A, The temporal augmentation area includes the temporal hollowing region (TR) and the possible frontal transition region (FTR). B, The advocated cannula entry site is located at the medial border of the junction of the hairline and the temporal line (red circle). B, The deep injection plane includes the upper temporal compartment (UTC) and the lower temporal compartment (LTC). C, The superficial injection plane includes the lateral temporal-cheek fat compartment (LTFC) and the lateral orbital fat compartment (LOFC). D, An illustration demonstrates the superficial temporal fascia (STF) and the association between the superficial and deep injection planes. Reproduced from Aesthetic Surgery Journal,9 © 2017, The American Society for Aesthetic Plastic Surgery, Inc.
A and D, Each patient was scanned to obtain a preoperative 3-dimensional image of the temporal region. B and C, The required volume for each temple was analogized according to the outline of the total face and the expectation of the patient. E, A postoperative 3-dimensional image was obtained at least 12 months after the last procedure. D through F, Preoperative and postoperative 3-dimensional images were overlapped to calculate the augmentation volume. Graphs below the rows of images show the colorized area, which represents the required augmented volume, and the color bars represent the depth of the hollowness. The values above the bracketed segments represent the percentage of the corresponding color area.
A, The preoperative photograph shows that the patient had mild temporal hollowness and the required volume of 8 mL for the right and 7 mL for the left temporal regions. B, During the first fat-grafting procedure, 10 mL of fat was grafted into the right temple and 9 mL was grafted into the left temple. Three months later, temporal hollowing improved. C, The patient requested a second procedure, and 3 mL of fat was grafted into the right and left temples to achieve a smoother contour. The patient appeared to have no hollowness in either temple 15 months after the second procedure. The hollowness augmentation rate of the right temple was 97.3% and of the left temple was 103.5%. The survival rate of the fat grafts at the right temple was 59.9% and at the left temple was 60.4%. The patient was fully satisfied with the results.
eFigure 1. Temporal Hollowing Characteristics and Facial Area
eFigure 2. Cannula Entry Site for Temporal Augmentation Procedure
eFigure 3. Hollowness Severity Rating Scale Grading of the Temples
eFigure 4. Satisfaction Rates Evaluated by the Patients, Surgeons, and Laypersons
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Huang R, Xie Y, Wang W, Tan P, Li Q. Long-term Outcomes of Temporal Hollowing Augmentation by Targeted Volume Restoration of Fat Compartments in Chinese Adults. JAMA Facial Plast Surg. 2018;20(5):387–393. doi:10.1001/jamafacial.2018.0165
Is the targeted fat-grafting technique an effective and safe procedure for temporal hollowing augmentation?
In this cohort study of 96 patients, 142 autologous fat-grafting procedures were performed. A low complication rate was reported, and all patients showed an improved appearance after the fat-grafting procedure, with 74% of the temples exhibiting clinical improvement by more than 2 grades.
This technique can yield a natural, long-term result in temporal augmentation and avoid severe neurovascular injury.
Previous anatomical and clinical studies have suggested that targeted restoration of the volume and distribution of fat compartments using appropriate cannula entry sites and injection planes is an excellent fat-grafting technique for facial contouring and hand rejuvenation.
To perform subjective and objective evaluations of the safe and effective profile of the targeted fat-grafting technique for temporal hollowing augmentation.
Design, Setting, and Participations
In a retrospective cohort study, a total of 96 consecutive patients with temporal hollowing were treated at the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, China, with the targeted fat-grafting technique from January 1, 2009, to January 1, 2017.
Main Outcomes and Measures
The safety and efficacy profile of this technique was evaluated by the following methods: (1) a quantitative measurement of fat-graft survival and temporal augmentation rates by using 3-dimensional laser scanning, (2) a subjective assessment using a satisfaction survey and the Hollowness Severity Rating Scale (grades range from 0-3, with higher grades representing more hollowness), and (3) the complication rate.
Of the 96 study patients, 94 (97.9%) were women and the mean (SD) age was 34.4 (7.4) years. Of the 142 autologous fat-grafting procedures performed, the mean (SD) total follow-up time was 16.3 (3.2) months, with a mean (SD) of 1.5 (0.7) procedures performed. The mean (SD) baseline volume requirement per temple for each patient was 12.8 (4.8) mL, and the total volume of the fat graft per temple was 17.8 (7.5) mL. Quantitative analysis revealed that the mean (SD) total augmentation volume per temple was 11.7 (3.0) mL, the total survival rate of the fat grafts was 65.7% (12.6%), and total augmentation rate of hollowness was 91.4% (23.4%). Subjective analysis revealed that all patients showed an improved appearance after fat grafting, and 142 temples (74.0%) exhibited clinical improvement by more than 2 grades. In all, 88 patients (91.7%) were satisfied with the outcomes, with a low complication rate reported.
