Fat Injection From Filling to Regeneration

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Part III • Clinical Applications • Face and Neck: Reconstructive
E x p l ori n g th e E x p a n d i n g A p p l i ca ti on s
o f F a t G ra ti n g
A ew initial positive clinical observations about at gra ing were noted and inspired clinicians to use
the benef cial adipose tissue properties not only or volume replacement but also or regeneration. A er
Rigotti’s published experience with treating the radionecrosis o irradiated breast tissue,3 I started to
gra at to other areas o the body, including the cranio acial region.
Fig. 30-1
One o the f rst amazing results I achieved was in this 7 -year-old patient with a deep radionecrotic
ulcer a er irradiation to the orehead or the treatment o basal cell carcinoma. Injecting processed
at to the indurated, purulent tissue with exposed necrotic bone did not garner much enthusiasm and
support rom my colleagues. I too was skeptical about the possible result in this patient. Surprisingly, at
ollow-up, the patient showed so much improvement that I was inspired to repeat the at gra ing a er
months. T e patient’s nearly healed ulceration is shown a er debridement o the necrotic bone, two at
trans ers, and a skin gra . Macroscopic neovascular regeneration was clearly visible in areas that were
previously necrotic and def cient in blood vessels. T e amazing results that could occur based on the
regenerative properties o at trans er were evident. T e neovascularization potential o ADSCs has been
thoroughly investigated and well described.4

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
A er this particular case, I started to use structural at gra ing in many di cult clinical cases, where the
“traditional” approach did not produce results that were satis actory aesthetically or unctionally. Going
orward, I employed at gra ing to reconstruct, regenerate, rejuvenate, and repair.
In oncologic patients, reconstruction with metal plates and ree tissue trans ers o en produces unsatis-
actory results. It exposes these individuals to multiple procedures, with urther progressive scarring and
the possibility o microsurgical compromise. A high rate o complications, including extrusion, is o en
very disappointing or both the patient and surgeon. T us the ability o at gra ing to acilitate wound
healing now plays an important role in these cases.5-7
T e neovasculogenic properties o at can heal radionecrotic ulcerations and cover exposed metal im-
plants, such as plates and screws. Conservative management with multiple at gra ing sessions can o en
minimize a so tissue de ect over an exposed plate and provide secondary closure.
In malnourished, immunocompromised patients or in those undergoing oncologic treatment, at gra -
ing may be the only solution or nonhealing radionecrotic ulcerations, de ects a er ailed ap surgery, or
the treatment o persistent orocutaneous f stulas. T is use o at gra ing is not very well described in the
literature, so there may be doubt regarding the likelihood o a success ul outcome.
However, on many occasions, structural at gra ing has helped me to salvage nonadhering aps that had
been trans erred to previously irradiated wound beds, thus preventing urther dehiscence. Perseverant
debridement in combination with the injection o at into the tissue surrounding a f stula has enabled
healing without major surgical procedures and their potential complications.
In general, at gra s can be used to replace volume in contour de ects, to restore symmetry, and to
improve the quality o so tissue, including scars and keloids. Small de ects and disf guring scars can
be treated with a simple procedure instead o complicated so tissue manipulation and ap surgery.
Major posttraumatic so tissue volume de ects that would usually require microsurgical trans er can
be very well reconstructed with structural at gra ing, which can be repeated to produce a satis actory
result. What can be rustrating and discouraging in such cases is the unpredictability o the wound
with regard to the acceptance o injected at.
In act, surgeon patience and patient understanding are necessary to succeed in cases in which there
are large-volume losses, extensive scarring, and the presence o allogenic implants. T e results are
not guaranteed because o the unpredictable take—or, rather, predictable at gra necrosis—and the
partial loss o original volume. Fat gra ing is a minor surgery with a minimal complication rate that
can be repeated until the optimal result is achieved. A er the completion o a sometimes long process,
these procedures actually carry a very high patient satis action rate.

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Part III • Clinical Applications • Face and Neck: Reconstructive
Table 30-1 Current Uses o Structural Fat Graf ing in Cranio acial Surgery
Category

Condition

Treatment
Congenital

Hemi acial microsomia
Craniosynostosis
Facial cle s
Cle lip/palate
Microtia
Preorthognathic symmetrization
Postorthodontic treatment or contour de ects
Preparing bed or ear reconstruction
Managing contour irregularities a er remodeling
Symmetrization and managing contour
irregularities
Secondary de ormities o the vermilion or nose
Periauricular so tissue def ciencies and contour
de ormities
Preparing bed or cartilage gra
Traumatic

Fractures
So tissue atrophy or loss
resulting rom injury
Burns
Postf xation contour de ormities
Filler with regenerative properties to improve
scars a er suturing or skin gra
Improvement o scars o skin gra ed areas
Iatrogenic/oncologic Postreconstruction de ormities
Radiation damage
Failed reconstruction procedures
Symmetrization and f lling o contour
Treatment o radionecrosis and ulcers
Treatment o exposed bones
Treatment o poorly vascularized areas with
chronic wounds or ulceration
Treatment o contour irregularities due to ap
ailure or its partial loss
Oculoplastic

Anophthalmic eyes
Postradiation damage
Posttraumatic enophthalmos
Scarring
Touchups a er f tting prosthetic eyes
Improvement o skin quality and contour
de ormities
“Stretching” tissue be ore f tting a prosthesis to
improve the appearance o existing de ormities
Minor adjustment o ill-f tting prosthetic eyes
Correction o sunken eye appearance a er orbital
racture
Improvement o scar quality
Correction o ectropion
Correction o canthal displacement due to
scarring
Idiopathic

Parry–Romberg syndrome
HIV-related lipoatrophy
Filler or the correction o asymmetry and contour
de ormities
Filler to correct acial wasting
Aging

Fat atrophy
Loss o skin elasticity
Filler to restore the three-dimensional
construction o the ace
Induction o neocollagenesis
Pigmentation
changes
Induction o neovascularization
Examples o current uses o at gra ing in cranio acial surgery are summarized in the table.

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
M
a teri a l a n d M
eth od s
Planning the reconstruction is the most crucial part o the preparation or surgery and should include
the ollowing:
• Detailed analysis o the de ect
• Assessment o the types o tissue that need to be reconstructed (bone, so tissue, muscle, skin)
• Design o a one-stage or multistage reconstruction
• Assessment o the completion o acial growth, when applicable
• Evaluation o any comorbidities
• Determination o patient expectations
My approach is to f rst correct bony abnormalities, which can be treated with a so tissue cover in the
same procedure or during a second stage. Volume replacement is essential or the f nal aesthetic result
and should be dealt with during the f nal stage i not corrected at the time o the original reconstruction.
Despite ongoing debate about the optimal method or harvesting and processing at and what instru-
mentation to use, there is still no consensus. T e best described, most researched, and most commonly
used method is the method described by Coleman (see Chapter 1). His technique includes the harvest-
ing o at through a handheld syringe, centri ugation o at at rpm or minutes, and then injec-
tion o the lipoaspirate through a blunt inf ltration cannula with layered placement.8 Eto and colleagues
documented this method and illustrated how the at trans er behaves in the recipient site9; their research
describes the pathophysiology o at survival in great detail. With the use o the in ormation provided by
these researchers, it is easy to predict the at take/absorption ratio. T is makes planning much easier, and
there is a level o com ort regarding the results that are likely to be achieved.
PLANNING
Planning or complex cases can be di cult. Designing a cranio acial procedure with at gra ing must
be very precise. For patients with very severe posttraumatic or congenital de ormities, it may be use ul
to stage the reconstruction. I recommend that bony de ects be addressed f rst, delaying so tissue re-
construction or at least 6 to 12 months to ensure settling o residual swelling and the completion o the
healing process.
For patients with congenital abnormalities such as acial cle s, the main purpose o the at gra is to
provide cover or the de ect to allow bone to grow, with possible interim distraction or bone gra ing, i
necessary, until acial growth is completed.
MARKING
Markings should be done with the patient in a standing or sitting position. T ese are reassessed on the
operating table with the patient in a supine position to avoid gravity-dependent irregularities, asymme-
tries, or overcorrections. T e originally marked areas, especially on the ace, drape di erently when the
patient is in a supine position on the operating table. It is very easy to lose orientation o the depth o the
urrows or irregularities. T ere ore it is important to be consistent with placing injections as previously
marked when the patient was in an erect position. It is also help ul i marking is done in a way that indi-
cates the amount o at to be injected and that shows the need or more passes and more layers.

