Craniofacial Microsomia Soft-Tissue Reconstruction Comparison: Inframammary Extended Circumflex Scapular Flap versus Serial Fat Grafting:

The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis

BACKGROUND

The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction.

METHODS

A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection.

RESULTS

A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2.

CONCLUSION

The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.

Treatment of Progressive Hemifacial Atrophy by Cartilage Graft and Free Adipofascial Flap Combined with Three-Dimensional Planning

BACKGROUND

Progressive hemifacial atrophy (PHA) is a rare disease characterized by progressive atrophy of skin, soft tissue, muscles, and underlying bone structures. For severe PHA patients with obvious bone deformities, skeletal framework reconstruction is needed in addition to soft-tissue augmentation. The authors propose a new combinatorial surgical method using rib cartilage graft and free adipofascial flap for restoring facial symmetry. To improve the surgical accuracy, preoperative three-dimensional planning and printing was used.

METHODS

Twelve patients with severe facial atrophy were included in the authors' study. Three-dimensional facial image analyses were performed preoperatively to quantify the facial asymmetry. Rib cartilages were harvested and sculptured to the appropriate shape created by three-dimensional planning and fixed to the atrophic bone. The circumflex scapular artery-based adipofascial flap was transplanted to repair soft-tissue deficiency. A residual small monitor flap was left with the adipofascial flap. A revision surgery was performed to perfect the repair if the contour was suboptimal 6 months postoperatively.

RESULTS

The adipofascial flaps survived in all 12 patients. All patients achieved good healing without complications. At 1 more year after surgery, the rib cartilage was still in position and rarely absorbed. The morphologic and volumetric difference between the affected side and the unaffected side was improved significantly postoperatively. All patients were satisfied with the results, and no more additional operations were required.

CONCLUSION

The combinatorial surgery of rib cartilage graft and free adipofascial flap in the setting of three-dimensional planning and printing can be a good choice in restoring facial symmetry in severe cases of PHA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Quantifying outcomes of autologous fat transplantation in different facial deformities: A systemic review and meta-analysis

BACKGROUND

Autologous fat transplantation has become a common treatment for facial deformities. However, facial deformities are the result of complex diseases with different causes, and there has been no review on the effectiveness of autologous fat transplantation for facial deformities of different aetiologies.

METHODS

A systematic literature search of the Web of Science, Embase, and Medline Ovid databases was performed up to December 2022. Two investigators independently performed screening and data extraction according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by a meta-analysis using random-effects model for surgeon and patient satisfaction, facial symmetry, and complication rates. Twelve-month postoperative fat graft retention was estimated by meta-regression.

RESULTS

Thirty-one studies met the criteria, including 13 case series studies, 14 cohort studies, and four randomized clinical trials, with a total of 1572 patients. Follow-up visits within 6-12 months were performed in most of the studies. The results of the meta-analysis showed high overall surgeon satisfaction of 97% (95% CI: 92%-100%) and patient satisfaction of 95% (95% CI: 89%-99%), with a low complication rate of 3.4% (95% CI: 1.9%-5.9%). At 12 months postoperatively, a lower retention rate of 43% (95% CI: 28%-58%) was estimated in cases of acquired atrophic deformities compared with 64% (95% CI: 57%-71%) in cases of mixed deformities. Overall, autologous fat transplantation improved facial symmetry by 13% (95% CI: 8.4%-18%).

CONCLUSION

Autologous fat transplantation is generally a safe and effective procedure that can compensate for facial volume deficits and improve facial symmetry but may be less effective in cases of acquired atrophic facial deformities.

Ferroptosis in Autologous Fat Transplantation: A New Hypothesis

Autologous adipose tissue transplantation is widely used for cosmetic and reconstruction of various areas in the body, often to repair soft tissue volume loss or contoured deformation. However, the application of fat transplantation is limited by unstable and unpredictable volume retention rates. At present, promoting adipose tissue survival and inhibiting its death is the key to improve the effect of autologous fat transplantation. In this paper, we propose a hypothesis that ferroptosis exists in fat transplantation. The bases of this hypothesis include the following: (1) the association between ferroptosis and other programmed cell death; (2) the association between ferroptosis and ischemia-reperfusion injury; and (3) the use of ferroptosis inhibitors in the field of fat transplantation.

Injectable Pectin-Alginate Hydrogels for Improving Vascularization and Adipogenesis of Human Fat Graft

Autologous fat grafting (AFG) is the most prevailing tool for soft tissue regeneration in clinics, although efficiency is limited to unpredictable volume resorption due to poor vascularization and eventual necrosis. This study sought to improve the AFG efficiency using a hydrogel as a carrier for human fat graft (F) with and without platelet-rich plasma (PRP). PRP is clinically well known for the local release of several endogenous growth factors and has been in clinical use already. A human-fat-graft-encapsulated pectin-alginate hydrogel (FG) was developed and characterized. PRP was added to F to develop a human fat graft with PRP (FP). FP was admixed with a pectin-alginate hydrogel to develop FGP. FG and FGP showed the smooth injectable, elastic, and shear-thinning properties. FG and FGP groups showed enhanced cell viability and proliferation compared to the control F in vitro. We also investigated the in vivo angiogenesis and neo-adipogenesis ability of F, FG, FGP, and FP in nude mice after subcutaneous injection. After 2 and 4 weeks, an MRI of the mice was conducted, followed by graft explantation. The explanted grafts were also assessed histologically and with immunohistochemistry (IHC) studies. MRI and histology results revealed better vascularity of the FG and FGP system compared to fat graft alone. Further, the IHC studies, CD 31, and perilipin staining also revealed better vasculature and adipogenesis of FG and FGP systems. These results indicate the enhanced angiogenesis and adipogenesis of FG and FGP. Thus, developed pectin-alginate hydrogel-based fat graft systems FG and FGP replenish the native microenvironment by mediating angiogenesis and adipogenesis, thereby maximizing the clinical outcomes of autologous fat grafting.

