Autologous Adipose Tissue Grafting
Richard A. Gangnes
INTRODUCTION
The ability to enhance facial contour and structure using autogenous adipose tissue has been one of the most important adjuncts in the facial plastic surgeon’s armamentarium to have been popularized in the last 20 years. I now use adipose tissue to provide volume and shape to the aging face during facial surgery and as a stand-alone procedure. It is used to restore traumatic or iatrogenic soft tissue defects; it is used for acquired or congenital facial contour abnormalities or asymmetries; to improve the quality and texture of severely actinically damaged skin; and to help restore facial shape, symmetry, and eyelid closure after facial nerve dysfunction secondary to eighth cranial nerve tumor surgery. The ability to graft adipose tissue to the face precisely, easily, and effectively should be in every facial plastic surgeon’s skill set, along with the knowledge of its benefits, limitations, and risks.
Aesthetic surgery of the aging face has traditionally focused on excisional techniques. Surgery was aimed at counteracting the natural descent of facial structures and removing redundant soft tissue. In recent years, however, the concept of volume restoration has increasingly become recognized to be of vital importance in treatment of the aging face. A look back into history reveals that plastic surgeons of the previous century understood the need of volume restoration. Reports from the literature of the early 20th-century describes efforts to augment tissues with a wide array of injectable substances, such as paraffin, petroleum jelly, latex, gold, silver, ivory and cow horn.
Different types of face-lifts were popularized and promulgated as ways to lift and elevate with the consequence of thinning and flattening the face. As we have learned more about the aging face, we know that the changes involve more volume changes than a falling or laxity, particularly after the recognition that part of the aging process involves a shrinking of the underlying bony skeletal framework. What appears as facial laxity is not just intrinsic laxity of the soft tissue and the skin envelope but it is having the envelope reside over a shrinking skeletal support. With the realization that volume restoration alone, as Dr. Coleman demonstrated in the early nineties with structural adipose tissue grafting, achieved in many cases a remarkable youthful enhancement without the tightening, elevation, or tissue removal, we began to see the value of volume restoration as an important adjunct to surgery of the aging face. What began as an either-or proposition evolved into a simultaneous operation with ever-improving results and with greater patient and surgeon satisfaction. Now, volume restoration is an important part of the surgical and nonsurgical treatment of both the aging face and other facial abnormalities. In fact, with the increasing numbers of injectable fillers with varying characteristics that have been brought to the cosmetic market in the last 10 years, both surgeons and nonsurgeons have seen the volumizing of the face as an increasingly important part of their practice. With that, however, we are seeing an increasing number of patients “overvolumized” as patients, surgeons, and nonsurgeons choose to use volume enhancers instead of surgery for a variety of reasons, when the best outcomes are more often achieved with a blend of both volumizing and surgery. It is clear that the medical profession has recognized the importance of volume restoration in the treatment of the aging face, and now the dilemma is to choose the most appropriate way to achieve those soft,
round, energetic, and beautiful contours of the youthful face. After using nearly all of the facial fillers including injectable collagen introduced over 20 years ago, adipose tissue remains one of the most valuable volume- and contour-enhancing materials that we use both as an adjunct to surgery and as a procedure by itself.
round, energetic, and beautiful contours of the youthful face. After using nearly all of the facial fillers including injectable collagen introduced over 20 years ago, adipose tissue remains one of the most valuable volume- and contour-enhancing materials that we use both as an adjunct to surgery and as a procedure by itself.
A review of the past efforts to rejuvenate the aging face reveals that excisional-based surgery has not provided sufficiently good results for facial rejuvenation. These traditional excision-only approaches do little to improve cheek or temporal hollowing. Indeed, the tightening and lifting procedures may accentuate volume loss by flattening facial contours. Adipose tissue and skin removal during a blepharoplasty may even worsen the hollowed-out, aged appearance of the eyes. Many contemporary aesthetic surgeons now routinely employ adipose tissue transfer or injectable fillers to enhance their outcomes. Several types of commercial fillers have been used with varying degrees of success and longevity. On the other hand, adipose tissue grafting has demonstrated excellent availability and biocompatibility as well as improved overall skin quality in treated areas for reasons that are unknown. Early criticisms of adipose tissue grafting were the variable and seemingly high degrees of adipose tissue graft loss. However, today, with more experience and improved understanding of atraumatic tissue handling and refined harvest and injection techniques, graft retention has improved significantly. Autologous adipose tissue transfer is now well regarded as an invaluable tool in the plastic surgeon’s armamentarium that can be used either alone or in combination with traditional excisional techniques in facial rejuvenation.
