Due to the request of numerous
patients to improve the aspect of the perioral area in combination with other
types of cosmetic and reconstructive surgery, we started to use autologous
fillers. In fact, there are numerous potential fillers that can be utilized
during various operations executed in many bodily areas, such as the breast,
abdomen, and face.
The muscular fascia as well as the dense connective tissue which the surgeon
encounters in various bodily areas during some stages of the operation, in fact,
can be removed and replaced both by themselves or superimposed in order to
increase their thickness.
The insertion of the grafts is carried out by using a needle, but other methods
can also be used with the same success. The consistency of the area treated,
after a few days of edema, is very similar to the host area, and the volume
obtained remains uniform in time (our followup is after 24 months).
The time utilized for the removal and the insertion in the chosen area was only
a few minutes. The result was extremely satisfactory in all the 30 patients
treated, and there was no complication or side effects.

1. Introduction
The use of fillers to improve the aesthetic aspect of the face is now a
frequently used methodology. Numerous products have been proposed and utilized
with variable success. Generally, what is required of these products is their
biocompatibility, stability, naturalness, and reproducibility of the result
obtained. Another important factor is that the consistency of the area treated
with these fillers is such that at the end of the filling there are no
differences of consistency between the surrounding areas. Certainly, the fact
that these products are easily available, utilizable, and having a minimum of
side effects is also very important. However, since there is a good deal of
research for new products going on, this seems to be indicative of the fact that
the objectives proposed have not yet been reached.

Two of the most interesting areas for the application of various products are
those of the nasal-labial folds and the lips. In fact, in these areas, the
passing of time as well as in many cases the bad habit of smoking, dental
prosthesis that are not perfect and other elements directly harm their aesthetic
aspect. In any case, the presence of well-defined turgid lips is the guarantee
of aesthetic attractiveness regardless of one?s age. This desire, therefore,
explains why there are so many requests to correct these areas, both as a single
procedure or in association with other plastic surgery operations.

The tissue utilized must guarantee an adequate consistency, so that it can be
easily shaped and inserted in the area. Tissues which certainly have these
characteristics are that of the muscular fascia so as the most compact tissue
that is found, in varying amounts, in the subcutaneous thickness of all bodily
regions. Therefore, with this principle in mind and considering how it was
possible to find suitable autologous tissue, we began to select and utilize this
material in different operations.

2. Materials and Methods
After having evaluated the requests and expectations of the patients, also in
relation to the type of operation programmed, we started to graft the muscular
fascia which had been removed during some operations. In the case of mastoplasty
operations [1], both of augmentation and reduction, the pectoral muscle fascia
was easily accessible for a large tract allowing us to remove a large quantity
of tissue. In addition, we utilized the rectus abdominis fascia or other muscles
that are usually exposed during an abdominoplasty. Even in this case, the
extension of the exposed muscle, also in the case of reduced undermining of a
miniabdominoplasty, consented to the obtaining of enough autologous material to
treat all the chosen areas. In the literature, the utilization of the temporal
muscular fascia for the facial lifting as well as the grafts from the
superficial musculoaponeurotic system (S.M.A.S.) for the lip and nasal-labial
folds augmentation is wellknown [2?4].

Instead, in the case of operations where the exposition of the muscular plane is
not foreseen, we utilized the tissue which more closely offered the
characteristics of compactness and adequate thickness suitable for the graft.
During an arm lifting or a thighlifting, there was a very compact and easily
moulded tissue available in the deeper subcutaneous layer which provides a
satisfactory result (Figure 1(a)).

Figure 1: (a) Graft prepared and ready to be inserted during a tight lift, (b)
available and utilizable tissue during an otoplasty operation.
In the case of otoplasty operations, we were also able to obtain tissue with the
required characteristics. In this case after removing the skin, we removed and
utilized the underlying tissue, even bilaterally, which presented a proper
thickness and firmness and which is usually eliminated to make room for the
replaced concha auriculae (Figure 1(b)). In order to place the removed tissue,
after moulding it, we used a needle which, after entering through a very small
incision at one end of the area involved, was passed and came out at the other
end. The graft was then fastened to the needle by means of a nylon thread and
was replaced internally withdrawing the needle. However, other methods can be
easily utilized (Figure 2). In the case of a thin muscular fascia, it is also
possible to superimpose two pieces of it and insert them together. The insertion
plane is subcutaneous at the level of the nasal-labial folds and is submucosa in
the lips. The point of entry as well as that of exit of the needle was closed
either by using the cutaneous glue Dermabond or by a stitch in catgut in the
case of an incision of the labial mucous membrane. Finally, in the area of
removal, it is only necessary to coagulate the exposed underlying muscular
fibres or to stitch the two margins of the fascia together.

Figure 2: Technique for the insertion of the graft at the intern of the mucous
membrane of the labium.



Figure 1: (a) Graft prepared and ready
to be inserted during a tight lift,
(b) available and utilizable tissue during an otoplasty operation.
Figure 2:
Technique for the insertion of the graft at the intern of the mucous
membrane of the labium.

3. Results
The results of the treatment of 30 patients were extremely satisfactory (Table
1). The time needed for the insertion was only a few minutes and therefore did
not interfere with the total duration of the main operation. Normally using
local anaesthesia and sedation in our operations, before the graft, we proceeded
with a local anaesthesia of the area to be treated, evidently trying not to
alter either the contour or the thickness in order not to compromise the final
result. A modest edema lasted for about 5?7 days after the operation. It is also
interesting to note that even after more than 20 months from the first graft, we
did not find any resorption, and the result obtained appeared to be extremely
stable, and such that no initial hypercorrection was carried out (Figures

Table 1: Synoptical table concerning a case series of interventions of tissues

Table 1: Synoptical
table concerning a case series of interventions of tissues





material used

Complications or revisions

F.T. 38 F LA SRAL 20 None
G.F. 42 F NLFL PMF 26 None
A.V. 36 F LA/NLFL RAF 30 None
R.V. 46 F NLFL TDSL 26 None
V.S. 41 F LA PMF 28 None
I.M. 44 F NLFL PMF 31 None
F.G. 33 F LA SRAL 29 None
L.C. 36 F LA PMF 29 None
V.R. 44 F LA/NLFL RAF 29 None
F.D.G. 51 F NLFL TDSL 29 None
L.A. 39 F LA/NLFL PMF 30 None
A.M. 42 M LA PMF 36 None
G.T. 56 F NLFL RAF 29 None
A.P. 52 F NLFL TDSL 34 None
B.V. 31 F LA SRAL 25 None
M.S. 45 F NLFL PMF 26 None
D.V. 47 F NLFL PMF 30 None
R.M. 55 M NLFL RAF 36 None
E.D.M. 52 F LA RAF 36 None
R.B. 51 F NLFL TDSL 27 None
P.O. 44 F NLFL PMF 31 None
A.L.M. 42 F LA PMF 36 None
R.S. 59 F NLFL RAF 32 None
R.D.F. 52 F NLFL ADSL 31 None
A.C. 50 F NLFL PMF 28 None
R.P. 53 F NLFL RAF 27 None
S.P. 46 F NLFL PMF 33 None
M.G. 51 F NLFL ADSL 39 None
T.C. 38 F LA PMF