Mechanical Stress Improves Fat Graft Survival by Promoting Adipose-Derived Stem Cells Proliferation

Cell-assisted lipotransfer (CAL), defined as co-transplantation of aspirated fat with enrichment of adipose-derived stem cells (ASCs), is a novel technique for cosmetic and reconstructive surgery to overcome the low survival rate of traditional fat grafting. However, clinically approved techniques for increasing the potency of ASCs in CAL have not been developed yet. As a more clinically applicable method, we used mechanical stress to reinforce the potency of ASCs. Mechanical stress was applied to the inguinal fat pad by needling. Morphological and cellular changes in adipose tissues were examined by flow cytometric analysis 1, 3, 5, and 7 days after the procedure. The proliferation and adipogenesis potencies of ASCs were evaluated. CAL with ASCs treated with mechanical stress or sham control were performed, and engraftment was determined at 4 weeks post-operation. Flow cytometry analysis revealed that mechanical stress significantly increased the number as well as the frequency of ASC proliferation in fat. Proliferation assays and adipocyte-specific marker gene analysis revealed that mechanical stress promoted proliferation potential but did not affect the differentiation capacity of ASCs. Moreover, CAL with cells derived from mechanical stress-treated fat increased the engraftment. Our results indicate that mechanical stress may be a simple method for improving the efficacy of CAL by enhancing the proliferation potency of ASCs.

A decade of clinical research on clinical characteristics, medical treatments, and surgical treatments for individuals with craniofacial microsomia: What have we learned?

AIM

This article provides a review of a decade of clinical research studies on clinical features, medical interventions, and surgical interventions for individuals with craniofacial microsomia (CFM). We also provide recommendations for future clinical research.

METHOD

A systematic search of literature was conducted in Embase and PubMed/MEDLINE Ovid. All publications from 2010 to 2020 that included at least 10 individuals with CFM were considered relevant for this study.

RESULTS

A total of 91 articles were included. In the past decade, many new studies on CFM have been published providing more insight on the diagnosis and management of patients with CFM. This review encompasses findings on the clinical difficulties patients with CFM encounter, including the craniofacial and extracraniofacial characteristics of patients with CFM and its related clinical consequences on breathing, feeding, speech, and hearing.

CONCLUSIONS

A considerable number of large multicenter studies have been published in recent years, providing new insights in the clinical consequences of CFM. The phenotypic variety between patients with CFM makes patient-specific treatment tailored to individual needs essential. The research and development of clinical care standards might be challenging because of the heterogeneity of CFM. Future research on clinical and patient-reported outcomes can help identify optimal treatment strategies. Cooperation between craniofacial centers, using uniform registration and outcome measurement tools, could enhance research and future care for these patients.

LEVEL OF EVIDENCE

Level IV.

Oculo-auriculo-vertebral spectrum: new genes and literature review on a complex disease

Oculo-auriculo-vertebral spectrum (OAVS) or Goldenhar syndrome is due to an abnormal development of first and second branchial arches derivatives during embryogenesis and is characterised by hemifacial microsomia associated with auricular, ocular and vertebral malformations. The clinical and genetic heterogeneity of this spectrum with incomplete penetrance and variable expressivity, render its molecular diagnosis difficult. Only a few recurrent CNVs and genes have been identified as causatives in this complex disorder so far. Prenatal environmental causal factors have also been hypothesised. However, most of the patients remain without aetiology. In this review, we aim at updating clinical diagnostic criteria and describing genetic and non-genetic aetiologies, animal models as well as novel diagnostic tools and surgical management, in order to help and improve clinical care and genetic counselling of these patients and their families.

Clinical evaluation of autologous fat graft for facial deformity: a case series study

Objectives

The use of fat grafts in maxillofacial sculpturing is currently a common technique. Unlike fillers, autologous fats unite with facial tissues, but long-term results may still be unsatisfactory. Sharing long-term follow-ups can be helpful in making outcomes more predictable.

Materials and Methods

The data from patients who were admitted from 2014 to 2016 for fat augmentation were collected. In all cases, fat grafts were injected by blunt cannula using a tunneling technique in different planes. A fan shape order for the malar, periorbital, nasolabial fold, mandibular angle and body, and perioral area was established.

Results

Autologous fat was used for different sites of the maxillofacial regions. Of 15 patients, two patients were not satisfied due to fat graft resorption. For this, further injections were performed six months after the first injection using preserved fat grafts. One patient continued to be dissatisfied. There were no other complications related to fat transplants.

Conclusion

Fat transplantation is a safe, reliable, and non-invasive method for facial contour and facial soft tissue defect restoration. Additional methods such as mesenchymal stem cells along with fat injection increase the survival rate of transferred fat.

