Fat Injection From Filling to Regeneration

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Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-13
VOLUMES PLACED
(total 98 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Frontal bandeau,
supraorbital ridge
Zygomas
Marionette
Upper lip
Lower lip
Jawline
4
14
5
16
4
8
6
20
5
16
T is patient had palsy o the seventh le cranial nerve. She is shown 1 year a er reanimation o the
orbitopalpebral region with transposition o a temporalis muscle ap, combined with at gra ing. In a
second procedure, at gra ing improved her hemi acial atrophy. A total o 4 cc o at was injected.
When a acial palsy is treated with microvascular aps, the volumes are usually too bulky. I di erent
techniques are used, such as myo ascial temporalis ap transposition to the eyelids and/or to the corner
o the mouth or static suspension, at gra ing is the complementary treatment o choice to improve so
tissue atrophy. T e temporalis muscle ascia restores palpebral movements and/or movements o the
corner o the mouth. However, when a patient presents with acial palsy, this is usually a condition o
long standing, which has led to signif cant hypotrophy o the hemi ace. Multiple layers o at gra ing
improve volumes and texture and three-dimensional acial contours.

601
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Fig. 32-14
VOLUMES PLACED
(total 46 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Temporal area
Infraorbital area
Nasolabial folds
Marionette grooves
Upper lip
Lower lip
Philtrum
3
2
5
2
6
4
10
6
4
T is 7-year-old man presented with an anophthalmic right orbit as the result o an evisceration per-
ormed when he was a child or a retinoblastoma. T e patient had dislocation o his right eye prosthesis.
o improve this situation, a cranial bone gra was placed on the right orbital oor and on the lower
orbital rim. In another stage, 5 cc o at was harvested rom the abdomen, ref ned to 7 cc, and injected
in the periorbital area and the orbital cone to create better projection o the prosthesis. o improve acial
symmetry, at was also placed bilaterally in the temporozygomatic area.

602
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-15
VOLUMES PLACED
(total 27 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Periorbital area
Orbital cone
Temporozygomatic area
12
6
3
6
T is woman had an aesthetic treatment with the permanent f ller polyalkylimide (Bio-Alcamid). A er
about 1 years she developed a severe in ection, with granulomatosis o the le cheek. T e treatment
consisted o removing the f ller by intraoral access. T e result was a signif cant de ormity o the le
side o her ace. Fat gra ing was initiated in the ollowing months, or a total o 145 cc injected in three
stages. wo years a er the third stage o at gra ing, the aesthetic result was satis actory. T e regenera-
tive e ects o at gra ing can be seen in the postprocedure photos.

603
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
Fig. 32-16
VOLUMES PLACED
(total 145 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Zygomatic area
Cheek
71
74
T is woman presented with the sequelae o a severe le orbital trauma that had been treated in another
center. Over years she underwent several reconstructive procedures: Z-plasties, bilateral canthopexy,
bilateral temporal li ing, and a le lower eyelid mucosal palatal gra . For the next years, three at
gra ing procedures were per ormed, with a total o 14 cc injected bilaterally in the periorbital area,
temporal ossae, zygomas, and lips. We injected 1 cc o the at in the contralateral zygoma to balance
her eatures. Again, the regenerative ef ects o at gra ing are evident.

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Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 32-17
VOLUMES PLACED
(total 140 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Temporal fossa
Periorbital area
Zygoma
Lips
25
10
10
10
25
25
35
A traumatic injury had lef this patient with a permanent right orehead palsy, hollowness o the tem-
poral ossae, and in raorbital irregularities. Af er staged reconstruction, a direct right brow lif was also
per ormed. T en two at graf ing procedures were per ormed; a total o 85 cc was placed to correct his
residual temporo rontal de ormities.
VOLUMES PLACED
(total 80 cc)

Right Face (cc) Other Subunits (cc) Left Face (cc)
Zygoma
Chin
Jawline
Temporalis fossa
Lips and perioral
20
4
3
8
12
25
5
3
Fig. 32-18
T is woman complained that her ace was very asymmetrical and requested aesthetic procedures to
improve her appearance. We per ormed blepharoplasty, otoplasty, rhinoplasty, and genioplasty as well as
extensive acial at graf ing (a total o 8 cc). She eels that these procedures have changed her ace rom
being rather plain to a more attractive and re reshed look, while maintaining a “nonsurgical ace.”

605
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
C om p l i ca ti on s
Aesthetic complications o acial at gra ing include placing an inaccurate volume o at (either too
much or too little), sur ace irregularities, lumps and bumps, and at migration. For volume stability, the
patient should be reevaluated a ew months a er the initial procedure. ouchups can be planned to in-
ject additional at, to correct irregularities, or to remove lumps and bumps.
Other complications in the maxillo acial region include damage to underlying structures such as nerves,
muscles, glands, and blood vessels. However, permanent injuries are extremely rare. When at gra ing
is per ormed in the nasal and periorbital areas, the nasolabial olds, and even in the lower lip, perhaps
the most devastating potential complication is embolization a er inadvertent intravascular injection. o
avoid such complications, the use o sharp needles is orbidden. Additionally, the size o the at parcel
injected must be limited, digital pressure avoided, the syringe size should be small (only mm syringes
used in the ace), and ratcheting guns should not be used. Injection o vasoconstrictors is help ul. Irreg-
ularities and de ormities may occur in the donor areas, as happens in liposuction. T e pa tient wears an
abdominal binder or approximately 7 to 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 ascia.
Moreover, the binder reduces the possibility o donor site irregularity. T is will be particularly evident
in thin patients.19-21
D i scu ssi on
Fat gra ing can be an excellent method or acial recontouring. Recent studies have proved that human
adipose tissue is a rich source o mesenchymal ADSCs that exhibit multilineage potential and that ea-
ture the secretion o angiogenic and antiapoptotic actors in animals. As the f eld o regeneration biology
progresses, new strategies are being developed or treating cranio acial disorders. T ese disorders are
unique in that they a ect multiple tissues simultaneously and occur across the ull spectrum o patient
age and development.22-23
C oncl u si on
Congenital and acquired de ormities in the acial and orbito-cranio- acial region can have great social
impact and unctional importance or the patient. Various surgical techniques have been used to treat
such pathologies, but o en these have had high morbidity and could not be used or correcting smaller,
more subtle contour irregularities. So tissue augmentation by at gra ing represents a technical revolu-
tion and is increasingly used worldwide and has evolved in recent years into more complex restoration
procedures. Moreover, the advent o regenerative medicine promises repair or regeneration o oral and
cranio acial structures that are absent or lost as a result o congenital anomalies, trauma, and various
pathologic conditions.
oday tissue engineering and regenerative medicine are a multidisciplinary science that is evolving along
with biotechnologic advances. T e proposed uses or ADSCs in tissue repair and regeneration are quite
impressive. Recent works on ADSCs would suggest that this adult stem cell may prove to be an equally
power ul tool in treating congenital and acquired disorders. T e availability o and the processes or ob-
taining stem cells remain a challenge or surgeons and scientists pursuing regenerative medicine.
T us ADSCs are a promising source o autologous stem cells or numerous tissue engineering and regen-
erative medical applications. So tissue augmentation by at gra ing must be part o the armamentarium
o any reconstructive surgeon, not only as an ancillary treatment, but also as a basic surgical technique
or various acial and orbito-cranio- acial restorations.24-25

606
Part III • Clinical Applications • Face and Neck: Reconstructive
ACKNOWLEDGMEN
We would like to thank Dr. Barbara Zavan rom the University o Padua (Biomedical Sciences Institute) or
her contributions to the study and research on autologous tissue trans er in reconstructive surgery, particu-
larly in relation to the painkiller e ect/ actor in certain types o trigeminal neuralgia.
REFERENCES
1. Coleman SR, Katzel EB. Fat gra ing or acial f lling and regeneration. Clin Plastic Surg 42:289, 2 15.
2. Clauser L, ieghi R, Consorti G. Parry-Romberg syndrome: volumetric regeneration by structural at
gra ing technique. J Craniomaxillo ac Surg 38: 5, 2 1 .
3. Clauser L. Optimizing maxillo acial and cranio acial results. In Coleman SR, Mazzola RF, eds. Fat Injec-
tion: From Filling to Regeneration. St Louis: Quality Medical Publishing, 2 9.
4. Atiyeh BS, Hayek SN. Numeric expression o aesthetics and beauty. Aesthetic Plast Surg 32:2 9, 2 8.
5. Burnou M, Bu et M, Schwarzinger M, et al. Evaluation o Coleman lipostructure or treatment o acial
lipoatrophy in patients with human immunodef ciency virus and parameters associated with the e -
ciency o this technique. Arch Dermatol 141:122 , 2 5.
. Clauser LC, Consorti G, Elia G, Galiè M, ieghi R. T ree-Dimensional Volumetric Restoration by Struc-
tural Fat Gra ing. Craniomaxillo ac rauma Reconstr 7: 3, 2 14.
7. Caviggioli F, Klinger F, Villani F, et al. Correction o cicatricial ectropion by autologous at gra . Aesthetic
Plast Surg 32:555, 2 8.
8. Pu LL, Yoshimura K, Coleman SR. Future perspectives o at gra ing. Clin Plastic Surg 42:389, 2 15.
9. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs M. Megavolume autologous at trans er: Part I.
T eory and principles. 133:55 , 2 14.
1 . Consorti G, ieghi R, Clauser LC. Frontal linear scleroderma: long-term result in volumetric restoration
o the ronto-orbital area by structural at gra ing. J Cranio ac Surg 23:e2 3, 2 12.
11. uin AJ, Domerchie PN, Schepers RH, et al. What is the current optimal at gra ing processing tech-
nique? A systematic review. J Craniomaxillo ac Surg 44:45, 2 1 .
12. Coleman SR. Long-term survival o at transplants: controlled demonstrations. Aesthetic Plast Surg
19:421, 1995.
13. Clauser L. Personal communication with Sydney Coleman, New York, Nov 2 7.
14. Kakagia D, Pallua N. Autologous at gra ing: in search o the optimal technique. Surg Innov 21:327, 2 14.
15. Enlow DH, ed. Facial Growth, ed 3. Philadelphia: WB Saunders, 199 .
1 . Coleman SR. Lower lid de ormity secondary to autogenous at trans er: a cautionary tale Aesthetic Plast
Surg 32:415, 2 8.
17. essier P. T e def nitive plastic surgical treatment o the severe acial de ormities o cranio acial dysosto-
sis. Crouzon’s and Apert’s diseases. Plast Reconstr Surg 48:419, 1971.
18. Coleman SR. Structural at gra ing: more than a permanent f ller. Plast Reconstr Surg 118(3 Suppl):1 8S,
2 .
19. Coleman SR. Fat injection—toward regenerative medicine. Presented at the International Symposium,
Milan, Sept 2 7.