Conclusions and Relevance
The targeted fat-grafting technique allows the transplant of fat tissue into 4 separate fat compartments in a double-plane manner through a unique cannula entry site that avoids severe neurovascular injury. The long-term results demonstrate that this technique is an effective, reproducible, and safe approach for temporal hollowing augmentation.
Level of Evidence
Autologous fat grafting is a well-accepted technique for soft-tissue augmentation and has been advocated in facial contouring and body shape remodeling. In clinical practice, the safety and efficacy issues of fat grafting remain the most important considerations for clinicians. Historically, various fat-grafting techniques have yielded promising results in clinical conditions, such as structure fat grafting,1 the 3M3L technique,2,3 cell-assisted lipotransfer,4 and nanofat grafting.5 The term 3M3L refers to the multitunnel, multilayer, and multipoint manner in which the fat tissue is injected into the donor site. The fat tissue should then be harvested by low-pressure suction, be centrifuged at low speed, and the total column of grafted fat tissue be controlled at low volume. These techniques mainly focus on the issue of efficacy and focus more attention on the methodological aspects of fat harvesting, processing, and general grafting skills to enhance the survival rate of the recipient sites. However, clinical observations and retrospective studies have demonstrated that, even when the same fat-grafting technique was used in total facial contouring, the long-term outcomes and complication rates were diverse in different facial subunits.6 In particular, the temporal area is a well-accepted region with a low patient satisfaction rate and a high complication risk, such as blindness and cerebral fat embolism.7,8 We believe that the diversity of the safety and efficacy profile results from various anatomical characteristics in the different recipient sites, which may directly influence the survival of the fat grafts, the incidence of neurovascular injury, and the retention of fat tissue. Based on these considerations and our anatomical studies in the temporal region,9 the mid-face,10 and the hand,11 we developed the concept of the targeted fat-grafting technique. This technique involves the targeted restoration of the physiologic volume and distribution of fat compartments by using anatomically appropriate cannula entry sites and injection planes. Previous clinical studies have demonstrated its efficacy and safety profile in facial contouring10 and hand rejuvenation11 and its potential applicability in other regions of the body.
The shape of a youthful face is characterized by a smooth, convex contour of the temples in which the anterior bony margin of the skull is concealed. With aging, the superior part of the face becomes more concave, and the bony margins of the zygomatic arch, the temporal line, and the lateral orbital rim appear more prominent, which leads to a sunken contour in the temporal region. Temporal hollowing is an early sign of aging, and it occurs in patients with low body fat, skeletal growth inhibition,12 atrophy of the superficial temporal fat pad,13 and soft- or bony-tissue injury in the temporal region.14 In Asian populations, temporal hollowing can easily result in an old and gaunt appearance. Consequently, the demand for aesthetic correction of temporal hollowing has grown rapidly. Autologous fat grafting has been widely applied in temporal hollowing augmentation for decades because of its impressive results in the correction of facial contour deformities.15 There is no consensus on fat-grafting techniques in this subunit of the total face. According to the anatomical study, we suggested that fat tissue should be grafted into the deep plane (containing the upper temporal and the lower temporal compartments) and the superficial plane (the lateral temporal-cheek fat and the lateral orbital fat compartments) of the face to target restoration of the physiologic volume and distribution of the 4 fat compartments.9
In this study, we reviewed our experiences with temporal hollowing augmentation using the targeted fat-grafting technique in 96 patients. With the use of long-term data and illustrative cases, we investigated the survival rate of fat grafts in the temporal area and the incidence of neurovascular injury in an attempt to assess the efficacy and safety profile of the fat-grafting procedure.
A total of 96 patients with temporal hollowing who underwent aesthetic temporal augmentation by the targeted fat-grafting technique from January 1, 2009, to January 1, 2017, were included in the study. The study was approved by the Ethics Committee from the Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Each patient was fully informed regarding the procedure and the goal of the study and provided written consent. Individual goniometric and procedural data, relevant demographic information, surgical procedure factors, perioperative characteristics, and postoperative complications were collected for each patient.
