CC
A 46-year-old female presents for consultation regarding the shape of her nose and progressive changes in her face.
HPI
The patient has felt the process of aging since a few years ago. She has used several hydrating over-the-counter products and uses a lot of makeup to conceal skin changes and improve her upper lip contour.
PMHX/PDHX/medications/allergies/SH/FH
The patient is a healthy nonsmoker. (Smoking may negatively affect graft survival.). She has is no history of a bleeding disorder or use of blood thinners (Aspirin and other nonsteroidal antiinflammatory drugs should be withheld 2 weeks before surgery, as should smoking. Vitamin E and some herbal products that interfere with bleeding are also discontinued before surgery.)
Examination
The examination starts with a comprehensive interview. It is feasible to discuss the risks and limitations of fat grafting in comparison with dermal fillers.
Donor sites are to be evaluated preoperatively. In extremely lean patients as in the present patient, there are no massive fat sources, and multiple donor sites may be needed. The inner and outer sides of the thigh provide four possible donor sites without the need for intraoperative position changes. In addition, using multiple donor sites may be beneficial to avoid donor site contour changes. In case of inadequate donor reservoirs, it would be better to think about alternative treatments such as fillers.
Imaging
A standard series of photography needs to be done before and after surgery. Photography is the best tool to communicate with the patient during the preoperative consultation sessions and record the preoperative condition and postoperative changes ( Fig. 84.3 ).
Labs
No routine laboratory testing is indicated for cosmetic rhinoplasty unless dictated by the medical history.
Assessment
Comprehensive examination and evaluations of the patient show the early signs of aging; hollowing of temporal areas on both sides are evident. Malar prominences are flattened, and submalar depressions are apparent. Nasolabial grooves are deepened. The vermilion show is near zero. Marionette lines are visible. Skin quality is the other complaint of the patient. Dry and brittle skin has developed in the past few years.
Treatment
Fifty mL of the fat graft was planned and performed. The donor sites were discussed with the patient, and since because was relatively lean, lateral and medial sides of both tight prepared and draped to avoid possible contour changes from single donor sites. Then the following steps were performed consecutively:
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Mapping and marking the face based on the treatment plan.
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Injection of a total of 50 mL of wetting solution (almost equal to the volume of fat to be harvested) on four donor sites (250 cc of normal saline, 5 cc of lidocaine, 1 cc of epinephrine 1/1000) ( eFig. 84.4 , Fig. 84.5 , eFig. 84.6 to Fig. 84.7 ).
