[Duhan Plastic Surgery Facial Fat Grafting] - [Fat Grafting Rhinoplasty]

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Nose augmentation

Soft and beautiful facial contours

Create them with microlipofilling.

Rhinoplasty using microlipofilling

Nose fat grafting is applied when the goal is to naturally augment mainly the nose bridge.

It is used when there is discomfort with foreign materials such as silicone, when you need to return to daily life immediately after the procedure, or when you only want a slight augmentation of the nose.

Sometimes it can also be applied to correct a crooked nasal bridge.

Indications for microlipofilling rhinoplasty

◇ Flat nose tip

◇ Low glabella (the area between the eyebrows)

◇ Low nose bridge

◇ A nose that appears crooked

◇ Depression of the nasal bridge (saddle nose) or a curved nasal bridge

◇ When a boundary line is visible after inserting an implant such as silicone and needs to be softened

There are various methods for raising the nose, including silicone and Gore-Tex.

When raising the nose with autologous fat grafting, there are several advantages, such as being able to return to daily life immediately, having little swelling and bruising, and using one’s own tissue, which reduces side effects and rejection concerns. As a result, preference for fat grafting is increasing.

When raising the nose with fat, it should be applied only after carefully selecting the indication and only when it is expected to be effective.

There are also cases treated with fillers (Artecoll, Restylane, Aquamid), but fillers are products that should not be used for raising the nose.

Fillers should only be used for purposes such as correcting fine wrinkles around the eyes, fine forehead wrinkles, or small depressed scars.

Injecting fillers into the nose is completely outside their intended use, and because of concerns about side effects such as skin necrosis or inflammation, the procedure should be performed with caution.

For a natural augmentation, fat grafting can be considered one of the good methods.

How fat grafting is performed for rhinoplasty

Usually, fat is harvested from the lower abdomen. The reason the lower abdomen is preferred is that the harvest is easy, the fat cells are sturdy, there is plenty of fibrous tissue, and there is less swelling and bruising, allowing faster return to daily life and recovery.

If there is no fat at all in the lower abdomen, it is sometimes harvested from the thighs.

Usually, about 40cc of fat is harvested in preparation for a second procedure.

Unprocessed fat collected immediately after harvesting usually contains about 80% impurities.

The largest portion of impurities is local anesthetic, followed by oily components mixed in with the fat cells.

In addition, there is serum and a small amount of blood mixed in, so all impurities except the fat cells must be removed.

Removing impurities cannot be done by centrifugation alone; in addition to centrifugation, an oil-removal step is added.

The purified fat is transferred into a 1cc syringe, fitted with a microlipofilling cannula, and then used for the procedure.

We use the Microneedle microlipofilling cannula developed in-house.

Microneedle is a special grafting cannula used only at our clinic that allows ultra-precise grafting.

The procedure is performed by inserting the needle from the tip of the nose, and usually 1–2cc of fat is grafted.

Examples of rhinoplasty using fat grafting

When nose fat grafting is appropriate

Nose fat grafting is not a procedure that can be applied to everyone.

First, the thickness of your own skin needs to be a certain level, and the skin of the nose must also have some flexibility for the fat to take.

When using nose fat grafting to raise the nose bridge, it is usually about 3mm, and the procedure should be planned with a second session in mind.

Conversely, if the skin is thin, firm, and lacks flexibility, even if the procedure is performed, all of the fat may be absorbed and there may be little to no effect.

Whether the procedure will be effective can be confirmed through a direct examination.

The effect of correcting a low nose with fat grafting

Nose fat grafting is a procedure designed to naturally augment only the nose bridge.

In many cases, it is not enough to raise the nose tip as well.

When raising the nose bridge with fat grafting, it is usually about 3mm, but this varies depending on the individual’s skin thickness and flexibility.

The survival rate of nasal fat is on average 30–50%, and a second procedure is often performed after about 3 months.

The reason the survival rate is lower than in other areas is that the skin of the nose continuously presses on the fat from above, causing the fat to be compressed.

Nose fat grafting is mainly applied when only a slight natural augmentation is desired or when the area between the eyebrows appears low.

The effect of correcting a crooked nose with fat grafting

A nose may become crooked if the nasal bone collapses due to severe trauma or if a nasal bone fracture was not properly treated.

The conventional method of correcting a crooked nose often involves re-cutting and lifting the nasal bone, but because the surgery is too extensive and burdensome, a slightly crooked nose can be corrected to some extent with fat grafting.

