Date Published: April 27, 2017
Publisher: Springer US
Author(s): C. K. Chou, S. S. Lee, T. Y. Lin, Y. H. Huang, H. Takahashi, C. S. Lai, S. D. Lin, T. M. Lin.
Frontal fullness in Asians is often considered to indicate one’s public popularity and leadership skills. Numerous materials and techniques have been applied clinically to recontour or volumize the frontal area, with variable results. The micro-autologous fat transplantation (MAFT) technique proposed by Lin et al. (2nd academic congress of Taiwan Cosmetic Association Taipei,
Taiwan) in 2007 has demonstrated its feasibility in facial rejuvenation. In the present study, we used an innovative instrument to apply the MAFT technique to frontal augmentation with fat grafting and reported the results.
MAFT was performed on 178 patients (167 female, 11 male) during a 5-year period starting in January 2010. Fat was harvested by liposuction, processed and refined by centrifugation at 1200×g for 3 min. The purified fat was micro-transplanted for frontal contouring with the assistance of an instrument, the MAFT-GUN. The patients were followed up regularly, and photographs were taken for comparison.
On average, the MAFT procedure took 52 min to complete. The average amount of delivered fat was 10.2 mL. The follow-up period was 34 months on average. No complications, including neurovascular injury, skin necrosis, abscess, nodulation, calcification or irregularity, were noted. A patient-rated satisfaction 5-point Likert scale demonstrated that 83.1% of all patients had favorable results (48.3% were satisfied, and 34.8% were very satisfied).
The concept and technique of MAFT has changed fat grafting from an operation with unpredictable clinical results to an easy, reliable and consistent procedure. Furthermore, the use of a precisely controlled instrument enabled surgeons to perform highly accurate micro-fat grafting. In comparison with other strategies for volume restoration, the MAFT procedure demonstrated high patient satisfaction with the long-term results. Therefore, the use of MAFT as an alternative approach to forehead contouring and volumizing was addressed.
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The online version of this article (doi:10.1007/s00266-017-0883-2) contains supplementary material, which is available to authorized users.
Originating from the Latin “frons,” “frontal” means “the forehead or brow.” Anatomically, the top of the forehead is outlined by the hairline, the edge of where hair grows from the scalp. The bottom of the forehead is marked by the supraorbital ridge, the bony feature of the skull above the eyes. Bilateral temporal ridges comprise the lateral boundary of the forehead [1, 2]. In Asian cultures, the coordination and fullness of the shape of the frontal area without either soft tissue deficiency or bony irregularity of the frontal area is believed to indicate prosperity and leadership capabilities. It is also important for the balance and harmony of the face, especially in the lateral and oblique views . A slight convex forehead without wrinkles will add more attractiveness to a person’s face and to the general perceived image .
The mean age of the 178 patients was 47.7 years (range, 21–72 years). The entire MAFT procedure (from harvesting to transplantation) took an average of 52 min to complete. On average, the fat volume delivered in this study was 10.2 mL. All patients were monitored for an average of 34 months (ranging from 8 to 68 months). No major complications (e.g., infection, skin necrosis, nodulation, fibrosis, calcification, asymmetry or vascular insults) were recorded. Twenty-two patients asked for a second MAFT procedure as a touch-up refinement. The patient-rated satisfaction scores (Table 1) obtained during their final visits showed that 27.5% (43/156) of patients were very satisfied, 53.2% were satisfied (83/156), and 19.6% (21/156) rated their outcome as neutral after one MAFT session. Twenty-two patients (12.6%, 22/178) requested a second session of MAFT (touch-up) for further augmentation and contouring. The satisfaction scores of patients undergoing two sessions showed that 86.4% (19/22) were very satisfied, and 13.6% were satisfied (3/22). Four cases of MAFT for forehead contouring/volumizing are illustrated in Figs. 4, 5 and 6.Fig. 4(Case 1) This 54-year-old woman presented for recontouring with fat grafting to increase the youthful appearance of her forehead. MAFT was performed to place a 12-mL fat graft (Pre-op in a, b, c, d and e, left). Six months after a single MAFT session, the volume restoration of the frontal area was maintained with fullness (Post-op in a, b, c, d and e, right). Chin-up, chin-down and close-up views showed the improved contouring (Pre-op in f, g, h and iupper; Post-op, lower)Fig. 5(Case 2) This 25-year-old woman presented for augmentation of her forehead and temporal areas with fat grafting. MAFT was performed on her frontal area to place a 20-mL fat graft (Pre-op in a, b and c, left). Two years after a single MAFT session, the volume was maintained on the frontal area (Post-op in a, b and c, right). Chin-up, chin-down and close-up views show the improved contouring of the frontal area, which shows a smooth and abundant appearance (Pre-op in d, e and fupper; Post-op, lower)Fig. 6(Case 3) This 33-year-old woman presented for fat grafting to restore her frontal contour. MAFT was performed to place a 10-mL fat graft (Pre-op in a, b and c, left). Six months after a single MAFT session, the fullness and volume restoration of the hollowing frontal area were maintained (Post-op in a, b and c, right). The improved appearance of frontal unevenness and the rejuvenating effect of the skin are illustrated in a close-up quarter view (Pre-op in d and e, left; Post-op in right). Chin-up, chin-down and close-up views showed the recontouring of her uneven frontal area (Pre-op in f, g and h, upper; Post-op in lower)
Numerous clinical strategies, such as the application of autologous grafts (e.g., bone grafts and fat grafts), synthetic implants and soft tissue fillers, are available for augmenting the frontal area [4–8]. The most common synthetic implant materials, such as silicone prostheses, polyethylene implants, and bone cement, are reliable and achieve acceptable results in selective cases. However, their long-term feasibilities have not been demonstrated. Potential complications, such as infection, deviation, incompatibility and skeletonization, remain a challenge for surgeons [4, 5]. Although fillers such as hyaluronic acid have recently become popular, these materials are not used in all patients due to their expense, the necessity of repeat injections and the possibility of an allergic reaction [7, 8]. Autologous tissues, such as bone grafts, dermal grafts and fat grafts, are preferable due to their biocompatibility and effectiveness in certain cases [4, 5]. However, in fat grafting, dissatisfaction in terms of unpredictable absorption rates, potential morbidities, and a lack of evidence regarding the long-term results remains an unresolved problem [10, 11].
Various strategies can be employed to restore forehead contouring in Asian patients. Implants or fillers do not appear to be feasible, appreciated or preferable for all patients. Although not all cases requiring frontal contouring can be solved with one session of fat grafting, MAFT is an alternative strategy of restoring volume and remolding the foreheads of Asian patients.