Advanced Techniques in Dermatologic Surgery - part 3 pot

discomfort. Here, corticosteroid creams and possibly intradermal corti- costeroid injections may be necessary. Uneven filler distribution may be corrected with further product placement to fill in the defects. Conversely, intralesional corticosteroid injections may be used to diminish a robust response. Should intradermal granulomas form, dermabrasion, imiqui- mod cream, infrared laser therapy or radiofrequency dermal heating may be used with limited success . These lesions may require excisional surgery. Intralesional corticosteroid injections may be useful to soften dislodged nodules that ha ve migrated. Care must be taken on injecting the glabellar region due to the watershed properties of this anatomic area and the theoretical possibility of tissue necrosis upon occlusion of the tenuous arter ial blood supply. There is a case report of a woman who developed blindness and total ophthalmoplegia after injection of PMMA microspheres in the glabellar region (40) . A similar problem was reported in a patient treated with bovine-based collagen (13). Telangiectasia Formation Patients at highest risk for telangiectasia formation are those with thinner skin, making the elderly susceptible. Most post-treatment telangiectasias disappear within 6 to 12 months of injection. Persistent lesions can be effectively treated with electrocautery, laser treatment, or intense pulsed light therapy. Allergic Reaction With proper testing prior to product placement, the chances of an allergic reaction occurring are less. If an allergic reaction occurs, such as the delayed type IV hypersensitivity reaction, intralesional triamcinolone injections into the injection site are recommended. If the reaction is to a permanent filler, excision is likely necessary. Even though anaphylaxis is unlikely, a practitioner should always be mindful of the possibility and be ready to respond accordingly with the administration of 5 cc intramus- cular injection of epinephrine 1:1000. Hypertrophic Scarring/Keloid Formation Post-treatment hypertrophic scars or keloids are best treated with multi- ple intralesional triamcinolone or 5% 5-fluorouracil injections to flatten the lesions. Light treatment with either the pulsed dye laser or intense pulsed light may serve to diminish any erythema of scar tissue. Topical application of imiquimod and occlusive materials such as silicone gel sheetings may diminish the scar thickness. Granuloma Formation It has been reported that granulomas form in 0.01% to 0.1% of patients undergoing exogenous soft-tissue filler therapy. Granulomas are 64 Rao et al. collections of histiocytes (derived from monocyte-macrophage differentia- tion) that may form within the dermis of the skin in an attempt to envelop and destroy or contain immunogenic foreign material. Although more common with permanent fillers (39,58), temporary filling agents may also cause granuloma formation. These have been reported for therapy that is both collagen based (59) and HA based (60). Intralesional injection of corticosteroid is a good initial therapy for managing granulomas. The use of Aldara Õ (topical imiquimod 5%) may also be beneficial, as illustrated in the case of a granulomatous reaction to silicone oil injection (54). Chronic recalcitrant cases, however, are most amenable to surgical excision alone. CONCLUSION The use of soft-tissue augmentation as part of aesthetic medicine is evolving at a rapid rate as demand puts further pressure on industry to produce newer and more improved technology and health care providers to provide this service. The art and science of soft-tissue filler administra- tion offers an excellent rejuvenation option to the ever-increasing baby boomer population in their quest to age more gracefully. With recent cos- metic trends toward less invasive, less costly , and less risky procedures with little downtime, fillers make for ideal treatment in many instances. The number of products available can be intimidating, but this chapter has provided a basis for familiarity and background knowledge of the most common items in this expanding group. As the practice of skin rejuvenation itself advances gracefully, it is a combination therapy of various cosmetic modalities that will prevail. With this philosophy, exogenous soft-tissue fillers are perfect adjuncts to Botox treatment, laser and light-based therapy, microdermabrasion, and topical preparations as it does not compete, but complements these modalities (61,62). It is believed that