Cosmetic Medicine

Aesthetic Surgery Journal

2021, Vol 41(5) 603–612
Ultrasound to Improve the Safety and © The Author(s) 2020. Published
by Oxford University Press on behalf
Efficacy of Lipofilling of the Temples of The Aesthetic Society. All rights re-
served. For permissions, please e-mail:
journals.permissions@oup.com
DOI: 10.1093/asj/sjaa066
www.aestheticsurgeryjournal.com

Jonathan Kadouch, MD ; Leonie W. Schelke, MD; and Arthur Swift, MD

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Abstract
Background: Autologous fat is known for a reliable and natural safety profile, but complications do occur—even serious
vascular adverse events.
Objectives: The authors sought to examine doppler-ultrasound (DUS) imaging for the harvesting and subsequent facial
implantation of autologous fat tissue.
Methods: All patients underwent lipofilling treatment of the temporal fosse of the face. DUS examination was performed
for preprocedural vascular mapping and imaging of previously injected (permanent) fillers. In addition, the injection of au-
tologous fat was performed DUS-guided.
Results: Twenty patients (all female; mean age, 57.9 years; range, 35-64 years). DUS examination showed that 16 of the
20 patients (80%) had been injected with resorbable or nonresorbable fillers elsewhere in the past. The temporal artery
could be visualized and avoided in all cases. An average of 1.1 cc of autologous fat was injected in the temporal fossa per
side. One case of edema and nodules was described, but no other adverse events were reported.
Conclusions: The utilization of DUS can add valuable information to a lipofilling procedure and should be considered an
integral part of a safe lipofilling treatment.

Level of Evidence: 4

Editorial Decision date: March 4, 2020; online publish-ahead-of-print March 11, 2020.

