Aesthetic surgeons have been using AlloDerm (Lifecell Corp, The Woodlands, TX) for soft-tissue augmentation for almost a decade. Many innovative uses and new techniques have been developed during that time. In 1997, I began injecting AlloDerm in the lip and nasolabial-fold region in an effort to reduce the fairly significant temporary morbidity that resulted from strip-type allograft insertion. My objective was to provide an easily administered, longer-lasting augmentation with more volume and more permanence than other injectables.

It has been argued that because AlloDerm is a cadaveric allograft, the human body will reject it and that the effect will disappear with time. However, multiple reports of its long-lasting effect attest to the efficacy of antigenic protein removal during the processing period.The patient in Figure 1 had particulate AlloDerm injected into her nasolabial folds in 1998. Five years later, the effect of the AlloDerm remains, despite obvious aging in other facial areas.

Technique

Reconstitute a 3.5 × 7-cm sheet of AlloDerm in accordance with the manufacturer’s suggestions. Use a pituitary rongeur, held over a medicine cup, to fragment or “particulate” the sheet into 2-mm particles. Use a spoon-type curette to load the moist allograft into the back end of a 1-mL syringe.

After administering a regional or local anesthetic, use a number 11 blade to make a small nick in each oral commissure within the vermilion. To target the nasolabial folds, make a small perialar nick. Use a 16- or 18-gauge Jelco intracath to tunnel under the area of soft-tissue deficiency. Remove the stylet and inject a thin, toothpaste-like tube of AlloDerm as you withdraw the catheter. Perform multiple levels of tunneling to avoid creating ridges under the skin.

Approximately 2.5 to 3.2 mL of filler can be fashioned from the 3.5 × 7-cm AlloDerm sheet, depending on the thickness of the AlloDerm and the skill of the processor. The AlloDerm sheet costs a little more than 1 mL of most available soft-tissue fillers, but it provides as much as 3 times the volume. It takes a skilled nurse 20 to 25 minutes to soak, chop, and load the AlloDerm into a syringe.
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One sheet of AlloDerm can provide enough material to achieve dramatic lip augmentation or moderate nasolabial-fold correction. If the soft-tissue deficit is severe, you can add more volume or use a combination of AlloDerm and fat grafting. Fat grafting alone may be used in patients who need a large volume of augmentation material.

This technique has evolved over time. Here are modifications I have added to achieve the very best results:

Create smaller particles by soaking the AlloDerm for a shorter period, 8 to 10 minutes, so that the AlloDerm is not entirely soft (Figure 2). Train operating-room personnel to focus on the quality of the end product rather than on speed. There are 2 reasons for creating small particles: (1) They facilitate the use of a smaller-gauge blunt-tipped metal cannula that can inject without blockage and subsequent “blob” formation, and (2) take is better, with decreased risk of lumpiness, when this substance is injected under thinner skin. Smaller amounts are injected per pass for the same reasons. Additionally, in light of recent reports of embolic complications with all types of injectable substances, using a blunt needle and injecting small aliquots under very low pressure while withdrawing will reduce the risk of stroke, blindness, or local skin slough.
• Perform a subdermal injection, especially in the nasolabial-fold region, to decrease ridging. Intradermal injection of AlloDerm can cause lumpiness or formation of permanent ridges.
• Inject from multiple angles and directions, rather than a single tubular track, to enhance the natural appearance of the augmentation.
• Ideally, use “like” tissue to replace what is missing. Use stiffer, more substantial dermis in an area where the density and stiffness are advantageous, such as in the lips and nasolabial folds in patients without extremely thin skin.

Because of the limited volume available with this technique, reserve injection of particulate AlloDerm for patients who desire modest improvement in a very localized area. This procedure is ideal for patients who want an injection, not surgery, with no donor-site morbidity and a relatively short recovery period.

Fat grafting has become my primary modality in those patients who require large-volume augmentation over a large surface area (Figure 3).

The patient depicted in Figure 4 has had 2.8 mL of particulate AlloDerm injected. She is shown at 3 and 5 days after injection. To help achieve rapid recovery, I urge patients to limit activity, apply intermittent icing, and use perioperative Arnica montana.