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Mastering Volume in Facial Aesthetic Surgery

Mustoe, Thomas A. M.D.

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Plastic and Reconstructive Surgery: November 2016 - Volume 138 - Issue 5 - p 1138-1139
doi: 10.1097/PRS.0000000000002723
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As a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format for review.

Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Arun K. Gosain, M.D., Review Editor, Plastic and Reconstructive Surgery, Brookriver Executive Center, 8150 Brookriver Drive, Suite S-415, Dallas, Texas 75247.

Arun K. Gosain, M.D.

Review Editor

This 2-hour video presents Tonnard and Verpaele’s updated thinking on the minimal access cranial suspension lift with incorporation of fat grafting for which they have an innovative approach. The video in its entirety takes us through the preoperative marking and actual surgery for one older patient with considerable loss of facial fat. The video is well organized into 20 chapters, which makes it easy to advance when parts of the procedure are familiar or routine, and to linger or revisit parts that are particularly interesting. There is perhaps more time spent than necessary on injections, a skin-only upper blepharoplasty, and repeated surgery on the second side, but dividing the procedure into chapters is invaluable in allowing quick referencing when returning, and provides opportunities to skip around. The title is a little misleading: most of the video is taken up with details of the minimal access cranial suspension lift and the temporal brow lift that have been extensively presented in the past and, for those familiar with the technique, represent largely review. Nevertheless, there is considerable value in revisiting a technique that the surgeons Tonnard and Verpaele have performed over 1500 times, and it is reassuring to see that the basic details of the procedure have not changed much, indicating satisfaction with the procedure.

As the title implies, the major new take is their approach to fat transfer. The preoperative markings and explanation by Tonnard are clear and give excellent insights that are applicable to any method of facial rejuvenation, with or without surgery. There are many described methods of fat transfer. Most of them are not evidence based but rely on clinical practices that work in that surgeon’s hands, and this video presents Tonnard and Verpaele’s individual approach. The authors claim of 80 percent or more volume preservation is impressive and exceeds previous reports but, without volumetric analysis by photographic or other imaging systems, must be taken with some skepticism. Nevertheless, the authors’ extensive experience and track record give considerable credibility. The concept of grafting with very fine cannulas, with finely particulate fat, makes eminent sense on several grounds, and they appropriately reference Coleman’s contributions. What is most innovative is their use of “nanofat” grafting, which is very finely prepared fat that can be administered through a 27-gauge sharp needle into the deep dermis or just below, thus largely eliminating the risk of emboli in a larger vessel. I do think the video could have had considerable added value with some extended discussion of the indications and some before and after photographs allowing more thorough evaluation of the benefits of the technique, which necessitates extensive preparation of the fat. The postoperative photographs are presented, which is a key point, but the video would have benefited from a detailed critique emphasizing how volume restoration improved the results.

In summary, the video is well organized and executed, with a narrative by Verpaele emphasizing some key points in the procedure performed by Tonnard. In terms of actual volumes of fat transferred, the authors are fairly conservative compared with many others presenting in the field, but I think the approach is a good one that enhances rather than changes facial shape. The video overall is a useful addition to the field.

Copyright © 2016 by the American Society of Plastic Surgeons