the sides of the face into relief, but it lights the central face very flatly. Consequently, the photography is unrealistically forgiving around the eyes and lower lids, minimizing deformities that would be visible in more vertical room light.
As in many aspects of plastic surgery, the complication rate increases with the location and the volume of fat placed. In my experience, there are two basic complications from injected fat: swelling and irregularities.
It seems from the text that the author favors performing corrections in one step. With the trauma of placing large volumes of fat, certain areas of the face, primarily the cheeks and lips, can swell hugely and for a considerable time after surgery. The swelling can be far beyond what is seen in standard plastic surgery procedures. Though the author mentions swelling several times in the text (“up to 16 weeks, swelling still present”), I have seen patients subjected to full-face fat injection have swelling that renders them housebound for a longer period than this. I believe that very few results justify this degree of down time, less so if the results are frequently difficult to photograph, as these are.
In my experience, most of the swelling complications can be reduced by limiting the amount of fat that is placed initially and planning on multiple stages. I find there to be much less down time with multiple small procedures than with one large procedure.
Injected fat can lead to uncorrectable problems in some areas. The lower lid and tear trough area are notorious for making lumps. Because this area is the perceptual epicenter of the face, an irregularity has more of an effect here than in other parts of the face. Specifically, it casts a shadow lower than the shadow being corrected, thus making the patient look considerably worse than before. These irregularities are very difficult to correct. Unfortunately, the text does not offer much help in solving this very common problem. Dr. Coleman stresses, and I agree, that the tear trough is for the experienced surgeon. The advent of injectable fillers such as Restylane makes for a much safer, if more temporary, solution for the area.
This is a “how-I-do-it” book, and though Dr. Coleman’s technique may certainly work, other injection techniques work equally well. As to the centrifuge versus washing versus no preparation debate for preparing fat, the consensus at this time is that preparation of the fat simply makes very little difference, if any, in its eventual take.
This book has a failing common to other cosmetic surgery texts in that the author seeks to show how his technique reverses his concept of aging (whether a young configuration is the right configuration for an aging face is beyond the scope of this discussion, but worth considering). The author has lovely drawings showing his concept of facial aging. Other authors have equally lovely drawings showing how the face ages according to them. In all these cases, the model of aging is an intuitive or surgical one and not supported by fact. If the author has data that show how the face ages other than as a hypothetical model, he should present or reference them.
This book has a good deal of value for the cosmetic surgeon. Fat injection in the face done conservatively can lead to greatly improved clinical results in a way different from the standard techniques. Most plastic surgeons will probably find that injected fat is better used as an adjunctive, rather than a primary, treatment for the aging face, and in small quantities.
Val Lambros, M.D.
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