Autologous Fat Transfer

Dimitrije E. Panfilov

Charles Conrad Miller from the USA described his method with infiltration of fatty tissue through hollow metal cannulas in 1926. He wrote: "The end-results in free fat transplantation depend, aside from various local and general factors, on the method and technique." As Miller was some kind of controversial physician and not a "real" surgeon, his work was soon forgotten. The reinventor of this method was Yves Gerard Illouz (known as the father of liposuction) from France, but the real breakthrough was made by Jose Guerrerosantos from Mexico and Sydney Coleman from New York.

There are many synonyms for autologous fat transfer (AFT): microlipofilling, structural fat grafting, liposculpturing, liposhifting, liposhaping, and lipo-styling. Years ago we all were telling our patients that autologous fat does not stay for more than 4-6 months. It does though. When we implant a fat lump 3-5 cm in diameter, only the periphery of 1 mm can survive, the rest will be transformed into an oil cyst and it will be resorbed. The reason for that is that capillary sproutings cannot grow into the fat for more than 1 mm. We had to change our philosophy.

Lumps After Fat Transfer
Fig. 59.1. a First patient with facial lipoatrophy we treated in 1997. b 6 months postoperatively: only hollow cheeks have been augmented with 8 ml purified fat cylinders on each side

Fig. 59.2. a Our youngest patient was 18 years old and had Barraquer-Simon's syndrome (lipodystrophia circumscripta buccalis). b Her appearance 2 years after autologous fat transfer (AFT) into her cheeks. c Dermographic markings to be filled up with 12 ml purified autologous fat, on each side. d One day postoperatively. e Six months postoperatively we augmented malar regions with 6 ml fat each and refilled cheeks with 3 ml ► each. f Her appearance 3 years after the first operation. g After 5 years she became pregnant; it seems that oestrogen has influenced further enlargement of transplanted fatty cells in her face. Half profile contour of the patient h preoperatively and i 3 years after "contouroplasty"

Healthy AestheticLipofilling Syringes
Fig. 59.3. a Our oldest patient with AFT, 81 years of age. b Six months after transplanting 38 ml purified fat into her face. Note the relatively good result of the glabellar folds, which is rather seldom
Lipofilling Syringes
Fig. 59.4. a A 2 ml syringe and Coleman cannula ready for lipofilling. b Simulation on a layer of gauze: by pulling back we fill up the empty channel with a fat cylinder (diameter 1 mm). c Different cannulas d with different tips

Fat cells which survive 2, 3, or 5 years do not have and did not want to undergo the risk of another face-

any reason not to survive for all the other years up to lift at this age, so we did the less risky procedure -

physiological fat decline of old age. Our oldest patient AFT to her face. is 81 years old. She had a facelift some 20 years ago

Byron Cannulas
Fig. 59.5. a Simulating cannula over the lower lip and b performing microlipofilling of the lower lip. Female patients very often wish to enlarge both their c upper and d lower lips

The new philosophy means that we have to create tunnels of 1 mm diameter each. Sydney Coleman created cannulas for doing this and they are manufactured by Byron with a Luer-Lock. Any ingenious idea is simple when it is proven. But it has to be realized by the first one who had this simple idea. That is why a genius is and stays a genius. After making channels of 1 mm in diameter, we slowly pull this cannula back and fill up the tunnel with purified fat cells. Capillary sproutings can grow into these cylinders and keep fat cells alive. Cannulas have to be blunt, so as not to provoke bleeding.

The best recipient of fat cells is between muscle fibres because of good irrigation with a lot of capillary sproutings, for instance among muscle fibres of the orbicularis oris, for enlargement of lips.

Lipofilling Oder Liposculpturing
Fig. 59.6. a Early fat decline; age mid-30s. b Dermographic e Depressed semicontour. f Improved half profile after 6 markings of structures, folds, and wrinkles to be augmented. months - contouroplasty c One week postoperatively. d Six months postoperatively.