To date, no procedural golden standard exists for au-
tologous fat transfer. Because of this and namely for
nonfacial acceptor sites, this treatment approach of
volume loss or subcutaneous defects remains a highly
debated subject.1-8 Data from The Aesthetic Society
show that fat transfer to the breast and face are both
in the top 5 surgical procedures that increased the
most significantly in 2016 (41% and 17%, respectively).9
Because the autologous fat is harvested from the pa-
tient, the procedure is associated with an excellent
safety profile not subject to hypersensitivity reactions,
foreign body reactions, or auto-inflammatory responses
(ie, autoimmune/autoinflammatory syndrome induced by
adjuvant, or ASIA syndrome).3,6,10-13 In addition, human
adipose tissue is a known source for multipotent stem
cells.14,15 These so-called adipose tissue-derived stem
cells are suggested to have regenerative properties pos-
itively influencing both the subcutaneous tissue as well
as the overlying skin after implantation.15,16
Crucial to the success of fat transplantation is the per-
centage of fat cells that survive. Proper technique and
Dr Kadouch is a dermatologist in private practice in Amsterdam, the
Netherlands. Dr Schelke is an aesthetic physician, Department of
Dermatology, Erasmus Medical Centre, Rotterdam, the Netherlands.
Dr Swift is a plastic surgeon in private practice in Montreal, Canada.
Corresponding Author:
Dr Jonathan Kadouch, Department of Dermatology, ReSculpt Clinic,
Postbus 2040, 3000CA Rotterdam, the Netherlands.
E-mail: jonathan.kadouch@gmail.com
604
handling of the fat tissue is of paramount importance
for survival.6,17-20 One of the main issues in autologous
fat transplantation to date is the lack of a defined gold
standard for harvesting, cleansing, and subsequent im-
plantation.1,6,16,17 However, this subject extends beyond the
scope of this article and will not be further addressed.
As for all medical interventions, the harvesting and im-
plantation of autologous fat can be subject to adverse
events (AEs) and complications. Typical AEs that can occur
are bruising, swelling, dysesthesia, and contour imper-
fections at the donor and/or the recipient site.6 Contour
imperfections at the donor site can be because of too su-
perficial or uneven harvesting. At the site of implantation,
contour imperfections can be the result of too superficial or
uneven deposition of the fat graft. One of the most serious
AEs that can occur with fat injection is the risk of vascular
compromise.21-23 It has been noted that the initial signs
of vascular occlusion may be misinterpreted as injection-
related bruising, pain, and swelling.24 In its most serious
form, intravascular injection or vascular compression of
end-arteries by autologous fat or filler material can lead to
skin necrosis or blindness.21,25 Recently, a world literature
review was performed by Beleznay et al to identify all the
reported cases of vision changes resulting from filler injec-
tions.21 Ninety-eight cases of partial and complete visual
loss and ophthalmoplegia related to filler injections were
reported. Autologous fat was the most common filler type
to cause this complication (47.9%), followed by hyaluronic
acid (23.5%).21
Several articles have been published on optimizing
treatment safety for the nonautologous fillers such as
hyaluronic acid.26-30 However, no effective protocol for
avoiding vascular AEs after injection of autologous fat has
been described to date.21,22,24,25 Unlike hyaluronic acid
injections where enzymatic reversal of injectate is pos-
sible, no dissolving agent or antidote exists for autologous
fat, thereby emphasizing that prevention is of paramount
importance.31,32
Doppler-ultrasound (DUS) is commonly employed in
dermatology to evaluate dermatological conditions of the
skin and subcutaneous vascular structures.33-35 With DUS
examination, visualization of the skin and underlying tissue
(fat, fascia, and muscles) and vital vascular structures
(veins and arteries) can be accomplished noninvasively.
Furthermore, imaging with DUS may increase efficacy and
safety during harvesting (liposuction) and subsequent im-
plantation (lipofilling) of autologous fat tissue and support
the postoperative management. Ultrasound identifies fat
grafts as hypoechoic, well-defined masses with a hetero-
geneous texture and some hyperechoic linear septae.36
Harvesting of autologous fat tissue is usually done at the
site most resistant to weight loss (ie, abdomen, iliac crests,
trochanters, and knees). Adding DUS to the procedure may
Aesthetic Surgery Journal 41(5)
Table 1. Sonographic Descriptions of Fillers and Nodules
Filler Sonographic description
Hyaluronic acid Well-defined, oval to round-shaped anechoic
homogeneous deposits with no internal echoes
and acoustic enhancement
Polycaprolactone Ill-defined hypoechoic matrix with bright
hyperechoic spots and mini-comet-tail artifacts
Polyalkylimide Well-defined hypoechoic mass often with
internal echoes and acoustic enhancement
Silicon oil Ill-defined, hyperechoic band-like deposits
that produce diffuse posterior reverberation
(“snowstorm pattern”) and posterior shadowing
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Poly lactic acid nodules Hypoechoic round irregular deposit with