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Part III • Clinical Applications • Face and Neck: Reconstructive
ANESTHESIA
I pre er the use o general anesthesia or patients undergoing cranial and acial procedures. Cranio acial
patients o en have higher anxiety levels related to the procedure and may have trouble truly under-
standing or rationalizing what will happen during surgery. Children, patients who have been through
trauma, and those with congenital mental challenges are not candidates or local anesthesia during these
procedures.
T e positioning o patients or these procedures can be quite complicated. Stability is required during
at gra ing and must be maintained so that the surgeon can precisely administer the correct amount o
lipoaspirate.
Cranio acial procedures o en involve at gra ing near alloplastic implants, which may cause a oreign
body reaction and a certain degree o biof lm ormation or scarring with a def cient blood supply. T ere-
ore minimizing the possibility o larger amounts o at than the expected average is quite an important
issue.
T ere is an ongoing discussion about inf ltration o local anesthetic, the choice o an anesthetic agent,
and how the amount o inf ltration to the donor and recipient areas in uences the outcome o at gra
take, although more research should help with the understanding o the physiology o at take. Certainly,
more emphasis has been put on the regeneration o new adipose cells rom preadipocytes and the role
o other cells rom the stromal vascular raction as compared with the survival o at cells as a gra .10
My general rule is not to inject any vasoconstrictive or anesthetic agents into the recipient site. Donor
areas are injected with : , epinephrine and, i necessary, 2% lidocaine solution at a maximum :
inf ltration-to-aspiration ratio. Bu ering solutions are not routinely added to the donor area.
T e choice o donor site or cranio acial procedures can be limited, because quite o en patients are
children or very lean individuals. T ere is no level I evidence to prove that certain donor areas are better
than others. My choice is based on convenience, accessibility, and the least risk o de ormation in adults.
In growing children, my donor site o choice is the upper outer quadrant o the buttock. In most cases,
this area provides enough at or trans er while at the same time having a very low chance o de ormity
or uture contour problems.
TECHNIQUE
All o the areas o adherent scarring need to be elevated with rigottomies. T e technique that I use has
been described by Gino Rigotti; it involves the breaking up o scar tissue or f brotic attachments to a-
cilitate easier injection o the processed lipoaspirate, thereby creating more tissue planes and releasing
contour de ormities that occur in these areas.11 T is needs to be done immediately be ore the injection
o at during the same procedure. It usually creates more bleeding in the area that has been addressed, to
the point o almost appearing to be a hematoma. T e expression o blood ollowed by the application o
pressure usually solves the problem.
T is is a blind procedure that involves the multilayered transection o existing scars with a 2 -gauge
injection needle or a special cannula with a V-shaped dissector. Areas o elevated scarring may require
larger amounts o injected at, but the take o at is usually poor in this tissue, especially in signif cantly
depressed areas. In some cases, another at gra ing procedure will be necessary 3 to 2 months later.

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
T ere are a ew important points to mention about the injection technique itsel . First, it is better to
slightly undercorrect than to overcorrect. A minimal amount o at (less than .1 cc per pass) should be
placed through a maximal number o passes and layers to ensure even distribution o at and maximal
survival. echnically, this means placing at with the use o thin, multihole cannulas with ast move-
ments and minimal pressure on the plunger while avoiding previous planes o injection. T e cranio acial
region can be distinguished rom other regions o the body by the act that at is usually placed closer
to the bone and the periosteum. T ese areas are less vascularized and involve tighter spaces than the
subcutaneous or subdermal layers, where the presence o so tissue involves more interstitial space that
allows or easier at take.
Box 30-1 Surgical Principles o Structural Fat Graf ing in Cranio acial Surgery
1. reat at gra ing as volume replacement.
2. Plan precisely, with the patient in both erect and supine positions.
. reat skeletal de ormities f rst, then address so tissue de ormities.
4. Stage the reconstruction, i necessary.
. Do not overcorrect.
6. Use proven and well-described methods o harvesting, processing, and placing at (such as the Coleman
method).
7. Inject minimal amounts o at in multiple, multilayered passes.
8. Use antibiotic therapy.
9. Use kinesiotherapy.
I routinely use f nal molding and kinesiotherapy (such as taping injected areas to immobilize them),
although there are no proper trials that prove the better survival o the at when using these adjunctive
techniques. A summary o the surgical principles o at trans er is given in the box.
R esul ts
Employing structural at gra ing to improve the quality o the scars, replace volume, and so en the con-
tour de ormities a er craniotomies, osteotomies, and cranioplasties is rapidly becoming a standard tool
in cranio acial surgery. T e outcomes are usually surprisingly satis ying, but a word o caution needs to
be introduced when it comes to congenital abnormalities, composite procedures with alloplastic mate-
rials, and large posttraumatic de ects. Results with these conditions are not always predictable, and at
gra ing may need to be repeated in a ew sessions to obtain satis actory results.
In treating cranio acial de ormities in aesthetically sensitive areas, the ollowing actors need to be con-
sidered:

1. T e composition o the di erent types o tissue

2. T e areas in which reconstruction will be complex involving more than one type o tissue, such
as so tissue and skeletal tissue

. T e additional scarring o the surrounding donor area that may in uence the outcome o at
gra ing

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Part III • Clinical Applications • Face and Neck: Reconstructive
In sof tissue trauma in an aesthetically demanding region such as the upper lip, a single structural at
graf ing procedure can result in an outcome that is aesthetically acceptable to the patient.
Fig. 30-2
T ese points are very well illustrated in this 24-year-old patient, who presented with posttraumatic sof
tissue loss o the upper lip with a vermilion de ect, gingival show, and hypertrophic scarring treated
with one at graf ing session only. T e injury was caused by a human bite, and it was primarily su-
tured without reconstruction. Because o the high level o bacterial contamination o the wound, recon-
struction was delayed months. We decided to treat this patient with at graf ing because o the highly
complicated composite vermilion border and skin de ect, which could only otherwise be treated with
traditional lip-sharing procedures that might have resulted in a narrow oral aperture and loss o the
oral commissure. Fat graf ing was also chosen to improve the texture and appearance o this patient’s
hypertrophic scarring. T e amount o at injected was 3 cc to the vermilion border o the lip and 2 cc to
the surrounding skin. No other operative interventions were per ormed. T e closeup o her perioral area
be ore the procedure shows the sof tissue de ect and hypertrophic scarring. T e ollow-up images show
the patient at 2 weeks and 3 months postoperatively and reveal that a proper oral seal has been achieved,
and there is an improved appearance o the scarring. T e vermilion de ect and gingival show have been
eliminated.

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
A

B

C
D

E
Fig. 30-3
T is woman had a posttraumatic contour de ormity with loss o the right zygomatic bone, an orbital
racture, lateral canthal detachment, and a right cheek degloving injury. She is shown be ore the acci-
dent (A) and a er surgery in which a right zygoma Medpor implant was placed and the degloved cheek
reattached (B and D). T ere was a visible contour de ormity, ectropion, and canthal malposition. She
underwent two at gra ing sessions; the results are shown in C and E. T e second session was per ormed
6 months a er the f rst, and the result is shown 1 year a er the second session. No canthal repositioning
was per ormed, because there was no canthal ligament preserved a er the original trauma. T e lower
eyelid contained more scar tissue; at trans ers were layered on the Medpor implant, but suspension o
this area to the canthal region was impossible. Despite the aesthetically in erior result in the canthal re-
gion, patient satis action was high, and she opted or no urther reconstruction.
Another approach is to per orm major reconstructive procedures with high risks o complications and
then use at gra ing or touchups or to correct any complications or irregularities that may arise. How-
ever, my pre erence is to per orm minor, repeatable surgeries over longer periods to allow ADSCs to
convey their regenerative benef ts.
Currently the most popular way to use adipose tissue in cranio acial surgery is in the correction o
volume-depleted de ects related to congenital acial asymmetry. In such patients, at gra ing can be
temporizing and can precede f nal orthognathic treatment when the patient’s ace reaches ull growth.

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Part III • Clinical Applications • Face and Neck: Reconstructive
Patient with Pruzansky type III, at ages 4 and 6
At age 7, with markings for fat grafting
Before and after orthodontic treatment
At age 11, after rib graft
After fat grafting
Fig. 30-4
Fat gra ing can be used to make asymmetry less obvious in a young patient during the years when peer
pressure can play a signif cant role in his or her psychosocial development. T is boy with hemi acial mi-
crosomia (Pruzansky type III) involving the mandible was treated with at gra ing and a costochondral
rib gra . T e procedure was staged. T e at was injected as shown into the le mandibular and cheek
regions. A total o 10 cc o at was injected, and the results are shown 1 year a er the procedure. T is
boy subsequently underwent a costochondral rib gra a year a er the at gra and underwent le ear re-
construction at 10 years o age. He will be ollowed up by the cranio acial unit until he reaches ull acial
growth to assess the need or any urther orthognathic procedures.