Autologous fat can survive if:

  • Harvesting is gentle
  • Fractioning is gentle
  • Purification is proper
  • Implantation is proper
Images Viginas And Penisis

Fig. 59.7. a Removing of 1-mm-thick fat cylinder from the lower eyelid, 6 months after implanting it. b In lower eyelids we do not expect longitudinal fat cylinders but fat pads in three compartments. Penis c before augmentation with 58 ml of AFT and d 3 years later. A circumference increase of more than 25% remained stable for years

Penis Fat Pad

Fig. 59.7. a Removing of 1-mm-thick fat cylinder from the lower eyelid, 6 months after implanting it. b In lower eyelids we do not expect longitudinal fat cylinders but fat pads in three compartments. Penis c before augmentation with 58 ml of AFT and d 3 years later. A circumference increase of more than 25% remained stable for years

Our first AFT was in 1997, 2 weeks after I had visited Sydney Coleman in New York, watching and filming his technique. It was a patient who wished for a nose reduction and enlargement of his penis. I transplanted 58 ml of purified fat into his penis. The initial circumference was 84 mm (measured below the glansnot erect), after 6 months it was 112 mm and after

6 years 106 mm. I followed up this patient for 7 years and the circumference remained stable at the same level. He was young, active, and has had another child in the meantime. We also do handliftings with AFT and in both hands and penis we can measure the circumferences. We have found that 60-80% of fat cells stay stable for years.

Fat Transfer Lips
Fig. 59.8. a Not only lips, but also hollow cheeks are frequent regions patients would like to improve. b Result 4 months later. Another patient with the same indication c before and d 13 months after surgery

Further proof that autologous fat survives was given when I had to remove a cylinder of fat I had implanted into a lower eyelid after 6 months because of prolonged swelling. Frank Trepsat from Switzerland has had very good results with microlipofilling into both lower and upper eyelids but in my hands it does not work so well. As only one third of my results with implantation of autologous fat were good, I had to redo the operation because of permanent oedema in lower eyelids. We have done conventional lower

  1. 59.9. a This patient wanted to improve the projection of her "cheek bone". b Six months after surgery
  2. 59.9. a This patient wanted to improve the projection of her "cheek bone". b Six months after surgery
Improve Cheek Projection
Fat Cheeks Surgery
Fig. 59.9. Continued. c The whole face shows grooves, folds, and dimples. d Dermographic planning. e We are now able to "shape" and to "style" the face, to achieve more spherical harmony by adding 40 ml fat in this case. f A beautiful woman g can become even more beautiful

blepharoplasty. I could identify, isolate, and remove a longitudinal fat formation about 1 mm thick. It was the autologous fat graft I had put inside 6 months ago. And it has survived (Fig. 59.7a).

The best acceptability of fat grafts is, according to Guerrerosantos on the body below the level of the umbilicus. After how long is the final result achieved? Coleman says after 4 months. We would say also between 4 and 6 months.

What is the amount of fat we may transplant into face? Coleman transplants 80 ml; our own upper limit is 40 ml. We know that resorption of fat tissue occurs until the final result from 20-40% of implanted lipocytes. I prefer to make a slight overcorrection, grafting some 115% of the volume I consider to be optimal.

What Autologous Fat Transplant
Fig. 59.10. a Freezer with packets of fat syringes of different patients to be stored for 6 months. b Each packet should have a sticker with the patient's name, date of surgery, and number of syringes available inside
What Autologous Fat Transplant
Fig. 59.11. a Most patients want to accentuate also their malar prominence, which has been achieved b 4 months after surgery. c Very rarely do patients insist on achieving really "baby faces" emphasizing the cheeks themselves, not the malar prominence. d We can also fulfil such demands
Meme Faces 2018

Fig. 59.12. a Muller-Lyer optical trick. The two lines are equally long, although the lower one seems to be longer. The eyes of my reception clerk Maggy with make-up shadow at b the medial part of her upper eyelids and c the lateral parts of them. Now, the interoccular distance seems to be longer!

Plastic surgeon is now able to become really sculptor in vivo. Sculptors themselves say that they have to respect 60 planes, compared with a single plane for a painter. We can add two planes more: we are acting with the living material, which is mobile and changeable, and secondly there is the psychological level of our patients, who are emotional sculptures who cry and smile; therefore, we are acting in 62 planes.

Shadow takes something of the contour away and shining skin emphasizes this area. Richard Corson, a make-up stylist in many Hollywood productions, made a rule for make-up not to accentuate the malar bone medial to the imagined line from the middle of the eye downwards. With narrow faces one should stop more lateral from this line to make the face look wider. With broad faces, make-up accentuation of the malar bone should stop much more distant from the ears to make the face look narrower.

Before starting to do lipofillings we have to think of those rules and to follow them to be able to achieve more harmony in the faces of those who gave us their trust.