607
Chapter 32 • Fat Gra ting in Orbitocranial and Maxillo acial Restoration
. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 4: 4 , 199 .
1. Foyatier JL, Mojallal A, Voulliamume D, et al. [Clinical evaluation o structural at tissue gra (Lipostruc-
ture) in volumetric acial restoration with ace-li . About 1 cases] Ann Chir Plast Esthet 49:4 , 4.
. Yoshimura K, Coleman SR. Complications o at gra ing. How they occur and how to f nd, avoid, and
treat them. Clin Plastic Surg 4 : 8 , 15.
. Bui P. [Complications o autogra ing] Ann Chir Plast Esthet 49: , 4.
4. Habal MB. Cranio acial surgery: a perspective on the advances made in 4 years o surgery, principles
f rst. J Cranio ac Surg 19: , 8.
5. Kawamoto HK. (1) From today to the uture, ( ) Facial ractures, ( ) Anophthalmic orbital reconstructive
strategies, (4) Rare cle s. Presented at the Cranio acial Plastic Surgery International Congress, Rome,
June 5.

(Trang không có chữ)

609
C h a p t e r 3 3
T h ph c ch h ccu HIV-p p u h m l k ly w ll d -
pp d c d c m ul d c m , bu d du l c d
d y, h ch h c d b dy bl d m z d d h ju y -
l pp ch. F , wh ch h ub l l ud l d cum xc p-
l ul f ll m l, p d p m ph c h -
d du l . B c u m y HIV-p p d h f c ubcu u d p ,
m u h qu wh h h d phy HIV c b l d w h h u
u l u , h p c b d w h j c y h c m l .
H w , p w h h ch c d wh ch h xp c p u
h l , h u y h c m l u u bl , b c u p w ll d m cycl c l
c u ch h f ll b d. I y xp ph c b y d h
c . P m m l uch l c m h c yl c b p , bu h k d
m l d l d m c mpl c wh h h lum u d, d h p
qu h h lum , clud h c .
Ab m l ch b dy d bu c HIV-p p w d c b d h
l d w c ll d HIV-associated lipodystrophy.1-3 T ch clud p ph l
l l p phy (LA), c l ccumul l p hyp phy, c mb b h
h yp ch h m p . T m cl c l u p ph l LA
h c , l mb , d bu ck d c l l p dy phy (LD) w h h bd m , b , ck,
pub c , d h d c c l p (“bu l hump”), w ll ubcu u l p -
m d m b l c d u b c ( ul c , hyp ch l l m , d hyp lyc -
d m ). T p l c h b d c b d b b w % d 8 %.
T p h HIV LD ly l d h h hly c l h py, wh ch
m y c h xp h k c uch h d du l’ c u c p b l y,
HIV cl c l , c , x, x c l l, h l h py, d m y
h c .4
T p ych l c l mp c , p c lly c l phy (FA), c b d m y p -
, l d h m l dh h l m m .5,6 T y d l p
l d b dy m d m y b c m d p d d x u h h bl ch w ll
d cl h h h y c d, d hu h y xp c c l d d l .7-9
S m m p h h y f d w l w h LD h w h HIV.10,11
Fat Gr a t ing in HIV-Posit ive
Pat ient s
Joan Fontdevila

610
Part III • Clinical Applications • Face and Neck: Reconstructive
Earlier detection and treatment o HIV in ection, as well as the use o antiretroviral drugs with less delete-
rious e ects on body at, make it reasonable to hypothesize that there will be a decrease in the prevalence
o LD in HIV patients in the coming years. However, currently there is no specif c treatment or established
LD. LA can potentially be reversed by switching rom antiretroviral drugs known or their adverse e ects
on adipose tissue to regimens that are less toxic in this regard, even though complete subcutaneous at re-
covery cannot be expected. For this reason, it is necessary to establish a symptomatic treatment.12-14
M
a teri a l a n d M
eth od s
AESTHETIC CONSIDERATIONS
Fig. 33-1
DISCLOSURE: Some data contained in this chapter have been made possible thanks to research grants provided by the
Spanish Ministry o Health: Instituto de Salud Carlos III, Fondo de Investigación Sanitaria 03/0393, and Fondo de Inves-
tigación Sanitaria 08/0285.

611
Chapter 33 • Fat Gra ting in HIV-Positive Patients
Among all the eatures o LD, neck at hypertrophy (bu alo hump) and LA are probably the most sig-
nif cant, because they are typical eatures o this syndrome and may lead to identi ying the person as
in ected with HIV.
LA areas in the ace comprise temple wasting, which makes the temporal ossa noticeable, and loss o
subcutaneous at rom the cheeks showing an emaciated appearance (especially noticeable between the
nose and the anterior rim o the masseter muscle and between the lower rim o malar bone to the man-
dible), prominent nasolabial olds, acial skeletonization (when the skin lies directly on bony and muscu-
lar acial structures), negative vector (concave cheek), and orbital hollowing. Other accompanying acial
signs in the LD patient are submental at accumulation and an increase in the parotid volume, which
together with the FA con ers a widened appearance to the ace. LA can also be easily seen surrounding
the zygomatic arch, but in this area it does not have the same repercussions or acial appearance as does
atrophy in the cheeks.
Subcutaneous tissue in these patients is also depleted rom the arms below the shoulders, buttocks,
and lower limbs (peripheral wasting), with the distinctive prominence o the superf cial veins in these
sites, and the intermuscular grooves and bony prominences ( emoral condyles) are especially noticeable.
Patients complain o buttock attening, not only because o the obvious aesthetic impairment, but also
unctional di culty in holding up pants, shorts, or skirts, even when wearing a belt. Women used to be
more worried than men about visible leg veins, because these are not common in healthy women; how-
ever, visible veins are common in healthy, lean, athletic men.
Because at gra ing can play an important role in modi ying the stigmata o LD, surgeons should keep
this in mind when discussing a liposuction procedure with such a patient. T e act that this at could
be use ul or treating atrophic areas elsewhere in the body should be presented as an option in the f rst
patient consultation.

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Part III • Clinical Applications • Face and Neck: Reconstructive
ANATOMIC CHANGES AND CLASSIFICATIONS
C scans and MRIs have demonstrated thinning o the subcutaneous at as well as an increase in density
o this tissue. For this reason patients develop a sunken appearance in the anatomic areas where there is
a lack o bony or muscular support, as in the cheeks, or between muscular compartments, such as in the
thighs. However, contrary to what was believed when the f rst cases o HIV-related FA were diagnosed,
the deep atty bags in the ace, such as the buccal at pads, do not play a signif cant role in the physical
appearance o FA, because they are not depleted.15
Fig. 33-2
T e patient on the le has mild atrophy; subcutaneous atty tissue is still present, as well as buccal at
pads. In the patient on the right, atrophy o the subcutaneous tissue is severe, but the buccal at pads are
still preserved.
Di erent methods have been described to clinically assess and classi y the patients by the severity o
their LD, but most proposed classif cations are very subjective and only consider the ace; they lack an
objective method or categorizing all the eatures o LD in the body.

613
Chapter 33 • Fat Gra ting in HIV-Positive Patients
Quantitative measure o the subcutaneous at has been per ormed using imaging methods (C scans,
MRIs, ultrasonography, DEXA), but none o these has been used to establish criteria or severity. For
this reason the diagnosis o LD has been subjective, through the physician’s evaluation and the patient’s
observations.12
Fig. 33-3, A-F
Grade 0
A
B
C
Grade 1
D
E
F
We recommend the ollowing classif cation system because o its simplicity and ease o use or both FA
and LD o the buttocks. o assess FA, a correlation is drawn with acial at volumes measured by C
scan,16 which classif es the patients in our degrees o atrophy. With no FA (grade 0), the cheekbone area
has a convex contour rom the orbital rim to the nasolabial old. When there is a minor degree o atro-
phy (grade ), the patient shows only a loss o this convexity, as well as some attening o the malar em-
inence. T ese signs may also be seen in persons without HIV but who have acial skeleton dysmorphia.

614
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 33-3, G-L
Grade 2
G

H

I
Grade 3
J
K

L
Progression o FA (grade 2) is characterized by urther shrinkage o the malar eminence, leading to a
clinical impression o sunken skin under the malar lower rim. Patients classif ed as having the most se-
vere degree o FA (grade 3) have easily identif ed prominence o the zygomatic major muscle and other
superf cial muscles o the ace; the sunken areas extend rom the lateral aspect o the upper lip to the
lateral aspect o the malar bone, giving the ace a skeletonized appearance.

615
Chapter 33 • Fat Gra ting in HIV-Positive Patients
Fig. 33-4
Mild
Moderate
Severe
We have also published a clinical classif cation or assessing atrophy o the buttocks.17 When the prof le
o the buttocks becomes attened, but the contour still projects more than the sacrum, this is considered
to be mild atrophy; when the projection o the buttocks is at the level o the sacrum, along with a slight
ptosis, this is considered moderate atrophy; and when complete atrophy o the at is present, along with
skeletonization and the appearance o urrows in the bottom o the buttocks, this is considered severe
atrophy.
A structured classif cation or lower and upper extremity LA is currently lacking, but it can be consid-
ered that when the veins o the lower limbs are readily discernable, this is the maximum degree o sever-
ity. T is is the aspect that concerns patients most in regard to lipoatrophy o the limbs.

616
Part III • Clinical Applications • Face and Neck: Reconstructive
TREATMENT OPTIONS
Symptomatic treatment o LA involves the trans er o autologous at or injection o synthetic materials.
T e treatments most o en used, especially or correction o FA, are at gra ing, polylactic acid, calcium
hydroxylapatite, and hyaluronic acid.18 Other materials that have been used are silicone (United States),
polyacrylamide (Europe), polyalkylimide gels (Europe, Mexico), and methacrylate (South America).
Every suggested treatment presents advantages and drawbacks, and their results vary.
Fat gra ing to the atrophied area seems to be the most valid option, because this method restores “like
with like,” using the same kind o tissue that the disease has caused to atrophy.19,20 Other advantages are
that gra ed at is autologous, permanent, biocompatible, nontoxic, and has physical eatures like those o
the tissue it restores. For these reasons our discussion will ocus on at gra ing or the correction o LA.
Although the durability o at gra s in HIV-a ected patients has been a topic o discussion, our experi-
ence, and that o others who have used this technique, is that there is little resorption o properly gra ed
at,19-21 and it tends to behave like the tissue o the area rom which it was harvested. T is is an advantage,
because LA is chronic in HIV-positive patients, and even administration o the newer antiretroviral
drugs does not improve the patient’s condition enough to achieve ull restoration o the patient’s eatures.
T e cost o at gra ing can ultimately be less than that when synthetic f llers are injected, because al-
though at injection requires more material and time, the large amounts o exogenous f ller required in
these patients increases the price o the treatment, and the results with synthetic f llers are temporary,
compared to that with at gra ing.
Fat gra ing is indicated as the f rst option in HIV patients with LA when lipoaspirate can be obtained rom
any area o the body, o en rom the areas where these patients experience lipohypertrophy, such as the bu -
alo hump, in raumbilical area, pubis, back rolls, and male breasts. When a patient’s ace has more severe
FA, at gra ing is the optimal choice o treatment, because a large amount o f ller will be necessary, and it
must be durable. In these patients, a reabsorbable f ller material will ail to provide good volumetric correc-
tion over time, which will give the patient an oscillating appearance, with periods in which the ace appears
ull, alternating with periods o leanness. Furthermore, synthetic materials in large amounts are more likely
to present complications such as in ection, granuloma, nodulation, and an unnatural appearance. It has
been possible to f nd a source o subcutaneous at to treat FA in more than 5 % o our patients. Correction
o atrophy o the buttocks and limbs can be di cult in many HIV-positive patients, because these areas
require a huge volume o at, as much as ten old or more than is needed to treat the ace.
It is best to per orm a at gra ing procedure when the patient’s HIV LD has stabilized so that the surgeon
can work with stable adipose tissue compartments, both in the donor and recipient sites. T is helps to
avoid unexpected changes in at volume associated with the evolution o the disease, although it does not
alter the at injection technique used.
A contraindication to at gra ing in these patients is previous implantation o synthetic injectables.
T ese individuals must be rejected or at gra ing, because the synthetic material o these injectables can
be contaminated, and this can lead to an in ection or can induce granuloma or nodulation. T e residual
synthetic material can also inter ere with the take o at gra s. Patients must be asked during history-
taking to speci y which material was used and when it was injected. I it was a reabsorbable material,
the patient is advised to wait or at gra ing until all o the synthetic material has been absorbed, usually
year a er the injection, and its presence can be assessed by ultrasonography i necessary.