Facelift Surgery Turns Back the Clock: Artificial Intelligence and Patient Satisfaction Quantitate Value of Procedure Type and Specific Techniques

BACKGROUND

Patients desire facelifting procedures to look younger, refreshed, and attractive. Unfortunately, there are few objective studies assessing the success of types of facelift procedures and ancillary techniques.

OBJECTIVES

The authors sought to utilize convolutional neural network algorithms alongside patient-reported FACE-Q outcomes to evaluate perceived age reduction and patient satisfaction following various facelift techniques.

METHODS

Standardized preoperative and postoperative (1-year) images of patients who underwent facelift procedures were analyzed by 4 neural networks to estimate age reduction after surgery (n = 105). FACE-Q surveys were employed to measure patient-reported facial aesthetic outcome. We compared (1) facelift procedure type: skin-only vs superficial musculoaponeurotic system (SMAS)-plication, vs SMAS-ectomy; and (2) ancillary techniques: fat grafting (malar) vs no fat grafting. Outcomes were based on complications, estimated age-reduction, and patient satisfaction.

RESULTS

The neural network preoperative age accuracy score demonstrated that all neural networks were accurate in identifying our patients' ages (mean score = 100.4). SMAS-ectomy and SMAS-plication had significantly greater age-reduction (5.85 and 5.35 years, respectively) compared with skin-only (2.95 years, P < 0.05). Fat grafting compared to no fat grafting demonstrated 2.1 more years of age reduction. Facelift procedure type did not affect FACE-Q scores; however, patients who underwent fat grafting had a higher satisfaction with outcome (78.1 ± 8 vs 69 ± 6, P < 0.05) and decision to have the procedure (83.0 ± 6 vs 72 ± 9, P < 0.05).

CONCLUSIONS

Artificial intelligence algorithms can reliably estimate the reduction in apparent age after facelift surgery. Facelift technique, like SMAS-ectomy or SMAS-plication, and specific technique, like fat grafting, were found to enhance facelifting outcomes and patient satisfaction.

Adipose matrix complex: a high-rigidity collagen-rich adipose-derived material for fat grafting

Due to the low percentage of collagen, the rigid support capacity of fat grafts remains unsatisfactory for some clinical applications. In this study, we evaluated a strategy in which adipose matrix complex (AMC) was collected via a mechanical process and transplanted for supportive filling of the face. Our AMC samples were collected from adipose tissue by a filter device consisting of a sleeve, three internal sieves, and a filter bag (100 mesh). AMC derived from adipose tissue had fewer cells than Coleman fat, but much higher levels of collagen and stiffness. Retention rates 90 days after transplantation in nude mice were higher for AMC than for Coleman fat (75±7.5% vs. 42±13.5%; P < 0.05). In addition, AMC maintained a higher stiffness (~6 kPa vs. ~2 kPa; P < 0.01) and stably retained a higher level of collagen. Our findings demonstrate that mechanical collection of AMC from adipose tissue is a practical method for improving fat graft retention and rigid support. This strategy has the potential to improve the quality of lipoaspirates for patients requiring rigid supportive filling.

Rapamycin and 3-Methyladenine Influence the Apoptosis, Senescence, and Adipogenesis of Human Adipose-Derived Stem Cells by Promoting and Inhibiting Autophagy: An In Vitro and In Vivo Study

OBJECTIVE

We aimed to clarify the changes in apoptosis, proliferation, senescence, and adipogenesis after promoting and inhibiting autophagy in adipose-derived stem cells (ADSCs) by rapamycin and 3-methyladenine in vitro and in vivo.

METHODS

After rapamycin and 3-methyladenine pretreatment, ADSC autophagy was detected by immunofluorescence for LC3, RT-PCR for ATG genes, and western blotting (WB) for the LC3 II/I and p62 proteins. TUNEL staining, PCR of BAX, and WB of Caspase-3 were preformed to assess ADSC apoptosis. The adipogenesis of ADSCs was evaluated by Oil red O staining and PCR of PPAR-γ. CCK8 assays were conducted to detect proliferation. Senescence was tested by Sa-β-gal staining and PCR of the P16/ 19/21 genes. Moreover, the mass and volume retention rate were determined, and perilipin and CD31 staining were performed in vivo.

RESULTS

Rapamycin and 3-methyladenine pretreatment increased and decreased autophagy of ADSCs, respectively, under normal and oxygen-glucose deprivation conditions. Apoptosis and senescence of ADSCs were decreased, and adipogenesis was increased along with the upregulation of autophagy. However, the proliferation of ADSCs was inhibited after either rapamycin or 3-methyladenine pretreatment. In vivo, the volume and mass retention rate and the angiogenesis of the grafts were also improved after rapamycin pretreatment.

CONCLUSIONS

Rapamycin pretreatment reduced apoptosis, delayed senescence, and promoted adipogenesis of ADSCs. These effects were inhibited by 3-methyladenine, indicating that the changes may be mediated by autophagy. Moreover, the survival rate and angiogenesis of the grafts were increased after upregulation of ADSC autophagy in vivo, which may help improve the efficiency of clinical fat transplantation.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Senescence of donor cells impairs fat graft regeneration by suppressing adipogenesis and increasing expression of senescence-associated secretory phenotype factors

Background

Fat grafting has been regarded as a promising approach for regenerative therapy. Given the rapidly aging population, better understanding of the effect of age on fat graft outcomes and the underlying mechanisms is urgently needed.