559
Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
Alternatively, at gra ing can be used in cases o completed treatment a er bone gra ing, distraction,
and orthognathic and orthodontic adjustment, when minimal asymmetry can be easily corrected to the
highest o patient expectations.12
In patients with idiopathic progressive hemi acial atrophy (Parry–Romberg syndrome) or HIV-related
lipodystrophy, at gra ing is a use ul reconstructive tool. It recently has been used in such patients to
replace traditional ap surgeries.13-16 T is requires a large volume o trans erred at. T e take o the gra
may be severely compromised by coexisting problems, so multiple procedures are o en necessary. In
patients who are a ected by HIV treatment –related lipodystrophy, it is wise to use at harvested rom
normal, nona ected areas. T e use o at rom pathologic areas is not well investigated, and its ability to
take may be rather unpredictable.
In some cases, the correction o any de ormities results in additional benef ts. It is quite signif cant that
large-volume at gra ing to the whole ace can change the ollowing:
• Facial proportions and symmetry
• How specif c regions can be more def ned (such as malar area, angle o mandible)
• How the ace can become more aesthetically pleasing
Fig. 30-5
In patients with posttraumatic or iatrogenic disf gurement or those with an aged appearance, structural
at gra ing not only can be used to correct the distortion, but also o ers the benef ts o neocollagenesis,
which has a signif cant e ect on the quality o scarred tissue. T is patient presented with an iatrogenic

560
Part III • Clinical Applications • Face and Neck: Reconstructive
de ormity o the lower ace that had resulted rom at gra ing or acne scarring; she had been treated
with cc o at gra ed to the whole ace. She is shown 1 week a er the procedure and 1 year later, with
stable results. Her acial contour is more balanced, and there is noticeable improvement o rontal and
temporal wasting.
T e periorbital region is very aesthetically demanding because o its complex tridimensional structure.
Even minimal asymmetries in the position o the globe or canthal irregularities can a ect the general
acial appearance. With at trans er, many adjustments can be made with single procedures, including
the ollowing:
• Socket volume adjustment
• Deepening o ornices by adding volume to the eyelids
• Improvement o cicatricial ectropion
• Small canthal adjustments
• Symmetry o the periorbital region by addressing three-dimensional irregularities
• Correction o temporal volume def ciencies
• Skin quality improvement a er radiotherapy
• Correction o iatrogenic round eye de ormity and volume replacement in the aging eye
For these patients, a meticulous approach to the analysis o the de ects and to the surgical planning will
ensure aesthetically satis actory results, o en with a single procedure.
C

D
A

B
Fig. 30-6
Frequently, incorrectly f tted prosthetic eyes can be adjusted by just adding a volume o at to the specif c
area o the eye socket to elevate the prosthesis, deepen the ornices, or treat the surrounding damaged
skin. During childhood, this patient underwent radiotherapy or rhabdomyosarcoma. He presented with
an ill-f tted prosthetic eye and a contour de ormity o the le temporal and zygomatic areas (A). He un-
derwent a single at gra ing session (B). T e results are shown 3 weeks (C) and 3 months (D) a er the
procedure.

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
One o the most complex problems in cranio acial surgery is cranial bony de ects af er remodeling pro-
cedures or craniosynostosis. T ese de ects represent a particular reconstructive challenge, because the
ability o cranial bones to grow is completed at a very early age, and of en patients are lef with areas
o sof tissue cover over the brain and the dura. T ere have been early attempts to create regenerative
options that have combined Vicryl mesh, BMPs, and stem cells, but these are still in the early stages o
clinical use.17
A variety o reconstructive options exist or posttraumatic de ects and de ormities o the cranium, in-
cluding autologous and alloplastic options. With the recent development o three-dimensional recon-
structive techniques, the shapes and sizes o pre abricated plates are very accurate, but minor adjust-
ments when there are residual contour de ormities can be easily per ormed with at graf ing. However,
placing a at graf close to alloplastic material can increase the possibility o complications, such as in-
ection (especially in cases involving porous materials, like Medpor), poor at take, and a high rate o
resorption (especially in cases involving alloplastic materials with smooth sur aces, such as methylmeth-
acrylate).
In my clinical practice I have observed that some areas o cranio acial de ects do not accept at trans er
as readily as other parts do, which may result in graf ailure despite multiple at graf ing procedures.
Also o note, at graf s to areas o embryologic usion (such as acial clef s) can cause the overgrowth o
trans erred at.
Fig. 30-7
T is is illustrated in this patient with anophthalmia and a acial clef that was treated with a single injec-
tion o at to the depressed temporal area to improve his contour de ormity. T e deposits o at caused
bulging and palpable and visible overgrowth o the trans erred at, which clinically resembled lipoma.
T is is accidental and sporadic observation, but brings the attention to poorly understood interaction
between ADSCs and embryologic mismatched tissue.

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Part III • Clinical Applications • Face and Neck: Reconstructive
C om p l i ca ti on s
Fat trans er to the cranio acial region has a low complication rate compared with that o traditional cra-
nio acial procedures. It is a sa e means or treating major volume de ects, acial asymmetry, and minor
contour de ormities. T e initial swelling and bruising resolve much more quickly (within to 3 weeks)
compared with the prolonged swelling that occurs a er traditional cranio acial, ap, or microsurgical
procedures; such swelling can last up to 3 months.
T ere is increasing concern about the possibility o at embolism when injecting at into the periorbital
region, which may result in blindness, although the use o blunt microcannulas and the extremely care-
ul placement o at to avoid anatomically sensitive areas like the in raorbital oramen help to ensure that
a complication o that caliber will not occur. When placing at in that area, it is also important to inject
while withdrawing the cannula rather than pushing orward into the tissue to lessen the possibility o
injecting at directly into the accidentally per orated vessel.
T e take o the at gra is probably the most serious concern, as it a ects the f nal aesthetic outcome.
T ere are varying data rom di erent authorities on the subject, but generally it is well accepted that
anywhere rom 0% to 0% o the injected at volume should survive.18 With developing research, we
already know that although a portion o injected at will die o , preadipocyte activation in the recipient
area will lead to a renewal o the volume, but this will not likely reach the ull volume o the original
gra . T ere is evidence o the very dynamic remodeling o adipose tissue a er nonvascularized gra -
ing. Most adipocytes die within the f rst days a er gra ing. However, day 7 resident stem/progenitor
cells in the transplanted tissue remain alive or become activated, thereby causing the regeneration o
adipocytes. T is compensatory proli eration results in the specif c amount o at that is considered to
have “taken.” T at amount will depend on specif c characteristics that di er in accordance with each
treated individual’s microenvironment.19 T e individual ability o each patient also plays a signif cant
role in the f nal amount o at that is transplanted. Clinical experience conf rms that some patients are
better “takers” than others. Some patients will require more at trans er procedures than others, despite
standardization o the technique, because the level o activation o the preadipocytes varies rom person
to person.
D i scussi on
T e biggest challenge in cranio acial surgery is that we are dealing with complex, tridimensional, mul-
tilayered structures o di erent embryonic origins. T e human ace and cranium are regions o high
unctionality, with protective properties or perceptive organs that support appropriate interactions o
the individual with the environment. T us their repair involves high aesthetic demands in surgical out-
comes, o en on top o restoring unctionality.
Maintaining symmetry, avoiding sur ace irregularities and color mismatch, and keeping to the aesthetic
canons o acial proportions are crucial actors or obtaining satis actory results in such a sensitive area.
T us ar none o the traditional reconstructive surgery procedures, even sophisticated ones (such as
composite ree hybrid aps), has been able to provide the per ect outcome.
Comparing at gra ing with any other surgical technique underscores the act that volume replacement
by injecting processed adipose tissue, even taking into account the loss o some volume a er gra -
ing, can be much more precise and is an easily repeatable procedure. It can be per ormed many times
without major preparation on the patient’s part, o en in an ambulatory setting. T ere ore f ne aesthetic
tuning as well as repeatable regenerative treatment (such as scar and volume def ciency treatment versus
enhanced wound healing) can easily be achieved.