617
Chapter 33 • Fat Gra ting in HIV-Positive Patients
TECHNICAL GUIDELINES
Preparation
Candidates should have good virologic control o their disease and a satis actory immunologic status. An-
tiretroviral treatments do not inter ere with at gra ing surgery, so it is not necessary to withhold the drugs.
Patients can take their medications until the date o surgery and reinitiate them a er the procedure.
Fig. 33-5
Be ore the procedure, standardized photographs o the patient rom all angles must be obtained to
document the degree o lipoatrophy. With the patient standing, the contours o the areas o de ect are
marked using a waterproo pen. Intravenous ce azolin g, or 400 mg o endovenous cipro oxacin in
penicillin-allergic patients, is administered in the perioperative period.
Anesthesia
Our pre erred anesthetic technique is local anesthesia with sedation, which is adequate or FA treatment
and allows the patient to be discharged only an hour a er the procedure. General anesthesia is indicated
or patients who have a large bu alo hump, when aggressive liposuction o the hump in the prone posi-
tion is mandatory, or when at gra ing will be per ormed in multiple areas o the body.
We use local anesthesia o the donor site using tumescent solution with lidocaine 0. % and 0 mEq o
sodium bicarbonate per liter. Meanwhile, the harvested lipoaspirate is centri uged, and the ace is anes-
thetized with mepivacaine 2% and epinephrine :20,000 using a 0-gauge needle to create a block o the
in raorbital nerve. T e entry point or the injection cannula is inf ltrated, using a discrete amount o an-
esthetic to avoid swelling o the cheek, which can distort the anatomy and induce a volumetric bias. T e
epinephrine helps to limit bleeding, which can cause swelling in the recipient area, and it also reduces
postoperative bruising.

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Part III • Clinical Applications • Face and Neck: Reconstructive
Fat Harvesting, Processing, and Implantation
Harvesting o lipoaspirate is per ormed using aspiration cannulas such as those designed by Coleman
(such as COL-ASP 5), because their atraumatic design allows bloodless harvesting. For acial treatment
we aspirate by means o a 0 cc syringe with cc o air in the syringe to limit the negative pressure. For
buttocks and limbs we use a closed system connected to a vacuum machine that limits the negative pres-
sure to 0.4 atm.
For FA, harvested at is centri uged at 3000 rpm or 3 minutes. T is provides a concentrated, dry gra ,
which is important or controlling injected volume with precision. For the buttocks or limbs we use a
f ltering device specif cally designed or this kind o procedure (Puregra , Solana Beach, CA), which
makes the procedure aster than centri uging and provides a wetter gra that is more convenient or
gra ing in large areas and makes implantation easier.
Inf ltration is per ormed by means o a blunt closed-point cannula such as COL-I9 or COL-I7, because
even minimal bleeding can cause swelling in the treated area that can cause errors in the calculation o
the volume o injectate required. Some patients present with a near-total lack o subcutaneous at, and
the subcutaneous space is more f brous. T us the surgeon might erroneously think that it would be bet-
ter to work with a sharper cannula such as COL-III9 or COL-V9, but in these patients bleeding is more
likely to occur, because the injection is directly to subdermal, f brous, and muscular tissues.
Fig. 33-6
Only two stab incisions or each side o the ace are necessary to treat all o the a ected acial areas, one
lateral to the malar bone body ( rom where we can also reach the temporal area) and another at the
lower limit o the nasolabial old, with a -gauge needle or a COL-V7 cannula. For limb atrophy, as
many incisions are made as necessary, depending on the morphology o the de ect.
T e length o the cannula or the ace must be short (7 cm) to provide optimal control o the tip position
in these f brous tissues. For the buttocks and limbs, longer cannulas (9 cm or more) are needed to reduce
the number o incisions, although we pre er to use the shortest possible cannula to reduce the trauma to
the gra site.

619
Chapter 33 • Fat Gra ting in HIV-Positive Patients
Despite the high volumes o at needed, injection in the ace is per ormed using cc syringes or more
precise technique. In the limbs and buttocks, 0 cc syringes can be used, taking care to introduce the at
slowly and with gentle pressure.
Fig. 33-7
T e injection area ollows the concentric lines o the markings. Injection is per ormed in a anlike ash-
ion. T e depth o injection encompasses the so tissue thickness o the ace. In these patients we will not
succeed i we try to inject in a specif c type o acial so tissue (muscle, connective tissue, subdermis, or
periosteum). T e increased density o the atrophic acial tissues makes initial inf ltration more di cult
until more tunneling is achieved. It is important to be very cautious with injections in the perioral area,
because these tissues are thinner, and an overcorrection may lead to a “gumboil” or “candy in the mouth”
appearance, as seen above.
In the buttocks, both subcutaneous tissue and muscle can be injected; the recipient tissue is thick, and
much more volume can be injected than in the ace. However, the surgeon must proceed cautiously to
avoid the deep vascular and nervous structures, because the tendency to use large volumes in this area
can lead to major complications, such as a lethal at embolism. In the limbs, injections should be placed
subcutaneously to avoid damage to important structures such as vessels and nerves, especially in the
legs, because the saphenous vein and common f bular nerve lie superf cially.
Volume Ranges and Number of Procedures
Most patients need only one procedure to achieve a satis actory correction o FA—less than % o our
patients have required a second procedure. It is di cult to achieve the desired result, even i a second
procedure seems necessary because o a patient’s limited available at and the huge volume that these
areas require.
T e mean volume o at implanted, based on our 5 years’ experience, is as ollows:
• Cheeks: Grade , 7 cc; grade 2, 0 cc; grade , 4 cc.
• Buttocks: A signif cant range o volumes may be needed, depending on the patient’s anatomic
eatures; typically 50 to 00 cc is used in each buttock. Volumes less than 00 cc probably will not
satis y the patient’s expectations.
• Limbs: Areas o concern or the patient, such as around the knees and the inner aspect o the
lower thigh, require a range o 200 to 00 cc on each side.

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Part III • Clinical Applications • Face and Neck: Reconstructive
R esul ts
In the large series o patients with LA that we have treated, the results have been lasting over time with
no resorption, as observed clinically and by means o C scan volume measurement.20-21 It is easier to
check the ef ectiveness o the gra s in these severely atrophied patients than in those looking only or an
aesthetic improvement. T e appearance o the treated area is natural, the touch is so , and patients do
not have the stif sensation that a huge amount o synthetic material produces in the ace i they are used.
T e edema rom at injection, which lasts rom 3 weeks to month, makes the recovery period longer
than when synthetic materials are used, perhaps because these are injected using small needles instead
o a cannula, and because this is a gra , a procedure involving living tissue, with associated phenomena
such as angiogenesis and resorption o damaged tissue.
Fig. 33-8
T is 43-year-old patient is seen preoperatively and and months a er at gra ing. His FA was
grade . Each cheek was injected with 8 cc o at. In grade atrophy, the technique does not dif er much
rom the technique used in a nonin ected patient.
Fig. 33-9
T is 39-year-old man is seen preoperatively and and months a er at gra ing. His FA was grade .
In the right cheek we injected cc o at, and in the le cheek we injected 3 cc. Most o the volume o
the gra should be placed over the malar bone, with a discrete amount o at placed in the sunken areas
lateral to the mouth to avoid overcorrection and lumps.

621
Chapter 33 • Fat Gra ting in HIV-Positive Patients
Fig. 33-10
T is 4 -year-old woman, with grade FA, is seen preoperatively and and months a er at gra ing.
We injected 5 cc o at in the right cheek, cc in the le . T e strategy or grade patients should be the
same as or grade patients, but we place a larger amount o at. We recommend not implanting more
than about 5 cc to avoid the risk o creating “hamster syndrome.”
Fig. 33-11
T is 4 -year-old woman presented with atrophy o her lower limbs. She is seen preoperatively and
months a er at gra ing; 00 cc o at was injected in each area surrounding the inner aspect o her
knees. Huge superf cial veins are in the target area, so care must be exercised to avoid intravenous injec-
tion o the at. T e location o the veins should be marked on the skin be ore the procedure.
Fig. 33-12
T is -year-old man with atrophy o the buttocks is seen preoperatively and months a er at gra -
ing; 500 cc o at was injected in each buttock.

622
Part III • Clinical Applications • Face and Neck: Reconstructive
C om p l i ca ti on s
Fig. 33-13
T is grade patient, 47 years old, is seen preoperatively and at , , and 1 months a er at gra ing.
Each cheek was injected with 1 cc o at. T e volume increase over time is evident, which ultimately
resulted in the “hamster syndrome” evidence o hypercorrection. T is complication is di cult to reverse.
Although immediate complications o at gra ing occur in requently, a late complication to be avoided
is hypercorrection (4% o the patients in our experience), resulting in an appearance called the hamster
syndrome.22 T is type o hypercorrection has been described in FA patients; the dif erence rom com-
mon hypercorrection is that over time the patient exhibits a progressive volume increase o the injected
at, presenting characteristically heavy cheeks, like a hamster. In our experience and the experience o
other authors, this complication is di cult to treat; sometimes the only way to achieve a satis actory
correction is to excise the redundant at by per orming a ace li . I have ound that this complication is
associated with a patient’s increase in weight in addition to a higher volume o at having been injected.23
Limiting the volume o at injected and ensuring that patients are in a steady state o weight are the
most important measures or avoiding hypercorrection without compromising the aesthetic results. (See
Chapter 5 or additional discussion o complications and their prevention.)

