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Surgical Pearls |

Fluid Fat Injection for Volume Restoration and Skin Regeneration of the Periocular Aesthetic Unit

Francesco P. Bernardini, MD1; Alessandro Gennai, MD2
[+] Author Affiliations
1Oculoplastica Bernardini, Genova and Milan, Italy
2Gennai Chirurgia, Bologna, Italy
JAMA Facial Plast Surg. 2016;18(1):68-70. doi:10.1001/jamafacial.2015.1146.
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This report of surgical cases describes the successful use of superficial enhanced fluid fat injection for rejuvenation of the periocular aesthetic unit.

Atrophy of the skin and volume loss are the 2 major contributors to facial aging and affect, early on, the periocular region where they contribute to the formation of periorbital skin wrinkles, thinning and descent of the eyebrows, deepening of the superior sulcus, infraorbital hollowing, and pseudodescent of the cheek.1 In our opinion, facial rejuvenation should target primarily the age-related changes of the periocular aesthetic unit in association with various surgical procedures necessary to address the specific needs of each individual patients. Autologous fat has the potential to provide volume restoration and skin regeneration, and fat grafting is regarded as the procedure of choice for facial rejuvenation. Yet the eyelids are still considered by most surgeons to be off limits for fat grafting because even the smallest irregularity may become visible through the thin eyelid skin, causing unsatisfactory aesthetic results.

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Figure 1.
Surgical Tools Used to Harvest and Inject Superficial Enhanced Fluid Fat Injection (SEFFI) Grafting Material

A, Cannulas with different-size side ports: from left to right, 2 × 3 mm (the traditional Coleman cannula), 0.8 mm, 0.5 mm, and 0.3 mm. The 3 smaller-port cannulas are viable options for harvesting SEFFI material. B, Syringes of SEFFI material before and after centrifugation. C, Syringes of SEFFI material and platelet-rich plasma (PRP) ready to be mixed. D, Multiple 3-cm3 syringes of PRP and SEFFI mixture ready to be used.

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Figure 2.
Four Patients Shown Before and After Undergoing Facial Plastic Surgery That Included Superficial Enhanced Fluid Fat Injection (SEFFI)

A, A 57-year-old woman who underwent minimal-incision vertical endoscopic lift (MIVEL), SEFFI, upper and lower blepharoplasty with transconjunctival fat transposition, and minipinch skin excision. One year postoperatively, there is improved fullness of the brows and upper eyelids, improvement of the lower eyelid–cheek continuum with improved projection of the malar fat pads, and an overall improvement of the periocular lines and facial rhytids. B, A 47-year-old woman who underwent MIVEL, SEFFI, upper and lower blepharoplasty with transconjunctival fat transposition and minipinch skin excision. One year postoperatively, there is a substantial improvement of the lower eyelid skin, a better eyelid-cheek transition with fullness of the medial fat pad, and concomitant reduction of the nasolabial folds. C, A 36-year-old woman who had excisional upper and lower blepharoplasty 2 years before the left picture was taken is showing unnatural deepening of the upper sulcus, skeletonization of the frontal bone in the brow, rounding of the lateral corner, and bilateral scleral show. Fifteen months after SEFFI and lateral canthoplasty, a substantial improvement of the brow–upper eyelid complex is seen, where a more natural fullness has been reestablished. D, A 34-year-old man before and 24 months after a lateral canthoplasty with SEFFI to correct a severe cicatricial ectropion and deep infraorbital hollowness resulting from an overly aggressive previous lower eyelid blepharoplasty.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Demonstrations of the Superficial Enhanced Fluid Fat Injection (SEFFI) Procedure

At first, the video shows a mock injection of the 0.3-mm SEFFI flowing easily and uniformly through a 23-gauge needle under minimal digital pressure showing a yellow paste with the consistency of commercial fillers. The SEFFI material is injected into the brow and upper eyelid sulcus above the eyelid crease including at the apex of the A-deformity at the medial third of the upper eyelid. The lower eyelid is approached from its lateral side to correct the temporal depression at this level, and it is extended along the infraorbital hollow, the eyelid-cheek junction, and the tear trough just below the medial canthal tendon.

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