Because the procedure is much simpler than forcing a surgical osteotomy of the nasal bone, in cases that are not severely crooked, the nasal axis can usually be corrected to some degree with fat grafting.

Correction is also possible with fat grafting when the silicone implant shifts after silicone augmentation rhinoplasty and the nose appears crooked.

Fat grafting does not take above the silicone, but some fat survival can occur along the side boundary area.

If the silicone shifts once, correction is only possible by removing it and reinserting it 6 months later, so correcting by replacing the silicone is very complicated and time-consuming. In contrast, correcting with fat grafting is simpler and more effective because it is done while leaving the silicone in place.

Cases in which nose fat grafting is difficult

♥ When additional augmentation is desired while silicone or another implant is already inserted

Fat cannot survive on top of silicone.

However, fat grafting can be used to soften the boundary line at the edge of the silicone.

♥ Within 3 months after removing silicone or another implant

If the capsule surrounding the silicone has not dissolved, all grafted fat will be absorbed.

Therefore, after implant removal, at least 3–6 months must pass before grafting is possible.

♥ When the skin over the nose bridge is thin and firm

For fat to take, blood circulation must be good and the pressure compressing the skin must be low.

Thin, firm skin has poor circulation and strong compressive pressure, so the fat is crushed and absorbed.

Advantages of rhinoplasty (augmentation) using fat grafting

① The procedure is simple.

② Because no foreign material such as silicone is used, there is no need to worry about side effects.

③ Because the procedure does not require an incision in the skin, the burden of surgery is low.

④ Unlike surgery, there is no need to keep the area fixed with tape for several days immediately after the operation.

⑤ There is almost no swelling or bruising.

⑥ Normal daily life is possible immediately after the procedure.

⑦ Because one’s own tissue is used, natural augmentation is possible.

Precautions when having rhinoplasty with fat grafting

① Nose fat grafting is not a procedure for everyone, so before the procedure you should receive a consultation and examination to determine whether your nose is suitable for fat grafting and then decide whether to proceed.
② Nose fat grafting is effective for augmenting the glabella or nose bridge area, and it is difficult to apply to the nose tip. Sometimes, if the skin is flexible, it may be possible to augment the nose tip as well, but this is not common.
③ The nose has a lower fat survival rate than other areas, so a second procedure should usually be planned.

Number of nose fat grafting sessions

Nose fat grafting is performed as few as once and on average about twice.

The interval between procedures is 3 to 10 months, and when repeating the procedure, the fat that was collected during the first grafting can be thawed and used.

Lasting effect of nose fat grafting

Some people say that fat grafting has no effect because much of the fat is absorbed, but if done correctly, satisfactory results can be achieved. Once the grafted fat takes, it is no longer absorbed and remains as your own fat tissue for life, making it one of the safest and most effective methods.

On average, two sessions of fat grafting can produce a permanent, satisfactory augmentation effect.

Comparison of various methods for nasal augmentation

	Fat grafting	Silicone	Filler products
Suitable candidates	When the goal is to naturally augment the nose bridge	When the goal is to augment both the nose bridge and the nose tip at the same time	Intended for correcting fine wrinkles and should not be used to raise the nose.
Advantages	* Less swelling and bruising. * Immediate return to daily life. * Almost no side effects. * Less discomfort because it uses one’s own tissue.	* A definite augmentation effect can be achieved. * Few side effects. * Can be removed relatively easily if undesired.	* There are no advantages for the purpose of nasal augmentation.
Disadvantages	Because of the survival rate, more than one session is often needed.	* As a foreign material, there is concern about side effects. * There may be discomfort with a foreign body. * Swelling and bruising make immediate return to daily life difficult.	* Inflammatory reactions may occur due to a foreign-body response. * Side effects such as skin discoloration or necrosis due to vascular occlusion of the nasal skin may occur. * If side effects occur, removal is almost difficult.

How to perform fat grafting without side effects

♥ Perform the procedure in a sterile state

As with all surgery, fat grafting must also be performed with completely sterilized instruments and materials.

After the procedure, any remaining fat inside the cannula or grafting instrument must be thoroughly cleaned with a brush and sterilized with a high-pressure steam sterilizer so that no residue remains. Anesthetic solution, saline, and other materials must also be carefully managed to prevent contamination.

Thorough sterilization and material management can prevent bacterial infection and inflammation.