Volume loss has been studied by many and is understood to be a fundamental component of the aging process. Coleman, one of the most influential pioneers of adipose tissue grafting, regarded atrophy of adipose tissue as the primary factor in aging. He also proposed that a significant amount of volume loss was due to colloidal fluid loss with aging. Gonzalez-Ulloa described facial aging as volume loss involving all the structures of the face, including the muscles, bone, skin, and adipose tissue. Lambros singled out specific areas (the brows, the tear trough, the cheeks), and demonstrated how the addition of volume may give results better than traditional methods. A radiologic study by Pessa demonstrated the effect of bony changes on volume loss in the aging process. More recently, the anatomic cadaver work by Rohrich and Pessa illustrated the loss of adipose tissue in specific compartments of the face. While the mechanism for age-related volume loss continues to be investigated, the role of volume restoration in facial rejuvenation is well accepted.
As more research and study has been conducted into the basic science, biology, and technique of grafting over the last 20 years, autologous adipose tissue grafting has assumed an important role in nearly every facial plastic surgeon’s practice. Just as the explosion in popularity of liposuction of the body and the face in the early eighties resulted in many patients having contour irregularities that subsequently required correction with adipose tissue and other techniques, we will be seeing problems related to autologous adipose tissue grafting because of the marked increase in the number of procedures performed in the last few years. Just as we saw in the eighties the increasing numbers of complications that tempered our enthusiasm for liposuction and forced a critical look at the science and technique behind this new procedure, we are beginning to see similar problems with adipose tissue grafting as the techniques have become more commonly used by plastic surgeons. It is now more important than ever to adopt a judicious approach to structural adipose tissue grafting; learn what has worked, what problems we have seen, and where this valuable procedure benefits our patients; and learn about ideal facial shape and contour in both the youthful face and the aging face so that we can bring both science and art to the benefit of those entrusted to our hands.
HISTORY
As with any surgical procedure, a history of previous surgery, medical problems, medications, previous fillers, cosmetic surgery, and allergies, must be obtained. It is also important to ask questions about expectations, goals, and, if previous surgery was performed, whether the patient was satisfied with the results. Expectations and psychological suitability are important parts of the assessment based on history and are explained additionally later. The patient’s age and body habitus as well as the degree of regular physical activity has a direct impact on the long-term results of adipose tissue grafting, the degree of overcorrection that one should consider, how to counsel the patient with regard to expectation, and the location and amount of donor adipose tissue. The patient’s menstrual history in the case of female patients and whether they are pre-, post-, or perimenopausal will impact one’s decisions as to patient suitability and the volume of adipose tissue to be used at any one time.
PHYSICAL EXAMINATION
Initial Consultation and Evaluation
For any consultation regarding evaluation of the aging face, we ask that the patients bring in photos of themselves smiling and not smiling from 10 to 15 years ago including their twenties and thirties. This is particularly important and pertinent in the evaluation of patients for adipose tissue grafting for several reasons. It allows an illustrative discussion on the aging process in general and the volume loss that occurs over time to specific areas of the face. It is educational for the patient to see the changes that have occurred over time and relate that to what
we are seeing now and can form a basis of discussion regarding the utility of fat to restore these softer, rounder, more energetic contours of their more youthful face. We find that in the discussion of adipose tissue grafting with patients, it is just as much a matter of educating the patient about this procedure as it is evaluating the patient for technique, amount, and location of the area to be grafted. The two common misperceptions among patients with regard to adipose tissue grafting in that “it doesn’t last” or “all goes away” or that their face will look puffy and overdone as they see now more increasingly with the widespread injudicious use of fillers by so many specialties.
we are seeing now and can form a basis of discussion regarding the utility of fat to restore these softer, rounder, more energetic contours of their more youthful face. We find that in the discussion of adipose tissue grafting with patients, it is just as much a matter of educating the patient about this procedure as it is evaluating the patient for technique, amount, and location of the area to be grafted. The two common misperceptions among patients with regard to adipose tissue grafting in that “it doesn’t last” or “all goes away” or that their face will look puffy and overdone as they see now more increasingly with the widespread injudicious use of fillers by so many specialties.