Methods

C57/BL6 mice [old (O, 18–20-month-old) and young (Y, 4-month-old)] were randomized to four fat graft groups [old-to-old (O-O), young-to-young (Y-Y), old-to-young (O-Y), and young-to-old (Y-O)]. Detailed cellular events before and after grafting were investigated by histological staining, RNA sequencing, and real-time polymerase chain reaction. The adipogenic differentiation potential of adipose-derived mesenchymal stem cells (AD-MSCs) from old or young donors was investigated in vitro. Additionally, adipogenesis of AD-MSCs derived from old recipients was evaluated in the culture supernatant of old or young donor fat tissue.

Results

After 12 weeks, the volume of fat grafts did not significantly differ between the O-O and O-Y groups or between the Y-Y and Y-O groups, but was significantly smaller in the O-O group than in the Y-O group and in the O-Y group than in the Y-Y group. Compared with fat tissue from young mice, senescence-associated secretory phenotype (SASP) factors were upregulated in fat tissue from old mice. Compared with the Y-O group, adipogenesis markers were downregulated in the O-O group, while SASP factors including interleukin (IL)-6, tumor necrosis factor-α, and IL-1β were upregulated. In vitro, AD-MSCs from old donors showed impaired adipogenesis compared with AD-MSCs from young donors. Additionally, compared with the culture supernatant of young donor fat tissue, the culture supernatant of old donor fat tissue significantly decreased adipogenesis of AD-MSCs derived from old recipients, which might be attributable to increased levels of SASP factors.

Conclusions

Age has detrimental effects on fat graft outcomes by suppressing adipogenesis of AD-MSCs and upregulating expression of SASP factors, and fat graft outcomes are more dependent on donor age than on recipient age. Thus, rejuvenating fat grafts from old donors or banking younger adipose tissue for later use may be potential approaches to improve fat graft outcomes in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02383-w.

Volume Retention After Facial Fat Grafting and Relevant Factors: A Systematic Review and Meta-analysis

BACKGROUND

Autologous fat grafting is common in facial reconstructive and cosmetic surgeries; the most important drawbacks are the high absorption rate and unpredictable volume retention rate. Surgeons usually make clinical judgements based on their own experience. Therefore, this study aimed to systematically and quantitatively review the volume retention rate of facial autologous fat grafting and analyse the relevant influencing factors.

METHODS

A systematic literature review was performed using the Medline, EMBASE, Cochrane Library, and Web of Science databases in October 2019 for articles that reported objectively measured volume retention rates of facial fat grafting. Patient characteristics, fat graft volumetric data, and complications were collected. A meta-analysis using a random-effects model was conducted to pool the estimated fat retention rate. Relevant factors were analysed and reviewed on the basis of subgroups.

RESULTS

We included 27 studies involving 1011 patients with facial fat grafting. The volume retention rate varied from 26 to 83%, with a mean follow-up of 3-24 months. The overall pooled retention rate was 47% (95% CI 41-53%). The volume measurement method significantly influenced the reported retention rate. A trend towards better retention was found for secondary fat grafting procedures and patients with congenital deformities. Only 2.8% of all patients had complications.

CONCLUSION

The exact percentage of facial fat grafts retained is currently unpredictable; the reported rate varies with different estimation methods. This review analysed studies that provided objectively measured volume retention rates, the pooled average percentage of facial fat graft retention (47%, 95% CI 41-53%), and relevant factors.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Early Fat Grafting for Augmentation in Craniofacial Microsomia

ABSTRACT

Patients with craniofacial microsomia often require multiple surgical interventions to address both hard and soft tissue defects. For improvement of soft tissue defects, microvascular free tissue transfers have been widely performed after puberty. To camouflage facial asymmetry, early fat grafting was performed on five six-month-old patients, and acceptable outcomes were obtained without overcorrection. This result suggests that early fat grafting in craniofacial microsomia is useful to camouflage asymmetrical facial contours.

Aesthetic and therapeutic outcome of fat grafting for localized Scleroderma treatment: From basic study to clinical application

BACKGROUND

Localized scleroderma (LoS) is a rare autoimmune disease characterized by skin fibrosis and subcutaneous tissue atrophy, resulting in aesthetic impairment on patients. Fat grafting has been used to treat LoS patients, achieving aesthetic and therapeutic improvement.

AIMS

This article summarized the epidemiology and pathophysiology of LoS and the current progress and thorny questions of basic and clinical research on fat grafting treating LoS.

METHODS

The literature of the last 20 years concerning fat grafting of treating LoS was reviewed.

RESULTS

Fat grafting has been proved to produce aesthetic and therapeutic outcomes on LoS patients, including the improvement of soft tissue atrophy, skin fibrosis and pigmentation. Due to the inflammatory microenvironment of scleroderma, however, fat grafting still faces many difficulties, such as low fat retention. Novel fat grafting methods in order to supplement the deficiency of adipose-derived stem cells and improve fat retention in LoS groups have been proposed whose effectiveness and feasibility is still needed further study.

CONCLUSION

Currently, fat grafting has been regarded as an effective treatment with a combination of aesthetic and therapeutic outcomes on LoS patients.