623
Chapter 33 • Fat Gra ting in HIV-Positive Patients
D i scu ssi on
One reason that at gra s or HIV-positive patients were questioned in the past was the idea that i the
patient was losing subcutaneous at, there would be signif cant resorption o the gra ed tissue. However,
considerable experience has demonstrated that this is not true, because the gra is obtained rom areas
with accumulation instead o areas with active atrophy, so even though we are gra ing in an atrophic
area, the recipient site will not experience atrophy, because the gra will behave as in the donor site.20
For the extremities we have ew alternative treatment options, but or the buttocks, implants are a pop-
ular option among these patients, especially or those without enough atty tissue to accommodate ull
restoration by at gra ing. With implants, at gra ing can still play a role as an ancillary procedure to
improve the results, increasing the thickness o the so tissues surrounding the implant and making it
less noticeable.17
Synthetic materials can be an option or patients without at depots, but it is di cult to justi y the use
o synthetic materials as the f rst therapeutic option with the present evidence o the e ectiveness o at
gra ing in those or whom it is easible.
C oncl usi on
LD is a disturbance in body at distribution that can unctionally and aesthetically limit the lives o
HIV-in ected patients. For this reason, symptomatic treatment based on relocating subcutaneous atty
tissue to atrophic areas makes excellent sense. Patients should be treated only when their disease status
is stable; one should not treat patients in whom LD is still evolving, because the atty tissue is a living
f ller and can experience changes that could lead to undesirable results. Areas with accessible at depots
in these patients are the bu alo hump, abdomen, male breasts, pubis, and back rolls.
T ese areas may provide su cient lipoaspirate to treat the ace, but or the buttocks and limbs, at
sources may be scarce. T e surgeon must advise the patient about what can realistically be achieved and
should conf rm during consultation that the patient has reasonable expectations.
Especially in at gra ing to the ace, an inexperienced surgeon may inadvertently overcorrect. T is can
be avoided by conservative injection during a f rst procedure and per orming a second session some
months later. T is approach is likely to produce the most aesthetic result and is pre erable because at-
tempting to remove at rom the ace is di cult. Following these basic rules, at gra ing can be highly
rewarding or these patients.
REFERENCES
. Carr A, Samaras K, Burton S, et al. A syndrome o peripheral lipodystrophy, hyperlipidaemia and insulin
resistance in patients receiving HIV protease inhibitors. AIDS :F5 , 998.
. Viraben R, Aquilina C. Indinavir-associated lipodystrophy. AIDS :F , 998.
. Lo JC, Mulligan K, ai VW, et al. Body shape changes in HIV-in ected patients. J Acquir Immune Def c
Syndr Hum Retrovirol 9: , 998.
4. Carr A. HIV lipodystrophy: risk actors, pathogenesis, diagnosis and management. AIDS Suppl :S 4 ,
.
5. Duran S, Savés M, Spire B, et al. Failure to maintain long-term adherence to highly active antiretroviral
therapy: the role o lipodystrophy. AIDS 5: 44 , .

624
Part III • Clinical Applications • Face and Neck: Reconstructive
. Garcia-Viejo MA, Ruíz M, Martínez E. Strategies or treating HIV-related lipodystrophy. Expert Opin
Investig Drugs 10:1 3, 001.
7. Collins E, Wagner C, Walmsley S. Psychosocial impact o the lipodystrophy syndrome in HIV in ection.
AIDS Read 10:5 , 000.
8. Dukers NH, Stolte IG, Albrecht N, et al. T e impact o experiencing lipodystrophy on the sexual be-
haviour and well-being among HIV-in ected homosexual men. AIDS 15:81 , 001.
9. Blanch J, Rousaud A, Martínez E, et al. Impact o lipodystrophy on the quality o li e o HIV-1-in ected
patients. J Acquir Immune Def c Syndr 31: 0 , 00 .
10. Blanch J, Rousaud A, Martinez E, et al. Factors associated with severe impact o lipodystrophy on the
quality o li e o patients in ected with HIV-1. Clin In ect Dis 38:1 , 00 .
11. Rankin M, Borah GL. Perceived unctional impact o abnormal acial appearance. Plast Reconstr Surg
111: 1 0, 003.
1 . Guaraldi G, Stentarelli C, Zona S, et al. HIV-associated lipodystrophy: impact o antiretroviral therapy.
Drugs 73:1 31, 013.
13. Sutinen J. Interventions or managing antiretroviral therapy-associated lipoatrophy. Curr Opin In ect Dis
18: 5, 005.
1 . Moyle GJ. Bridging a gap: surgical management o HIV-associated lipoatrophy. AIDS Read 1 : 7 , 00 .
15. Berenguer J, Pujol , omaselo A, Fontdevila J, Milinkovic A, Martínez E. Computerized tomography
f ndings o acial lipoatrophy in HIV-in ected patients. Antivir T er 8:L , 003.
1 . Fontdevila J, Berenguer J, Prades E, et al. Validation o a simple classif cation or acial lipoatrophy in
HIV-in ected adults. Antivir T er 1 :L31, 007.
17. Benito-Ruiz J, Fontdevila J, Manzano M, et al. Hip and buttock implants to enhance the eminine contour
or patients with HIV. Aesthetic Plast Surg 30:98, 00 .
18. Guaraldi G, Fontdevila J, Christensen LH, et al. Surgical correction o HIV-associated acial lipoatrophy.
AIDS 5:1, 011.
19. Serra-Renom JM, Fontdevila J. reatment o acial at atrophy related to treatment with protease inhibi-
tors by autologous at injection in patients with human immunodef ciency virus in ection. Plast Reconstr
Surg 11 :551; discussion 55 , 00 .
0. Fontdevila J, Serra-Renom JM, Raigosa M, et al. Assessing the long-term viability o acial at gra s: an
objective measure using computed tomography. Aesthet Surg J 8:380, 008.
1. Fontdevila J, Guisantes E, Martínez E, et al. Double-blind clinical trial to compare autologous at gra s
versus autologous at gra s with PDGF: no e ect o PDGF. Plast Reconstr Surg 13 : 19e, 01 .
. Guaraldi G, De Fazio D, Orlando G, et al. Facial lipohypertrophy in HIV-in ected subjects who under-
went autologous at tissue transplantation. Clin In ect Dis 0:e13, 005.
3. Fontdevila J, Martínez E, Rubio-Murillo JM, et al. Factors involved in lipohypertrophy in acial at gra -
ing or the treatment o lipoatrophy. Antivir T er 11:L59, 00 .

625
C h a p t e r 3 4
T x v v d w
d . A d f d b w -
d d d d v , , d , w -
d . T v v v w d d b kw d
d , w d x
w w d d . T d w d
d b w d x d . z , -
, v v , d -
b v k d x v .
T w b w x d x d velopha-
ryngeal (VP) port sphincter. I v v v ,
x v , b d
. T d d velopharyngeal incompetence insuf ciency (VPI);
, d b b , d d . N
d d w w .
I VPI d , v q v b
d, w , b .
F b x d d
w d , v , S d 1 d-
v d - . T d b - Z- q w v
d v w z d U d S
b F w.2 I 9 D d B f d3 d b d b k d
b v f b b kw d z x
b w v d w .
Ov , d , - d v , v b
d. T d w d b w -
x d x, b d -
w d d v ,4-7 b d w
r eat ment o Vel ophar yngeal
Incompet ence Wit h Aut ol ogous
Fat Gr a t ing
Riccardo F. Mazzola, Giovanna Cantarella
I
625

626
Part III • Clinical Applications • Face and Neck: Reconstructive
o the two heads o the palatopharyngeus muscle to the midline and suturing them to the posterior
pharyngeal wall.8 Velopharyngoplasties are e ective in diminishing the passage between the nasal cavity
and the oropharynx, but they may have a relevant morbidity in the immediate postoperative period with
severe pain and risk o bleeding, or in the long term with snoring and obstructive sleep apnea (OSA).
For moderate VPI, velopharyngoplasties are considered to be an overtreatment, whereas advancement
o the posterior pharyngeal wall is one o the oldest solutions or VPI, beginning in with Passa-
vant,9 who proposed creating a mucosal ridge on the posterior pharyngeal wall to enhance the contact
between the velum and the pharynx. Since then, a large variety o implants10-12 or autologous tissue13,14
have been positioned into the retropharyngeal space, with the aim o pushing the posterior wall o the
pharynx orward and reducing the size o the nasopharyngeal port. o achieve a success ul unctional
outcome, the implant or the autologous tissue must be located cranially in the pharynx at the point o the
velar contact. However, over time, extrusion or dislocation o the implant in a caudal position has o en
been reported, making the prognosis or this technique questionable.
Recently, at gra ing to the velopharynx has proved success ul in the treatment o VPI, and the regener-
ative properties o autologous at are being widely studied.13-16
M
a teri a l a n d M
eth od s
PATIENT SELECTION AND TREATMENT GOALS
Patient selection or at gra ing to treat persistent VPI is a critical step. Fat gra ing can success ully
correct only mild to moderate gaps o VP closure. Preoperative assessment is based on thorough evalua-
tions per ormed by the surgeon, a well-trained phoniatrician, and a speech therapist.
T e diagnostic assessment includes:
• Perceptual evaluation, with spontaneous speech, repetition o sentences and phonemes to assess
resonance, audible air escape and turbulence, articulation de ects and dysphonia
• Acoustic measurements, such as nasometry
• Aerodynamic evaluation to calculate the nasal air leakage
• Video uoroscopy in multiple projections to estimate the size o the VP port
• Videonasopharyngoscopy
In our clinical practice, perceptual evaluation, with video recording o speech samples and videonaso-
pharyngoscopy, are the standard assessments or patient screening, whereas aerodynamic measurements
are per ormed in selected cases and or research purposes. For evaluation o the results, the videos are
blindly assessed by independent listeners with specif c expertise in VP unction. T e results provide us
with quantif able data. It is o paramount importance to distinguish between VP insu ciency, related to
anatomic de ects that require surgical management, and VP dys unction, associated with mislearning or
neuromotor disorders, which can be primarily treated conservatively with speech therapy. Videonaso-
pharyngoscopy is per ormed by introducing a exible scope with a diameter smaller than mm through
the middle meatus. T is procedure is also well tolerated by children. T e data thus obtained in orm the
surgeon o the size and location o the VP closure gap. Videonasopharyngoscopy has been ound to be
superior to video uoroscopy or identi ying small VP de ects and establishing their size, which is essen-
tial or surgical planning.17

627
Chapter 34 • reatment o Velopharyngeal Incompetence With Autologous Fat Gra ting
Depending on the considerations just described and on the nasopharyngeal gap closure, we rate patients
according to a 5-point scale13: 0 = complete VP closure; = an inconstant gap demonstrated by mucus
bubbling; = a gap involving less than 5% o the VP port at rest; = a gap involving 5% to 50% o
the VP port; = a severe gap involving more than 50% o the VP port. Patients with gaps to (up to
50% o the VP port) are good candidates or VP at injection, whereas patients with a number gap are
best suited or velopharyngoplasties,6-8 because the augmentation resulting rom at gra ing in in the
our walls o the VP port would not be su cient to reduce the size o the port and minimize the nasal
air escape.
SURGICAL TECHNIQUE
T e procedure is carried out under general anesthesia. Fat is usually harvested rom the lower abdomen;
however, in very slender patients, lipoaspirate is obtained rom the inner knee or inner thigh. T e area is
inf ltrated with .0% mepivacaine with a : 00,000 epinephrine solution. A stab incision is made in the
lower pole o the umbilicus with a No. blade. A mm three-hole disposable blunt cannula connected
to a 0 cc Luer-Lok syringe is used. o provide negative pressure, the plunger o the syringe is retracted
and is maintained in that position by means o a towel clamp. Once the necessary amount o at is har-
vested, usually to 0 cc, the incision is closed with a 5-0 nylon suture and an elastic garment is placed
over the donor area to avoid possible hematoma ormation. We routinely centri uge the lipoaspirate at
000 rpm. T e atty raction o the lipoaspirate is trans erred to a cc Luer-Lok syringe or injection.
T e patient is then positioned supine with a roll placed behind the shoulders to extend the neck. Endo-
tracheal intubation is used. A Dingman mouth gag, suspended on a horizontal stand, acilitates exposure
and depresses the tongue.
Fig. 34-1
Placement is the critical step o the procedure and should be per ormed with utmost care. A Nelaton
probe is inserted into each nostril, passed through the corresponding choana into the mouth, and the
two heads o the probe are tied together so that the velum is gently retracted superiorly. T e velum is
then gently retracted to allow easy access to the nasopharynx where at is to be placed. Fat gra ing is
per ormed to improve the contact between the velum and the posterior pharyngeal wall, which is clearly
exposed.