We will now consider the procedure step by step. The patient should have had a Betadine shower at home (or in our clinic) before coming to see us on the day of surgery. Then we make photographic documentation if this has not been done before. The patient stands in front of the mirror and we make der-mographic markings on her/his face. We follow our plan made at the initial or second consultation, but we accept also "last-minute" wishes and suggestions from the patient. Some patients call our dermography "Aborigine paintings", but it is useful after all.

Eye Trough Injections
Fig. 59.13. Individuals with preoperative markings showing where, what, and how much should be augmented by AFT

In the operating theatre we prefer to operate on the patient with intravenous sedation as described in Sect. 36.2. Through two 2-3 mm incisions in the inguinal region, we instill 200 ml of very dilute local anaesthesia in a special solution. In 1 l Ringer's lactate we put 50 ml 1% lidocaine and 0.25 mg epinephrine in each inside thigh, which is the best donor site in my opinion. This solution should be allowed to work for 45 min before we start harvesting fat. In-between we can perform some other surgery on the same patient, like eyelids, forehead lift, or breast augmentation, or we can just leave the theatre for that time. We could do some surgery in the next theatre.

After 45 min we start to harvest fat as one can see in Fig. 59.14. It is important that the syringe should not be bigger than 10 ml. Too high a negative pressure could denature fat cells. And we want to do "lipofill-ing, not lipokilling", as one of pioneers in liposurgery Giorgio Fisher from Rome used to say. It is also important that our movements are gentle and we should not act against resistance - the same principle as in liposuction.

In this way we can easily harvest 30-60 ml of fat from each inside thigh. Women have 27% fat tissue in their bodies and men only 15%; consequently, fat harvesting is much easier in women. It is most difficult to harvest fat in HIV-positive patients treated by protease inhibitors. They have almost no subcutaneous fat - we have to harvest in many locations, not only inside thighs.

Harvest Centrifuge Fat
Fig. 59.15. a Syringes are put in an upright position in the rack for precipitation and segregation for 10-15 min. b Into sterile tubes of the centrifuge we put four 10 ml syringes c to be cen-
Liposuction Syringe
  1. 59.14. a Liposuction cannula between 2 and 3 mm in diameter with five to 15 apertures has been inserted superficially into the inside thigh. b We have pulled out the plunger of the syringe, producing a vacuum, which we arrest with four fingers of the hand holding the syringe. c By gentle movement in and out (without working against any resistance) the 10 ml syringe is filled up with fatty cells after 20-50 movements
  2. 59.14. a Liposuction cannula between 2 and 3 mm in diameter with five to 15 apertures has been inserted superficially into the inside thigh. b We have pulled out the plunger of the syringe, producing a vacuum, which we arrest with four fingers of the hand holding the syringe. c By gentle movement in and out (without working against any resistance) the 10 ml syringe is filled up with fatty cells after 20-50 movements
Vacuum Syringe

trifuged for 3 min at 3,000 rpm. d All actions have to be done under sterile conditions

  1. 59.16. a Oil of the upper layer to be removed from the syringe with a strip of gauze, and lowest layer as fluid we allow to flow out by opening the plug for a few seconds. b Recharging from 10 ml- to 2 ml-syringes without exposure to the air, so we prevent infection and avoid oxygenation of fat cells which
  2. 59.16. a Oil of the upper layer to be removed from the syringe with a strip of gauze, and lowest layer as fluid we allow to flow out by opening the plug for a few seconds. b Recharging from 10 ml- to 2 ml-syringes without exposure to the air, so we prevent infection and avoid oxygenation of fat cells which could be damaged in this way. c Purified fat in 2 ml syringes closed with Luer-Lock plugs is ready to be grafted. d To recognize changing contours better, we sometimes use tangential illumination

Segregation and centrifuging make three fractions in the syringe: (1) the upper layer is oil of ruptured fat cells, (2) middle layer (35-70%) is purified parcels of fat tissue containing living fat cells, (3) the lowest level is serum, water, and lidocaine.

Fat Grafting For Nasolabial Folds
Fig. 59.17. Microincision a near to the lateral canthus and b at the deepest point of the nasolabial fold. Cannula inserted for malar augmentation from c above and d below to place liposuction micrografts in a crisscross pattern

The incisions in the recipient area are just 1 mm long; we call them microincisions. We make them with a semirotating movement with scalpel blade no. 12 in the corners of the mouth, eye, nose, below the earlobes, or at the end of skin folds or wrinkles we are going to augment.