Three-Dimensional Planning of the Mandibular Margin in Hemifacial Microsomia Using a Printed Patient-Specific Implant

Hemifacial microsomia (HFM) is also known as malformation of the first and second branchial arches (BAs), oculoauriculovertebral dysplasia syndrome, and Goldenhar syndrome. Possibilities resulting from CAD/CAM may be a valuable tool to existing procedures to treat these abnormalities. The aim of this study was to report a case where the planning and implementation of an intraorally inserted 2-part patient-specific mandible implant was used for the treatment of HFM esthetic remained problem after orthognathic surgery. A 20-year-old female patient who continued to suffer from the esthetic defect of the unilateral hypoplastic mandible after completion of the orthognathic surgery attended for consultation. Using CT scan and the software Geomagic Freeform (3D Systems, USA), a 2-piece titanium implant was designed and printed to restore the osseous frame of the basal border of the mandible. The base was made of solid polished titanium to minimize soft tissue abrasion. Due to its split design, the implant could be placed anatomically exactly at the mandibular margin via an intraoral access and to avoid damage of the mental nerve. There were no postoperative complications such as infections, soft tissue reactions to the implant, sensitivity disorders, or dehiscence. The occlusion was regular. A measurement of the postoperative x-rays showed a clear increase in bony symmetry. No postoperative pain or trismus was seen. Functionally, the therapy ended with the completion of wound healing and the jaw was fully resilient again. A combined treatment using PSI and additional autogenous fat grafting may represent a valid treatment option for the treatment of facial asymmetry in patients with HFM.

Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study

BACKGROUND

The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients.

METHODS

A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry.

RESULTS

There were significant (all P < 0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons.

CONCLUSIONS

Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

Applications of Fat Grafting in Pediatric Patients

Autologous fat grafting has become a widely utilized technique for a variety of cosmetic and reconstructive procedures. Its potential for volume restoration and tissue regeneration has made it a popular method for treating soft tissue defects in both adult and pediatric populations. While autologous fat grafting in the pediatric setting is not as well characterized as it is in the adult setting, various reports have demonstrated the safety and utility of its applications in nonadult patient populations. In this article, we present the first comprehensive review of the current applications of autologous fat grafting in pediatric patients. Specific challenges to fat grafting in the pediatric setting and future applications will also be discussed.

Autologous Fat Graft for Soft Tissue Camouflage in Craniofacial Microsomia

INTRODUCTION

In India, a large majority of patients with craniofacial microsomia are unable to undergo complex reconstructions owing to unaffordability, lack of access to good craniofacial centers, or reluctance of parents to accept the surgical risk. There is also considerable social stigma attached to the resultant facial scars of surgery, especially in a girl child. Hence, we have explored autologous fat graft transfer as a "stand-alone" reconstructive option for soft tissue camouflage and aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II.

MATERIALS AND METHODS

Twelve patients who were seeking aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II, and who had adequate fat in the preferred donor sites of lower abdomen and antero-medial thighs, were selected. Patients with Grade III deformity, facial palsy, and previous skeletal surgeries were excluded. Autologous fat harvesting was done with the standardized Coleman's technique and injected after decantation. Volumetric augmentation was assessed by clinical comparison with normal side for facial symmetry, skin pinch thickness at four reference points, and by two-dimensional analysis of pre- and postoperative standardized photographs at periodic intervals.

RESULTS AND ANALYSIS

Eleven of our patients were female and one was a male (N = 12). In each session, 20-40mL (mean 28.75 ± standard deviation [SD] 5.69) fat was aspirated and 12-35mL (mean 23.67 ± SD 6.07) fat was injected. The average operating time was 35min (mean 32.91 ± SD 4.05). Majority of our patients needed three sessions (mean 2.8 ± SD 1.03) of serial fat injections to achieve bilateral facial symmetry. Increase in skin pinch thickness was 6.4167 ± 1.31 mm. The mean patient satisfaction score was 8.83 ± SD .717.

CONCLUSION

Based on our results, we conclude that autologous fat transfer, when used for soft tissue camouflage, is a versatile, easy, effective, and inexpensive method for obtaining consistent long-term aesthetic goals in mild to moderate cases of craniofacial microsomia.

Efficacy and Safety of Autologous Fat Transfer in Facial Reconstructive Surgery: A Systematic Review and Meta-analysis

Importance

The use of autologous fat transfer (AFT) or lipofilling for correcting contour deformities is seen as one of the major breakthroughs in reconstructive plastic surgery. Its applications in facial reconstructive surgery have been of particular interest owing to the prospect of achieving autologous reconstruction by a minimally invasive approach. However, its unpredictability and variable degree of resorption have limited its utility and much skepticism still exists regarding its efficacy. Furthermore, more than 2 decades of clinical research have produced a highly fragmented body of evidence that has not been able to provide definite answers.

Objective

To investigate the safety and efficacy of AFT in facial reconstruction through a systematic review and meta-analysis.

Data Sources

A literature search was performed in PubMed, Embase, and the Cochrane Library from inception to October 11, 2017.

Study Selection

All published studies investigating the efficacy and safety of AFT in facial reconstructive surgery.

Data Extraction and Synthesis

Two independent reviewers performed data extraction systematically, adhering to the PRISMA guidelines. Summary measures were pooled in a random-effects model meta-analysis.

Main Outcomes and Measures

The patient and surgeon satisfaction, graft survival, number of AFT sessions, and the incidence of AFT-related complications were the main outcomes of interest in this meta-analysis.

