www.PRSGlobalOpen.com1In Asian people, the superior sulcus in the upper eyelid frequently becomes visible because of aging or overzealous removal of the orbital fat through blepharoplastyorotherunknownetiologies.The hollow or sunken appearance is often accompanied bymultipleeyelidfolds,whichresultfromvariable insertion levels of levator palpebrae superioris, with consequent thinning of the skin and orbicularis oc-ulimuscleand/orpreaponeuroticfatatrophy.The coalescenceofbothphenomenaresultsinatired, weary, and even exhausted appearance.Certain strategies, such as autologous fat grafting, dermalfatgrafting,orallogenousdermalgrafting, havebeendescribedanddetailedintheliterature for correcting the aforementioned problems.15 Cur-rently,numeroussoft-tissuellersarewidelyused despitetheirshortdurationofefcacy.6Areliable strategy with favorable long-term effects that leads to higher patient satisfaction and higher condence of surgeons has not yet been developed.Fat grafting was initially addressed over a century agobyNeuber.7Thereafter,fat-graftingtechniques, methods, and protocols have been enhanced numer-ous times to improve the fat survival or fat retention Copyright 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRSGlobalOpenisapublicationoftheAmericanSocietyof Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives3.0License,whereitispermissibletodownload and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.DOI: 10.1097/GOX.0000000000000141From the *Charming Institute of Aesthetic and Regenerative Surgery,Kaohsiung,Taiwan;DepartmentofPlasticSur-gery,KaohsiungMedicalUniversity,Kaohsiung,Taiwan; andDepartmentofSurgery,YuansGeneralHospital, Kaohsiung, Taiwan.ReceivedforpublicationNovember30,2013;accepted May 20, 2014.Presented at 20th ISAPS, August 1418, 2010, San Francisco; IPRAS, May 2227, 2011, Vancouver, Canada; 1st ISPRES, March 911, 2012, Rome, Italy; and 3rd WAPSCD, October 1214, 2013, Xian, China.Background: Although fat grafting has been clinically applied by surgeons inestheticandreconstructivesurgery,ithaswidelyevolvedinprocesses such as harvesting, processing, and placement of fat, using the fat-grafting procedure,whichdatesbackover100years.Surgeonsfrequentlyusefat grafting to recontour, augment, or ll soft-tissue defects, facial wrinkles, or skin problems such as depressions or scars. However, fat grafting has not been thoroughly understood and has not been conclusively standardized to ensure superior clinical results.Methods:Thisstudywasintendedtodeterminetheroleofmicroautolo-gous fat transplantation (MAFT) under evidence-based medicine, particu-larly in accurate delivery of small fat parcels. The research method involved the conceptualization of MAFT and the development of an innovative sur-gical instrument for fat placement. Clinically, 168 patients with sunken up-per eyelids with multiple folds underwent this procedure.Results: The major ndings suggested that MAFT exhibits promising clini-cal results and offers a superior guideline for fat placement. Details of the technique and theoretical implications are also discussed.Conclusions: The therapeutic effects of MAFT and the long-term clinical results of patients with sunken upper eyelids with multiple folds indicated satisfactory outcomes. Based on the results, MAFT offers an alternative op-tion to surgeons for performing fat grafting and provides a more favorable optionforthebenetandwelfareofpatientsbyreducingthepotential complications.