a component analysis, with sub- sequent multimodality treatment, will yield maximal results as each component is specifically addressed. With that in mind, knowledge of the soft-tissue fillers, particularly their indications and pitfalls, will make this treatment a powerful tool in skin rejuvenation. It is theref ore impor- tant to be aware of the new agents and indications as they become avail- able. Over the next few years, the list of soft-tissue fillers may be come twice the present length. In a world where patients are becoming increasingly well educated about various therapies, it is important for care providers to remain a ‘‘step ahead’’ of the public to maintain credibility and offer the best treat- ment options. This is particularly true for cosmetic patients who take special interest in researching new products and technologies. With the public’s increasing curiosity of all things aesthetic, marketing and media have capitalized on bringing new product information into the spot- light, allowing for greater information access to consumers. It is the Soft-Tissue Augmentation: Skin Fillers 65 responsibility of care providers to give their patients realistic expectations so that they can make informed decisions regarding their cosmetic treat- ments. Informed treatment strengthens the provider–patient relationship and minimizes disappointing results. 66 Rao et al. REFERENCES 1. Ferreira M. What are we doing and where are we going? Aesthetic Plast Surg 2003; 27:5. 2. Smart T. Not acting their age. US News & World Report 2001; June 4:54–60. 3. Fagien S. Facial soft tissue augmentation with injectible autologous and allogeneic human tissue collagen matrix (autologen and dermalogen). Plast Reconstr Surg 2000; 105:362–373. 4. Gross J, Kirk D. The heat precipitation of collagen from neutral salt solutions. J Biol Chem 1958; 233:355–603. 5. Knapp TR, Kaplan EN, Daniels JR. Injectible collagen for soft tissue augmentation. Plast Reconstr Surg 1977; 60:389. 6. Watson W, Kaye RL, Klein A, Stegman S. Injectible collagen: a clinical overview. Cutis 1983; 31:543–546. 7. Skouge JW, Diwan RV. Soft tissue augmentation with injectible collagen. In: Papel ID, Nachlas NE, eds. Facial Plastic and Reconstructive Surgery. St. Louis: Mosby Year Book, 1992:208. 8. Knapp TR, Luck E, Daniels JR. Behavior of solubilized collagen as a bioimplant. J Surg Res 1977; 23:96–105. 9. Burgess L, Goode R. Injectable collagen. Facial Plast Surg 1992; 8:176–182. 10. Cooperman LS, Michaeli D. The immunogenicity of injectible collagen. Part 2: A retro- spective review of seventy-two tested and treated patients. J Dermatol Surg Oncol 1984; 10:647. 11. Hanke CW, Hingley HR, Jolivette DM, Swanson NA, Stegman SJ. Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. J Am Acad Dermatol 1991; 25:319–326. 12. Bailin PL, Lailin MD. Collagen implantation: clinical applications and lesion selection. J Dermatol Surg Oncol 1988; 14:49. 13. McGrew RN, Wilson RS, Havener WH. Sudden blindness secondary to injection of common drugs in the head and neck. Part 1: Clinical experiences. Otolaryngology 1978; 86:147–151. 14. Klein AW. Bonfire of wrinkles. J Dermatol Surg Oncol 1991; 17:543–544. 15. Elson ML. The role of skin testing in the use of collagen injectible materials. J Dermatol Surg Oncol 1989; 15:301. 16. Armstrong R. Injectible collagen for soft tissue augmentation. In: Roretos JW, Edne M, eds. Contemporary Clinical Applications: New Technology and Legal Aspects. Parkridge, NJ: Noyes Publications, 1984:528–536. 17. Saray A. Porcine dermal collagen (permacola) for facial contour augmentation: prelimin- ary report. Aesthetic Plast Surg 2003; 27:368–375. 18. Kelman CD, DeVore DP. Human collagen processing and autoimplant use. US Patent No. 5, 332, 802; July 26, 1994. 19. Sclafani AP, Romo T III, Parker A, McCormick SA, Cocker R, Jacono A. Autologous collagen dispersion (Autologenrpar; as a dermal filler: clinical observations and histologic findings. Arch Facial Plast Surg 2000; 2:48–52. 20. Hotta T. Dermal fillers: the next generation. Plast Surg Nurs 2004; 24:14–19. 21. Krauss M. Recent advances in soft tissue augmentation. Semin Cutan Med Surg 1999; 18:119–128. 22. Moody BR, Sengelmann RD. Self-limited adverse reaction to human-derived collagen injectible product. Dermatol Surg 2000; 26:936–938. 23. Klein AW. Commentary on: Self-limited adverse reaction to human-derived collagen injectible product. Dermatol Surg 2000; 26:936–938. 