Results

This systematic review resulted in the inclusion 52 relevant studies consisting of 1568 unique patients. These included 4 randomized clinical trials, 11 cohort studies, and 37 case series. The overall follow-up averaged 1.3 years after AFT. Meta-analysis revealed a very high overall patient satisfaction rate of 91.1% (95% CI, 85.1%-94.8%) and overall surgeon satisfaction rate of 88.6% (95% CI, 83.4%-92.4%). The number of AFT sessions required to achieve the desired result was 1.5 (95% CI, 1.3-1.7) and 50% to 60% of the injected volume was retained at 1 year. Only 4.8% (95% CI, 3.3%-6.9%) of procedures resulted in clinical complications.

Conclusions and Relevance

To our knowledge, this study provides the first overview of the current knowledge about AFT in facial reconstructive surgery. Our results confirm that AFT is an effective technique for treating soft-tissue deformities in the head and neck, with low rate of minor complications.

Level of Evidence

NA.

Fat Grafting in Managing Craniofacial Deformities

BACKGROUND

The successful correction of craniofacial contour deformities remains a major challenge in plastic surgery. This article reviews important concepts and strategies for craniofacial fat grafting and presents a SOBRAPAR Hospital algorithm focused on achieving craniofacial contour symmetry as early as possible without compromising function.

METHODS

Principle-based methods (i.e., anatomical facial fat compartments, fluid accommodation model, multistage site-specific craniofacial fat grafting, and structural fat-grafting technique) were itemized into an algorithm to aid in planning and selecting the best surgical approach (i.e., bone and/or soft tissue procedures) in order to obtain craniofacial contour symmetry.

RESULTS

The treatment plan and choice of surgical technique implemented to address bone and/or or soft tissue deformities were determined by specific diagnosis, patient age at presentation, and functional status. Bony reconstruction in skeletally immature patients is reserved solely for those patients with functional issues.

CONCLUSION

By adopting principle-based methods and fat compartment theory, we are able to achieve craniofacial contour symmetry and aesthetically pleasing outcomes without compromising function.

Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model

BACKGROUND

Soft-tissue deficits associated with various craniofacial anomalies can be addressed by fat grafting, although outcomes remain unpredictable. Furthermore, consensus does not exist for timing of these procedures. Whereas some advocate approaching soft-tissue reconstruction after the underlying skeletal foundation has been corrected, other studies have suggested that earlier grafting may exploit a younger recipient niche that is more conducive to fat graft survival. As there is a dearth of research investigating effects of recipient age on fat graft volume retention, this study compared the effectiveness of fat grafting in younger versus older animals through a longitudinal, in vivo analysis.

METHODS

Human lipoaspirate from three healthy female donors was grafted subcutaneously over the calvaria of immunocompromised mice. Volume retention over 8 weeks was evaluated using micro-computed tomography at three experimental ages: 3 weeks, 6 months, and 1 year. Histologic examination was performed on explanted grafts to evaluate graft health and vascularity. Recipient-site vascularity was also evaluated by confocal microscopy.

RESULTS

The greatest retention of fat graft volume was noted in the youngest group compared with both older groups (p < 0.05) at 6 and 8 weeks after grafting. Histologic and immunohistochemical analyses revealed that improved retention in younger groups was associated with greater fat graft integrity and more robust vascularization.

CONCLUSION

The authors' study provides evidence that grafting fat into a younger recipient site correlates with improved volume retention over time, suggesting that beginning soft-tissue reconstruction with fat grafting in patients at an earlier age may be preferable to late correction.

Autologous Free Fat Grafting for Management of the Facial Contour Asymmetry

BACKGROUND

The purposes of this study were to report autologous free fat grafting as the workhorse procedure to augment the facial soft-tissue envelope and restore facial contour symmetry of patients with asymmetric facial malformations; to detail the SOBRAPAR Hospital algorithm for soft-tissue reconstruction of patients with facial contour asymmetry; and to assess facial symmetry after fat grafting.

METHODS

A retrospective analysis of consecutive patients (n = 178) who underwent fat grafting to restore the facial contour symmetry according to the SOBRAPAR Hospital algorithm between 2009 and 2016 was conducted. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed.

RESULTS

There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement, with a mean fat graft procedures per patient of 1.6 ± 0.7, ranging of 1 to 3.

CONCLUSION

A significant improvement of facial contour symmetry was obtained in a subset of patients using fat grafting according to the SOBRAPAR Hospital algorithm.

Sustained Overcorrection After Autologous Facial Fat Grafting in the Pediatric Population: A Case Series

INTRODUCTION

Autologous fat grafting is a valuable tool in the correction of facial soft tissue asymmetry and volume deficits. Pubertal growth and fluctuations in body mass present unique challenges to achieving satisfactory results after autologous fat transfer in the pediatric population. Few studies exist describing the outcomes and complications of pediatric facial fat grafting. The objective of this study is to identify the complication profile and outcomes after autologous fat grafting for the correction of facial asymmetry and volume deficits in the pediatric population.

METHODS

Retrospective chart review was performed identifying 19 patients having undergone autologous fat grafting to the face for correction of facial volume deficits or asymmetry. Intraoperative variables were analyzed including blood loss, tumescent volume, lipoaspirate volume, graft volume transferred, donor fat processing technique, and donor site. Patient growth parameters were evaluated using body mass index (BMI) at the time of grafting and most recent follow up. Outcomes were evaluated based on adequacy of the graft, number of revisions or corrections, and complications.