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Chapter 30 • Structural Fat Gra ting in Cranio acial Surgery
Fat can also be used or auxiliary and touchup procedures to enhance the results o previous or concur-
rent planned surgeries, or in some instances, both together ( or instance, posttraumatic so tissue acial
de ects or correcting minor asymmetries in a secondary step a er cle lip repair on the nose or lips).
T e most crucial aspect o the reconstruction o the so tissue component may be the act that cranial
neural cells are also the primary contributor to the development o adipogenic progenitor cells in the
ace, whereas elsewhere adipose progenitor cells are o mesodermal origin. In addition, the di erent
embryologic origins o progenitor adipocytes may be important when designing regenerative technolo-
gies o that region, and they may in uence the outcome o the trans erred at.20 T ere ore we must also
consider the appropriateness o the donor area or cranial region de ects and whether gra survival will
be improved i the donor at comes rom a specif c area.
T e ongoing disputes about the properties o the at that comes rom certain donor areas are not going
to be resolved in the near uture unless well-designed and statistically signif cant studies with high levels
o evidence are conducted and published. In clinical practice, when applying at gra ing to the cranio-
acial region, I have not ound the use o at o truncal mesodermal origin to be detrimental, because its
survival is similar to that o other types o at.
C oncl u si on
T e uture role o adipose tissue in cranio acial surgery extends beyond simple at trans er as a volumizer
or a regenerative tool to improve scarring or the quality o the tissue. T e idea o reconstructing like with
like using the regenerative abilities o the human body rom its own natural sources and pre abricated
biocompatible or biodegradable sca olds to achieve a three-dimensional construct is being investigated
in many tissue engineering laboratories and slowly approaching clinical study. T e new avenues that
will soon be available in cranio acial regenerative medicine are exciting and approaching quickly. T ese
include scar-less wound healing, biodegradable sca old–assisted repair, guided nerve and vessel regen-
eration, tooth and gum repair, metal implant–supported critical size repair, and integrated muscle and
bone constructs.21
REFERENCES
. Hollenbeck S , Senghaas A, Komatsu I, et al. issue engra ment o hypoxic-preconditioned adipose-
derived stem cells improves ap viability. Wound Repair Regen :87 , .
. Garland CB, Pomerantz JH. Regenerative strategies or cranio acial disorders. Front Physiol :4 , .
. Rigotti G, Marchi A, Galiè M, Baroni G, Benati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment
o radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived
adult stem cells. Plast Reconstr Surg 9: 4 9, 7.
4. Neels JG, T innes , Loskuto DJ. Angiogenesis in an in vivo model o adipose tissue development.
FASEB J 8:98 , 4.
. Gao W, Qiao X, Ma S, et al. Adipose-derived stem cells accelerate neovascularization in ischaemic dia-
betic skin ap via expression o hypoxia-inducible actor- α. J Cell Mol Med : 7 , .
. Lau K, Paus R, iede S, et al. Exploring the role o stem cells in cutaneous wound healing. Exp Dermatol
8:9 , 9.
7. Mukhopadhyay A, Do DV, Ong C , et al. T e role o stem cell actor and c-KI in keloid pathogenesis: do
tyrosine kinase inhibitors have a potential therapeutic role? Br J Dermatol 4: 7 , .
8. Pu LL, Coleman SR, Cui X, et al. Autologous at gra s harvested and ref ned by the Coleman technique:
a comparative study. Plast Reconstr Surg :9 , 8.
9. Eto H, Kato H, Suga H, Aoi N, Doi K, Kuno S, Yoshimura K. T e ate o adipocytes a er nonvascularized
at gra ing: evidence o early death and replacement o adipocytes. Plast Reconstr Surg 9: 8 , .

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Part III • Clinical Applications • Face and Neck: Reconstructive
10. Guo J, Widgerow A, Banyard D, et al. Strategic sequences in at gra survival. Ann Plast Surg 7 :37 ,
201 .
11. Khouri RK, Smit JM, Cordoso E, et al. Percutaneous aponeurotomy and lipof lling: a regenerative alterna-
tive to ap reconstruction? Plast Reconstr Surg 132:1280: 2013.
12. anna N, Broer PN, Roostaeian J, et al. So tissue correction o cranio acial microsomia and progressive
hemi acial atrophy. J Cranio ac Surg 23(7 Suppl 1):202 , 2012.
13. anna N, Wan DC, Kawamoto HK, et al. Cranio acial microsomia so tissue reconstruction comparison:
in ramammary extended circum ex scapular ap versus serial at gra ing. Plast Reconstr Surg 127:802,
2011.
1 . anikawa DY, Aguena M, Bueno DF, et al. Fat gra s supplemented with adipose-derived stromal cells in
the rehabilitation o patients with cranio acial microsomia. Plast Reconstr Surg 132:1 1, 2013.
1 . Clauser LC, ieghi R, Consorti G. Parry-Romberg syndrome: volumetric regeneration by structural at
gra ing technique. J Craniomaxillo ac Surg 38: 0 , 2010.
1 . Lim AA, Fan K, Allam KA, Wan D, et al. Autologous at transplantation in the cranio acial patient: the
UCLA experience. J Cranio ac Surg 23:10 1, 2012.
17. T esle , Lehtimäki, K, Niskakangas , et al. Cranioplasty with adipose-derived stem cells and biomate-
rial: a novel method or cranial reconstruction. Neurosurgery 8:1 3 , 2011.
18. Yu NZ, Huang JZ, Zhang H, et al. A systemic review o autologous at gra ing survival rate and related
severe complications. Chin Med J (Engl) 128:12 , 201 .
19. Eto H, Kato H, Suga H, et al. T e ate o adipocytes a er nonvascularized at gra ing: evidence o early
death and replacement o adipocytes. Plast Reconstr Surg 129:1081, 2012.
20. Garland CB, Pomerantz JH. Regenerative strategies or cranio acial disorders. Front Physiol 3: 3, 2012.
21. Sanchez-Lara PA, Warburton D. Impact o stem cells in cranio acial regenerative medicine. Front Physiol
3:188, 2012.

r eat ment o Romber g Disease
Yun Xie, Qing Feng Li
R
omberg disease (RD), l c ll d Parry–Romberg syndrome, , cqu d d d
ch c z d y p v h c l phy h k d u . S c ul
phy u cl , c l , d h u d ly y uc u . T c u ll u cl .
S v l h h v p d p h :
• I c
• Sy p h c v dy u c
• l v v lv
• Au u y, clud cl d
• u
• H d y
• N u cu u y d
• A l u l u c c ll
• C l v cul l
• D u c l
• E d c d u c
T cc l RD c l l d p c p d p . S u h h v
u d h d h c u l d w h c pl p c . Ac-
c d u v y ly u RD p , h h d d h v y
l v du h p cy, d h h w l h l hy, wh
ly h l h RD p h d h y u . T cl c l RD clud u -
l c, ph h l l c, c d c, h u l c, c u , d c , x ll c l, d h -
d c w ll u u d , c l d , d p cy.1
T d l h c l phy w , uch h ll w :

. D l p u pl : T ch qu u l ld d
d l c l z d ph c u c u d l . M v , h p -
u d y d f p v , w h v l w
p c du l 6 h . T p h d l 20% 40%.

. M c v cul u pl , v lv l u pl -
, u cl pl , d p u p pl . T l
w h d v d h p l c pl c c d w h h d l
c v y.
Al h u h h h d c l c l y y,2-7 h w ll v u d c ,
h y l d d y dy u c . T c p lw y ul ulky pp c ,
C h a p t e r 3 1
565

566
Part III • Clinical Applications • Face and Neck: Reconstructive
leading to an unnatural expression. One or more operations are required to thin the bulky ap. In addition,
the skin rom another part o the body is not likely to match the color o the acial skin, and scars will be
evident. T e procedures require hospitalization, with multiple procedures under general anesthesia, which
costs more. Patients have been dissatisf ed with the results o all o these approaches.
Alloplastic materials f rst came into use in plastic surgery during the s and 7 s.8,9 Historically, many
prosthetic materials have been used to treat hemi acial atrophy, including silicone rubber, expanded e on,
polytetra uoroethylene (P FE), and others. All o these materials cause an unnatural sensation in the f lled
area, and they may become displaced, revealing the presence o the prosthesis. Heterologous so tissue
f ller such as collagen was reported to produce good results,10 but these lasted or only a very short period
o time; other authors indicated that collagen also might depress the body’s immune mechanisms. Acellular
dermal matrix has a high resorption rate and o en triggers allergic responses.
Flaps and alloplastic materials have been used to treat the atrophy o RD patients traditionally, but at
gra ing has become more popular and provides more satis actory results. With at trans er, the contours
o ace as well as the texture o skin are improved, a natural acial expression is restored, and no scars or
donor site issues are involved.
P a tho p h ysi ol o g y o f R omber g D i sea se
Pensler et al11 reported that % o RD patients have atrophy o both so tissue and bone. I atrophy
began a er the individual was more than years o age, when his or her acial bones had developed
almost completely, only the so tissue o the ace would be a ected. However, i the condition began
be ore years o age, the atrophy would lead to acial mal ormation and a distorted appearance. Histo-
pathologic examination o a ected RD skin usually reveals atrophy o the epidermis, dermis, subcutane-
ous tissue, skin adnexa, vessels, and hair ollicles, as well as skin f brosis with collagen f ber thickening
and skin edema. Some patients show bandlike alopecia, homolateral segmental vitiligo, hyperpigmenta-
tion, morphea, and linear scleroderma en coup de sabre.
Fig. 31-1
T is three-dimensional C construction shows the bone atrophy in the le side o the ace in an RD
patient.