♥ Multi-step purification of the fat

Fat must go through several purification steps to completely remove impurities and maximize the effect.

The harvested fat usually contains about 80% impurities, and the portion actually usable is only around 20%.

If the remaining impurities (blood, serum, anesthetic, oil, moisture, etc.) are not removed, the results will be poor no matter how well the grafting is performed.

♥ Preconditioning before fat grafting

A high survival rate should make it possible to achieve a satisfactory result with a single procedure if possible.

Microscopic fat should be evenly placed in multiple layers, and before that, space should be secured in the grafting area so that the previously grafted fat is not compressed by surrounding tissue. Only then can the fat avoid pressure and take well.

♥ Precise and even grafting in multiple tissue layers

The expression of a soft and natural contour is the key to fat grafting.

For a soft contour, it is better to graft in a three-dimensional manner, distributing it evenly across multiple layers.

The grafting sites include the subcutaneous layer, muscle layer, and fascia layer, and the fat must be spread through the tissue as if scattering seeds evenly to obtain a smooth contour without unevenness.

Misconceptions about fat grafting

Question) The effect of fat grafting in the buttocks or breasts

Answer) Fat grafting is also sometimes performed for buttock depressions or breast augmentation.

However, there are problems with this.

In the case of the buttocks, because it is an area that must keep moving, the fat survival rate is extremely low, and if grafted incorrectly, side effects such as pigmentation may occur.

Fat grafting to increase buttock volume is inevitably burdened with difficulties.

For breast augmentation using fat grafting, at least about 1000cc of fat must be harvested, and it is difficult to harvest that amount.

The reason is that people with small breasts usually do not weigh much, so they often do not have enough fat in the lower abdomen, waist, or thighs for harvesting, making it difficult to collect the desired amount and also difficult to graft as much as desired.

Also, most importantly, if a large amount of fat is grafted into the breast area, the fat may partially necrose, leading to abscesses or calcification and hardening as side effects.

If an abscess formed by pus develops, it can be very difficult to treat and may leave significant long-term aftereffects even after healing.

In addition, calcification can become a critical problem because it may prevent the detection of breast cancer in future breast cancer screenings. Therefore, in principle, breast fat grafting should not be performed.

Plastic surgery has principles.

Because both good and bad outcomes must be considered, if there is even a 1/10 chance of a bad outcome after surgery, that is a procedure that should not be performed.

Breast fat grafting falls into the above case, so the decision to do breast augmentation with fat should be made very carefully.

Question) The theory that fat harvested from the thighs takes well

Answer) The place from which fat is harvested is not fixed.

If anything, the thighs are not a preferred harvesting site.

The problem is that the fat contains a lot of oily components.

Oil is an impurity and does not help survival.

After the procedure, there may be a lot of bruising and swelling, and until the bruising subsides, you should not walk more than necessary, which can make daily life inconvenient. If too much is harvested, changes in the shape of the thigh or pigmentation problems may occur.

Choosing a fat-harvesting site is not determined solely by survival rate.

You must consider whether there is enough fat, the convenience of harvesting, swelling and pain after the procedure, the degree of bruising, how easy it is to return to daily life after harvesting, the survival rate of the harvested fat, and also the shape of the harvested area and any future aftereffects.

First, fat must be harvested from an appropriate site for grafting.

The choice of harvesting site is determined by the amount of fat that needs to be suctioned. When a small amount is being grafted, such as under the eyes, the nose, or the nasolabial folds, the lower abdomen is usually the most common harvesting site.

The reason the lower abdomen is preferred is that it is easy to harvest, post-procedure swelling and pain are mild, and daily life is more comfortable.

If a large amount needs to be grafted, such as to the cheeks or forehead, it must be confirmed whether sufficient fat can be harvested from the donor site.

If there is a lot of excess fat in the lower abdomen, it is harvested from there. If there is little fat in the lower abdomen, or if abdominal skin laxity has significantly decreased due to aging or childbirth, harvesting may not be possible even if there is some fat.

This is because the abdomen may sag after fat harvesting.

In such cases, fat is harvested from the thighs, and the harvesting site is divided into the inner thigh, outer thigh, and back of the thigh, with the area that has the most excess fat being selected.

Fat is harvested with delicate suction so that no deformity or depression occurs at the donor site.

In some cases, if the patient specifically wants a certain area, harvesting may be done from that desired area whenever possible.