Part of the educational process is aided by the use of photographs during these times of one’s life. We now consider much of facial aging resulting from changes in the soft tissue envelope of the face, which include the progressive changes involved in connective tissue support and bony support and skin changes. Part of the change we experience in the volume loss is depletion and change of the adipose tissue, but also a considerable portion of the deflation is a decrease in the extracellular fluid space consisting mostly of glycosaminoglycans. It is also well established that bony changes occur that accentuate these soft tissue changes including a loss in vertical dimension of the midface accompanied by an increase in size and volume of the orbit along with a shrinkage in the height and projection of the both midface and mandible. Photos at several ages help us illustrate these changes as part of the educational process of the patient.
As we evaluate facial volume and shape through the decades of life with photos and assess these changes in the context of the patient’s ideal proportions, most patients would say, and we would generally agree, that the refinement of more juvenile adipose tissue contours and bony maturation of our 30’s represent the optimal appearance with regard to facial volume. By bringing in photos during these decades of life, it gives us an idea of contours that patients generally like and would be worthwhile pursuing. It is also important to bring in photos both smiling and in repose as the facial musculature during animation lifts and alters adipose tissue contours that hide areas of hollowing that can be seen in repose. They may also disclose areas where one may need to be more cautious such as the crowding of the eye that can occur in some patient’s with smiling. Photographs remain very helpful for both planning and education.
The face is typically assessed in terms of volume as consisting of two major components. Because the eyes are truly the focus of conversation and the most beautifying segment of the face, it is evaluated as a complex involving the periorbital area and adjacent contours of the temple and forehead. The second major component for preoperative assessment is the lower face, which includes the neck. Both of these components are assessed preoperatively for volume, contour, and profile considerations to determine the location, amount, and insertion site of the grafted adipose tissue.
The periorbital area includes the lateral and inferior orbital rims, medial orbital rim, part of which is described as the tear trough, and also an area that is termed the anterior triangle, which will be discussed further. Preoperative evaluation of the inferior orbital rim segments involves the assessment of the degree of depression along the rim or degree of hollowing and the amount of adipose tissue that may be required to soften these areas of volume depletion. The aesthetic unit of the brow and upper eyelid is assessed together as the insertion site for adipose tissue grafting for both areas is within the brow just lateral to the notch or foramen of the supraorbital nerve. The amount of adipose tissue grafted here is dependent on the degree of hollowing and deflation of the upper lid infrabrow and supratarsal fold area medially, in addition to the shape, height, and convexity of the brow laterally. The degree of temple fullness or hollowing, shape of the forehead, and the degree and depth of horizontal frontalis and vertical glabellar lines completes the preoperative evaluation of the upper face and eye aesthetic unit. The preoperative evaluation of this complex involves not only the degree of deflation and hollowing that exists but also whether there is a negative, neutral, or positive vector of the globe as adipose tissue grafting is able to change the relative vector by changing the soft tissue volumes that contribute to this characteristic. The areas of adipose tissue grafting for the eye complex that require preoperative evaluation are
Tear trough or medial orbital rim
Inferior orbital rim
Anterior triangle
Lateral orbital rim
Medial infrabrow
Lateral infrabrow
Temple subcutaneous
Temple subfascial
Suprabrow laterally
Suprabrow medially
Forehead
The lower face is likewise treated as a unit and further divided into the component regions to determine whether grafting is necessary and in what volumes. This is particularly done in the context of both the patient and the surgeon’s sense of aesthetics in conjunction with previous photos in an effort to maintain the essence of the face to which we have been entrusted. Photographs of patients in their 20s and 30s are very helpful in the decision-making process when adipose tissue-sculpting the aging face. It helps the patients understand the aging process and allows them a better understanding of the value of volume augmentation. It also helps the
surgeon in the preoperative analysis of where and how much adipose tissue is grafted particularly in the lower face. The lower facial segments that require evaluation for adipose tissue graft consideration are
surgeon in the preoperative analysis of where and how much adipose tissue is grafted particularly in the lower face. The lower facial segments that require evaluation for adipose tissue graft consideration are
Medial cheek below the anterior triangle
Upper nasolabial fold to the deep nasal fat pad
Malar eminence
Medial zygomatic arch or lateral cheek
Lateral zygomatic arch at light reflex point
Nasolabial fold
Subcutaneous cheek
Prejowl sulcus
Lateral mandible, angle of mandible
Later subcutaneous cheek
Chin
Oral commissure
Lips
Premaxilla
INDICATIONS
The Periorbital Complex
Adipose tissue used as an augmentation material to the inferior orbital rim area is used primarily to decrease orbital hollowing in those patients without significant orbital adipose tissue pseudoherniation. It can camouflage prominent orbital adipose tissue while filling the orbital rim and thereby shortening the effective vertical height of the lower eyelid and can be used as an adjunct to either adipose tissue removal or adipose tissue repositioning blepharoplasty to accomplish those same goals. We have also used adipose tissue successfully to improve lower lid malposition and dystopia from previous blepharoplasty and have used it to improve dry eye syndrome in patients with facial nerve injury from tumor removal and Bell’s palsy.