Serum For Nasolabial Folds
  1. 59.18. a A patient with a minimal-invasive, deep-intensive (MIDI) facelift planned together with AFT, 33 years of age. b One day postoperatively; 30 ml purified fat has been transplanted to her face; reasonable swelling and bruising. Patient c before (a beautiful woman - no question) and d 3 weeks after both procedures. She is a TV announcer and intends now to stay in this cruel profession for the next 5 years
  2. 59.18. a A patient with a minimal-invasive, deep-intensive (MIDI) facelift planned together with AFT, 33 years of age. b One day postoperatively; 30 ml purified fat has been transplanted to her face; reasonable swelling and bruising. Patient c before (a beautiful woman - no question) and d 3 weeks after both procedures. She is a TV announcer and intends now to stay in this cruel profession for the next 5 years

Facial incisions are only anaesthetized at the entrance point, not further. Some patients do not want any sort of sedation or anaesthesia and they do not feel the advancement of the cannula through the subcutaneous layer or among muscle fibres as unendur-ably painful. We do not suture these microincisions; we just stick them with suture strips or Dermabond. After a few days scars are not visible and nobody has claimed they are.

If patients do not want to interrupt their taking of oral contraceptives or hormone therapy, haematomas can occur, but they disappear after 10-14 days.

How much fat should we transplant to certain areas of the face? There is a very good German proverb: "Enough is better than too much." Our upper limit is 40 ml. In this way patients will be resocialized earlier - after 1 week, on average - and we can add stored fat cells after 4-6 months by doing relipofilling. Not more than 30% of our patients come to us for secondary lipofilling. In that case we have to thaw frozen syringes at least 3 h before the secondary procedure.

Lipofilling Syringes
Fig. 59.19. a Patient planned for a MIDI facelift and AFT, 35 years of age. b Three days postoperatively; haema-tomas due to hormonal influence
Lipofilling Syringes
Fig. 59.20. Patient a before the first procedure of AFT and b 6 months after secondary microlipofilling. The same patient c before in posterior semiprofile. and d after finished contouroplasty
Lipofilling Syringes
Fig. 59.21. a Malar region: 4-8 ml. b Nasolabial fold: 1-4 ml. c Marionette groove: 0.5-1 ml. d Upper lip: 2-6 ml. e Lower lip: 1-4 ml. f At the end of grafting we apply modest digital

Patients in Europe and especially in Germany do not want to look overdone and they pay great attention to resuming their usual activities as soon as possible. We have to respect the wishes of our patients when deciding how much fat is to be grafted.

Nasolabial Flap End Result

>4

■ A^ JL -

d

pressure to smooth grafting areas; dispersion of fat grafts look harmoniously

One of our nurses in the theatre should write down the regions and the appropriate numbers of millilitres of fat on the first side we do lipofilling. When we do the opposite side, we can ask for these numbers so we can work symmetrically. We are always trying to achieve harmonious results.

Autologous Fat Grafting

pressure to smooth grafting areas; dispersion of fat grafts look harmoniously

Fig. 59.22. a Lips and nasolabial folds to be grafted. b We have put 3 ml into the upper lip, 2 ml into the lower lip, and 3 ml below each nasolabial fold

Fig. 59.23. Cooling of the treated areas directly postoperatively

After surgery we apply cold gel to the operated structures to reduce swellings and bruising.

If it seems that we have overdone the lipofilling, it is possible to "kill" the fresh lipocytes by well-dosed digital pressure within the first 2-3 weeks. At the beginning, when I was inexperienced with the new method and my patients were inpatient, I did digital "squeezing" three times in over 500 treatments. In two of those, I had to do refilling after 4 months. Now I know to convince the patient that the volume of transplanted fat will reduce by 30% on average. Now I do squeezing sometimes just on the margin of the grafted area, to harmonize it, if it seems to be necessary.

Fig. 59.23. Cooling of the treated areas directly postoperatively

Fat Transfer After Weeks Images
Fig. 59.24. Digital compression to reduce grafted volume within the first 2-3 weeks
Autologous Fat Transfer For Lips
Fig. 59.25. a Rough smiling folds ought to be corrected. b One week postoperatively
Ergotrid Fat Graft
Fig. 59.26. a The upper lip should be augmented. b We put 4 ml purified fat grafts into upper lip

There are some specific applications of AFT. Even slight nose irregularities can be improved

One of the lips can be made more prominent. with autologous fat grafting. We mostly need two or three sessions for this indication.