628
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 34-2
o better visualize the nasopharynx and the sof palate and to make at graf ing as precise as possible,
a 70-degree Storz 4 mm rigid nasal endoscope is connected to a videocamera and a monitor is used. A
3 cc Luer-Lok syringe is used or at injection.
Injecting Fat Into the Posterior Pharyngeal Wall
wo stab incisions are made on the posterior pharyngeal wall at the level o the odontoid process, 5 mm
lateral to the midline on both sides, with an 1 -gauge needle or a No. 11 blade. In the past, we used a
19-gauge cannula or at graf ing, but of en at oozed out rom the entry point. Currently we pre er to
use a 1-gauge 0 mm long disposable, malleable microcannula (T iebaud Medical, France), which is
bent as needed. T e entry point is through a very small incision to reduce the risk o at leakage. T e can-
nula is advanced in a cephalad and oblique direction, reaching the axis and then more laterally toward
the ipsilateral pharyngeal wall in the submucosal plane. However, i excessive resistance is encountered
while at is being injected with the 3 cc syringe, a lipoinjection dosage handle (Medicon Instruments,
üttlingen, Germany) acilitates the release o at.

629
Chapter 34 • reatment o Velopharyngeal Incompetence With Autologous Fat Gra ting
Fig. 34-3
T is cadaveric dissection shows the correct at injection site into the nasopharynx at the level o the axis.
Fat should injected in the submucosal plane (arrow) within the f bers o the superior constrictor muscle.
On the right is a simulation o the gra ed at (shown in blue) (arrow).
Fig. 34-4
T e level o inf ltration is o paramount importance. Endoscopic assistance is critical to conf rm assess-
ment o the position o the cannula, the injection site, and the amount o at released. T e parcels o atty
tissue should be injected anterior to the prevertebral ascia, possibly within the f bers o the superior
constrictor muscle at the level o the axis. However, injecting at behind the prevertebral ascia, in the

630
Part III • Clinical Applications • Face and Neck: Reconstructive
loose space that exists immediately anterior to the bodies o the vertebrae (as shown in the cadaveric
dissection above), potentially results in dislocation o the graf caudally, along the natural cleavage plane.
T e dissection clearly shows this important detail. Numerous tunnels are made to maximize the contact
between the graf ed at and the host tissue. Micro at parcels are released in multiple directions, always as
the cannula is withdrawn, leaving a spaghetti-like thread o at.18
An average o 2 cc o at is injected per side. T e entry points are then closed with a 5- absorbable su-
ture, i necessary. Injecting at centrally along the posterior pharyngeal wall is not risky. However, as we
shall see later, the risk increases when at is injected laterally, where the large vessels o the neck course.
Injecting Fat Into the Sof Palate
Fig. 34-5
When injection o the nasopharyngeal area is complete, at is graf ed into the velum, particularly along
the midline on the nasal side o the uvula, with a dual goal o sof ening the scars that resulted rom the
previous clef palate procedure and creating a bulge to improve the contact between the velum and the
posterior pharyngeal wall.

631
Chapter 34 • reatment o Velopharyngeal Incompetence With Autologous Fat Gra ting
Fig. 34-6
ypically, f ve stab incisions are made on the velum, the f rst one on the nasal sur ace o the uvula.
Above, dots indicate the position o stab incisions at the level o the velum. I the midline velar scar is
particularly sti , scar release is carried out with an 8-gauge sharp needle using continuous clockwise
and counterclockwise movements; 2 or cc o at is then inserted in the plane between the nasal mucosa
and the oral mucosa. T e second stab incision is made at the level o the arch o the tonsillar ossa; an
average o 2 cc o at is injected. T ird, the same amount is placed in the contralateral side. A ourth and
f h incision is placed on either side o the velum musculature, 0 mm rom the midline.
Fat gra ing to the so palate is a sa e procedure with minimal risks o complications. T e overall amount
o injected at between the pharyngeal walls and so palate ranges rom .5 to 2 cc, depending on the
gap severity and on the patient’s age, and is less in small children. However, it is well known that trans-
planted at undergoes a certain degree o reabsorption, which varies rom 20% to 80%, depending on
numerous actors. For this reason, it is essential that the in ormed consent indicate the possibility o
urther procedures to optimize the results.

632
Part III • Clinical Applications • Face and Neck: Reconstructive
SPECIAL CASES
In patients with a submucous cle , the congenitally separated heads o the levator muscle are sutured,
and concurrently, at injection is per ormed to improve the results. T e technique is as ollows. A 5 mm
incision is made along the midline o the palate at the junction between the velum and the posterior na-
sal spine and the bony area is exposed. T e levator muscle bundles attached to the posterior nasal spine
and to the palatal plate are identif ed, released with a blunt dissector, retropositioned, and sutured end-
to-end along the midline with interrupted 4-0 nylon sutures. Fat injection is carried out concurrently
on the our walls o the VP port to improve the results obtained by suturing o the levator sling and to
diminish the closure gap by creating an overall augmentation o the pharyngeal walls and o the velum
itsel .
POSTOPERATIVE CARE
No special care considerations are required in the postoperative course. Prophylactic antibiotic treat-
ment is administered in every case. Patients are usually discharged a er 4 hours.
R esul ts
None o our patients experienced respiratory obstruction a er surgery. No negative sequelae such as hy-
ponasality, sleep apnea, or airway compromise was seen a er at gra ing. However, it has been reported
that obstructive sleep apnea (OSA) related to a signif cant weight gain, with consequent at growth at
the VP port, may present a potential risk.19 In our series we observed a similar case, ortunately without
OSA consequences. At the site o the right posterior pharyngeal wall, the patient developed a moderate
at accumulation year a er at gra , which became more pronounced over years in connection with
the patient’s signif cant weight gain (see Fig. 4- ).
Fig. 34-7
T is patient presented with retracted scars a er a cle palate repair. He is shown 5 months a er one at
gra ing session to the velopharynx, with a so ened scar. T e total amount injected was 0 cc.

633
Chapter 34 • reatment o Velopharyngeal Incompetence With Autologous Fat Gra ting
Fig. 34-8
T is patient had retracted scars a er a cle palate repair. T e resultant so ened scars are shown 1 year
a er two at gra ing sessions in which a total o 20.5 cc (9 cc and 11.5 cc per session) was injected.
Fig. 34-9
T is patient had a submucous cle and a bif d uvula and is shown 1 year a er levator sling reconstruc-
tion and a concurrent at gra ing session into the posterior and lateral pharyngeal walls and velum. T e
total amount injected was 11 cc.
Fig. 34-10
T is nasopharyngoscopic view o the VP port is o a patient who underwent pharyngeal ap surgery
elsewhere. Note the persistence o the closure gap, which was responsible or nasal air escape. T e result
is shown 1 year a er one session o at gra ing; velopharyngeal competence has been achieved. T e
closure o the gap obtained with the injection o at is evident. T e total amount o at gra ed was 1.5 cc.

634
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 34-11
In this patient, moderate at accumulation is seen in this nasopharyngoscopic view o the VP port at
the site o the right posterior pharyngeal wall year a er at injection ( cc injected). Seen years a er
the procedure, during which time the patient had a signif cant weight gain, the bulge became more pro-
nounced, but ortunately, there were no unctional consequences.
C om p l i ca ti on s
No complication occurred in our series o patients. However, like every procedure, at gra ing is subject
to complications. o avoid them it is essential or the surgeon to have excellent knowledge o anatomy
o the head and neck, in particular o the course o the large vessels o the neck. T ere is a risk o in-
jecting at into the pharyngeal vessels or into the carotid artery. Potential catastrophic complications
may occur. In per orming at injection into the velopharynx, it is essential to use blunt cannulas only,
never sharp needles, to avoid injecting at into the vessels or injuring the internal carotid artery, which
courses laterally, but in some syndromic patients, such as in those with a velocardio acial syndrome,20
the artery could be more medially dislocated. In a dramatic event occurred in a British hospital:
small amounts o at ( . to . cc) were injected in the posterior and lateral pharyngeal walls to treat
VPI in an 8-year-old girl with sequelae o cle palate repair. T e gra ed at was accidentally introduced
into the carotid artery. Instead o a blunt cannula, the surgeon used a -gauge needle connected to a
cc syringe. Sadly, immediately therea er, the patient su ered a massive stroke as a consequence o at
embolism. At years a er the incident, the patient is still aphasic, hemiplegic on the right side, and her
le eye is amaurotic.21
D i scu ssi on
Surgical management o VPI is per ormed to improve voice resonance and correct nasal air escape by
restoring a competent VP sphincter. It is critical to select patients properly, so that the most e ective
procedure can be chosen. Assessment o VPI requires examination o multiple variables, rom percep-
tual evaluation o speech intelligibility to aerodynamic assessment o nasal air escape. A key actor or
surgical planning is the dynamic study o the VP sphincter movements during speech and quantif cation
o the closure gap, using exible videonasoendoscopy and/or video uoroscopy.
Mild to moderate VPI, the so-called borderline conditions, characterized by minimal nasal air escape,
constitute a true dilemma or surgeons. In these cases, velopharyngoplasty represents an overtreatment,
potentially causing permanent sequelae such as respiratory obstruction, snoring, and OSA. Augmenta-
tion o the posterior pharyngeal wall using the currently available biomaterials is o en unsuccess ul. Re-
absorbable implants vanish within a ew months, whereas permanent implants may migrate, extrude, or
give rise to oreign body reactions.10-12,22,23 Commonly, the wait-and-see approach involves endless and
stress-producing speech therapies, ocused on improving oral articulation and increased velar “strength-

