How To Harvest Fat From The Infratemporal Fossila

Transcription

1 Techniques in Cosmetic Surgery Harvesting Fat from the Infratemporal Fossa Bahman Guyuron, M.D., and Kevin Rose, M.D. Cleveland, Ohio As part of forehead rejuvenation and surgical treatment of migraine headaches, the mass of the corrugator supercilii, the procerus, and the depressor supercilii muscles is replaced with fat for optimal aesthetic contouring of this region and to help prevent recurrence of the glabellar lines. The authors propose a new fat graft donor site that is convenient and safe and that adds only minutes to the total operating time. This fat is located between the deep layer of deep temporal fascia and the temporalis muscle as it approaches the zygomatic arch. The temporal musculofascial anatomy as it relates to the available fat donor sites is described. This source has been used on 74 occasions at 128 sites, from July 1, 2002, to December 31, 2002, with no complications attributable to the technique. (Plast. Reconstr. Surg. 114: 245, 2004.) As part of forehead rejuvenation, the glabellar musculature that contributes to the formation of frown lines is often excised piecemeal. The mass of the corrugator supercilii, the procerus, and the depressor supercilii muscles should ideally be replaced with soft tissue for optimal aesthetic contouring of this region. This will accomplish three distinct goals: it will avoid flattening or depression resultant from the loss of muscle bulk, even though it may be minimal; it will restore a more rejuvenated contour, because flattening of the glabellar region is one of the cardinal features of forehead senescence; and it will help prevent reattachment of residual or regenerate muscle fibers to the cranial bones, the effectiveness of the regenerated muscle and therefore the potential for recurrence of frown lines, 1 or migraine headaches, associated with this trigger site. 2 5 Various substances have been used for replacement of this volume, including fat obtained from the periorbital preaponeurotic fat, abdominal fat, or elsewhere. 6,7 Neuber, 8 in 1893, was the first to use autologous fat as a graft. Since then, surgeons have learned that maintenance of the graft volume is dependent on two factors: the total volume of fat used and the vascularity of the recipient site. Central necrosis of the fat surrounded by a zone of inflammation with viable adipocytes results when the volume of fat grafted is too large. This may result in the loss of as much as 50 percent of the volume or more. Thin grafts (i.e., less than 1 cm) will be revascularized and will not reabsorb significantly In forehead rejuvenation and surgery on frontal trigger points to treat migraine headache, only a small amount of fat is needed to fill the glabellar frown lines, replace the muscle bulk, and contour the forehead. We propose a new site for harvesting fat graft that is convenient and safe and adds only minutes to the total operating time. This is the fat located deep to the deep temporal fascia cephalad to the zygomatic arch in the temporal fossa. This technique has been used by the authors for obtaining fat graft during endoscopic forehead corrugator resection for aesthetic reasons and for surgery on patients with frontal trigger points. 1,12 MATERIALS AND METHODS Anatomy The deep layer of the deep temporal fascia is directly adherent to the temporalis muscle and inserts along the zygomatic arch. The fat to be harvested is located deep to the deep temporal fascia immediately cephalad to the junction of the zygomatic body with the zygomatic arch From Case Western Reserve University. Received for publication May 20, 2003; revised September 17, DOI: /01.PRS

2 246 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004 and extends slightly under the zygomatic arch. All of the fat bulk is anterior to the temporalis muscle. The temporalis muscle, which is deep to this fat, overlies and protects the many important structures of the infratemporal fossa, including the deep temporal arteries and nerves and the maxillary artery and nerve and pterygoid plexus of veins. 13,14 The infratemporal fat should not be mistaken for the temporal fat pad. The latter is located superficial to the deep temporal fascia and more cephalad to the infratemporal fat (Fig. 1). Technique Because this new procedure is used in conjunction with forehead rejuvenation or surgery for migraine headache, the details of which have been reported elsewhere, only the harvesting portion of the procedure is described here. As part of an endoscopic forehead lift, the safe plane of dissection immediately superficial to the deep temporal fascia is continued toward the zygomatic arch. Care is taken to ensure that the superficial and intermediate layers of the deep temporal fascia are identified, separated, and elevated, protecting the frontal branch of the facial nerve safely away from the plane of dissection. Early identification of the deep temporal fascia at the time of insertion of the endoscopic access device is the key to the safe dissection. One may make an incision in the deep temporal fascia deliberately to visualize the temporalis muscle cephalically to ascertain safe dissection, until sufficient experience is attained. An important key guide is dissection deep to any adipose tissue. By so doing, it will be unlikely that the dissection will be conducted in between the intermediate and superficial temporal fascia. The dissection is carried subperiosteally along the zygoma and on the superomedial aspect of the zygomatic arch (Fig. 2, above, left). The sharp edge of a curved periosteal elevator is used to incise the deep layer of the deep temporal fascia just cephalad to the zygomatic arch medially (Fig. 2, above, right). The fat projects through the incision immediately (Fig. 2, center, left). A Struempel-Voss nasal forceps is used to bluntly retract the fat several times before its removal (Fig. 2, center, right). With a final pull, the fat is detached and removed in one piece or in piecemeal fashion (Fig. 2, below). By applying external pressure on the deep fascia or the buccal area, the fat bulges out through the incised fascia, further facilitating its removal. Often, no significant bleeding is encountered, but if bleeding is encountered, it is easily controlled with a suction Bovie electrocoagulator. The deep temporal fascia is left open. The fat is then placed in the target site. This fat could be used for fat grafting elsewhere as the surgeon determines. RESULTS Seventy-four patients have undergone either forehead rejuvenation or migraine headache surgery for frontal trigger points from July of 2002 through December of In all patients, the fat was harvested bilaterally to provide sufficient volume of fat graft. None of these patients have complained about any limitations with chewing or the presence of a depression above their zygomatic arch, nor were any contour deformities detected by the surgical team (Fig. 3). FIG. 1. Artistic rendering of the anatomical planes. DISCUSSION It is advisable to consider fat grafting in the glabellar region to avoid postoperative depres-

