In the mid-1960s, the French physician Paul Tessier revolutionized the treatment of a wide range of craniofacial anomalies by introducing new concepts and surgical techniques.1 Subsequently, further surgical and technological advances2,3 have been incorporated into Tessier’s seminal principles, and there has also been a paradigm shift in the treatment of a subgroup of patients with congenital or acquired craniofacial volume deficits, with the adoption of autologous free fat grafting to optimize patient outcomes in a longitudinal and comprehensive fashion.
This article reviews the use of fat grafting for managing craniofacial contour asymmetries by incorporating established and evolving principles of anatomy, craniofacial surgery, and fat-graft surgery. A detailed review of all relevant published articles is beyond the scope of this study. However, published in-depth reviews4–8 of other related fat-grafting concepts (e.g., theories regarding fat-graft survival and remodeling; fat harvesting; and processing, injection, and storage) can be accessed in previous issues of Plastic and Reconstructive Surgery.
The successful surgical treatment of craniofacial contour deformities remains challenging because it often requires multiple surgical interventions beginning in early childhood to address soft-tissue and bone defects.9–23 Treatment protocols vary widely, and no consensus has been established regarding the optimal surgical procedure type and/or timing.20–38 Nevertheless, fat grafting has been widely adopted as an essential procedure to augment the craniofacial soft-tissue envelope and restore craniofacial contour symmetry, as it can be adapted to different clinical scenarios (e.g., fat grafting in an isolated format and fat grafting performed along with major bone surgery).9–23
Based on our previous experience9–12 and evidence-based data,13–23 the SOBRAPAR Hospital algorithm has focused on achieving craniofacial contour symmetry as early as possible without compromising function. The specific algorithm that is chosen depends on key factors, including an accurate diagnosis of deformity (i.e., craniofacial deformity–related volume/contour/asymmetry), patient age at presentation (i.e., skeletally mature or immature), and functional status (i.e., presence or absence of functional impairment) (Fig. 1). A meticulous preoperative strategy with a thorough assessment of global craniofacial deformity (i.e., systematic diagnostic workup of functional issues and craniofacial contour asymmetry status) before surgical decision-making that includes the creation of a careful multistage reconstructive surgical plan is essential to achieving optimal functionality and aesthetically pleasing outcomes. Each component of our therapeutic algorithm (explained in depth below) has evolved in a standardized and evidence-based manner by the adoption of relevant surgical strategies routinely used by other groups.
SEQUENCE OF INTERVENTION
Surgical management of soft-tissue craniofacial defects has historically been undertaken only after reconstruction of the underlying skeleton.24 Skeletal reconstruction in early childhood has largely been championed as superior in the craniofacial literature, and significant results have been published with protocols using a craniofacial bone surgical approach.25 However, aggressive surgical management in young and/or skeletally immature patients does not guarantee long-term craniofacial symmetry and lasting positive aesthetic outcomes.26,27 In addition, some data have shown that bone surgery as an isolated therapeutic modality rarely corrects craniofacial soft-tissue volume deficits.11,26,27 Thus, some craniofacial groups9–12 prefer to perform conservative operations to prevent growth alterations in skeletally immature patients without functional impairments, whereas other groups prefer to wait until craniofacial skeletal growth has reached 85 percent (approximately 7 years of age) before performing any craniofacial bone surgical interventions.28,29 The risk of potential relapse and morbidity rates has been used to justify the delayed approach.26,27
The successful marriage of bone and soft-tissue reconstruction is the goal of the SOBRAPAR Hospital9–12 and other groups.13–23 Because there are critically distinct differences in each patient (e.g., diagnosis of deformity, age at presentation, and functional status) that guide the planning of craniofacial surgical procedures and/or fat grafting, all stages of treatment are approached on an individualized basis.