no internal echoes
help the physician when treating aesthetic zones prone to
irregular contours by determining the right suction-plane,
thereby minimizing irregularities. In the case of facial autol-
ogous fat injections where anatomical variations in facial
vasculature abound, DUS can aid in preoperative vascular
mapping as well as in determining the presence of (perma-
nent) filler depots from previous treatments (Table 1).35,37
In this study, we investigate such a role for DUS in the
harvesting and subsequent facial implantation of autolo-
gous fat tissue.
METHODS
DUS-guided lipofilling was performed in 20 patients
referred to our outpatient clinic (Amsterdam, the
Netherlands) during the period February to September
2018. Documented data included age, sex, treatment in-
dication, sites of injection, preoperative DUS-guided vas-
cular mapping and screening of the treatment areas for
presence of (permanent) soft-tissue fillers, and both pre-
operative and postoperative ultrasound evaluation of po-
tential AEs. Both harvesting of the autologous fat as well
as the DUS-guided injection in the face were performed
in an office-based environment and under local tumescent
anesthesia alone.
Exclusion criteria were pregnancy or intent for preg-
nancy, lactation, any inflammatory or infectious condi-
tion of the face, allergy for one of the components of the
local (tumescent) anesthesia, or any contraindication for
liposuction. DUS was performed with the Philips Lumify
Portable Device high-frequency compact linear probe 4-12
MHz2 with color Doppler (Philips Benelux, Eindhoven, the
Netherlands). No other modes than B-mode and Doppler
were employed during preoperative or postoperative DUS
screening or during DUS-guided fat injection. All study pa-
tients provided written informed consent for the treatment
Kadouch et al605
A B
Figure 1. (A, B) The treatment area defined as temporal fossa: located between the zygomatic arch inferiorly, the palpable
zygomaticofrontal structure anteriorly, the hair line posteriorly, and the temporal crest superiorly.
procedure. The study was conducted in accordance with
the guidelines of the Declaration of Helsinki.
Harvesting of Autologous Fat Tissue
The harvesting liposuction was performed at the site most
resistant to weight loss unless the patient specifically re-
quested another harvesting site. The existing guidelines
for liposuction utilizing tumescent local anesthesia (TLA)
were followed and, when necessary, adjusted to the re-
cently locally published guidelines of the Dutch Society for
Dermatology and Venerology.38
The donor area was cleaned with alcohol (70%) and a
povidone iodine or chlorhexidine scrub. Infiltration was
performed manually through multiple points utilizing a
20G 70-mm needle connected to a 50-cc Luer-Lock sy-
ringe (BD, Franklin Lakes, NJ). Because the liposuctions
were performed for fat transfer purposes only, the ad-
ministered lidocaine dosage never exceeded 5 mg/kg
body weight. After infiltration, the administered TLA so-
lution (500 mg/L lidocaine, 1 mg/L adrenaline, 10 mL/L
NaHCO3 8.4% in 0.9% saline solution) was allowed to
diffuse evenly for approximately 30 minutes. Harvesting
of the autologous fat was performed manually utilizing
a 2.5-mm 15-cm disposable multihole canula (Blink
Medical Ltd, Solihull, United Kingdom) connected on a
30-cc Luer-Lock syringe (BD B.V.) inserted in the subcuta-
neous fat compartment through 2- to 3-mm small (NoKor,
1.6 × 25 mm 16G BD, BD B.V.) stab incisions.
DUS was utilized for imaging of the plane of injection
(below or above Scarpa’s fascia) during TLA injection and
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fat harvesting. In all patients, we verified if the needle or
cannula positioning relative to Scarpa’s fascia was vis-
ible. However, this was not one of the primary endpoints
of this study. The harvested fat was processed in 50-cm3
Puregraft bags (Puregraft LCC, Solana Beach, CA) utilizing
2 washes with 50 cm3 sterile NaCl 0.9% and transferred to
1-cc luer-lock syringes (BD B.V.).
DUS-Guided Facial Injections of
Autologous Fat Tissue
Implantation was performed with a 22G 50-mm blunt can-
nula (TSK Laboratory, Oisterwijk, the Netherlands). The
autologous fat was injected utilizing a retrograde fanning
technique, placing small rivulets while withdrawing the
cannula. The target level of injection was the deeper,
supraperiosteal plane and the subcutaneous level (ie, the
lateral temporal-cheek fat compartment and the lateral or-
bital fat compartment were injected). A maximum of 10 cc
of autologous fat was employed per patient; the minimum
amount was 6 cc in 1 very slim patient. In all cases, the
aesthetic temporal fossa, defined as located between the
zygomatic arch inferiorly, the palpable zygomaticofrontal
structure anteriorly, the hair line posteriorly, and the tem-
poral crest superiorly, was treated (Figure 1). Other facial
treatment areas were defined in accordance with the pa-
tient and documented.
Before temple lipofilling, the treatment area was sub-
jected to diagnostic DUS for vascular mapping and to deter-
mine the presence of previous (permanent) filler treatment
followed by DUS-guided instillation of fat. The transducer