567
Chapter 31 • reatment o Romberg Disease
Fig. 31-2
Patients are sometimes diagnosed as having localized scleroderma. T is patient has scleroderma en coup
de sabre. Actually, distinguishing RD rom localized scleroderma is very di cult. T ese conditions have
a similar age o onset and present as lesions that progress over time until they stabilize a ew years later.
T ey have been ound to coexist in many patients. Both may respond to immunosuppressive treatment.
M
a teri a l a n d M
eth od s
CLINICAL EVALUATION
Because there has been no uni orm classif cation standard or RD, we have instituted the ollowing
method that divides patients into three groups: slight, moderate, and severe atrophy. Depending on the
atrophic depth, the scores are as ollows:
• Involving skin or subcutaneous: point
• Involving muscle: 2 points
• Involving mucosa: points
• Involving bone, cartilage, or teeth: 4 points
V1
V2
V3
Fig. 31-3
T en, depending on the area o atrophy, the ace can
be divided into upper, middle, and lower parts, just as
in the three branches o the trigeminal nerve: the oph-
thalmic nerve, maxillary nerve, and mandibular nerve
distribution areas. T e scores are as ollows:
• Involving one area: point
• Involving two areas: 2 points
• Involving three areas: points
T en we summarize the two scores:
• Slight atrophy: 2 or points
• Moderate atrophy: 4 or points
• Severe atrophy: or points

568
Part III • Clinical Applications • Face and Neck: Reconstructive
SELECTED OPTIONS FOR RECONSTRUCTION
Patients with slight atrophy and some with moderate atrophy can be success ully treated with at gra ing
only. T ose with severe or partial moderate atrophy may have involvement o hair, eyebrows, or teeth,
which cannot be corrected with at gra ing. For severely a ected patients with alopecia, we recommend
reconstruction with a so tissue expander. T e expander can be embedded under the scalp during the
same procedure in which at gra ing is per ormed. A er to months o tissue expansion, the second
at gra ing procedure can be done and the tissue expander removed as the alopecia is repaired. Patients
with sparse eyebrows will have sunken arcus superciliaris (the supraorbital margin); these individuals
will require hair transplantation to months a er at gra ing, when the surviving at can provide a
more robust blood supply and nutrition to the hair ollicles. T e so at will provide better “soil” than
atrophic skin attached to bone or “seeds” (hair ollicles) to be implanted.12 For male patients, i the eye-
brow on the una ected side is very ull and bushy, a ree scalp transplantation to replace the alopecic
eyebrow will be a better choice or reconstructing a new eyebrow.
An atrophic de ect o the nasal ala is challenging to correct. Only rarely can an atrophic ala be enlarged
and recontoured with at gra ing. In most patients, auricular composite tissue may need to be trans-
erred to the atrophied ala, or a part o the una ected ala can be transplanted. I the patient does not
want a permanent e ect or any scarring, he or she can choose to have the def cient ala injected with hy-
aluronic acid (HA). Some patients may not want a scar on their orehead area (as might occur rom the
use o a tissue expander to provide tissue or nasal reconstruction) or a de ect o the ear rom cartilage
harvest. A ew RD patients may also develop a malocclusion, in which case orthognathic surgery can be
per ormed be ore at gra ing is undertaken.
It is important to ensure that the patient is within his or her stable phase. According to a number o pub-
lished reports, Parry–Romberg syndrome slowly progresses over to 0 years be ore stabilizing.13-21 T e
stable phase should be longer than years; otherwise the at gra may atrophy along with the surround-
ing tissue. In patients with severe de ects who have correctable skeletal abnormalities, skeletal contour
surgery should be completed be ore correction o so tissue with at gra ing. When the subcutaneous
tissue is almost completely atrophic, earlier intervention can improve or prevent urther atrophy o the
overlying skin and may prevent or lessen subsequent skeletal wasting.
Every RD patient should be well in ormed about at gra ing as an option or treatment o hemi acial
atrophy, including its potential benef ts, limitations, and complications. Maximal e orts during preop-
erative teaching are made to ensure postoperative compliance. Patients must understand that they could
require two or three sessions o at gra ing with intervals o to months between procedures. I at
gra ing is per ormed during a patient’s stable phase, there is no evidence that he or she will redevelop
atrophy. Most patients will remain stable a er adolescence. Care ul examination during the preoperative
visit is essential to conf rm the extent and thickness o acial recontouring required and to determine the
quantity o at gra s needed. Standard preoperative photos, Visia scans, and three-dimensional scans are
taken o each patient. T e images can be used to discuss the extent o the procedure and the expected
results.
OUR PREFERRED TECHNIQUE FOR FAT GRAFTING:
3LS AND 3MS
o restore the volume o an atrophic ace, at gra ing is the ideal choice. T ere are many techniques or
at harvesting, processing, and injection, among them the Coleman technique and others related to his
procedure, cell-assisted lipotrans er, and our 3Ls and 3Ms technique, which stands or “low pressure,
low speed, and low volume and multitunnels, multiplanes, and multipoints.” All o these techniques can
present good results.22,23

569
Chapter 31 • reatment o Romberg Disease
In the integrated technique we call Ls and Ms, at gra s are harvested under low pressure with sy-
ringes, processed with low speed centri ugation, and then injected into the a ected areas o the ace with
low volume or each pass through multiple tunnels, planes, and points. We pre er to choose donor sites
in the lower part o the body, using low-pressure suction or harvesting and low speed or centri uga-
tion. T e lower abdomen or thigh is typically chosen as the donor site. A tumescent solution containing
0.08% lidocaine and : 00,000 o epinephrine is inf ltrated into the donor site. T e inf ltration is always
done on one side o the donor site and then the other.
A er the second side has been inf ltrated, the lidocaine and epinephrine will have taken e ect on the
f rst side, and it too will be ready or suctioning. A er the f rst side has been harvested, the second side
will be ready to be suctioned. A 2. mm blunt-tipped suction cannula with two holes in the tip is con-
nected to a 0 ml syringe or harvesting at. An appropriate amount o at is gently aspirated with f nger
pressure on the plunger o the syringe without using a suction machine to minimize trauma to the atty
tissue.
T e lipoaspirate is then washed with normal saline solution inside the syringe with sterile conditions to re-
move lidocaine, oil, and residual red blood cells. A plug is added to each syringe, and all syringes are placed
in a centri uge. T ey are then spun at low speed ( 000 rpm, which creates a g orce less than 00 g) or 2
minutes. A er centri ugation, the plug is removed and the lower raction, consisting o tumescent solution,
debris, and red blood cells, is drained away. T e middle layer o the lipoaspirate, primarily consisting o
usable at parcels, is trans erred to multiple or 2 ml syringes through a Luer-Lok tube in preparation or
at injection. T e syringes remain upright to prevent the viable at cells and the oil rom mixing again. A er
the middle ( at cell) layer has been injected into the recipient site, the top layer o oil is discarded. T e entire
procedure is done within 0 minutes, rom harvest to injection, and the ambient temperature is controlled
at 2 ° C (77° F) throughout.
iny parcels o at are injected into multiple tissue areas (within subcutaneous tissue and under the
superf cial myoaponeurotic system) in multiple tissue planes and tunnels with a syringe connected to
a blunt cannula with an external diameter o 2 or mm. Care is taken to inject at gra s in very small
quantities one point at a time, radially rom distal to proximal. T e fat parcel is laid down as the syringe is
withdrawn, not as it enters the tissue. In the buccal area the cannula should be parallel to the acial nerve
to avoid direct injury to the nerve. T e syringe should be drawn back be ore each injection to check
blood return to avoid hematoma or injection into blood vessels, which could cause at emboli. In the
periorbital area, extra care is exercised, such as using a smaller injection needle, to prevent intraarterial
injection.
We routinely inject about 20% to 0% more than the required volume o at; this overcorrection com-
pensates or possible later absorption a er acial recontouring. Gentle massage with the surgeon’s f nger
or palm ensures a smooth correction. In general, the entire procedure takes about 0 minutes and is
usually per ormed with one or two assistants. I necessary, a second at gra ing procedure can be done,
no sooner than months a er the f rst session. In patients with a signif cant contour de ormity, two or
three additional procedures may be required.
POSTOPERATIVE CARE AND FOLLOW-UP
T e gra ed site should be immobilized with a compression dressing or a week. Patients should be in-
structed to reduce or avoid the movements o acial muscles such as the rontalis, temporalis, and mas-
seter i possible, because these movements might traumatize the newly orming blood vessels around
the injected at gra s. I the volume o the injected area was stable but the outline o hemi acial atrophy
has not been completely ameliorated a er the f rst injection session, a second injection procedure is
indicated, usually a er months, or a er months in patients with mild hemiatrophy who require only
minimal additional correction, to add more volume to the hollow area.