635
Chapter 34 • reatment o Velopharyngeal Incompetence With Autologous Fat Gra ting
ening.” When one calculates the risk-to-benef t o the previously mentioned major procedures, o en
these patients are not considered good candidates or additional surgery.
Fat gra ing to reduce the passage between the oropharynx and the nasopharynx o ers several advan-
tages to the patient. Morbidity is considerably less than in traditional operations, anatomy o the pha-
ryngeal walls is not altered, the procedure can be repeated, i necessary, and f nally, the postoperative
course is unremarkable.
Fig. 34-12
T is patient had retracted scars a er cle palate repair. T e patient is seen 7 years a er three sessions o
at gra ing, with so ened scars. T e total amount o at injected was . cc ( . cc, cc, and cc per
session).
Fat injection or the treatment o VPI ulf lls a dual goal: it reduces the existing gap between the oral and
nasal cavity, thus limiting nasal air escape, and it so ens scar contractures in patients with VPI ollowing
cle palate repair. Once the midline scar has been released and has become more pliable, the velum’s el-
evation is improved, acilitating its approximation to the posterior pharyngeal wall. A urther advantage
o at injection is the possibility o maintaining the results by per orming repeat at injections when acial
growth takes place, i decompensation o velopharyngeal closure occurs.
In patients with submucous cle palate, which is o en associated with a congenital short palate,24 at
gra ing per ormed concurrent with the suturing o the congenitally separated heads o the levator mus-
cle has proved e ective in gaining palatal length and in diminishing the gap between the velum and the
posterior pharyngeal wall.16 T is is an innovative procedure that requires urther objective analysis.
C oncl usi on
Fat gra ing is a minimally invasive alternative to major surgery or the management o mild to moderate
VPI and minimizes the risk o complications and sequelae. T is versatile procedure can be per ormed in
a customized manner, depending on the requirements o each patient without modi ying the anatomy
o the VP port.
Overenthusiastic injection or injection o a at bolus to urther reduce the VP gap is an inappropriate
treatment; it can cause ormation o oily cysts.25 T e maneuver in which a very small, spaghetti-like parcel
of fat is injected as the cannula is withdrawn is the ideal technique to maximize sur ace contact with the
host tissue, thus enhancing the survival o at parcels.18

636
Part III • Clinical Applications • Face and Neck: Reconstructive
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
REFERENCES
1. Sommerlad BC, Mehendale FV, Birch MJ, et al. Palate re-repair revisited. Cle Palate Cranio ac J 9:295,
2002.
2. Furlow L Jr. Cle palate repair by double opposing Z-plasty. Plast Reconstr Surg 78:724, 198 .
. Dorrance GM, Bransf eld JW. T e push-back operation or repair o cle palate. Plast Reconstr Surg
(194 ) 1:145, 194 .
4. Schönborn K. Über eine neue Methode der Staphylorraphie. Arch Klin Chir 19:527, 187 .
5. Rosenthal W. Zur Frage der Gaumenplastik. Zbl Chir 51:1 21, 1924.
. Sanvenero Rosselli G. La Divisione Congenita del Labbro e del Palato. Roma: Pozzi, 19 4.
7. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg :128, 1950.
8. Orticochea M. Construction o a dynamic muscle sphincter in cle palates. Plast Reconstr Surg 41: 2 ,
19 8.
9. Passavant G. Über die Verbesserung der Sprache nach der Uranoplastik. Verh Dtsch Ges Chir 7:128,
1878.
10. Gersuny R. Über eine subkutane Prothese. Ztschr Heilk 21:199, 1900.
11. Sturim HS, Jacob C Jr. e on pharyngoplasty. Plast Reconstr Surg 49:180, 1972.
12. Brigger M , Ashland JE, Hartnick CJ. Injection pharyngoplasty with calcium hydroxylapatite or velopha-
ryngeal insu ciency: patient selection and technique. Arch Otolaryngol Head Neck Surg 1 : , 2010.
1 . Cantarella G, Mazzola RF, Mantovani M, et al. Fat injections or the treatment o velopharyngeal insu -
ciency. J Cranio ac Surg 2 : 4, 2012.
14. Filip C, Matzen M, Aagenaes I, et al. Autologous at transplantation to the velopharynx or treating per-
sistent velopharyngeal insu ciency o mild degree secondary to overt or submucous cle palate. J Plast
Reconstr Aesthet Surg : 7, 201 .
15. Bardot J, Salazard B, Casanova D, et al. Les séquélles vélopharyngées dans le entes labioalvéolopala-
tovélaires: pharyngoplastie par lipostructure du pharynx. Rev Stomatol Chir Maxillo ac 108: 52, 2007.
1 . Mazzola RF, Cantarella G, Mazzola IC. Regenerative approach to velopharyngeal incompetence with at
gra ing. Clin Plastic Surg 42: 5, 2015.
17. Lam DJ, Starr JR, Perkins JA, et al. A comparison o nasendoscopy and multiview video uoroscopy in
assessing velopharyngeal insu ciency. Otolaryngol Head Neck Surg 1 4: 94, 200 .
18. 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.
19. eixeira RP, Reid JA, Greensmith A. Fatty hypertrophy cause obstructive sleep apnea a er at injection or
velopharyngeal incompetence. Cle Palate Cranio ac J 48:47 , 2011.
20. Baek RM, Koo Y , Kim SJ, et al. Internal carotid artery variations in velocardio acial syndrome patients
and its implications or surgery. Plast Reconstr Surg 1 2:80 e, 201 .
21. Filip C. Response re: Autologous at gra ing or the treatment o velopharyngeal insu ciency: state o the
art. J Plast Reconstr Aesthet Surg 7:1155, 2014.
22. Gaza von W. Über reie Fettgewebstransplantation in den retropharyngealen Raum bei Gaumenspalte.
Arch Klin Chir 142:590, 192 .
2 . Hagerty RF, Hill MJ. Cartilage pharyngoplasty in cle palate patients. Surg Gynecol Obstet 112: 50, 19 1.
24. Weatherley-White RC, Sakura CY Jr, Brenner LD, et al. Submucous cle palate. Its incidence, natural
history, and indications or treatment. Plast Reconstr Surg 49:297, 1972.
25. Kato H, Mineda K, Eto H, et al. Degeneration, regeneration, and cicatrization a er at gra ing: dynamic
total tissue remodeling during the f rst months. Plast Reconstr Surg 1 : 0 e, 2014.

637
C h a p t e r 3 5
A v r v r r v ’ q
v q . I v r -
r ; r v r r j b r r r r
b b b r r v r r r
r v r r r r r . V r r q
v r , r r r ; r k r
v r b , br v , b r r r r -
r . O x b f r r , w
q r k , v zz b r r r
k . I , b r r v x b r r q r
b v .
B r , v r r q r v f r
v r b q v br v ; r r
rr rf r b v r v br r r . V
r b r r , b v
r .1 I v r r r r , r
v v r b . G r r
r v br v r r v q . T r r
rr z v x r
r rv r 2 r b j v w r r
.3 T b r r x-
,4 r x ,5 r ,6 r z r .7 T v
r , r 8; w v r, -
r, r b r , x r , r b , w
b r w r .9
T z r 10 .11-13 T w r
b M k 4 Br b r ,15 w r r r
r . S b q , v r r b r x r b
r r rr , r v r r .16-18 B
v r b r r , v (VFFA) w r r r rr -
r r , r r rr r -
2 r j b r , w bv r r ’ k r r-
v r .
Vocal Fol d Augment at ion
in t he Dysphonic Pat ient
Giovanna Cantarella, Riccardo F. Mazzola
637

638
Part III • Clinical Applications • Face and Neck: Reconstructive
A new interest in the use o at arose with the advent o the liposuction technique. In addition, basic
research over the last decades has demonstrated that at stromal vascular raction contains a popula-
tion o cells that have the typical eatures o mesenchymal stem cells (MSCs)19 capable o sel -renewal
and di erentiation into multiple cellular lineages. Several researchers around the world investigated the
di erentiation potential o the adipose-derived stem cells (ADSCs).20,21 A characterization study was
per ormed in our hospital on the lipoaspirate obtained rom patients undergoing VFFA; the results have
conf rmed the high concentration o MSCs in the lipoaspirate and the embryonic state and multipotency
o these cells.22
Autologous at obtained by liposuction is so and easily di uses into the vocal old layers. It does not al-
ter the elasticity o the glottic vibrator, even i injected in Reinke’s space, the superf cial layer o the vocal
old. Chan and itze23 demonstrated that the viscosity o at is similar to the content o Reinke’s space, so
no impairment o vibration should be expected.
However, despite these avorable characteristics, the role o VFFA is still debated, mainly because o the
unpredictability o the amount o resorption, possibly related to di erent modalities o at harvesting
and processing. Some authors reported good long-term results,24,25 whereas other retrospective studies
highlighted a high long-term ailure rate.17,18 Quantitative data about injected at survival are still con-
troversial.26,27 Coleman28 showed the importance o atraumatic at harvesting, processing, and injection
to preserve the integrity o the adipocytes and their f brovascular support. We applied these principles
while per orming VFFA.
In this chapter, the authors will describe the technique utilized to improve voice quality and swallowing
e ciency by means o VFFA in patients a ected by de ective vocal old closure during phonation and
swallowing.
M
a teri a l a n d M
eth od s
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS
OF THE VOCAL FOLDS
T e vocal olds are the source o the voice; sound is produced through vibration o the expiratory air-
stream. T e larynx acts as an energy transducer capable o trans orming aerodynamic power ( rom the
expiratory air ow) into acoustic energy (the voice sound). Yet the vocal olds have a crucial role in other
vital unctions; they are a highly mobile and specialized structure with three main activities: respiratory,
sphincteric, and phonatory. T ey open during inspiration to reduce resistance in the upper airway and
to let the airstream ow toward the lungs, and they tightly close the airway passage during swallowing
to prevent ood rom entering the airway. T e respiratory and sphincteric activities o the larynx are
essential or li e and are the two primordial unctions o this organ. Phonation is a more recent special-
ization o the vocal olds, essential or verbal communication and social relationships. T e vocal olds
close during phonation, thanks to contraction o the vocal old adductor and tensor muscles. Complete
vocal old closure is a critical actor in achieving an e cient voice, because it allows subglottal pressure
to rise up to a threshold that will elicit the olds’ vibration. A gap in closure gives rise to dysphonia; this
can be caused by a motility impairment (more commonly a paralysis or paresis o the recurrent laryngeal
nerve) or by a so tissue de ect o the vocal old itsel rom congenital or acquired conditions. Laryngeal
paralysis may be idiopathic, iatrogenic (mainly secondary to neck or thoracic surgery), or a consequence
o accidental trauma. T e majority o iatrogenic paralyses ollow thyroid ablative surgery. A vocal old
tissue de ect may be caused by previous endolaryngeal surgery or benign or malignant lesions or may
result rom minor mal ormations.29 Less requently, vocal old scarring is caused by external trauma
(laryngeal racture) or prolonged endotracheal intubation.