Because each person has a different distribution of excess fat and a different body type, the most suitable harvesting site should be chosen according to those physical characteristics and constitution.

The site from which fat is harvested does not determine the survival rate.

To achieve good results with fat grafting, meticulous harvesting, proper purification such as oil removal, preconditioning of the graft site, evenly grafting an appropriate amount of fat into the site, and grafting in a way that produces a natural shape are all necessary for good results.

In other words, good results are only possible when the entire series of procedures from start to finish is carried out properly.

Question) The misconception that grafted fat flows downward or moves

Answer) Fat is the transplantation of solid cells.

Either it takes and remains permanently as your own cells, or it melts away and disappears.

Solid cells do not move or flow downward. That never happens.

There are cases where unlicensed procedures inject industrial silicone or paraffin into the face carelessly, and because these are liquid substances, they often flow downward in the direction of gravity.

Liquids can move by seeping between cells.

Some people see or hear about side effects from unlicensed procedures and develop a bias, mistakenly thinking that fat grafting may also cause problems. But solid fat cells remain in the place where they were grafted and can never move to another area.

Sometimes, in other hospitals, fat is excessively grafted or grafted into the wrong area, making the shape look unnatural or sagging. Seeing this may lead people to think that the fat has moved, but in fact the fat has not flowed or moved; it is simply a case of improper grafting or excessive grafting that makes the area look saggy due to the weight of the fat.

Question) The theory that air exposure must be blocked during the fat purification process

Answer) No step in fat grafting can be neglected, and the purification process is no exception.

Fat purification is done to remove all unnecessary impurities other than fat cells.

The impurities removed during centrifugation are moisture, anesthetic, serum, and red blood cells.

What cannot be purified by centrifugation is the oily component of the fat cells themselves.

Oil is one of the impurities that must be removed from fat cells and makes up a significant proportion.

It exists both inside and outside the fat cells, so the fat cells can be said to be tangled with oil.

The only way to remove the oil is to wrap the fat, after centrifugation, in sterilized gauze and remove it through natural absorption, and at this time the fat is exposed to the outside.

Some argue that if fat is exposed to the air, the risk of infection increases or the fat is damaged by oxidation, but in reality such effects are almost nonexistent.

When viewed under a microscope, fat cells are surrounded inside and out by a thick oil film, so the fat cells themselves cannot directly contact the air.

Also, because diluted antibiotics are applied to the fat during the gauze purification process, bacterial infection can actually be prevented more effectively.

Question) Misconceptions and truth about the lasting effect of fat grafting

Answer) Although there are many hospitals that perform fat grafting, only a few can produce proper results.

If fat grafting is not performed correctly, the result may be worse than not doing it at all.

In principle, fat grafting can produce good results only when performed accurately.

Each hospital uses different methods, and there are large differences depending on experience.

The survival period of fat is about 3 months.

Fat that survives beyond that point remains permanently as your own fat cells.

Some people mistakenly think that the grafted fat disappears after 1–2 years and returns to the original state, but once fat has taken, it does not disappear without reason.

Also, the reason the second procedure is done after 3 months is to allow the fat from the first procedure to fully take and settle, and then to perform the next procedure based on the resulting shape.

Until about 3 months, while the fat is taking, some of it is absorbed, but fat that has taken and is not absorbed beyond 3 months is no longer absorbed and permanently remains as your own tissue.

However, the shape of the grafted area does not last forever.

As you age, the skin sags, wrinkles form, and the skeleton changes due to aging, so just because fat has been grafted does not mean aging will stop in that area.

For that reason, the effect of fat grafting is sometimes described as semi-permanent, and more strictly as permanent.

There is a difference in expression, but it can be said that the effect lasts until significant aging progresses later in life.

Features and pride of the Fat Grafting Clinic at Duhan Plastic Surgery

① All anesthesia is performed as local anesthesia (sedation anesthesia).

Local anesthesia is administered together with sedation anesthesia, and the procedure is performed without any pain during anesthesia or after the anesthesia ends.

② We have a systematic and advanced fat grafting system.

We harvest living fat cells and maximize purity through centrifugation, purification, and oil removal of unnecessary fat components.

Before grafting, we create space in the graft site through subcutaneous tunneling.

We perform precise grafting using a microlipofilling cannula.

We graft evenly into multiple layers in a three-dimensional manner to maximize survival rate and create soft contours.

③ We select appropriate and diverse fat harvesting sites.