RESULTS

A total of 19 patients were identified. The median age at the time of primary fat graft was 17 years. The average change in BMI from preoperative to the latest recorded date was +0.60 ± 1.90. The average time from primary procedure to most recent follow up was 1.7 years. Abdomen was the most common donor site utilized. Adequate correction was achieved with an average of 1.4 graftings. Complications included contour irregularity (n = 1) and persistent overcorrection (n = 3). One patient required lipoaspiration for treatment of overcorrection. An unpaired t test demonstrated no significant difference in preoperative BMI (P = 0.58), postoperative BMI (P = 0.28), or change in BMI after grafting (P = 0.56) between adequately corrected and overcorrected patients.

CONCLUSIONS

Fat transfer is a safe and viable method for the correction of facial asymmetry in the pediatric population. Repeat fat grafting procedures may be required to achieve adequate correction; however, postoperative overcorrection is unlikely to resolve spontaneously in the pediatric population and is unrelated to changes in BMI. Care should be taken to minimize the degree of primary overcorrection when treating facial asymmetry in the pediatric population.

Treatment of Isolated Zygomatic Arch Fracture: Improved Outcomes with External Splinting

BACKGROUND

The various approaches to reduction and fixation of isolated displaced zygomatic arch fractures have not been well studied. The authors compared established treatment methods for zygomatic arch fractures for both aesthetic and functional outcomes.

METHODS

Consecutive patients with isolated zygomatic arch fractures with a minimum of 6 months' follow-up were studied in five groups: group 1, intraoral approach (no fixation); group 2, temporal approach (no fixation); group 3, coronal flap plate fixation; group 4, external splint fixation; and group 5, no surgery. Perioperative complications, facial contour symmetry (aesthetic outcome), improvement in mouth opening (functional outcome), and reoperations were compared.

RESULTS

Patients undergoing external splint fixation had no perioperative complications. Coronal flap plate fixation had the highest rate of perioperative complications (46 percent), with facial nerve injury (4 percent), hematoma (8 percent), and persistent hyperesthesia (8 percent). Reoperations (fat grafting or bony reconstruction) were highest with coronal flap plate fixation (23 percent) and the temporal approach (7.7 percent); external splint fixation and the intraoral approach required no reinterventions. Patients treated with external splint fixation had the largest improvement in mean interincisor mouth opening. Mean postoperative interincisor opening in decreasing order was as follows: external splint fixation (51.6 mm), coronal flap plate fixation (47.1 mm), no surgery (39.8 mm), intraoral approach (39.6 mm), and temporal approach (38.9 mm). The highest volumetric symmetry was seen in external splint fixation (97.9 percent), followed by coronal flap plate fixation (94 percent), temporal approach (76.2 percent), intraoral approach (73 percent), and no surgery (68.3 percent).

CONCLUSION

For isolated zygomatic arch fracture, patients undergoing external splint fixation had the lowest risk of perioperative complications and the greatest improvement in functional and aesthetic outcomes compared with the intraoral approach (no fixation), the temporal approach (no fixation), coronal flap plate fixation, and no surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Surgical Management of Progressive Hemifacial Atrophy With De-Epithelialized Profunda Artery Perforator Flap: A Case Report

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA.

Isolated Autologous Free Fat Grafting for Management of Facial Contour Asymmetry in a Subset of Growing Patients With Craniofacial Microsomia

BACKGROUND

To report autologous free fat grafting as an isolated procedure to manage facial contour asymmetry of a subset of growing patients with craniofacial microsomia (CFM).

METHODS

A retrospective analysis of CFM patients (n = 11) with low socioeconomic and intellectual status, poor oral hygiene, living far from our center, Pruzansky-Kaban I/II mandibles, without functional concerns, and with no craniofacial skeletal surgery who underwent isolated free fat grafting between 2012 and 2013 was conducted. Surgeon and parent/patient satisfaction were elicited. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed.

RESULTS

All patients underwent isolated autologous free fat grafting to restore the facial contour symmetry. Surgeon and patient/parent were mostly satisfied. There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement.

CONCLUSIONS

A significant improvement of facial symmetry was obtained in this subset of growing CFM patients using only isolated free fat grafting.

An Overview of Fat Grafting

The use of autologous fat grafting for a wide variety of clinical applications has increased dramatically over the past few decades. The article provides an overview of the technique, a historic background, and briefly explores some of the current ways in which fat grafting is being used in plastic surgery.

Parry-Romberg reconstruction: beneficial results despite poorer fat take

OBJECTIVE

For the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied the volume retention and skin changes after autologous fat grafts within diseased regions.

SUMMARY BACKGROUND DATA

The long-term survival and volume retention of fat grafts used in soft tissue reconstruction of Parry-Romberg syndrome is still unknown, as are skin changes after fat grafting.

METHODS

Sex, age, severity of deformity, number of procedures, operative times, and augmentation volumes were recorded. Preoperative/postoperative 3-dimensional computed tomographic scans were also reviewed. A digital 3-dimensional photogrammetry system was used to determine "final fat take" and symmetry. Romberg fat grafting volumes were compared to nonaffected, cosmetic fat-grafted patients. For skin changes, a spectrophotometer was used to quantify percent improvement in melanin index. Physician and patient satisfaction surveys (5-point scale) were elicited, including overall outcome and skin color/texture.