(PlastReconstrSurgGlobOpen2014;2:e259;doi:10.1097/GOX.0000000000000141; Published online 24 October 2014.)Tsai-Ming Lin, MD, PhD*Tsung-Ying Lin, MDChih-Kang Chou, MDChung-Sheng Lai, MD, PhDSin-Daw Lin, MDApplication of Microautologous Fat Transplantation in the Correction of Sunken Upper EyelidMAFT and Sunken Upper EyelidLin et al.xxxxxx11MythiliPlastic & Reconstructive Surgery-Global Open20142Original Article10.1097/GOX.000000000000014120May201430November2013(c) 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The Amer-ican Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons.CosmeticORIGINAL ARTICLEPRS Global Open 20142rate.812 Numerous surgical mentors in this eld have investigatedinnovativemethodsforpotentiallyim-proving fat grafting.1317In this article, we advocate a new concept of micro-autologous fat transplantation (MAFT) and its applica-tion in correcting sunken upper eyelids with multiple folds.TheresultsindicatedthatMAFTfacilitatesre-duced morbidity, higher patient satisfaction, and favor-able long-term follow-up results. MATERIALS AND METHODSPatient DemographyAtotalof168patients(2menand166women) received fat grafting for correction of sunken upper eyelids with multiple folds from September 2007 to September2010attheCharmingInstituteofAes-theticandRegenerativeSurgery,Kaohsiung,Tai-wan.Thesepatientswereregularlyfollowedupat the outpatient clinic. Preoperative and postoperative photographstakenateachvisitwerecompared.In addition,complicationssuchascalcication,bro-sis, nodulation, uneven skin (irregular surface), and cyst formation were meticulously recorded.AnesthetizationUnlessaccompaniedwithothermajoradjunct procedures, all patients were anesthetized using total intravenousanesthesiafortheentireMAFTproce-dure. Concurrently, local anesthesia was administered at the incision sites (donor and recipient sites) by in-ltrating2%Xylocaine(LidocaineHydrochloride 20mg/ml,OrientalCo.,Taiwan)withepinephrine (1:1000). The fat-harvesting area, primarily the lower abdomen, was preinltrated with a tumescent solution preparedataratioof2%Xylocaine:LactateRinger solution:epinephrine (1:1000) = 10 mL:30 mL:0.2 mL.MAFT ProcedureFat HarvestingThedonorareawaspreinltratedwithatu-mescentsolutionaftertheincisionalsitewas anesthetized.Approximately10to15 minafterthe tumescentsolutionwasadministered,ablunt-tip cannula(diameter,3 mm)wasusedtoharvestthe fat,andthelipoaspiratedvolumewasthesameas that of the inltrated tumescent solution to achieve ahighproportionofpuriedfataftercentrifuga-tion. To ensure minimal damage to the lipoaspirate, the plunger of a 10-mL Luer-Lok syringe was pulled backfor2to3 mLandmaintainedsothat,whileit was connected to the liposuction cannula, the reac-tive aspirating negative pressure was maintained be-tween 270 and 330 mm Hg.18Fat Processing and RenementForfatprocessing,variousmethods,suchasthe sieve method, multiple-layer gauze ltration, and cen-trifugation,havebeenproposedintheliterature.19,20 The internationally accepted Colemans technique was used for processing the lipoaspirate through centrifu-gation because of its advantages of less environmental exposure and lower manual manipulation in the asep-tic procedure.17 A standard centrifugation of 3000 rpm, whichwasapproximately1200gfor3 minutes,was applied to process (purify) the fat.Fat TransferThe puried fat was carefully transferred into a 1-mLLuerSlipsyringebyusingatransducerand waspreparedfortransplantation(Fig.1A).(See Video1,SupplementalDigitalContent1,which displaysthemicroautologousfattransplantation for sunken upper eyelids. This video is available in the Related Videos section of the full-text article athttp://www.PRSGo.comandathttp://links.lww.com/PRSGO/A55.Afterthepuriedfatwastransferred,thefat-lledsyringewasloadedintotheMAFT-Gunin-strument(Fig.1B).Thepredeterminedvolume ofthefatparceltobeinjectedduringeachtrig-geringwasadjustedbyrotatingthedial(Fig.1C) with labeled numbers depicting the total injection frequenciesper1 mLoffatgraft.An18-Gblunt cannulawasusedtoinjectfatwhilewithdrawing theMAFT-Gun.Eachdeliveredfatvolumewas setat1/240mLandmeticulouslytransplantedin 3to4layers:adeeplayerabovetheinferioror-bital rim; a middle layer, the suborbicularis oculi muscle (deep in the muscle); and supercial layer, the supraorbicularis oculi muscle (just beneath the dermisoftheeyelid)(Figs.2AD).Postoperative carewasprovidedregularlyandwithoutanyspe-cial dressings or massage. Oral antibiotic and non-steroidanti-inammatory drugs were administered for 3 days, as required. All patients were regularly photographed at each follow-up visit, and the