570
Part III • Clinical Applications • Face and Neck: Reconstructive
R esul ts
Usually one to three at gra ing sessions are su cient to correct the atrophy o RD patients. T e volume
o so tissue augmentation in the injection site will typically be slightly resorbed until the third month
postoperatively. We have seen no obvious absorption o injected at in these patients a er the f rst 3
months, and the injection site in the ace has remained stable through long-term ollow-up. No in ec-
tion, subcutaneous nodules or cysts, or any other complications in the donor sites were ound during
the ollow-up. T e color o the hyperpigmented skin on the atrophied side o the ace was improved
noticeably.
Individuals with severe acial atrophy may require three injection procedures. T ose who have nasal
atrophy should undergo at gra ing in conjunction with a nasal reconstructive procedure to achieve
reasonable acial symmetry. In some hemialopecia patients, using an expander in the scalp may be ben-
ef cial to produce enough tissue to cover the area o alopecia.
Fig. 31-4, A-D
Preoperative
A

B
6 months after first fat grafting session
C

D

571
Chapter 31 • reatment o Romberg Disease
After second fat grafting session at 7 months
E

F
Result 18 months after first session and 11 months after second session
G

H
Fig. 31-4, E-H
T is 4-year-old man had begun to develop atrophy o the right side o his ace when he was years
old; this continued until he was . T en the condition remained stable or years. T e so tissue o his
mid and lower right ace was atrophic, but there was no atrophy o bone. He underwent two sessions o
at gra ing seven months apart. His results demonstrate signif cant correction o the atrophic so tissue.

572
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 31-4, I and J
I
J
T ese three-dimensional scans clearly demonstrate the changes in contour in the same patient be ore
and a er at gra ing. T e “cold” color (blue) to the “warm” color (red) indicates the changes be ore and 6
months a er at gra ing, rom 0 to .866 mm. T e average dif erence was nearly 1. 33 mm.

573
Chapter 31 • reatment o Romberg Disease
C

D
Expander in place
A

B
Preoperative
Fig. 31-5, A-D
T is 24-year-old man was diagnosed with scleroderma at another hospital. During his adolescence, he
had taken many Chinese traditional medicines in an attempt to correct the condition. His atrophy en-
compassed his scalp, orehead, and nasal ala, and his mid ace on the right side was slightly af ected. His
condition had stabilized or more than 2 years when he came to our outpatient clinic. We inserted a so
tissue expander to enlarge the scalp and the skin o the orehead.

574
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 31-5, E-H
E

F
3 months after correction of alopecia and reconstruction of nasal ala
First fat injection session
G

H

575
Chapter 31 • reatment o Romberg Disease
Second injection session 3 months later
I
J
Result 18 months after first session and 11 months after second session
K

L
Fig. 31-5, I-L
We corrected his alopecia and hyperpigmented skin with a ap o the expanded scalp and orehead
tissue. A partial expanded orehead ap was also used to reconstruct the right nasal ala. T e patient was
satisf ed with the f nal result. T is treatment combined expander technique and at gra ing to produce
an acceptable result.

576
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 31-6
A

B
C

D
T is 20-year-old woman, who was diagnosed with RD with en coup de sabre, had hyperpigmentation
rom the middle o her orehead to the tip o her nose. Eleven months af er one at graf ing session, her
pigmentation is improved, as demonstrated by using the Visia complexion analysis technology.
C ompl i ca ti on s
During ollow-up only a ew o our patients showed transient slight swelling and bruising that resolved
within a week. No in ections occurred. We ound that at parcels graf ed into the periocular area were
not as readily incorporated as injected at in other areas. Sometimes small sof nodes can be palpated
under the upper or lower eyelid without any abnormal outlook. T us in these areas it is better not to
overcorrect.

577
Chapter 31 • reatment o Romberg Disease
D i scu ssi on
Although the clinical eatures o RD are unique, the main pathologic problem is the insu ciency in
the a ected side in the bone and especially the so tissue.24 Surgeons have long search or suitable so
f llers to treat RD, and we have ound that at gra ing can be the ideal so tissue f ller, superior to both
alloplastic f llers and aps.
Table 31-1 Comparison o Autologous Fat With Other Sof Tissue Fillers
Alloplastic Filler

Autologous Fat
Source

Manu actured

Abundant, easy to obtain
Histocompatibility Allergenic response

Nonallergenic
Immune in uence Some will inhibit immune system No immune response
Cost

Expensive

Inexpensive
Sa ety

Poor

Good
T erapeutic e ect Unnatural sensation

Natural expression, and natural eel on palpation
Table 31-2 Comparison o Autologous Fat With Flap Restoration
Flap Transplantation

Autologous Fat
Source

Limited

Abundant
Donor

Obvious scar, de ormation,
hypo unction
Almost no scar
Operation

Long, complex
Relative short, easy
Hospitalization

Long

Can be per ormed on outpatient basis
Repetition

Poor

Good
Gra volume

Di cult to estimate

Easy to estimate
T erapeutic e ect Bulky, additional operation

Natural expression, and natural eel on palpation
Recovery time

Severely traumatic trans er o tissue,
prolonged healing time
Small wounds at donor and recipient sites, short
healing time
In our series, satis actory therapeutic e ects were achieved through at gra ing, especially in groups o
patients who were slightly or moderately a ected. For patients with severe RD, at gra ing can be an
adjuvant procedure to a traditional ap operation. We ound that the more times at was injected, the
more volume o at survived. A possible reason or this is that the atrophic side o the ace has a poorer

578
Part III • Clinical Applications • Face and Neck: Reconstructive
blood supply than the una ected side. A er the at parcels are trans erred rom donor sites in which cell
growth is normal, some vascular growth actors or some microvascular actors in the at might supply
more blood and nutrition to the transplanted tissue. T us when at is injected in a second procedure, the
blood supply in the recipient site is more robust than in the f rst procedure, and thus more at is likely
to survive. Illouz25 also ound this phenomenon in 199 and emphasized the trans er o at gra s to an
abnormal area such as is present in RD a ected individuals. His explanation was that there were %
precursor cells injected into the recipient site at each injection, and the precursor cells induced neovas-
cularization. T e more times precursor cells are trans erred in gra ed at, the more likely that a lasting,
acceptable result will be created, in addition to the f brosis induced.
Another observation rom our patient ollow-up showed that the survival rate in di erent recipient areas
was as ollows: (1) the rontal site, ( ) the zygomatic site, (3) the mandibular site, and (4) the buccal site.
It can be speculated that the activity o muscles in each region may squeeze the neovessles in the gra ed
at tissue; thus, the more active the muscles in an area, the lower the survival rate o at.
Research into at gra ing is ongoing, and studies o revascularization in gra ed tissue are yielding sig-
nif cant results.26,27 Clearly, a robust blood supply is essential to the survival o gra ed at, but it remains
unclear whether the at gra will trans er to other tissue and how it delipidates ree lipid? What in uence
the mature adipocytes trans orming to immature adipocytes? Further study may reveal the answers.
C oncl usi on
Fat gra ing can be the treatment o choice or patients with RD and serves as a good alternative to ree
tissue trans er or acial recontouring, producing minimal morbidity and improved long-term outcome.
Our 3L-3M technique can be used to treat RD success ully. In addition, one or more subsequent injec-
tion sessions may be required to ensure the optimal outcome in these patients.
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Chapter 31 • Treatment o Romberg Disease
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acial contouring. J Plast Reconstr Aesthet Surg 6 :2 0, 20 0.
24. Ru G. Progressive hemi acial atrophy: Romberg’s disease. In McCarthy JG, ed. Plastic Surgery. Philadel-
phia: WB Saunders, 0.
2 . Illouz YG. Adipoaspiration and “f lling” in the ace. Facial Plast Surg 8: , 2.
26. Bartynski J, Marion MS, Wang TD. Histopathologic evaluation o adipose autogra s in a rabbit ear model.
Otolaryngol Head Neck Surg 02: 4, 0.
2 . Langer S, Sinitsina I, Biberthaler P, et al. Revascularization o transplanted adipose tissue: a study in the
dorsal skin old chamber o hamsters. Ann Plast Surg 48: , 2002.