24. Burres S. Fascian. Facial Plast Surg 2004; 20:149–152. Soft-Tissue Augmentation: Skin Fillers 67 25. Niamtu J III. Fat transfer gun used as a precision injection device for injectible soft tissue fillers. J Oral Maxillofac Surg 2002; 60:838–839. 26. Burres S. Preserved particulate fascia lata for injection: a new alternative. Dermatol Surg 1999; 25:790–794. 27. Watson D, Keller G, Lacombe V, Fodor PB, Rawnsley J, Lask GP. Autologous fibro- blasts for soft tissue augmentation. Dermatol Surg 1998; 24:510–512. 28. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectible hyaluronic acid gel for soft tissue augmentation: a clinical and histological study. Dermatol Surg 1998; 24: 1317–1325. 29. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shaw K. Hyaluronic acid skin fillers: adverse reactions and skin testing. J Am Acad Dermatol 2001; 45:930–933. 30. Piacquadio D, Jarcho M, Goltz R. J Am Acad Dermatol 1997; 36:544–549. 31. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG. Safety data of injectible non- animal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg 2002; 28:491–494. 32. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double blind, multi-centre comparison of efficacy and tolerability of Restylane vs Zyplast for the correction of nasolabial folds. Dermatol Surg 2003; 29:588–595. 33. Manna F, Dentini M, Desideri P, De Pita O, Mortilla E, Maras B. Comparative chemical evaluation of two commercially available derivatives of hyaluronic acid used for soft tis- sue augmentation. J Eur Acad Dermatol Venereol 1999; 13:183–192. 34. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10 year his- tory, indications, techniques, and complications. Dermatol Surg 2003; 29(6):573–587. 35. Lemperle B, Ott H, Charrier U, Hecker J, Lemperle M. PMMA microspheres for intra- dermal implantation. I. Animal research. Ann Plast Surg 1991; 26:57–63. 36. Morhenn VB, Lemperle G, Gallo R. Phagocytosis of different particulate dermal filler substances by human macrophages and skin cells. Dermatol Surg 2002; 28:484–490. 37. McClelland M, Edbert B, Hanko V, Berg RA, DeLustro F. Evaluation of Artecoll poly- methylmethacrylate implant for soft-tissue augmentation: biocompatibility and chemical characterization. Plast Reconstr Surg 1997; 100:1466–1474. 38. Kim K-J, Lee H-W, Lee M-W, Choi J-H, Moon K-C, Koh J-K. Artecoll granuloma: a rare adverse reaction induced by microimplant in the treatment of neck wrinkles. Derma- tol Surg 2004; 30:545–547. 39. Rudolph CM, Soyer HP, Schuller-Petrovic S, Kerl H. Foreign body granulomas due to injectable anesthetic microimplants. Am J Surg Pathol 1999; 23:113–117. 40. Silva MT. Blindness and total ophthalmoplegia after aesthetic polymethylacrylate injec- tion: case report. Arq Neuropsiquiatr 2004; 62:873–874. 41. Stein J, Eliachar I, Myles J, Munoz-Ramirez H, Strome M. Histopathologic study of alternative substances for vocal fold medialization. Ann Otol Rhinol Laryngol 2000; 109:221–226. 42. Hobar PC, Pantaloni M, Byrd HS. Porous hydroxyapatite granules for alloplastic enhancement of the facial region. Clin Plastic Surg 2000; 27:557–569. 43. Mayer R, Lightfoot M, Jung I. Preliminary evaluation of calcium hydroxyapatite as a transurethral bulking agent for stress urinary incontinence. Urology 2001; 57:434–438. 44. Sklar JA, White SM, Radiesse FN. A new soft tissue filler. Dermatol Surg 2004; 30: 764–768. 45. Tzikas TL. Evaluation of the Radiance FN soft tissue filler for facial soft tissue augmen- tation. Arch Facial Plast Surg 2004; 6:234–239. 46. Vleggaar D, Bauer U. Facial enhancement and the European experience with Sculptra (poly-l-lactic acid). J Drugs Dermatol 2004; 3:542–547. 47. Humble G, Mest D. Soft tissue augmentation using sculptra. Facial Plast Surg 2004; 20:157–163. 68 Rao et al. 48. de Cassia NW, Berg A. Experiences with a new nonbiodegradable hydrogel (Aquamid): a pilot study. Aesthetic Plast Surg 2003; 27:376–380. 49. Smith EA, Oehme FW. Acrylamide and polyacrylamide: a review of production, use, environmental fate and neurotoxicity. Rev Environ Health 1991; 9:215–228. 50. Dearfield KL, Douglas GR, Ehling UH, Moore MM, Sega GA, Brusick DJ. Acrylamide: a review of its genotoxicity and an assessment of heritable genetic risk. Mutat Res 1995; 330:71–99. 51. Amin SP, Marmur ES, Goldberg DJ. Complications from injectible polyacrylamide gel, a new nonbiodegradable soft tissue filler. Dermatol Surg 2004; 30:1507–1509. 52. Spira M, Rosen T. Injectible soft tissue substitutes. Clin Plast Surg 1993; 20:181–188. 53. Benedetto AV, Lewis AT. Injecting 1000 centistoke liquid silicone with ease and preci- sion. Dermatol Surg 2003; 29:211–214. 