The orbital rim area consists of the evaluation of four primary areas for grafting:
The tear trough
Inferior orbital rim
Lateral orbital rim
Anterior triangle
The tear trough or nasojugal groove is one of the most widely talked about area of periorbital rejuvenation with a number of different surgical techniques, implants, and fillers used to soften the appearance of this area. Most of the widely used injectable fillers have been tried in this area with differing degrees of success and with some complications. It is generally agreed that the lower molecular weight and less hydrophilic hyaluronic gel fillers are safe in this area, while the more highly cross-linked fillers are fraught with problems although experienced injectors have used the more viscous and highly cross-linked hyaluronic acids in this area with local anesthesia or saline dilution with good success. One needs to be careful with any injectable filler here, including adipose tissue as vascular complications have occurred with retrograde embolic phenomenon causing both vascular compromise to the retina vessels with subsequent visual disturbance and necrosis of the periorbital skin. The anatomy of the orbicularis muscle medial to the infraorbital nerve needs particular attention when injecting adipose tissue. Contour irregularities are more likely to occur here than other areas of the orbital rim. The orbicularis is firmly attached to the periosteum in this location with no subcutaneous adipose tissue or areolar tissue, and the orbicularis tends to be thinnest in this area, corresponding to the tear trough.
Upper Eyelid, Brow, and Temple
Adipose tissue grafting to the area below the brow, the medial infrabrow and lateral infrabrow, has been one of the most important adjuncts to blepharoplasty and forehead surgery to beautify the eye. An evaluation of female eyes that are considered beautiful in Western culture reveal infrabrow fullness with a convexity that causes light to be reflected particularly beneath the lateral half of the brow. It is this light reflex that highlights the eye and makes it look more energetic and youthful and which makeup artists try to simulate with white highlights. As orbital hollowing occurs with aging along with some descent of the brow, the lateral brow becomes shadowed and deflated, and the light reflex can be lost. In addition to loss of infrabrow fullness laterally, we frequently see medial infrabrow hollowing, also termed deepening of the “A” frame, that becomes more pronounced as the orbit enlarges with age and relative volume loss occurs. I now perform adipose tissue grafting as a simultaneous procedure in the majority of both upper lid blepharoplasty and endoscopic forehead lifts. Adipose tissue as part
of upper lid blepharoplasty allows us to resect less tissue, create a subtler supratarsal fold that is more beautiful, and produce a smooth convex contour from the brow to the supratarsal fold. This is what patients are really asking for when they complain of “too much skin on the upper eyelid.” We also find that infrabrow adipose tissue grafting can create a lateral brow lift without surgery as the increased volume below the brow pushes the tail of the brow up. Adipose tissue grafting to this area can be performed either simultaneously with lid or forehead surgery or as an independent procedure depending on the patients’ needs.
of upper lid blepharoplasty allows us to resect less tissue, create a subtler supratarsal fold that is more beautiful, and produce a smooth convex contour from the brow to the supratarsal fold. This is what patients are really asking for when they complain of “too much skin on the upper eyelid.” We also find that infrabrow adipose tissue grafting can create a lateral brow lift without surgery as the increased volume below the brow pushes the tail of the brow up. Adipose tissue grafting to this area can be performed either simultaneously with lid or forehead surgery or as an independent procedure depending on the patients’ needs.