Temporal hollowing augmentation using the targeted fat-grafting technique includes the following steps: (1) fat harvest, (2) fat grafting, and (3) postoperative care. Fat-harvest procedures were performed as previously described by Coleman1 and Xie et al.2 Briefly, liposuction was performed using a 12-gauge, 2-holed, blunt-tip cannula attached to a 20-mL syringe. The fat was harvested from the thigh or abdomen via gentle manual liposuction with low negative pressure. The collected lipoaspirate was centrifuged at 200g for 3 minutes. Oil and aqueous layers were discarded; the refined fat was collected and transferred to 1-mL syringes for application.
Before fat grafting, the temporal hollowing region was marked by 4 borders: (1) superiorly, the superior temporal line; (2) anteriorly, the lateral orbital rim; (3) inferiorly, the superior border of the zygomatic arch; and (4) laterally, the temporal hairline (eFigure 1 in the Supplement). A small incision was made at the medial side of the head at the junction of the hairline and the temporal line (Figure 1A). An 18-gauge, single-holed, blunt-tip infiltration cannula was directly inserted into this entry site and was advanced along the surface of the skull until it entered the loose areolar tissue layer (eFigure 2 in the Supplement). Within this layer, the fat graft was placed into the upper temporal and the lower temporal compartments using a multiplane, multitunneling technique (Figure 1B). The infiltration cannula was withdrawn from the space under the superficial temporal fascia and was advanced into the subcutaneous fat layer in the temporal region. In this plane, the fat should be precisely grafted to the lateral temporal-cheek fat and the lateral orbital fat compartments to correct the irregularities of the skin caused by the deep plane injection (Figure 1C). To form a round and convex facial contour, the infiltration cannula may also be inserted into the subcutaneous fat layer in the forehead to adjust the contour between the temporal (Figure 1A) and forehead regions (Figure 1C).
Immediately after the procedure, a compression dressing was applied to the area for 5 to 7 days. For patients who were not satisfied with the augmentation outcome, a second surgical procedure was performed 3 to 6 months after the initial procedure to improve the contour.
All patients followed the same protocol: a preoperative assessment of temporal hollowing, the fat-grafting procedure, and the postoperative and outcome assessments. All patients were followed up for at least 12 months after the last procedure. The outcomes were assessed based on the following: (1) quantitative measurements, (2) subjective assessments, and (3) perioperative complications.
Quantitative measurements were performed based on the survival rate of the fat grafts and the temporal hollowing augmentation rate, which were measured using a 3-dimensional (3-D) laser scanning system (Figure 2). Images of each patient were collected before the fat-grafting procedure using 3-D measurement software (Konica Minolta Vivid 910 and Polygen 7 Editing Tools, version 2.21; Konica Minolta) as described previously.10,16 The required fat volume was analogized according to the outline of the total area of the face and the expectation of the patient with the use of 3-D reconstruction software (Rapidform 2006; INUS).10,16 The patients were scanned to acquire postoperative images at 12 months after the last fat-grafting procedure. The image data were processed with a hole-filling procedure, smoothed, and registered with the 3-D reconstruction software. Preoperative and postoperative images were overlapped to compare the profile changes according to selected reference points that would not be altered because of treatment. The discrepancy between these 2 images was calculated objectively, and a colored hypsographic image was obtained. The survival rate of the fat tissue was defined as Augmentation Volume/(Grafted Fat Volume ×100), and the augmentation rate was defined as Augmentation Volume/(Required Fat Volume ×100).
The subjective assessments included the Hollowness Severity Rating Scale (HSRS)17 assessment and the patient satisfaction rate. Three independent observers reviewed the preoperative and postoperative images. The HSRS (grade range, 0-3) was applied as follows: grade 0 indicates no visible hollowness; 1, mild hollowness; 2, moderate hollowness; and 3, severe hollowness. eFigure 3 in the Supplement illustrates a sample preoperative HSRS assessment. The patients, plastic surgeons, and independent investigators with nonmedical backgrounds completed a satisfaction survey using a comparison of the preoperative and postoperative photographs. The grade of improvement was classified as follows: fully satisfactory, satisfactory, or unsatisfactory.
Adverse events were categorized into minor and major complications. Adverse events managed conservatively were minor complications and those requiring surgical revision were major complications.
Statistical analysis was performed using a paired, 2-tailed t test to determine significant differences in preoperative and postoperative body mass index (calculated as the weight in kilograms divided by height in meters squared). Statistical significance was set at P < .05; values were 2-sided. All analyses were performed using SPSS, version 19.0 (SPSS Inc).