(Trang không có chữ)

581
C h a p t e r 3 2
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h w p p .1,2 H w v , h 9 0 ,
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v v pp p x v p . F
p w h k p q ,
w , f . I h
w p p , - w h .3,4
T p x f x - . F
p h p h v p .
T p h x j v -
z , p , h k , p , , h , j w , . R
pp h z ph ,
, x , p x , , h
ph ( x p , P –R , , ph h ).5,6
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I w k w h h v h k ( x , , h ) h
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Fat Gr a t ing in Or bit ocr anial
and Ma il l o acial Rest or at ion:
Fr om Sur ger y t o Regener at ion
Luigi C. Clauser, Manlio Galiè, Giovanni Elia,
Riccardo Tieghi
581

582
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-1
A

B
Fig. 32-2
T is patient had a Class 3 dento acial de ormity malocclusion (A). A er orthodontia, a high LeFort I (but-
ter y type) osteotomy and mandibular surgery (bilateral sagittal split osteotomy [BSSO]) were per ormed
in one stage. T ree years a er surgery (B), the skeletal and so tissue outcome is still stable, with high cheek
bones and acial ullness, in this case without need or at trans er. Another possibility is the insertion o
cheek implants during surgery or as a secondary procedure.7
M
a teri a l a n d M
eth od s
PREPARATION
Planning is always done with the collaboration o the patient, who must be ully in ormed o overall
procedures.
For maxillo acial and cranio acial patients, the ideal position during surgery is supine. T e head can be
moved in dif erent directions. Orotracheal intubation must allow movements o the tube, in particular
when injection into the oral and perioral areas is being done. T e surgeon must be able to evaluate the

583
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
patient’s contours three-dimensionally throughout the procedure. Preoperative photos are displayed on
the walls o the operating room or on a monitor.
MARKINGS
T e preoperative plan includes a photographic setup according to Coleman’s guidelines. Di erent col-
ored pencils are used on these photos in the areas to be injected, not injected, and, i necessary, areas
rom which excessive atty tissue is to be removed. T ese markings are duplicated on the patient’s ace
be ore surgery.
ANESTHESIA
Patients receive a local anesthesia with lidocaine . % and epinephrine : , and, i necessary, seda-
tion or general anesthesia. For local anesthesia, calcium carbonate is added to reduce pain.
FAT HARVESTING, DONOR SITES, AND INCISIONS
Common donor sites are the periumbilical area, the abdomen, the lateral, anterior, and medial thigh, the
“love handles,” and the knees. In children, buttock is an available source. Fat is taken rom those areas
through two or three small incisions ( to mm) that are large enough to permit insertion o the tip o
the cannula.
T e at is aspirated using a -gauge Coleman aspiration cannula, usually cm in length, attached to a
cc syringe. Cannulas or at gra ing must be atraumatic with a blunt tip to the gra ed tissue during
the harvesting and the placement as well.8
FAT PROCESSING AND PURIFICATION
Fat processing and purif cation ollows the classically described Coleman technique (see Chapter ).
We use centri ugation at rpm or minutes. A er centri ugation, only concentrated at is used or
injection.9,10
TECHNIQUE
Coleman’s technique o at gra ing di ers rom other at gra ing techniques in both the harvesting and
placement o the at. T e procedure is delicate. T e harvested at cells are gently centri uged, resulting
in a larger percentage o surviving tissue. Di erent kinds o cannulas have been used or harvesting and
placement, keeping in mind the goal o minimal trauma to the adipocytes.
Coleman blunt cannulas with openings on either the convex or concave side allow excellent volume col-
lection o at parcels. By gently grasping the skin, the surgeon li s away the subcutis rom the underlying
structures. Rapid movement o the syringe and needle in the subcutaneous plane allows atraumatic and
bloodless collection o at.
T e cannula is inserted through small incisions made with a No. blade or an -gauge needle. With
linear deposition, the at is layered into the area requiring enhancement, working rom the underlying
bone up to the skin sur ace. With each insertion, a very small quantity o at is deposited as the cannula
is withdrawn. T e at must be gently woven in several layers rom the periosteum to the subdermis to
optimize the potential or neovascularization, allowing the at cells to survive and maintain the f lamen-
tous architecture. Some o the at is slowly absorbed by the body, although the amount o resorption is
unpredictable; the percentage varies rom patient to patient but is usually rom % to %. I a signi -
icant amount o at is resorbed, a second or third procedure may be considered to improve the f nal re-
sult. In act, using more atty tissue in a single-step corrective procedure can cause poor vascularization
and more resorption, particularly in areas covered by a thin layer o so tissue, such as the maxillo acial
area giving the so-called choke e ect and the possible ormation o cysts and f brosis. In at gra ing,
overcorrection, overgra ing, and the choke e ect must be avoided.11-12

584
Part III • Clinical Applications • Face and Neck: Reconstructive
T ech ni ca l P ea rl s
• T e perioral area cannot be treated with a regular cannula. A 20-gauge needle should be used to e ec-
tively reshape the perioral area, particularly the white roll. T e lips should be treated in the same way
when nonpermanent f llers, such as hyaluronic acid, are injected.
• When the philtrum is absent or poorly def ned, resulting in a attening and lengthening o the prola-
bium, it can be restored and revolumized by at gra ing in two parallel lines beside the nasal alae with
a 20-gauge needle.
• In cranio acial de ormities, one must bear in mind that the patient’s growth potential is always altered.
Because o the high level o resorption, bone gra s should be per ormed a ew times. T e same situa-
tion applies to AF . Resorption is higher. Fat gra ing in patients with cranio acial de ormities should
be done as many as three to f ve times with a lapse o time rom 6 to 2 months.
• reacher Collins is a very complex syndrome to treat, because the SMAS and periosteum are missing.
Even a er repeated bony surgeries, the stigmata return, and the results might be unsatis actory. T ere is a
great amount o bony resorption, even a er cranial bone gra ing. Fat gra ing improves the f nal result.13
• In the anophthalmic socket, at gra ing provides an excellent solution to a volume def ciency. In the
so-called postenucleation socket syndrome (PESS) there can be a lack o so tissue, even a er posi-
tioning an endoorbital implant. T is can be improved by injecting the intraconal part as well as the
upper sulcus on the upper eyelid.
• Recalcitrant ectropion (congenital, cicatricial, ollowing trauma, or a er various reconstructions) is
challenging because o the resulting shortage o skin, muscles, and posterior lamellae. A palatal muco-
sal gra is use ul or rebuilding the lamella, but it does not restore skin and the orbicularis oculi mus-
cle. Lengthening o the lamella, combined in a second stage with very small parcels o processed at,
provides an e ective solution to this problem and results in a lengthened lower eyelid with improved
volumes and texture.14-18
Fig. 32-3, A and B
A

B
T is patient underwent many di erent cranio acial reconstructive procedures, beginning at age 2, or the
correction o a complex cranio acial mal ormation with hypertelorbitism ( essier cle 0- ). She was treated
by Dr. Paul essier in Paris. T e patient is seen at age 2 in preparation or a third at gra ing procedure.
T e ace was marked with the operative plan, and at gra ing was then per ormed under general anesthesia.

585
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
C
D
E
F
G
Fig. 32-3, C-G
T e donor sites were marked according to the classic Coleman protocol. Local inf ltration was per-
ormed with 0. % lidocaine with 1: 00,000 epinephrine. Small incisions were made in the donor sites
with .0 nylon or in pediatric patients using f brin glue with Steri-Strips. T en blunt cannulas were
inserted, and with a gentle negative pressure controlled with the hand, the at was harvested rom the
periumbilical area, abdomen, thighs, and knees. A er harvesting, donor areas should be massaged with
a f brinolytic ointment.
H
Fig. 32-3, H
T e surgeon should think three-dimensionally to assess volumes rom all angles. In complex situations,
the best position is to kneel, allowing a parallel view o the various acial contours.

586
Part III • Clinical Applications • Face and Neck: Reconstructive
I
J
K
L
Fig. 32-3, I-L
VOLUMES PLACED
(total 79.5 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Periorbital area
Upper marionette groove
Infraorbital-lateronasal
area
Nasolabial folds
Dorsum of the nose
Supraorbital forehead area
2
16
4
15
4
16.5
2
16
4
During each at graf ing session, the amounts o at in cubic centimeters are recorded on a sketch o the
ace and reported on a table so that the surgeon can keep track o the at injected in each area. T is is
use ul or the ollowing at transplant stages.

587
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
M

N
Fig. 32-3, M and N
Strips o Micro oam tape are meticulously placed on the inf ltrated areas and le in place or to days.
T is provides a protective barrier to reduce the ormation o edema and prevents the patient rom touch-
ing the skin. T e patient cannot massage the inf ltrated areas or approximately weeks. In the postop-
erative period, the donor sites should be protected by a corset, and the use o antithrombotic socks is
essential as in any other liposuction procedure.
O

P
Q

R
Fig. 32-3, O-R
T e patient is shown at years, at 1 years a er total skeletal surgery, at 1 years a er two at gra ing
stages, and at years a er six at gra ing stages and years a er the last procedure. A total o 0 cc
was transplanted over this period. Some procedures were also been per ormed on her nose and eyelids.