Sometimes we can improve irregularities after facelift surgeries like grooves and dimples.

Fat Transfer After Weeks Images
Fig. 59.27. a Saddle nose. b We have done microlipofilling. c Six months after the last procedure
Autologous Fat Transfer For Lips
Fig. 59.28. a Obviously, during facelift surgery too much of the superficial musculo-aponeurotic system was eliminated over the mandibular angle. b We could fill this defect with 8 ml fat and a marionette groove (1 ml each) with AFT. Six months postoperatively
Man Cheek Augmentation
Fig. 59.29. a Male patient with HIV facial stigma. b Augmenta- augmentation of cheeks (8 ml each) and upper (4 ml) and lower tion with 8 ml purified fat each side, 4 months postoperatively. (2 ml) lips c Female patient with the same problem. d Four months after

HIV-positive patients treated with protease inhibi- patients have very little subcutaneous fat on the whole tors have stigma through typical buccal lipoatrophy. body, especially men. This can be improved but there is a warning: those

Autologous Fat TransferFat Transfer Hiv

Fig. 59.30. Skin a with pigment marks before and b 4 months after AFT. Another female patient c before and d 6 months postoperatively

--for oestrogen. This hormone is known as a soft-mak-

Elixir phenomenon: FAT IS BEAUTIFUL er, fine-maker, or beauty-maker. Transplanting fat into face, we also bring oestrogen there and this is

Many plastic surgeons have noticed that the complex- probably the reason why skin starts to "blossom" after ion of the skin improves after fat transfer into the AFT, even in women who do not use make-up. It face. The skin becomes smoother, shining as if it were works like an elixir from inside. One can compare oiled and creamed from below, from inside. This is previous cases (even those with make-up afterwards)

probably due to the fact that fat cells contain receptors but there are some without make-up.

Man Becomes Woman With Surgery

Fig. 59.30. Skin a with pigment marks before and b 4 months after AFT. Another female patient c before and d 6 months postoperatively

Lipofilling Male
Fig. 59.31. a A man with a "tired look". b After transplanting 40 ml purified fat into his face, his look and also his complexion improved. c Male patient with planned facelift, forehead-lift, nose and ear correction, and AFT. d After 12 days his skin is "blossoming"

Make-up is applied over the skin, and autologous fat works from below. If there would not be a semantic confusion, we would introduce a new entity: make down (opposite to make up). Some male cases where we also have noticed the improvement of complexion are given in Fig. 59.31. And men do not use any make up.

Liposuction For Autologous Fat
Fig. 59.32. a We prefer harvesting fat b from inside thighs. c When performing liposuction we can reach the inside thighs also from the back side. d The upper arm is also a good donor, but we prefer inside thighs

The question arises: What is the best donor site for harvesting fat cells? Certainly, we could take fat from all parts of the body where we usually perform lipo-suction. The abdominal fat cells have unlimited ability to store fat in them. Otherwise most receptors for oestrogen are those fat cells which are near to the pri mary gender zones. These fat cells promise to give the best elixir effect to the skin, and that is why we harvest almost exclusively from inside thighs. And it is very easy and comfortable to harvest fat from thighs when the patient is lying on her/his back.

Fig. 59.33. Patient a before and b 1 year after biplanar facelift. c Three months after additional AFT

We had a patient who had had a classic facelift and was satisfied with it. But she inherited some money and asked what we could do additionally. So we suggested microlipofilling of her face (AFT). It was an unintended experiment. Figure 59.33 shows the step-by-step improvement.

Since that experience, I suggest more and more to my patients not to have only a facelift but also AFT into their faces. At least because of the "elixir effect". Not everybody is ready to do it, because of additional costs.