Of the 96 study participants, 94 (97.9%) were women and the mean (SD) age was 34.4 (7.4) years (range, 19-48 years). A retrospective review of medical records from the 96 consecutive patients, including evaluation of 192 temporal areas of the face, occurred from January 1, 2009, to January 1, 2017. A total of 142 autologous fat-grafting procedures were performed on the temporal areas. Among these 96 patients, 58 (60.4%) underwent 1 fat-grafting procedure, 30 (31.2%) underwent 2 procedures, and 8 (8.3%) underwent 3 procedures. A mean (SD) of 1.5 (0.7) procedures (range, 1-3 procedures) was performed per temple, with a mean (SD) interval of 3.7 (0.6) months (range, 3.0-6.0 months) between 2 subsequent procedures (some of the patients required unilateral temporal hollowing revision). The mean (SD) total follow-up time was 16.3 (3.2) months.
After the fat-grafting procedure using the targeted fat compartment volume restoration technique, the curvilinear line on the temporal region became smoother and less concave. A pleasing result of an elevated anterior projection of the temporal region was obvious. A sample of photographic results is shown in Figure 3.
Overall, the mean (SD) baseline volume requirement per temple was 12.8 (4.8) mL for each patient, the mean (SD) total volume of the fat grafts per temple was 17.8 (7.5) mL, and the mean (SD) augmentation volume per temple was 11.7 (3.0) mL. The mean (SD) total survival rate of the fat grafts was 65.7% (12.6%), and the mean (SD) augmentation rate of hollowness was 91.4% (23.4%) (Table 1).
All patients were graded postoperatively according to the HSRS to evaluate the changes in temporal hollowing. For the preoperative HSRS score, 12 of 192 temples (6.3%) had grade 1 (mild hollowness); 122 (63.5%) had grade 2 (moderate hollowness); and 58 (30.2%) had grade 3 (severe hollowness). After the last procedure, 182 temples (94.8%) displayed no or mild hollowness and only 10 temples (5.2%) showed moderate hollowness. All patients showed an improved appearance after the fat-grafting procedure, and 142 temples (74.0%) exhibited clinical improvement by more than 2 grades. The mean (SD) HSRS score improved from 2.24 (0.56) preoperatively to 0.44 (0.59) postoperatively for a mean (SD) temple hollowness improvement of 1.80 (0.53) grades. In terms of patient satisfaction, 88 of the 96 patients (91.7%) were satisfied or very satisfied, and only 8 (8.3%) reported being dissatisfied with their final outcomes. The results according to the 3 different groups of evaluators are compared and summarized in eFigure 4 in the Supplement.
Adverse events were recorded from the 142 fat-grafting procedures. After the adverse event, 13 patients recovered without treatment and 2 needed surgical revision. Table 2 summarizes the data regarding the perioperative complications of the 96 study patients.
Clinical studies in facial contouring and hand rejuvenation have revealed that targeted volume restoration of fat compartments by using the fat-grafting technique can restore the fat volume to the physiologic level and rebuild a natural and youthful shape of the face or hands without severe complications.10,11 Our data from 96 patients in the past 5 years further demonstrate that the targeted fat-grafting technique is a safe and effective fat-grafting technique for temporal hollowing augmentation.
Autologous fat grafting has been widely applied in temporal hollowing augmentation for decades because of its impressive results in the correction of facial contour deformities.15 However, as a subunit of the total face, there is no consensus on fat-grafting techniques for the temple area, including the entry site for the cannula and the plane for fat placement. The literature on temporal hollowing augmentation using fat grafting or other fillers, such as hyaluronic acid, suggests placing the filler into the subcutaneous space,18 deep to the superficial temporal fascia,17 or even within the temporalis19 through multiple entry sites, such as the lateral orbital rim or the tail of the brow.17,20 These suggested techniques are based on personal experiences and a lack of solid anatomical and clinical data support. In the present study, we focused on how to restore the physiologic volume in the temporal region with a high survival rate of the fat grafts, minimal tissue injury, and a low complication hollowing rate. According to anatomical studies,9,21,22 the temporal region is different from the anatomical term temporal fossa and is outlined by the superior temporal line, the temporal hairline, the zygomatic arch, and the lateral orbital rim. In this region, 4 separate fat compartments overlap in 2 separated fat tissue planes: the lateral temporal-cheek fat and lateral orbital fat compartments in the superficial plane and the upper temporal and lower temporal compartments in the deep plane. Several important neurovascular structures pass through these fat compartments, including the perforators of the middle temporal vein, the sentinel vein, the frontal branch of the superficial temporal artery, and the temporal branch of the facial nerve. The current understanding of temporal hollowing involves soft-tissue volume loss, especially fat compartments, in this region.23 Therefore, we placed fat tissue into the 4 fat compartments through a unique entry site located at the medial side of the intersection of the hairline and the temporal line. Several significant features indicate that this approach is an excellent fat-grafting technique for temporal hollowing augmentation: (1) this approach enables the targeted restoration of physiologic volume and the distribution of fat compartments; (2) the septum and ligament tissue surrounding the fat compartments can retain the grafted fat tissue in the compartments without drooping; (3) using a single cannula entry site, fat tissue can be easily grafted into the deep plane, the superficial plane, and the transition area between the temporal region and the frontal region; and (4) the fat compartments are relatively avascular; therefore, grafting fat tissue through the chosen entry site and planes can decrease the incidence rate of neurovascular and tissue injury (Figure 1D). Our clinical data showed a high patient satisfaction rate within the mean number of 1.5 fat-grafting procedures and no severe complications, indicating an excellent safety profile for temporal rejuvenation.
