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tions in almost 10% of the cases (exposure, infection, visibility, rupture of the device during implantation,
[3]
trephination hemorrhage), even having to remove the device in three cases . One of the authors, A.G.,
developed a stitch for paramedian fixation with the Reverdin needle, which will be referred to as the Gen-
nai stitch henceforth. The Gennai stitch has successfully been used for paramedian fixation in over 200
patients without complications. Two stab wounds are performed in the forehead at a certain distance from
the paramedian incision. The Reverdin needle is passed though the stab incision and exits at the paramedian
incision, and the suture is loaded and brought back to the stab incision, where only one of the branches is
brought back with the Reverdin needle through the subcutaneous tissue back to the paramedian incision,
where it is freed and tied to the other branch, thus grasping the tissue and elevating the eyebrow. This stitch
will cause a characteristic bulging that will disappear in the postoperative period.

Temporal fixation of the deep subcutaneous tissue of the elevated flap to the deep temporal fascia is simply
performed with a 3/0 Vicryl suture. Due to the extensive dissection, the inferior complex and the lateral
complex will be elevated as a whole with this fixation.

Bicoronal fixation can be used in 50% of the cases to enhance the elevation of the eyebrows.

SEFFI
Harvesting
For the preparation of the tissue for harvesting a solution of lidocaine (400 mg), sodium bicarbonate (5 mEq)
and epinephrine (1 mg), is prepared in a cold Ringer’s lactate solution (500 mL) and it is inflitrated into the
autologous collection site(s); most frequently the supra pubic region (55%), hips (22%), prethrocanteric area
[4]
(18%), inner thigh (3%), and inner knee (2%) . For SEFFI, manual aspiration of fat is performed with the use
of a 20 cm-long multi perforated cannula (with other 0.5-mm or 0.8-mm ports) mounted in a 10-mL syringe;
for micro-SEFFI, with a 15-cm long multi perforated cannula with 0.3-mm ports. Manual aspiration is be-
gun 15 min after infiltration of the preparation solution.

The aspirated material (0.6 mL per syringe) is cleaned with Ringer’s solution (0.4 mL) and left to decant in
vertical position for about 2 min. The liquid part collected at the bottom of the syringe is discarded. This
procedure is repeated once again to ensure that most of the blood and the anesthetic solution is eliminated
[5]
from the fat . The syringes are kept capped under a sterile cloth.
Autologous blood is drawn from the patient to obtain platelet rich plasma (PRP). It is poored into 4.5 mL
citrated Vacutainer and centrifuged at 2000 rpm for 4 min. The fat and PRP are mixed so that PRP is 20% of
[6]
the total harvested tissue .

Injection
The solution is then injected according to a comprehensive study of the facial arterial system, using a linear
retrograde injection technique. The M-SEFFI technique compliments the SEFFI technique; SEFFI performed
with cannula with distal ports of 0.8 mm is indicated for the larger volume defects in the cheek, temple,
forehead, chin and jaw line, and SEFFI performed with cannula with distal ports of 0.5 mm is indicated for
brow and lip volume restoration. M-SEFFI is best for the upper sulcus and infra orbital hollows and the fine
wrinkles in the periocular area, such as the smile lines that form in the lower eyelid, and the perioral fine
[4]
lines of the lips .

DISCUSSION
In the past, surgeons have focused on the rejuvenation of the frame of the face through extensive facelifts
and the periocular structures individually, correcting brow ptosis, dermatochalasis, eyelid bags, tear trough