639
Chapter 35 • Vocal Fold Augmentation in the Dysphonic Patient
Vocal fold
Vocal ligament
Vocalis muscle
Thyroid cartilage
Posterior view
Squamous
epithelium
Vocal ligament
(intermediate and
deep layers of
lamina propria)
Vocalis
muscle
Reinke’s space
(superficial layer of
lamina propria)
Posterior
Superior view
of vocal folds
Anterior
Fig. 35-1
Understanding the phonatory def cits caused by laryngeal paralysis requires knowledge o the vocal
old’s anatomy and physiology. T e above drawings show a posterior view o the larynx and a vocal old.
T e complex structure o the vocal olds is illustrated, with a detailed view o the vocalis muscle. T e vo-
cal old comprises several layers. T e innermost part is the vocalis muscle, which extends rom the aryte-
noid to the inner angle o the thyroid cartilage. On its sur ace lies the lamina propria, which is composed
o three layers: superf cial (rich in elastin f bers and uids, called Reinke’s space), intermediate, and deep
(these last two, rich in collagen f bers, constitute the vocal ligament). T e outermost layer is a stratif ed
squamous epithelium. T ese components have di erent viscoelastic properties and play di erent roles
in sound production. Schematically, they orm a body (the intermediate and deep layers o the lamina
propria and muscle) and a cover (epithelium with the superf cial layer o the lamina propria).
T e body-cover model helps explain how sound production takes place: a mucosal wave is generated by
the air pressure in the lower part o the vocal olds and ows upward, giving rise to the vibratory cycle
with repeated opening and closing o the olds.
T e body o the vocal old acts as a sti inner component that allows the overlying ow o the mucosal
wave generated into the pliable cover. It can be easily understood that a voice alteration may be caused
either by weak or de ective closure o the vocal olds or by sti ness o the superf cial layer, which plays a
key role in sound production.
I vocal old closure is inadequate, the sphincteric unction o the larynx can be a ected, and aspiration
o ood can occasionally occur, particularly oods with a liquid consistency. Hence patients a ected by
severe dysphonia caused by glottic incompetence o en report episodes o coughing while ingesting u-
ids, resulting rom episodes o leakage in the supraglottis or aspiration below the vocal olds.

640
Part III • Clinical Applications • Face and Neck: Reconstructive
Fat gra ing in the vocal olds ulf lls one or both o the ollowing goals:

1. Medialization o the de ective old to obtain complete closure during both phonation and sphinc-
teric closure o the larynx ( or example, swallowing, coughing, and the Valsalva maneuver)

2. Restoration o the de ective gliding tissue in the superf cial layer (cover) to reestablish oating o
the mucosal wave and sound production.
INDICATIONS AND CONTRAINDICATIONS FOR VOCAL FOLD
FAT AUGMENTATION
In our experience, the main indication or VFFA is insu cient closure o the vocal olds as a result o the
ollowing conditions:
• Unilateral laryngeal paralysis or paresis (caused by a lesion o the in erior laryngeal nerve, also
known as the recurrent nerve), which causes a accid paralysis o the unilateral vocal old
• Mal ormations o the vocal old structure, such as sulcus glottidis or sulcus vergeture (congenital
adherence o the epithelium to the ligament, with missing gliding tissue o Reinke’s space)
• Scarring rom previous surgery ( or benign or malignant lesions o the vocal olds)
• Scarring rom prolonged intubation or laryngeal racture or contusion
• So tissue de ects rom previous oncologic surgery
• Vocal old sti ness rom previous radiotherapy
• Aging-related laxity o the vocal muscles, (this condition is known as presbyphonia)
• A secondary procedure ollowing ailure o a previous augmentation by injection o an implant
(with an eventual in ammatory reaction and secondary tissue sti ness)
All the conditions mentioned have been encountered and treated in our practice.
T e ollowing contraindications have been identif ed:
• Recipient site: T e procedure is absolutely contraindicated i the patient is a ected by e ort dys-
pnea caused by glottic stenosis. T e typical case is paralysis o both vocal olds.
• Donor site: No contraindications are known; the procedure can be easily per ormed, even in un-
derweight patients, because the amount o at necessary to achieve VFFA is very limited.
PREOPERATIVE EVALUATION
Laryngeal Assessment and Voice Evaluation
A multidimensional assessment is essential or evaluating voice outcomes. It is important to highlight
not only the “aesthetic” acoustic changes o voice quality but also to demonstrate whether the atigue
determined by voice production has been reduced. T ere ore the patients undergo the ollowing evalua-
tions preoperatively and postoperatively:
• Videolaryngostroboscopy using a exible or 7 -degree rigid f beroptic endoscope, which allows
the preoperative documentation o the site and severity o the glottic gap, vocal old vibration
abnormalities, and objective assessment o postoperative changes
• Maximal phonation time measurements obtained during the production o a sustained vowel /a/.
T is is considered the simplest way to obtain an indirect measure o glottic closure. T is is an
aerodynamic parameter, which is also in uenced by the patient’s vital capacity.
• Perceptual voice evaluation by means o the GRBAS,30 which includes these f ve parameters:
– Grade o dysphonia (G)
– Roughness (R)
– Breathiness (B)
– Asthenia (A)
– Strain (S)

641
Chapter 35 • Vocal Fold Augmentation in the Dysphonic Patient
• Patient sel -assessment by means o the questionnaire Voice Handicap Index (VHI).31
• Acoustic analysis o a voice sample by the MDVP so ware (Kay Pentax).
• Measurement o aerodynamic parameters such as oral air ow during phonation and subglottic
pressure.
• In selected cases, radiologic studies (MRI and/or C scan) have been obtained either postopera-
tively or both preoperatively and postoperatively to evaluate persistence o the at gra within the
treated vocal old.
Laboratory Study
A sample o the lipoaspirate obtained rom some o the patients who received autologous transplantation
has been processed in the Cell Factory o our hospital, dedicated to basic and translational research or
cellular isolation and characterization, primarily intended to analyze the quantity and developmental
capabilities o the MSCs o the stromal vascular raction and to better def ne their identity. Methods and
results have been described in detail elsewhere.22,32
OPERATIVE TECHNIQUE
During the surgical procedure, the use o an operative microscope is mandatory or diagnostic and
therapeutic purposes. T e detailed anatomy o the vocal old may be better ascertained with magnif ed
tridimensional vision, and intraoperative vocal old palpation can be per ormed with the use o specif c
microinstruments. Palpation acilitates detection o requently overlooked congenital anomalies, such as
sulcus vocalis (invagination and adherence o the epithelial sur ace to the vocal old ligament).
Fat parcels must be placed in a multilayered pattern in the thickness o the whole vocal old and in the
paraglottic space to enhance gra vascularization.
Video recording o laryngoscopic assessments and the surgical procedure are o paramount importance
to objectively ascertain the obtained changes during ollow-up. Voice recording and analysis be ore and
at all postoperative ollow-up visits highlight the improvements in voice quality achieved through at
gra ing.
A multidimensional protocol or voice evaluation may highlight the voice changes a er surgery rom
di erent points o view: videolaryngoscopic, perceptual, acoustic, aerodynamic, and rom the patient’s
perspective.
Harvesting and Processing o Fat Graf
T e procedure is per ormed with the patient under general anesthesia, which is necessary to per orm
VFFA under direct rigid microlaryngoscopy. Fat is usually harvested rom the lower abdomen or the
lateral thigh, or the inner thigh or inner knee in slender patients. Donor sites are inf ltrated with 0 ml
o lidocaine and epinephrine : 00,000.
Fatty tissue is harvested by means o a curetting action under mild negative pressure. We use a 0 cc
Luer-Lok syringe connected to a mm three-hole cannula to reduce the negative pressure and limit
potential trauma to adipocytes. o provide negative pressure, the plunger o the syringe is retracted and
maintained in that position by means o a towel clamp.
T e lipoaspirate is processed according to the Coleman protocol.28 A er separation rom the blood and
oily components, the atty layer is trans erred to a cc Luer-Lok syringe using a Luer-Lok to Luer-Lok
adapter.

642
Part III • Clinical Applications • Face and Neck: Reconstructive
Determination o the Volume Needed
It is di cult to exactly quanti y the amount o gra ed at, because some o it oozes out while withdraw-
ing the needle, but a total o 0.5 to 3.0 cc (average 1.5 cc) is injected during this withdrawal motion in the
paralyzed or scarred vocal old. T e de ective vocal old is overcorrected until it approximately doubles
its initial volume. We usually inject a smaller amount o at (0. to 0.5 cc) in the healthy vocal old as well
to urther reduce the closure gap between the two olds, because the space available or hosting at in one
single vocal old is anatomically limited. I both vocal olds are treated, only one is overin ated to avoid the
risk o respiratory obstruction. Nevertheless, none o our patients has experienced postoperative dyspnea.
Placement o Fat Graf s
Fig. 35-2
T e operative setting or vocal old at injection under microlaryngoscopic vision is shown. Vocal olds
are visualized on a screen during the microlaryngoscopic procedure; the screen allows the assistant to
correctly place external manual pressure on the anterior neck to provide optimal visualization o the
sites to be injected.
T e patient is typically under general anesthesia and curarized with curare. A rigid laryngoscope allows
visualization o the vocal olds; it is usually suspended on a small table to avoid causing any movement o
the tiny surgical f eld and to allow the surgeon to use both hands while per orming the procedure. Mag-
nif cation allows the surgeon to identi y microscopic anatomic details to precisely place at microparcels
in multiple sites and eventually per orm other surgical procedures, such as release o any adherences or
tissue ablation with the use o microinstruments, as required.
Fig. 35-3
Fat parcels are placed with the use o a lipoinjection handle (Medicon Instruments, uttlingen, Ger-
many) attached to a 1-gauge, cm-long disposable bayonet needle (prototype, T iebaud Medical,
Margencel, France).

643
Chapter 35 • Vocal Fold Augmentation in the Dysphonic Patient
Fig. 35-4
T is videolaryngoscopic view is o a patient with a typical case o le vocal old paralysis. T e le para-
lytic old (right) is hypotrophic, with a bowing prof le. T e entry points are indicated (arrows): the para-
lyzed old is injected in f ve points, whereas the contralateral normal vocal old is injected in two points.
Fig. 35-5
A

B
T is intraoperative microlaryngoscopic view o the vocal olds is shown during the at injection pro-
cedure. Be ore injection (A), the atrophy o the paralyzed right vocal old is evident. At the end o the
procedure (B), the paralytic old has more than doubled its volume.
Small at parcels are injected under direct microlaryngoscopic vision. For vocal old paralysis, the level
o at injection is in the depth o the paralyzed vocalis muscle, usually starting at the posterior third. T e
injection is per ormed slowly to avoid excessive positive pressure, and the needle is gently retracted, al-
lowing the at to di use in several layers. Multiple injections are per ormed along the whole body o the
vocal old and in the paraglottic space, lateral to the vocalis muscle, until the paralyzed old has almost
doubled its volume, as shown above. For patients with so tissue de ects, injections are per ormed in
the whole thickness o the vocal old, especially in the superf cial layers, to ree and so en the cicatricial
tissue and to restore the vibratory capability.
Postoperative Care
Intravenous amoxicillin and clavulanate (1000 plus 200 mg) or clarithromycin 2 0 mg twice a day is
administered on the day o surgery, and then by mouth twice a day or the next days. No other special
postoperative care is required. Absolute voice rest is prescribed or the 2 hours a er surgery, with rela-
tive voice rest or 1 week. Patients are usually discharged within 2 hours a er the operation.