RESULTS

The mean number of procedures correlated to the severity of deformity: mild, 1.8 procedures; moderate, 3.4; and severe, 5.2. With Romberg patients, fat grafting injected: per case, 48 mL; total, 188 mL; and final measured volume, 101 mL. Romberg patients had less "fat take" than nonaffected grafted patients (final take, 41% vs 81%). Skin color/texture showed 3-fold improvement after fat grafting procedures. The mean melanin index improvement seen in the diseased regions of Romberg patients after fat grafting was 42% (+3%). Skin color and texture improvement was also shown in patient surveys (preoperative = 2.4 + 0.06 to follow-up = 3.4 + 0.09) and physician (preoperatively = 2.1 + 0.1 to follow-up = 3.6 + 0.1).

CONCLUSIONS

Despite poorer fat graft take within the disease region of Romberg patients, fat grafting resulted in long-term improvement in hypoplasia and skin hyperpigmentation.

Early Fat Grafting for Augmentation of Orbitozygomatic Region in Treacher Collins Syndrome

This report presents our preliminary experience with the effect of early fat grafting (FG) (at ≥ 6 months of age) in timely bone reconstruction of the orbitozygomatic area in patients with Treacher Collins syndrome. FG is performed 2 to 3 consecutive times after the age 6 months. Bone reconstruction is performed ≥ 6 months after the last FG session. This protocol was applied in 3 patients. There was no need for further reconstruction of the lower eyelids in 2 patients. Malar bone reconstructions, using calvarial bone grafts, were performed in all of the patients. Eighteen months after bone reconstruction, there was limited absorption of the bone grafts. Early FG of the orbitozygomatic area improves contour and tissue quality, restores volume, and can possibly minimize bone resorption following zygomatic bone framework reconstruction.

The Current State of Fat Grafting: A Review of Harvesting, Processing, and Injection Techniques

BACKGROUND

Interest in and acceptance of autologous fat grafting for use in contour abnormalities, breast reconstruction, and cosmetic procedures have increased. However, there are many procedural variations that alter the effectiveness of the procedure and may account for the unpredictable resorption rates observed.

METHODS

The authors highlighted studies investigating the effects of harvesting procedures, processing techniques, and reinjection methods on the survival of fat grafts. This review focused on the impact different techniques have on outcomes observed in the following: in vitro analyses, in vivo animal experiments, and human studies.

RESULTS

This systemic review revealed the current state of the literature. There was no significant difference in the outcomes of grafted fat obtained from different donor sites, different donor-site preparations, harvest technique, fat harvesting cannula size, or centrifugation speed, when tumescent solution was used. Gauze rolling was found to enhance the volume of grafted fat, and no significant difference in retention was observed following centrifugation, filtration, or sedimentation in animal experiments. In contrast, clinical studies in patients found more favorable outcomes with fat processed by centrifugation compared with sedimentation. In addition, higher retention was observed with slower reinjection speed and when introduced into less mobile areas.

CONCLUSIONS

There has been a substantial increase in research interest to identify methodologies for optimizing fat graft survival. Despite some differences in harvest and implantation technique in the laboratory, these findings have not translated into a universal protocol for fat grafting. Therefore, additional human studies are necessary to aid in the development of a universal protocol for clinical practice.

A systemic review of autologous fat grafting survival rate and related severe complications

OBJECTIVE

Clinical application of autologous fat grafting (AFG) is quickly expanding. Despite the widely acceptance, long-term survival rate (SR) of AFG remains a question not yet solved. Meanwhile, although rare, severe complications related to AFG including vision loss, stroke even death could be seen in the literature.

DATA SOURCES

A comprehensive research of PubMed database to June 2013 was performed according to guidelines of the American Society of Plastic Surgeons Fat Graft Task Force Assessment Methodology. Articles were screened using predetermined inclusion and exclusion criteria.

STUDY SELECTION

Data collected included patient characteristics, surgical technique, donor site, recipient site, graft amount, and quantified measurement methods. Patient cohorts were pooled, and SR was calculated. All the severe complications were also summarized according to the different clinical characteristics.

RESULTS

Of 550 articles, 16 clinical articles and 10 animal studies met the inclusion criteria and provided quantified measurement methods. Totally, 596 patients were included. SR varied from 34% to 82% in breast and 30-83% in the facial area. Nude mice were applied to investigate human fat grafting SR (38.3-52.5% after 15 weeks). Rabbits were commonly used to study animal AFG SR (14.00-14.56% after 1-year). Totally, 21 severe complications were reported, including death (2), stroke (10), vision loss (11, 8 of which accompanied with stroke), sepsis (3), multiple abscess (1) and giant fat necrotic cyst (2). Ten of these complications happened within 10 years.

CONCLUSIONS

There is no unified measurement method to evaluate fat graft SR until now and no clinical evidence to show better SR according to different donor and recipient cite. Body mass index change between pre- and postoperation may be the bias factor in evaluating fat SR. Fat embolisms of the ophthalmic artery and the middle cerebral artery are the most severe complication of AFG and still lack of effective treatment.

Future Perspectives of Fat Grafting

Autologous fat grafting is an exciting part of plastic and reconstructive surgery. Fat serves as a filler and its role in tissue regeneration will likely play a more important role in our specialty. As we learn more about the basic science of fat grafting and the standardized techniques and instruments used for fat grafting, this procedure alone or in conjunction with invasive procedures may be able to replace many operations that we perform currently. Its minimally invasive nature will benefit greatly our cosmetic and reconstructive patients, and may even achieve better clinical outcomes.