Fat Transfer Cost
  1. 59.34. Fig. 59.34. a At the end of the facelift we can insert fat grafts b under visual control. c And it brings d more effectiveness. e Because of severe rheumatism, the patient could not undergo facelift surgery. f Less aggressive method of AFT could help her sufficiently
  2. 59.34. Fig. 59.34. a At the end of the facelift we can insert fat grafts b under visual control. c And it brings d more effectiveness. e Because of severe rheumatism, the patient could not undergo facelift surgery. f Less aggressive method of AFT could help her sufficiently
Fat Transfer Face
  1. 59.35. Patient a before and b after complex facial beautification: facelift, endoscopic forehead-lift, eyelid surgery, and AFT. A 25-year-old patient c before and d after filtropexy of the upper lip and AFT. e 45 years old patient before and f after MIDI facelift, "optimistic sutures" and AFT
  2. 59.35. Patient a before and b after complex facial beautification: facelift, endoscopic forehead-lift, eyelid surgery, and AFT. A 25-year-old patient c before and d after filtropexy of the upper lip and AFT. e 45 years old patient before and f after MIDI facelift, "optimistic sutures" and AFT
  3. 59.36. a Face of a 40-year-old patient preoperatively. b Her look after AFT of 36 ml into her face. Her right hand c before and d 4 months after grafting of 16 ml into each hand
  4. 59.36. a Face of a 40-year-old patient preoperatively. b Her look after AFT of 36 ml into her face. Her right hand c before and d 4 months after grafting of 16 ml into each hand
Autologous Fat Transfer

"Handlifting" with AFT

Now we combine more and more mosaic stones of facial structures not only to rejuvenate, but also to harmonize and to enhance the whole appearance.

We all have seen wonderful facelifted actresses with a youthful facial appearance, but to those faces belong hands that look 15-20 years older, especially when they hold microphones. Some of them wear gloves to hide this obvious traitor of well-performed facelifts. Thanks to AFT below the wrinkled, crumpled skin of the dorsum of the hands and digits, we can now rejuvenate also hands to match the faces.

In general, under intravenous sedation and local anaesthesia of four dorsal incisions - two on radial and ulnar side of the wrist and over second and fifth metacarpophalangeal joint - we advance the Coleman cannula and by pulling it backwards, we fill up this tunnel with purified fat.

Second Metacarpophalangeal Joint
Fig. 59.37 a-h. Microincision a over the second metacarpophalangeal joint and b in the radial dorsum of the wrist. c Consecutive microlipofilling. d in a crisscross direction

proximal to the phalanx of e second and f third digit. g At the end of surgery. h Bandage for 1 day

Coleman Fat Transfer Cannula
Fig. 59.38. a Dermographic markings before surgery. b One week postoperatively
Coleman Fat Transfer Cannula
Fig. 59.39. a Left hand and b right hand before surgery. c One year after d AFT of 20 ml into each hand

Patients are advised to use their hands very cautiously for the first 3-4 weeks, avoiding any heavy manual work.

After 2-3 weeks the appearance of the hands is already not very suspicious and stable results are to be expected after 4 months. About 60-80% of fat is taken Only 15% of our patients with handliftings visit us for relipofilling after 6 months. In general, they are very satisfied.

Aft Treatment Before And After Photos
Fig. 59.40. Patient a before and b after AFT: 30 ml into the face and 16 ml purified fat per hand
Before And After Aft Facial
Fig. 59.41. Patient a before and b 4 months after facelift, crow's-feet treatment eyelid surgery, and AFT for both face (24 ml fat) and hands (18 ml each)

For our patients with facial structuring, we also offer to treat their hands if they show reasonable improvement after AFT.

It is not seldom that we combine facelift and eyelid surgery with AFT into both face and hands.

We now possess a very reliable, nonaggressive operating method with great resonance among patients. If we do not use a pistol injector, which could cause fat embolism of facial vessels, the procedure is not risky and has only minor complications and even these are extremely seldom if aseptic work has been done.

We can fill missing volume, and act as real "bio-sculptors", improving contours of the face in any direction, fulfilling volumetric principles. An overdose can be corrected by digital pressure and an underdose by relipofilling after 4-6 months. There is a remarkable elixir effect probably owing to oestrogen receptors with shining, rejuvenated skin. In contrast to wrinkle-fillers there is neither allergic nor foreign-body reactions and stable results for years with only 30% of average volume lost after first 4-6 months are available. We do not only want to earn money but also satisfied, happy patients. That is why we dare repeat: Fat is beautiful for both patients and surgeons.

Bibliography

Please see the general bibliography at the end of this book.

Fig. 59.42. a AFT to both face and hands. b Right malar silicone and d 4 days after surgery. e Four months later, her face and implant (from another clinic) is in place, the left is smaller and hands look much younger than her age of 52 displaced. AFT augmentation to be done. The patient c before
Fig. 59.43. a Ulnar skin excision to "lift" hands b has been abandoned because of the scarless AFT method
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