54. Baumann LS, Halem ML. Lip silicone granulomatous foreign body reaction treated with Aldara (Imiquimod 5%). Dermatol Surg 2003; 29:429–432. 55. Rapaport M. Silicone injections revisited. Dermatol Surg 2002; 28:594–595. 56. Orentreich D, Leone A-S. A case of HIV-associated facial lipoatrophy treated with 1000-cs liquid injectible silicone. Dermatol Surg 2004; 30:548–551. 57. Lee S, Yoo JH, Lee SH. Surgical pearl: the use of a teaspoon during dermal filler injec- tion. J Am Acad Dermatol 2004; 51:979. 58. Requena C, Izquierdo MJ, Navarro M, Martı ´ nez A, Vilata JJ, Botella R, Amorrortu J, Sabater V, Aliaga A, Requena L. Adverse reactions to injectible aesthetic microimplants. Am J Dermatopath 2001; 23:197–202. 59. Hanke CW. Adverse reactions to bovine collagen. In: Klein AW, ed. Tissue Augmenta- tion in Clinical Practice. Procedures and Techniques. New York: Marcel Dekker, 1998:145–154. 60. Shafir R, Amir A, Gur E. Long-term complications of facial injections with Restylane (injectable hyaluronic acid). Plast Reconstr Surg 2000; 106:1215–1226. 61. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Resty- lane) in combination compared with NASHA (Restylane) alone in severe glabellar rhy- tides in adult female patients: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003; 29:802–809. 62. Carruthers J, Carruthers A, Maberley D. Deep resting glabellar rhytides respond to BTX-A and Hylan B. Dermatol Surg 2003; 29:539–544. Soft-Tissue Augmentation: Skin Fillers 69 4 New Trends in Fat Augmentation Techniques with an Introduction to the FAMI Technique Kimberly J. Butterwick Dermatology/Cosmetic Laser Associates of La Jolla, La Jolla, California, U.S.A. Video 3: FAMI Technique: Harvesting Fat Video 4: FAMI Technique: Injection Techniques INTRODUCTION Fat has been declared as the ‘‘best friend of the plastic surgeon’ ’ owing to its usefulness in correction of defects of facial and body contour for over 100 years (1). The first report of fat augmentation in cosmetic surgery appeared in 1893 in which Neuber removed 1-cm-pieces of fat from the arm and transferred them to facial depressions caused by tuberculosis (2). Bruning (3) was the first to report the injection of fat through a needle in 1917. Later, Peer (4) reported on the retention of transplanted fat in the 1950s, noting 40% to 50% retention at one year. The advent of liposuction in the late 1970s and early 1980s brought a resurgence of intere s t infat transfer and exploration of fat transfer techniques. Illouz (5) developed new instrumentations and tech niques for b oth liposuc- tion and fat grafting in the e arly 1980s. Fat grafting was an open or semiopen procedure u ntil 1985 when Fournier (6) discovered, by self-described ‘‘seren- dipity,’’ that fat could be extracted with a syringe and a needle. The harvested tissue could t hen b e readily tran sferred v ia a closed system, thereby s implify- ing the procedure and increasing sterility. Fournier’s methods popularized fat augmentation and stimulated further inquiry, regarding optimal techniques for fat transfer. T he mai n debate was then, an d s till is, what are the methods of preparing and placing fat that result in its longest or even permanent retention? There are more unanswered questions than proven methodology in the literature, but there are a lso widespread opinion that the transferred fat can and does provide long-term results (7). FAT: TEMPORARY FILLER OR LIVING GRAFT? Autologous fat mostly fulfills all the criteria for an ideal filler substance; it is readily available in most patients, inexpensive and nonallergenic. There is 71 minimal morbidity associated with its use and few complications. Recovery time in fat augmentation can be minimized and it generally depends on how much is injected. Problems with fat augmentation have centered largely on its unpredictability in terms of symmetry and longevity of results. There are two schools of thought regarding fat transplantation. One is that injected fat cells are eventual ly resorbed and any permanent results are due to fibrosis generated by trauma (1). The other theory is that fat cells survive as a graft (5). These two schools have spawned dif- fering techniques of fat placement. The resorption theory led to the tech- nique of overcorrection, as was popular in the 1980s and early 1990s. As there was rapid resorption, large volumes of fat were placed, commonly with deform ing overcorrection of 30% to 50% (8). One could observe reabsorption of volume over time with variable and unpredictable