The temple injection is designed to soften the temporal concavity if hollowing is present and to smooth a skeletonized lateral orbital rim. This is accomplished using both a subcutaneous plane and a subfascial plane depending on the degree of temporal hollowing. Deflation in the temple both produces a skeletonized look and tends to cause some descent of the tail of the brow.
Adipose tissue placed in the forehead over the frontalis is done less often than to other areas but can be done as an isolated procedure or simultaneously with a forehead lift. Its primary benefit is to soften horizontal lines of the forehead caused by an active frontalis muscle usually the result of frontalis compensation for a low brow configuration and can be of benefit for very deep horizontal furrowing in patients with weathered skin with active frontalis function.
The Lower Face and Neck
The preoperative evaluation of the lower face and neck area begins as a continuation of the periorbital complex. I generally perform my adipose tissue grafting starting with the periorbital complex and upper face and then continue inferiorly similar to how our preoperative evaluation is done. As part of that progression and as a continuation of the periorbital complex, the area of the anterior cheek above the nasolabial fold, the malar eminence, and the anterior segment of the zygomatic arch are then evaluated as well as the interzygoma distance and ideal point of lateral cheek light reflex.
The anterior cheek tends to flatten and lose volume with age as the orbicularis and cheek pads descend so that on the profile view, there is a more vertical orientation of the anterior cheek below the orbital rim. Anterior projection of the cheek can be accomplished with adipose tissue grafting below the anterior triangle. Adipose tissue grafted here helps to augment the anterior triangle and improve profile balance in those patients and can also assist in changing a prominent globe, negative vector patient to a neutral or even slightly positive vector depending on volumes used. Too much adipose tissue to this area however can be problematic as it produces an operated look. One must be careful then to assess the anterior cheek just above the superior aspect of the nasolabial fold, and it is particularly useful to look at the profile view to assess this area.
Volume augmentation to the deep nasal adipose tissue pad just lateral to the nasal ala can accomplish softening of the nasolabial fold when adipose tissue is placed in the supraperiosteal plane. I have been using adipose tissue in this area for the last decade with good success in achieving reflation and softening of the nasolabial fold. The malar prominence, submalar area, and anterior zygomatic arch can be one of the most beautifying contours of the female face with nearly 60% of adipose tissue grafted patients receiving adipose tissue in this area. The artistic approach required here is dependent on one’s sense of aesthetics in addition to the patient’s sense of aesthetics, as one can achieve an increase in the intermalar distance and elevate the prominence of the lateral cheek that many patients desire. One, then, must assess the intermalar distance, overall shape of the face, and one’s artistic assessment of the patient, helped in part by previous photographs of the patient to determine whether the lateral malar area should be augmented.
Softening and rounding of the malar eminence and anterior zygomatic arch and cheek pad are achieved through two approaches. The first approach is accomplished through the lateral nasal alar insertion site. Sculpturing of the cheek, including intermalar distance and lateral cheek, is accomplished using the 7-cm × 1.2-mm curved cannula to course over the curvature of the zygoma. The adipose tissue may also be placed in a submalar location for those patients with submalar hollowing in much the same plane that submalar implants have been used for the last 20 years. In adipose tissue grafting, one must take into consideration both to the orbital rim and into the malar cheek area, the patient’s preexisting dynamics during smiling. Some patients appear to be hollow in repose, but upon smiling have a mild degree of eye and eyelid encroachment as the zygomaticus muscles and orbicularis muscle elevate the cheek adipose tissue pads crowding the eye. One must always assess this dynamic preoperatively and be careful to avoid putting too much volume both in the orbital rim and over the zygoma as it may cause crowding of the eye during smiling or facial animation. When this occurs, the patient will complain of eyes that have been made smaller by the procedure. Adipose tissue grafting to the malar area requires experience and a conservative approach until experience has been gained, but the results can be very rewarding to the surgeon and the patient.
The second insertion approach to the zygoma and lateral cheek area is through a stab incision with an 18-gauge needle that is lateral and below the body of the zygoma inferior to the zygomatic arch. This allows for access with the long curved cannula to the inferior malar area, malar area, lateral orbital rim, and lateral zygoma. Generally, the amount of adipose tissue that is placed through this approach is less than that placed through the lateral nasal alar approach, but can achieve additional volume and with the crossing of tunnels that occurs with these two approaches and together can aid in softer contours with a smaller chance of contour irregularities.