644
Part III • Clinical Applications • Face and Neck: Reconstructive
R esul ts
o date we have per ormed 180 VFFAs in 151 patients (27 o them required a second procedure, and
2 o them a third one to urther enhance the phonatory result). T e majority o patients were a ected
by unilateral laryngeal paralysis. Voice quality improved a er surgery in all patients, with a return to
a perceptually normal voice in most laryngeal paralyses. T e voice results stabilized within 3 months
postoperatively and remained stable a erwards with a trend o urther improvement over the ollowing
months. All patients reported reduced e ort during voice production and an improvement in their
social and pro essional lives.
A

B
Preoperative view: inspiration and phonation
C

D
5 years after VFFA
Fig. 35-6, A-D
T is 72-year-old man underwent esophagectomy and esophagogastroplasty or esophageal cancer 1 year
be ore our observation. He was a ected by severe breathy dysphonia caused by a lesion o the le recur-
rent laryngeal nerve and consequent le vocal old paralysis. Preoperative views o the vocal olds were
obtained by exible videolaryngoscopy: A, inspiration and B, phonation. Notice that the le vocal old
is hypotrophic, with a concave margin indicative o accidity. Consequently, during phonation the olds
did not approximate, causing a whispered voice. C and D, Videolaryngoscopy was per ormed 5 years a -
ter VFFA, during which 2 cc was injected in the paralyzed old. Voice improvement was evident the f rst
week a er the operation. T e paralyzed le old was trophic and had a straight margin; glottic closure
was still complete 5 years postoperatively. His voice sound was normal.

645
Chapter 35 • Vocal Fold Augmentation in the Dysphonic Patient
Fig. 35-6, E-G
E

F
G
MRI 26 months after VFFA
E through G, An MRI study o the larynx was per ormed 2 months a er VFFA. T e transplanted at
(red arrows) is easily visible inside the le vocal old, both in axial (lef ) and coronal (center and right)
planes.
Fig. 35-7
A

B
C Single
token
Threshold
D
Threshold
Single
token
T is -year-old man had a severely breathy voice 8 months a er a le carotid endarterectomy. Vid-
eolaryngoscopic images were obtained through rigid endoscopy. A, T e le vocal old was paralyzed
and signif cantly atrophic, and a wide gap o glottic closure was seen on phonation. He underwent in-
jection o 2. cc o at in the le vocalis muscle and regained a normal voice within a month. B, T e
result 9 months postoperatively is shown on laryngoscopy, demonstrating complete glottic closure and a
near-normal trophic le old. C, Preoperatively, the patient’s voice was a noisy whisper. MDVP acoustic
analysis showed that all considered parameters were outside normal limits, indicated by the green area
o the graph. D, Fourteen months a er surgery, MDVP analysis showed that voice requency and ampli-
tude stability indices were within normal limits.

646
Part III • Clinical Applications • Face and Neck: Reconstructive
Fig. 35-8
D
E
F
B
C
A
T is 39-year-old woman had severe dysphonia ollowing le vocal old injection with polydimethylsilox-
ane per ormed elsewhere 1 year earlier or a le vocal old paralysis. She recovered rom the paralysis but
not rom her dysphonia as she developed a severe oreign body reaction in the treated old. On the le
(A) the arrow indicates the hyperemic area where the in ammatory reaction took place, the two olds
are viewed during phonation, they do not close adequately due to rigidity on the le side. She underwent
direct microlaryngoscopy and a biopsy was taken in that area; histology showed in ammatory oreign
body reaction with giant cells surrounding the particles o silicone (D). T e postlipof lling laryngoscopic
view (B) reveals resolution o the superf cial in ammation 1 months a er surgery. Due to some per-
sistent vocal atigue she underwent a second lipoinjection; the result is shown in C: the le vocal old is
straight and no more in ammation can be seen; during phonation glottic closure is achieved. T e arrow
points at the at tissue that has created a cushion over the implant burying it. Voice results are stable a er
years. E through F show the intraoperative microlaryngoscopic view (second operation) be ore (E) and
a er injection (F) o the le old.
C om p l i ca ti on s
T e postoperative course is usually unevent ul. T e main potential complication, which can occur a er
any augmentation procedure per ormed within the larynx, is airway obstruction. T is could be caused
either by excessive vocal old medialization, edema, or both. Nevertheless, this situation is very un-
likely and never occurred in our series. No signs o in ection at injection sites have ever been detected;
nevertheless we require a postoperative examination 7 days a er surgery and in di cult cases, which
eventually show some vocal old rigidity due to in ammatory reaction, steroids are prescribed or a ew
days by mouth.

647
Chapter 35 • Vocal Fold Augmentation in the Dysphonic Patient
Some patients experience a sensation o ullness in the larynx in the f rst week a er the operation. We
in orm patients that this can occur but usually subsides in a ew days. However, none o our patients
developed stridor at any time.
D i scussi on
Vocal old injection is a straight orward and minimally invasive procedure or increasing vocal old vol-
ume and restoring glottic closure in cases o glottic incompetence. Autologous and alloplastic materials
have been used over the years. Implants and biomaterials, such as e on, silicone and calcium hydrox-
ylapatite, can migrate and give rise to oreign body reactions and the ormation o granulomas 9,33; vocal
old chronic in ammatory reactions cause tissue sti ness altering the vocal old vibratory properties,
and respiratory obstruction might also be a earsome consequence.34 A so autologous material with
rheologic properties similar to those o vocal old so tissue is desirable to preserve the viscoelastic
properties o the vibrating tissues.
In contrast to most authors who per orm a bolus injection into the vocal old we inject at into several
layers to avor cell nutrition, oxygenation, and integration, to maximize contact between at parcels and
host tissue. T is might explain the avorable stable results obtained in our series.
o evaluate whether VFFA could cause long-term impairment o respiratory ows and airway resistance,
we per ormed a spirometric and plethysmographic study that demonstrated that inspiratory and expi-
ratory ows are not modif ed postoperatively, while a subclinical increase o airway resistance occurs.
T is study has conf rmed the sa ety o VFFA, that does not modi y airway patency.35 Conversely, several
o our patients, especially those a ected by vocal old paralysis, report that a er surgery they perceive
higher patency o their airway, both during e ort and during speech. It is intuitive to understand why
they have no more speech dyspnea as there is no more air leakage through the vocal olds during phona-
tion. It is more cumbersome to explain why they spontaneously report a subjective reduction o airway
obstruction during e ort, in spite o the per ormed vocal old volume augmentation. We may explain
this phenomenon by a change o the aerodynamic behavior o the upper airway. T e paralyzed vocal
old, a er f lling and potential tissue regeneration, loses accidity consequent to the paralysis; there ore
during inspiration it will no longer move in the airway as a ag in the wind. As a f nal result o this “sta-
bilization,” the paralyzed old will not be sucked into the glottic space by the negative pressure caused by
airstream on inspiration and the airway will no longer be obstructed.
Our avorable clinical results with 80 VFFAs in patients since 200 are urther evidence o the
e cacy and low morbidity o at gra ing,11,36 supporting the hypothesis that the results o at gra ing
into vocal olds are technique dependent and that the regenerative potential o the lipoaspirate cellular
components may play an important role in vocal old augmentation and regeneration.
wenty-seven o cases ( . %) necessitated a reinjection to achieve urther voice improvement. All
these patients had obtained a voice improvement rom the f rst procedure, but a multistep treatment
was necessary due to the severe so tissue def cit. T e patients undergoing multiple procedures (2 pro-
cedures in 2 cases and in 2 cases) were treated either or an extensive so tissue de ect resulting rom
previous oncological treatment or or vocal muscle severe atrophy due to a long-term laryngeal paralysis.
In conclusion, at augmentation o the vocal olds is a simple and e ective procedure that o ers the
patients good and stable results or voice improvement. T e use o autologous material avoids the risk
o oreign body reaction, which would cause irreversible voice impairment. Furthermore, the regenera-
tive properties o a vital tissue are mostly desirable in the treatment o de ective vocal olds, in order to
reestablish an e cient source o the vocal sound, to achieve e ective verbal communication or social
relationships and pro essional requirements.

648
Part III • Clinical Applications • Face and Neck: Reconstructive
T ech ni ca l P ea rl s
• Correct identif cation o the vocal old area to be treated is critical or selective management.
• Use o a stroboscopic light during videolaryngoscopy is mandatory as a naked eye is unable to appre-
ciate a phenomenon as rapid as the vocal old’s vibratory cycle.
• Fat harvesting under mild negative pressure, manipulation according to Coleman,28 and immediate
multilayered reinjection in the vocal old are essential.
• Bolus injection should be avoided.
• Injection should be mainly in the deep layers in case o paralysis (in the accid and hypotrophic voca-
lis muscle, and in the paraglottic space) and in all the layers in case o so tissue de ects.
• Injection can be used to ree the superf cial layer and restore the gliding tissue responsible or sound
production; at has the same viscoelastic properties as the normal content o the vocal old superf cial
layer.23
• In case o a signif cant closure gap (which means most o the cases requiring treatment), both vocal
olds should be augmented. T e healthy vocal old should receive only a small amount in its depth to
avoid risks o respiratory obstruction.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
REFERENCES
1. Cantarella G, Viglione S, Forti S, Pignataro L. Voice therapy or laryngeal hemiplegia: the role o timing o
initiation o therapy. J Rehabil Med : , 010.
. Isshiki N. Progress in laryngeal ramework surgery. Acta Otolaryngol 1 0:1 0, 000.
. Courey MS. Injection laryngoplasty. Otolaryngol Clin North Am 7:1 1, 00 .
. Bergamini G, Alicandri-Ciu elli M, Molteni G, et al. T erapy o unilateral vocal old paralysis with
polydimethylsiloxane injection laryngoplasty: our experience. J Voice :119, 010.
5. Woo SH, Son YI, Lee SH, et al. Comparative analysis on the e ciency o the injection laryngoplasty tech-
nique using calciumhydroxyapatite (CaHA): the thyrohyoid approach versus the cricothyroid approach. J
Voice 7: , 01 .
. Halderman AA, Bryson PC, Benninger MS, et al. Sa ety and length o benef t o Restylane or o ce-based
injection medialization. A retrospective review o one institution’s experience. J Voice : 1, 01 .
7. an M, Woo P. Injection laryngoplasty with micronized dermis: a 10-year experience with 1 injections
in patients. Laryngoscope 1 0: 0, 010.
. Mallur PS, Rosen CA. O ce-based laryngeal injections. Otolaryngol Clin North Am : 5, 01 .
9. DeFatta RA, Chowdhury FR, Satalo R . Complications o injection laryngoplasty using calcium hydrox-
ylapatite. J Voice : 1 , 01 .
10. Pitman MJ, Rubino SM, Cooper AL. emporalis ascia transplant or vocal old scar and sulcus vocalis.
Laryngoscope 1 :1 5 , 01 .
11. Cantarella G, Mazzola RF, Domenichini E, Arnone F, Maraschi B. Vocal old augmentation by autologous
at injection with lipostructure procedure. Otolaryngol Head Neck Surg 1 : 9, 005.
1 . Hsiung MW, Pai L. Autogenous at injection or glottic insu ciency: analysis o 101 cases and correlation
with patients’ sel -assessment. Acta Otolaryngol 1 :191, 00 .
1 . amura E, Okada S, Shibuya M, et al. Comparison o at tissues used in intracordal autologous at injec-
tion. Acta Otolaryngol 1 0: 05, 010.
1 . Mikaelian DO, Lowry LD, Satalo R . Lipoinjection or unilateral vocal cord paralysis. Laryngoscope
101: 5, 1991.