long-term results (9). It was not necessary to handle the fat gently, as sur- vival of the adipocytes was not a goal. In the late 1980s, Coleman (10) championed the survival theory and developed a method called Lipo- structure TM . He advocated placing small aliquots of fat, injected with repetitive passes, into multiple tissue planes, reasoning that a blood sup- ply can easily be established and permanent survival is achieved. Gentle and atraum atic handling of the fat cells is a prerequisite for this techni- que. Others began to report better longevity with smaller injection volumes and less traumatic harvesting (1,11,12). The literature of the last 10 years suggests that the majority of surgeons now strive to achieve fat-cell survival in addition to trauma- induced fibrosis, with a variety of harvesting and injection techniques. After fat transplantation, fat cell survival and fibrosis have been demon- strated histologic ally (1,13). PREPARATION TECHNIQUES The plethora of recommended methods for harvesting and preparing fat for transplantation underscores the empirical nature of this procedure. The variety in technique also be gs the question, how fragile are fat cells? Several factors are said to effect fat cell survival (14), including: 1. choice of harvesting site, 2. vascularity and mobility of recipient sites, 3. manipulation and exposure of fat cells to air, blood, and lidocaine, 4. degree of negative pressure during harvesting, 5. diameter and type of the injecting cannula or needle, and 6. quantity of fat cells placed. Each of these factors has been examined to some degree but definitive answers are elusive. Recently, Sommer and Sattler (15) extensively reviewed reported techniques and survival rates, and concluded that good results are reported regardless of the technique as long as small volumes are utilized. In essence, adipocytes may not be as fragile as initially thought. 72 Butterwick The lack of standardization in technique reflects the difficulties in quantifying the results and longevity of fat augmentation. These limita- tions are outlined in Box 1. Within the context of our current difficulties in documenting results, some of the controversies in preparing fat for transplanta tion will be presented. Choice of Donor Site Many authors choose the outer thigh as the ideal site due to its nonfibrous nature and relative avascularity (11,12,16,17). The fat cells from this region will presumably show better survival in the initial hypoxic period. Hudson et al. (18) found that adipocytes from the buttock and outer thigh areas are the largest and have the greatest lipogenic activity. However, the optimal donor site has not been documented. Any site may be chosen, depending on the availability in a given patient. Areas that are diet- resistant are often recommended as, theoretically at least, the transplanted cells will be stable whether the patient loses or gains weight over time. Anesthesia of Donor Site According to Sommer’s review, similar survival rates are reported regard- less of the use of local anesthesia within the donor site (15). However, some studies have indicated that lidocaine has a negative effect on fat cell viability. This has been shown not only with lidocaine 1.0%, but also with diluted lidocaine 0.1% (19,20). The effect could be diminished by rinsing with saline. Despite this negati ve effect, lidocaine is widely used as donor site anesthesia, usually with Klein’s tumescent solution and lidocaine 0.1%. Differing dilutions of tumescent anesthetic have been recommended with or without epinephrine (15). A few authors recommend the use of Ringer’s lactate rather than normal saline, reasoning that glucose- containing solutions may enhance fat-cell viability (16,21). HARVESTING TECHNIQUES Avoidance of injury to fat cells is the goal of this component of the pro- cedure. There are numerous and sometimes conflicting reports regarding the harvesting techniques that are least likely to be injurious to the fat cell. Box 1 Difficulties in Measuring Outcome 1. Three dimensional results hard to capture with photographs 2. Lack of distinct histologic markers for transplanted fat cells 3. Expense of multiple MRI’s 4. Ongoing aging and weight changes of the patient 5. Inability to compare results due to variation in technique New Trends in Fat Augmentation Techniques with FAMI 73 [...]