588
Part III • Clinical Applications • Face and Neck: Reconstructive
POSTOPERATIVE CARE
As described by Coleman, light compression tapes are applied around the inf ltrated areas, and the pa-
tient wears a corset or approximately to 0 days i the at was harvested rom the abdomen, because
di erent layers o the abdomen are involved in the harvesting, with laxity o the muscles and asciae.
Early ambulation is suggested. Cool packs are applied to all recipient sites or 24 to 36 hours postopera-
tively. Antibiotics and antiin ammatory medications are administered or several days.17 Patients must
be instructed that postoperative swelling can last or 3 to 4 weeks. Only when the swelling has resolved
can the results be evaluated. T e recovery time will depend on the extent o the procedure and on the
type o pathology.
R esul ts
A

B
Fig. 32-4, A and B
T is 6-year-old girl shows the sequelae o reacher Collins syndrome. At age , she underwent orbital
reconstruction with cranial bone gra s. At age 6, she underwent advancement jumping genioplasty.
T e patient demonstrates complete skeletonization and a lack o so tissue coverage.

589
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Facial at gra ing did increase her so tissue volumes three-dimensionally and can be considered as a
valuable recipient bed in case a new osteoplasty must be per ormed. Probably uture protocols or the
treatment o Treacher Collins syndrome should include early acial at gra ing to compensate or the
so tissue def ciency, ollowed by the other reconstructive procedures.
C
D
Fig. 32-4, C and D
In the preoperative planning and markings, ollowing Coleman’s guidelines, the acial areas were subdi-
vided in di erent sectors, depending on where maximal augmentation was needed and the zones that
did not require touchup. In our preoperative planning, we have modif ed Coleman’s original type o
drawings while maintaining the meaning o each color.

590
Part III • Clinical Applications • Face and Neck: Reconstructive
E

F

G
Fig. 32-4, E-G
VOLUMES PLACED
(total 280 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Periorbital area
Temporal area
Infraorbital area
Nasal area
Frontozygomatic
area
Cheek
10
30
3
65
25
14
10
30
3
65
25
A total o 28 cc o at was injected in f ve stages in the perioral, in raorbital, nasal, and rontozygomatic
cheek and temporal areas. T e patient is shown at 16 at the end o bony surgeries, at 21 a er two at
gra ing procedures, and at 27 years a er a third at gra ing session, 2 years a er the last touchup.

591
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Fig. 32-5
A
B
C
D

T is patient has Crouzon disease (A). At age 7, he underwent a LeFort III osteotomy and a jumping
genioplasty (B). Because o the paucity o acial volumes, at graf ing was planned. In a third stage a total
o 6 cc o at was injected (C). T e patient is shown years postoperatively (D).

592
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-6
VOLUMES PLACED
(total 80 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Temples
Zygomas
Perioral area
Lips
Jawline
Nose
13
11
8
4
4
4
13
11
8
4
T is -year-old woman asked or improvement and correction o the volume def cit in her upper jaw
and lips resulting rom the numerous operations she had undergone or correction o the sequelae o
cle lip and palate. Fat gra ing was planned to f ll the def cit in the upper jaw and perioral area. Fat was
harvested rom the abdomen and medial thigh. A total o 4 cc was inf ltrated to the lower lip, the upper
lip into the f ltrum, the cupid’s bow, the white roll above the orbicularis muscle, the nasolabial olds,
the perialar area, and the nasal tip. Additional at was added to the cheeks and the le tip o the nose to
so en her acial appearance. T e results are shown 4 years postoperatively.
Fig. 32-7
VOLUMES PLACED
(total 42 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Upper lip
Lower lip
Nasal tip
Cheek
Nasolabial folds
and perialar area
5
6
12
6
2
5
6
T is boy underwent surgery at 1 months o age or brachycephaly. An hourglass de ormity became
evident during growth. When he was 1 , a at gra ing was per ormed. Lipoaspirate was harvested rom
the buttock; 4 cc was injected to the entire orehead in one stage. Note the volume-increasing e ect o
the gra as well as the regenerating e ect, which has also led to improved skin quality. T e patient is seen
18 months a er the procedure.

593
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Fig. 32-8, A-E
A

B
C
D

E
VOLUMES PLACED
(total 45 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Forehead

18

9

18
T is patient with Parry–Romberg syndrome presented with a severe case o hemi acial scleroderma
with total atrophy and underdevelopment o the acial skeleton muscles, at, subdermis, and skin. Dys-
chromia o the skin was also present. T e patient had f rst been treated about 8 years previously with
traditional reconstructive procedures: ree iliac bone gra ing to the mandible and maxilla, and dermis
at gra ing per ormed three times through a preauricular li ing-type approach. T e results were un-
satis actory, with almost complete resorption o bone and at. T e patient underwent our at gra ing
procedures, with good results. At the end o the procedures, the total amount o at injected was 6 cc.
T e sketch shows the areas gra ed. T e patient is shown at the end o the procedures with a stable result.

594
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-8, F-H
F
G
H
Hair transplantation
T e same patient with Parry–Romberg syndrome also had the typical alopecia o the cranial area. Af er
multiple Z-plasties, the alopecia was still present. T ree at graf ing procedures were per ormed (a total
o 3 cc o at). Five months af er the last procedure, hair transplantation was success ully per ormed.
T e strip technique was used, with hair harvested rom the occipital region; 00 ollicular units were
needed to achieve a 30 to 3 FU/cm2 density on the alopecic scarred area. Af er months, very good
regrowth o the transplanted hair was evident.

595
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Fig. 32-9
VOLUMES PLACED
(total 226 + 35 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Forehead
Temporal area
Eyebrow
Upper eyelid
Glabella
Malar
Tear trough
Cheek
Nasolabial fold
Upper lip
Lower lip
Marionette
Mandible area
Chin
Crown of head
15
21
10.5
4.5
28.5
9
26.5
15
12
36
15
7.5
10.5
15
35
T is -year-old woman had dentoskeletal malocclusion and an aging ace in a subtle orm o reacher
Collins syndrome. In the f rst stage procedure, she underwent a LeFort I osteotomy, an advancement
BSSO, and genioplasty. In the second stage, a acial-mask li , with extensive subperiosteal dissection,
bony remodeling, and repositioning o the deep acial tissues, were per ormed. Lateral canthopexy, an
eyebrow li , cranial bone gra s to the zygomas, and rhinoseptoplasty were per ormed at the same stage.
In the third and f nal stage, she underwent total acial autologous at gra ing to the orehead, cheeks,
nasolabial olds, upper and lower marionette grooves, and the border o the mandible with a total o
88 cc o at.

596
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-10
VOLUMES PLACED
(total 88 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Forehead
Cheeks
Nasolabial fold
Marionette grooves
Jawline
10
8
6
10
20

10
8
6
10
T is patient had class III dentoskeletal malocclusion. As a f rst stage, he underwent a LeFort I osteotomy,
a BSSO, and genioplasty. wo years later, volumetric improvement by at gra ing was per ormed to im-
prove his le acial asymmetry. A total o 88 cc o at was injected.

597
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
VOLUMES PLACED
(total 110 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Forehead
Nasolabial fold
Marionette
Cheek
Jawline
10
6
4
20
15
10
6
4
20
15
Fig. 32-11
T is 1 -year-old boy with the sequelae o cle lip repair requested improvement o his retrognathism
and chin-neck line. During counseling and planning discussions, we made the benef ts o chin aug-
mentation clear to him. Although we initially proposed osseous genioplasty, we chose chin-perioral at
gra ing because o the simplicity o the procedure and because o the young age o the patient. (Usually
osseous genioplasty is per ormed in men at the end o the growth period at the age o 1 or 18 years.) In
the uture, a touchup will probably be necessary or him. T e patient is shown 1 year a er chin-perioral
at gra ing. A total o cc was injected in all the layers o the chin and perioral area.

598
Part III • Clinical Applications • Face and Neck: Reconstructive
VOLUMES PLACED
(total 35 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Chin
Perioral area
Lips
20
11
4
Stage 1: Genioplasty and initial fat grafting
A

B
C
D
Fig. 32-12, A-D
T e main complaint o this 2 -year-old man was that he considered his ace to be too youth ul and
eminine. He requested a stronger and more masculine look, including enhancement o the zygomatic
arches, more hollowness in his cheeks, a more def ned chin, more pronounced supraorbital ridges with
greater prominence o the rontal bandeau, and volumization o the lips and prolabium.
Planning involved acial sculpturing in two stages. In the f rst operation genioplasty was per ormed
(advancement and lowering), combined with at gra ing o 3 cc to the jawline, lips, cheekbones, and
marionette lines.