3 Vol. 114, No. 1 / HARVESTING FAT FROM INFRATEMPORAL FOSSA 247 FIG. 2.(Above, left) Endoscopic view of the dissected area. The dissection is carried subperiosteally along the zygoma and the superomedial aspect of the zygomatica arch (Z) and the deep temporal fascia (DTF) is exposed. (Above, right) The sharp edge of a curved periosteal elevator is used to incise the deep temporal fascia close to the junction of the horizontal and vertical portion of the zygoma. (Center, left) The fat located below the deep temporal fascia protrudes through the incision immediately. (Center, right) A Struempel-Voss nasal forceps is used to pull the fat several times and advance deeper to collect more fat. (Below) With a slightly more forceful pull, the fat is detached and removed. sion. Also, as the role of surgical intervention in treating migraine headaches becomes solidified, use of fat graft will become more prevalent. Because the graft is small, it reduces the potential for necrosis and allows for a soft, aesthetically pleasing, and youthful forehead contour. Having knowledge of the temporal musculofascial anatomy as it relates to the available fat donor sites is invaluable for providing a safe and effective outcome. If one is performing blepharoplasty in addition to addressing the glabellar region, the postseptal preaponeurotic fat can be available for grafting if removal of fat is part of the aesthetic goal. However, fat removal from the eyelids is rapidly falling from favor, increasing the indication for harvesting

4 248 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004 FIG. 3. Preoperative (above) and approximately 1-year postoperative photographs (below) demonstrating unchanged contour of temple region after harvesting of fat graft during surgery for migraine headaches. the fat graft described here. Otherwise, it would be necessary to harvest the fat through a separate incision from another site. Having an alternative source of fat graft, the harvesting of which is safe and easy, is extremely helpful. The only real risk when harvesting this fat is bleeding which, should it occur, can easily be controlled. Loss of this fat does not seem to cause any deformity or difficulty in temporalis muscle function. The fat conveniently is devoid

5 Vol. 114, No. 1 / HARVESTING FAT FROM INFRATEMPORAL FOSSA 249 of facial nerve branches and sizable blood vessels. In a landmark anatomical study, Stuzin 15 described the anatomy of the temporal region, with specific reference to the frontal branch of the facial nerve after examining 12 fresh cadaver dissections. He noted that a constant plane along the undersurface of the temporoparietal fascia (superficial fascia) housed the frontal branch in all dissections. The nerve was quite superficial while crossing the zygomatic arch. Considering this information and based on our experience, as long as the dissection is conducted in a subperiosteal plane, injury to the facial nerve becomes extremely unlikely. Bahman Guyuron, M.D Cedar Road Lyndhurst, Ohio bguyuron@aol.com REFERENCES 1. Guyuron, B., and Michelow, B. Refinements in endoscopic forehead rejuvenation. Plast. Reconstr. Surg. 100: 154, Guyuron, B., Varghai, A., Michelow, B. J., Thomas, T., and Davis, J. Corrugator supercilii muscle resection and migraine headaches. Plast. Reconstr. Surg. 106: 429, Guyuron, B. Forehead rejuvenation. In Plastic Surgery Indications, Operations, and Outcomes, Vol. 5. Aesthetic Surgery. St. Louis: Mosby, Pp Guyuron, B., Tucker, T., and Davis, J. Surgical treatment of migraine headaches. Plast. Reconstr. Surg. 109: 2183, Knize, D. M. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast. Reconstr. Surg. 95: 52, Billings, E., Jr., and May, J. W., Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast. Reconstr. Surg. 83: 368, Chajchir, A., and Benzaquen, I. Fat-grafting injection for soft tissue augmentation. Plast. Reconstr. Surg. 85: 921, Neuber, G. Fat transplantation. Verh. Dtsch. Ges. Chir. 22: 66, Baran, C. N., Celebioglu, S., Sensoz, O., Ulusoy, G., Civelek, B., Ortak, T. The behavior of fat grafts in recipient areas with enhanced vascularity. Plast. Reconstr. Surg. 109: 1646, Coleman, S. R. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast. Surg. 19: 421, Michelow, B., and Guyuron, B. Rejuvenation of the upper face: A logical gamut of surgical options. Clin. Plast. Surg. 24: 199, Guyuron, B., Michelow, B., and Thomas, T. Corrugator supercilii muscle resection through blepharoplasty incision. Plast. Reconstr. Surg. 95: 691, Clemente, C. D. Anatomy: A Regional Atlas of the Human Body, 3rd Ed. Philadelphia: Lea & Febiger, Pp Gross, C. M. (Ed.). Gray s Anatomy of the Human Body, 28th Ed. Philadelphia: Lea & Febiger, Pp Stuzin, J. M., Baker, T. J., and Gordon, H. L. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast. Reconstr. Surg. 89: 441, 1992.