The most commonly used site is the lower abdomen. It is often chosen first because it has less pain after the procedure, less swelling and bruising, and is a more comfortable area for daily life.

The next preferred site after the lower abdomen is the inner thigh, followed by the outer thigh.

If there is not enough fat in the thighs, the lower buttocks or flanks may also be used.

There is no fixed answer as to which site gives the best fat survival rate.

The results are similar, and although the area with the most excess fat is ideal as a harvesting site, the decision should be made by considering the amount of fat needed and activities after the procedure.

④ We maximize the survival rate through a two-step purification process for the harvested fat.

The impurity that makes up the largest proportion of harvested fat is local anesthetic, followed by oil.

Other impurities include serum and red blood cells.

In the first step, the fat undergoes centrifugation for about 3–4 minutes, and then it enters the second step, the oil-removal process.

Oil is removed manually through natural absorption.

Through the second purification process, nearly 100% concentrated fat is obtained, maximizing the effect of fat grafting while increasing the survival rate as much as possible.

⑤ We secure space for fat grafting through subcutaneous tunneling.

Subcutaneous tunneling means creating space in advance in the area where the fat will be grafted. It is an essential process for a high survival rate and even grafting.

Using a thin probe, the area under the skin is moved repeatedly in a fan-like pattern to create the space where the fat will be placed.

The effect of subcutaneous tunneling is to increase the survival rate of the fat and prevent it from clumping, creating a uniform and soft contour.

⑥ Three-dimensional microlipofilling can produce a soft and even facial contour.

There are exceptions depending on the area, but the basic procedure of fat grafting is the three-dimensional method.

It is a method of dividing the fat into multiple layers and grafting small amounts evenly into each area.

⑦ We use a microlipofilling cannula for precise fat grafting.

In the past, methods using fat-injection machines pushed fat under the skin with high pressure, which caused various problems.

The absorption rate of the fat was high, survival was inconsistent, the contour became uneven, and it was difficult to graft into delicate areas such as under the eyes.

To solve these problems, the fat is transferred again into a 1cc syringe and grafted into the desired area.

We use the Microneedle (microlipofilling cannula) developed in-house.

Microneedle is a special grafting cannula used only at our clinic that allows ultra-precise grafting.

Fat grafting can also be performed on the upper eyelids, lower eyelids, forehead wrinkles, glabellar wrinkles, nasolabial folds, and the nose bridge, making fat grafting possible in almost all cases except fine wrinkles.

⑧ Immediately after fat grafting, molding is performed so that a uniform and soft facial contour is created.

Immediately after the grafting, delicate molding is performed so that the grafted fat spreads evenly and forms a smooth shape.

Molding is the final stage of fat grafting and one of the most important steps.

⑨ Rapid-freeze sterile storage of the remaining fat simplifies the second procedure.

When a second procedure is performed 3 months after fat grafting, additional fat is not harvested again; instead, the fat left over from the first procedure is used.

The remaining fat after the first procedure is stored after rapid freezing and sterile processing.

For the second procedure, the stored fat is thawed and the procedure can be carried out more conveniently.

The storage period for fat is up to 1 year, and if you visit within 1 year, the stored fat will be used for the procedure.

⑩ Our clinic performs multi-layer fat grafting (layer-by-layer in the skin).

The key to fat grafting is ensuring that the living fat cells have a high survival rate.

To increase survival, we do not inject a large amount into one spot; instead, we graft evenly into multiple layers.

Between the skin and bone there are multiple tissue layers such as the fat layer and muscle layer, so fat must be injected in a multi-layer structure without overlapping between the periosteum above the bone and the fascia above and below the muscle.

Multi-layer fat grafting lasts 3–4 times longer than conventional methods and also has a higher fat survival rate.

The fat grafting performed at the autologous fat grafting clinic of Duhan Plastic Surgery also includes a process called “tunneling,” which allows the grafted fat to make maximum contact with the surrounding abundant blood vessels and continuously receive nutrients.

Tunneling means using a microneedle just beneath the skin to create the space where the fat will go. In other words, the space is made as if drilling a tunnel, and then the fat is injected. Because of this, even after all the fat has been injected, it does not sag downward with gravity or become uneven.

In addition, a delicate injection method allows custom design.

Through thorough aftercare after fat grafting, we carefully monitor the progress until the fat is fully settled.

During follow-up, if necessary, we try to minimize dissatisfaction through swelling-reduction injections, shape correction, and molding.

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