Patients who have hollowing in the submalar area as described above may achieve softening with injections below the zygoma on the anterior face of the maxilla in the supraperiosteal plane in addition to adipose
tissue placed in the subcutaneous plane from above through that lateral nasal alar approach. The long 7-cm × 1.2-mm cannula is employed for this injection while being able to achieve softening down to the mandible. By fanning this injection out from the malar eminence down to the mandible, several things can be accomplished. The submalar hollowing that is seen in some patients can be reduced, but also patients who have deep rhytids in the anterior cheek with degradation of the dermal support of the skin from actinic damage can be improved. Patients who have hollowing in the submalar area as described above may achieve softening with adipose tissue with a subcutaneous injection using the long cannula. Normally, this is an injection using the lateral nasal alar approach in a fanning pattern using the longer cannula. In fact, we find that patients who have significant deep rhytids achieve their best results when a combination limited dissection face-lift along with adipose grafting in the subcutaneous plane and fractional CO2 laser is employed in a simultaneous procedure. Therefore, the subcutaneous injection of adipose tissue in the cheek is a valuable tool to achieve several goals.
tissue placed in the subcutaneous plane from above through that lateral nasal alar approach. The long 7-cm × 1.2-mm cannula is employed for this injection while being able to achieve softening down to the mandible. By fanning this injection out from the malar eminence down to the mandible, several things can be accomplished. The submalar hollowing that is seen in some patients can be reduced, but also patients who have deep rhytids in the anterior cheek with degradation of the dermal support of the skin from actinic damage can be improved. Patients who have hollowing in the submalar area as described above may achieve softening with adipose tissue with a subcutaneous injection using the long cannula. Normally, this is an injection using the lateral nasal alar approach in a fanning pattern using the longer cannula. In fact, we find that patients who have significant deep rhytids achieve their best results when a combination limited dissection face-lift along with adipose grafting in the subcutaneous plane and fractional CO2 laser is employed in a simultaneous procedure. Therefore, the subcutaneous injection of adipose tissue in the cheek is a valuable tool to achieve several goals.
As we evaluate the patient from superior to inferior, the prejowl sulcus and mandibular contour require assessment. As mandibular bony changes occur with loss of height and volume in the anterior mandible, accentuation of the jowl and jowl adipose tissue occurs. I have used adipose tissue over the last decade to augment the prejowl sulcus and anterior mandible producing softening and reduced prominence of jowl fat. Adipose tissue grafted to this area includes the triangle limited by the oral commissure, the prejowl sulcus, and the chin pad with the mandible. Adipose tissue grafted to this area can accomplish not only reduction in the prominence of the jowl but also reduction of the prominence of the labiomandibular or marionette line and some elevation of the oral commissure.
Likewise, the lateral mandible can be augmented with grafted adipose tissue as one loses prominence of the angle of the mandible sees flattening in this area. The choice and decision for adding volume to the posterior mandible and angle of mandible is most frequently dependent upon whether or not a limited dissection face-lift or an extended face-lift is performed simultaneously. Generally, if one is contemplating simultaneous surgery with adipose tissue grafting with a limited dissection or extended face-lift dissection, prominence and definition of the angle can be created with the surgical rotation and folding of the platysma at the angle, but increasing definition of the angle can also be achieved by placing adipose tissue under the platysma along the mandible if the subplatysma dissection is limited in this area. Most of the adipose tissue grafts that I perform in this area are done as an independent procedure in an effort to improve contour along the jaw in that area. I have seen a number of patients, including a few of my own, who appear to have had SMAS face-lifts who have lost volume in the posterior mandible and cheek corresponding to thinning and volume loss of the SMAS from wide SMAS undermining and tension placed on its closure. This may be a less recognized problem of SMAS face-lifts, but I think it is not uncommon if one specifically looks for volume loss over the posterior jaw and parotid area that would correspond to a SMAS dissection. Adipose tissue grafted into this area can provide an improved mandibular contour when volume loss has occurred from previous surgery. The insertion sites for the cannula can be both posterior and anterior with the posterior being toward the base of the ear lobule and the anterior closer to the jowl area, the same location of the prejowl sulcus insertion site. I generally use the 7-cm × 1.2-mm cannula for this purpose, and with its curved configuration, it allows me to nicely follow the contour of the mandible from both anterior and posterior approaches.
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