pre-operativeandpostoperativephotographsofeach patient were compared.Disclosure: Dr. Tsai-Ming Lin owns the patent rights ofMAFT-Gun,isthescienticadvisorofDPB,and received partial nancial support from DPB, which is the manufacturer of the MAFT-Gun device. None of the other authors has any nancial disclosures. The Article Processing Charge was paid for by the authors.Supplementaldigitalcontentisavailableforthis article. Clickable URL citations appear in the text. Lin et al. MAFT and Sunken Upper Eyelid3RESULTSThe average age of the patients was 35.5 years (range,2652years),andthetotalinjectionvol-umeoffatwas1.8 mLfortherightside(range, 1.22.3 mL)and1.7 mLfortheleftside(range, 0.82.4 mL).Theaverageoperationtimewas 34 minunlesscombinedwithotheradjunctive procedures such as upper or lower blepharoplasty orfatgraftingofotherareas.Nomajorcompli-cationswereencounteredexcept2casesofpro-longedswellingfor>2weeks.Allpatientswere satisfied with the results except one who request-edsecondaryfatgrafting[Cases1(Figs.3A,B), case2(Figs.4AC),case3(Fig.5),andcase4 (Fig. 6)].DISCUSSIONLiterature ReviewFor over a century, surgeons have struggled to ap-ply autologous fat grafting in plastic, reconstructive, andestheticsurgerywithvariableresults.In1893, the grand surgeon, Neuber,7 became the rst to re-construct a facial defect. Thereafter, several reports havedescribedfatgrafting:Kanavel21statedthat fatcellsarethebestfriendofthesurgeon,Peer8 described an approximately 55% fat-graft retention rate, and Bames9 reported convincing results regard-ing fat grafting for breast augmentation. In 1977, Il-louz10 reported on liposuction and developed the related medical instruments. Subsequently, fat graft-Fig. 1. A, The processed fat after centrifugation was transferred from a 10-mL syringe to a 1-mL Luer Slip syringe through a transducer. B, The fat-flled syringe was loaded into the MAFT-Gun, and the fat was ready for transplantation. C, The predetermined fat volume of each delivery by triggering could be adjusted by switching the dial (240 stands for each delivered fat parcel by pulling the trigger, which equals 1/240 mL). D, Panoramic view of the MAFT-Gun.PRS Global Open 20144ingwasne-tunedandappliedinplasticsurgery; forexample,Fournier11usedfatgraftingtollin-voluted facial tissues, and Chajchir and Benzaquen12 usedfatgraftingforrejuvenationoffacialwrinkles andtreatmentofhemifacialatrophy.Inaddition, various endeavors have been attempted for recipient sitepreparation;forexample,Asken13performed subcisiontoprepareapocketforfatgrafting,and Nguyenetal14reportedmuscleastheoptimalre-cipientsiteforfatgrafting.Inthepast2decades, prominent surgeons have illustrated numerous prin-cipaltheories.CarpanedaandRibeiro15,16postulat-edhigherfatgraftsurvival,andin1993and1994, they experimentally proved that the graft survival is higherwhenthegraftingiswithin1to2 mmfrom the margin. In 1994, Coleman17 presented the struc-ture fat graft method and emphasized that in special locations,suchasperiorbitalareas,eachfatparcel mustbebetween1/30and1/50 mL.Basedonthe review of the aforementioned literature, experts and scientists in the eld have demonstrated various fat-grafting techniques; however, no conclusive strategy has yet beendeveloped.22Evidence-based Medicine in Fat GraftingEvidence-basedmedicineappliesthemostreli-able evidence gained from scientic methods to clin-ical decision making.23 In autologous fat grafting, 2 theories were proposed by Carpaneda and Coleman, whichdemonstratetheimportanceofevidence-based medicine.Theory by CarpanedaCarpanedaandRibeiro15demonstratedonly 40%graftsurvivalat1.5 0.5 mmperipheralto thegraftmargin.Furthermore,theyreportedthat thickness and geometrical shape are the keys to suc-cessfulfattransplantationandconcludedthatthe diameter of the fat graft (either spherical or cylin-droid shaped) should be < 3 mm to achieve higher graft survival rates.16Colemans TheoryColeman17proposedtheconceptofstructure fatgraftingandemphasizedthatthefatparcels shouldbemanuallyarrangedinlayerswithavol-umeof