... was injected into rats After nine months, fat injected into the subcutaneous plane was completely absorbed and the only site in which autologous fat remained was that injected in the muscle Fat injection into muscles has also been helpful in other fields of medicine In otolaryngology, fat has been injected into the vocal cords , resulting in improved muscle function (46–48) In urology, fat has been injected... starting the in ltration of the tumescent solution Surgical Setting Sterile conditions and certain hygienic standards must be obeyed The elimination of microorganisms can be achieved by various sterilization procedures, such as boiling, steaming, autoclaving, or using radiation Before starting the surgery, the skin is disinfected; skin disinfection should be repeated at regular intervals during surgery. .. transplanted fat (15) Processing Fat Separation and Rinsing After collection, the fat in the syringe is undisturbed to allow its separation into supranatant and infranatant fractions New Trends in Fat Augmentation Techniques with FAMI 75 Figure 2 Syringes of collected fat capped off to minimize exposure to air, separating into supranatant and infranatant fractions The infranatant fluid is drained off the bottom... Borruel JL Treatment of urinary stress incontinence using paraurethral injection of autologous fat Arch Esp Urol 1991; 44:595–600 50 Shafik A Perianal injection of autologous fat for treatment of sphincteric incontinence Dis Colon Rectum 1995; 38 :5 83 587 51 Fulton JE Fat transfer: historical perspectives Am J Cosmet Surg 1999; 16(suppl 3) :1 93 194 52 Berman M Opinion: The aging Face: a different perspective... adipose graft in humans Aesth Plast Surg 19 93; 17: 43 36 Ersek RA, Change P, Salisbury MA Lipo layering of autologous fat: An improved technique with promising results Plast Reconstr Surg 1998; 101(suppl 3) :820–826 37 Guerrerosantos J Long-term outcome of autologous fat transplantation in aesthetic facial recontouring: sixteen years of experience with 1 936 cases Clin Plast Surg 2000; 27:515–5 43 38 Eremia... projections of the aging face Restore continuity of cosmetic units and jawline Support free margins of the face Restore aesthetic proportions is in ltrated into the fat surrounding the donor site, but Amar avoids injecting of solution directly into the donor tissue to minimize contact between adipocytes and lidocaine However, adequate anesthesia may be difficult to achieve unless Klein’s solution is in ltrated... placed into the lateral chin area into the depressor labii inferioris or anguli oris As much as 60 to 70 cc may be placed for a full-face procedure In a preliminary report, 20 to 30 cc was used on an average for partial face correction (55) With this amount, patients will have minimal bruising and swelling for five to seven days (Fig 12) The placement of fat in FAMI procedure is at a deeper plane than in. .. instruments is recommended in this area, as well as initial withdrawal of the plunger to assure one is not intravascular Retrograde fill and very low injection pressures will further minimize this risk Overcorrection is another potential problem, particularly in the infraorbital region resulting in visible, superficial lumps (42) Fat survival in this region is particularly good, perhaps owing to the relative... after 5 to 10 minutes (Fig 2) Because of the potential adverse effect of lidocaine and/or blood on fat-cell viability, many surgeons routinely rinse the fat with saline or Ringer’s lactate (16,17,21) However, others prefer minimizing trauma and do not rinse (10,24) According to a survey by Griffen (29), 62% of cosmetic surgeons wash the fat Sommer and Sattler (15) noted no difference in the reported... favored in the current literature (11,15,16 ,36 ,37 ) For injection, both blunt-tipped cannulae and needles have been advocated Some studies have suggested that diameter size be 18 gauge or larger with similar size orifices for transfer between syringes (31 ,38 ) In Shiffman’s study ( 23) , injection with smaller diameter 2 0- and 22gauge needles caused damage to the fat cells with histologic changes in cellular . marketing and media have capitalized on bringing new product information into the spot- light, allowing for greater information access to consumers. It is the Soft-Tissue Augmentation: Skin Fillers. be mindful of the possibility and be ready to respond accordingly with the administration of 5 cc intramus- cular injection of epinephrine 1:1000. Hypertrophic Scarring/Keloid Formation Post-treatment. epinephrine (15). A few authors recommend the use of Ringer’s lactate rather than normal saline, reasoning that glucose- containing solutions may enhance fat-cell viability (16,21). HARVESTING