Clinical observations and retrospective studies have shown that the temple area is one of the facial subunits with the highest fat absorption rate and the lowest patient satisfaction rate. This clinical phenomenon may be because of the frequent movement of the temporalis muscle and the relatively avascular nature of the upper temporal and lower temporal compartments (the deep injection plane). These characteristics of the temple lead to a low survival rate of the fat grafts and a low satisfaction rate. Quantitative evaluation of the efficacy profile of the fat-grafting technique remains a clinical challenge because of limited measurement methods. Quantitative measurement methods such as 3-D photography,24,25 ultrasonography,26 and magnetic resonance imaging27 have been applied in fat-grafting studies. Among these methods, 3-D photography is a well-accepted qualitative method for the assessment of volume changes after the fat-grafting procedure. Similar efficacy evaluation studies regarding temporal hollowing augmentation using the technique of fat grafting are few, and the reported results are simple and subjective. Lee et al19 reported long-term outcome observations of temporal hollowing augmentation using a microautologous fat transplant technique. On average, 6.8 mL of microfat tissue was grafted in each temple, but only a subjective 81.3% patient satisfaction rate was reported, which could not truly reflect the efficacy profile of this technique for temporal hollowing augmentation. In another study, a virtual 3-D photogrammetric system was applied to evaluate the final fat-grafting results of 45 patients with temporal hollowing caused by temporalis muscle flap transposition.28 This study reported a 97.7% satisfaction rate and few complications after 1 to 3 fat-grafting procedures. Unfortunately, detailed data regarding hollowness augmentation rates and survival rates of the fat grafts were not analyzed and shown in that study.
In the present study, a 3-D laser scanning system was used to quantitatively evaluate the long-term outcomes of targeted fat grafting in the temporal region. Our 3-D laser scanning data revealed a 65.7% survival rate of the fat grafts and a 91.4% augmentation rate in the temple area at long-term follow-up, indicating that the survival rate of the fat grafts had improved to a level comparable with that of the total face in another study that calculated the survival rate of the fat grafts using the same method.16
The limitation of the 3-D laser scanning system was that it could not directly show the survival and retention of the fat grafts in the compartments. We intend to apply techniques, such as computed tomographic scanning and magnetic resonance imaging, to investigate the fate of fat grafts in the compartments in the next study.
The results of our study indicate that the targeted fat-grafting technique represents an effective, reproducible, and safe approach for temporal hollowing augmentation. We advocate grafting fat tissue into the deep plane (containing the upper temporal and lower temporal compartments) and the superficial plane (containing the lateral temporal-cheek fat and lateral orbital fat compartments) through an entry site located at the medial border of the junction of the hairline and the temporal line. Subjectively, the technique is associated with minimal morbidity, a low complication rate, and high patient satisfaction. Objectively, 3-D image analysis data demonstrate a high hollowing augmentation rate and survival rate of the fat grafts at long-term follow-up.
Corresponding Author: Yun Xie, MD, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai 200011, China (email@example.com).
Accepted for Publication: January 14, 2018.
Published Online: April 19, 2018. doi:10.1001/jamafacial.2018.0165
Author Contributions: Drs Huang and Xie had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Huang, Wang, Tan, Li.
Drafting of the manuscript: Huang, Wang, Tan, Li.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Huang, Wang, Tan, Li.
Obtained funding: Huang, Xie, Li.
Administrative, technical, or material support: All authors.
Study supervision: Huang, Xie, Li.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by grants 81501679 (Dr Huang) and 81701917 (Dr Xie) from the National Natural Science Foundation of China and grant 17ZR1416500 from the National Natural Science Foundation of Shanghai.
Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the patients for granting permission to publish this information.
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