Micro-autologous fat transplantation for rejuvenation of the dorsal surface of the aging hand  Lin Yun-Nan, Huang Shu-Hung, Lin Tsung-Ying, Chou Chih-Kang, Huang Yu-Hao, Takahashi Hidenobu, Lai Chung-Sheng, Lin Sin- Daw, Lin Tsai-Ming  Journal of Plastic, Reconstructive & Aesthetic Surgery  Volume 71, Issue 4, Pages 573-584 (April 2018) DOI: 10.1016/j.bjps.2017.09.012 Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 1 (A) Surgical planning for aging dorsal hand outlined as black shadow. The X points are the insertion sites made using a #11 blade. (B) The human dorsal hand is composed of three layers: dorsal deep lamina (DDL), dorsal intermediate lamina (DIL), and dorsal superficial lamina (DSL), which are partitioned by dorsal deep fascia (DDF), dorsal intermediate fascia (DIF), dorsal superficial fascia (DSF), and the skin. (C) Fat parcels are transplanted in three layers: deep layer (parcels in pink) (DDL), which is the layer between DDF and DIF; middle layer (parcels in green) (DIL), which is the layer between DIF and DSF; and superficial layer (parcels in blue) (DSL), which is the layer between DSF and the skin. Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 2 (Case 1) A 70-year-old woman presented for re-contouring with fat grafting to increase the youthful appearance of her dorsal hands. MAFT was performed to deliver 25 mL fat graft in her left and right dorsal hands, respectively (preoperatively in A and B, left). Twelve months after the MAFT session, volume restoration of the dorsal hands was maintained with fullness (postoperatively in A and B, right). The appearance of the aging dorsal hands was changed, i.e., from extremely severe loss of fatty tissue and marked visibility of veins and tendons (MHGS, grade 4) to mild loss of fatty tissue and slight visibility of veins and tendons (MHGS, grade 2). Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 3 (Case 2) A 62-year-old woman presented for augmentation of her dorsal hands with fat grafting. MAFT was performed on her dorsal hands to deliver 10 mL fat graft in her left and right dorsal hands (preoperatively in A and B, left). Ten months after the MAFT session, the volume was maintained on both dorsal hands (postoperatively in A and B, right). The appearance of both dorsal hands was changed, i.e., from severe loss of fatty tissue and moderate visibility of veins and tendons (MHGS, grade 3) to no loss of fatty tissue (MHGS, grade 0). Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 4 (Case 3) A 54-year-old woman presented for fat grafting to restore her aging dorsal hands. MAFT was performed to deliver 15 mL fat graft in her left and right dorsal hands (preoperatively in A and B, left). Sixty-four months after the MAFT session, the fullness and restoration of both dorsal hands were maintained (postoperatively in A and B, right). The appearance of her left dorsal hand was changed, i.e., from severe loss of fatty tissue and moderate visibility of veins and tendons (MHGS, grade 3) to mild loss of fatty tissue and slight visibility of veins (MHGS, grade 1). The appearance of her right hand was changed, i.e., from moderate loss of fatty tissue and mild visibility of veins and tendons (MHGS, grade 2) to no loss of fatty tissue (MHGS, grade 0). Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 5 (Case 4) A 53-year-old woman presented for fat grafting to rejuvenate her aging dorsal hands. MAFT was performed to deliver 10 mL fat graft in her left and right dorsal hands (preoperatively in A and B, left). Fifty-four months after the MAFT session, the fullness and rejuvenation of both dorsal hands were maintained (postoperatively in A and B, right). The appearance of her dorsal hands was changed, i.e., from moderate loss of fatty tissue and mild visibility of veins and tendons (MHGS, grade 2) to no loss of fatty tissue (MHGS, grade 0). Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions

Figure 6 Dr. Carpaneda's theory reported only a 40% survival rate in the peripheral zone 1.5 ± 0.5 mm of the parcel margin.28 This theory further indicated that a tiny parcel with a radius of 1 to 2 mm is needed to avoid the central necrosis and subsequent complications.20 The conceptualization of MAFT (micro-autologous fat transplantation) advocated by Dr. Lin et al. in 200620 emphasized that each delivered fat parcel should be ideally smaller than 1/100 mL (0.01 mL) (rendering the real radius of such a parcel to be 1.3 mm) or should be 1/240 mL (0.004 mL) (rendering the radius to be 1.0 mm). Journal of Plastic, Reconstructive & Aesthetic Surgery 2018 71, 573-584DOI: (10.1016/j.bjps.2017.09.012) Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Terms and Conditions