Skeletally Immature Patients
When treating craniofacial contour deformities in skeletally immature patients (those aged 7 years or younger), our goal has been to achieve craniofacial symmetry before or during the critical school-age years because starting school is an important stage in a child’s development. Facial appearance is one of the most critical factors in interpersonal communication.30 Self-awareness of the craniofacial deformity usually begins to develop in children at approximately 3.5 years of age.31 Children with craniofacial deformities begin to feel different from their peers and lose interest in being in environments that include other children.30,31 Thus, early surgery has the potential to significantly reduce, in a wide range of social environments, the negative psychological impact, stigmas, and stereotypes faced by children with craniofacial deformities.30,31
In treating skeletally immature patients, we have two primary approaches depending on the level of functional status as initially determined during a screening by our multidisciplinary team. We use the first approach for skeletally immature patients with craniofacial contour deformities and functional impairments such as an absence of brain protection, elevated intracranial pressure, corneal exposure, respiratory disturbance, and/or difficulty feeding and attaining adequate weight gain. Those patients have been appropriately managed with bone mobilization, expansion, remodeling, advancements followed or not by distraction osteogenesis, tracheostomy, and/or tarsorrhaphy according to specific protocols.32–35 For most of these patients treated at an early age, bone reconstruction is not a definitive procedure; thus, concomitant fat grafting to manage postoperative contour deformities is recommended to improve craniofacial symmetry once the functional issues have been resolved.
We use the second approach for skeletally immature patients with craniofacial contour deformities but without severe functional concerns.9–12 These patients undergo early fat grafting beginning at 2 years of age. The earlier that treatment is started, the more fat-graft sessions that can be performed before children begin to socialize within their peer groups. The objectives in using fat grafting are to reduce the overall morbidity of subsequent bone surgical procedures to spare patients and their families significant stress during the postoperative process of bone surgical intervention, provide “craniofacial camouflage,” and expand the tight soft-tissue envelope (e.g., in cases of moderate/severe Treacher Collins syndrome) until facial growth finalizes instead of using early bone surgical procedures that can be performed to manage mild bony asymmetry, facial midline shift, and/or dental malocclusion, which are usually resolved once facial growth finalizes. Our group does not recommend bone surgical intervention for craniofacial symmetry improvement in skeletally immature patients (aged 7 years or younger) without functional alteration, because a lack of function is a primary motivating factor for early bone surgery.9–12
Skeletally Mature Patients
For skeletally mature patients with both bone and soft-tissue deformities and for patients with only bone deformities, the goals of treatment are a symmetric craniofacial contour and/or craniofacial midline, a harmonious craniofacial profile, and appropriate functionality (i.e., brain protection and class I occlusion) because functional status has already been addressed.9–23
We perform an intraoperative assessment on each patient and use concomitant fat grafting to optimize craniofacial soft-tissue symmetry and correct irregularities and then postoperatively use staged fat grafting (bone surgery first, followed by fat grafting 3 to 6 months later) because the final aesthetic craniofacial appearance is dictated by the degree to which the craniofacial soft-tissue envelope drapes over the altered skeletal foundation.9–23 As the complexity and range of osteotomies, bone mobilizations, and/or bone grafts may affect symmetry of the craniofacial skeleton and can result in additional asymmetries, the need for additional complementary fat grafting should be anticipated and planned beforehand.10,13,14
DISEASE PROGRESSION AND DEFORMITY SEVERITY
Disease progression status—specifically, active versus stable disease and/or soft-tissue and bony deficiency severity—does not majorly impact our surgical decision-making process. With progressive diseases (e.g., Parry-Romberg syndrome), we do not wait to stabilize because we want to minimize the adverse effects of craniofacial deformity on interpersonal relationships and patient quality of life.12 Delaying treatment until disease stabilization can result in psychological difficulties and can impede successful rehabilitation, even with a high level of psychological support provided by craniofacial centers.
Although severity degree has been considered an important factor in the determination of whether to perform fat grafting or microvascular free tissue transfer,18 fat-graft outcomes appear to be similar in patients with active versus stable disease.9–23 In skeletally immature patients, until the end of facial growth when orthognathic surgery can be performed, our group9–12 favors the use of fat grafting regardless of soft-tissue deficiency status.
Following a recent trend toward reducing the number of operations and general anesthesia exposure,36 some surgeons attempt single-stage intervention aimed at definitive craniofacial reconstruction. However, initial fat grafting serves as the first of many procedures in our multistep surgical approach toward achieving complete craniofacial symmetry resolution.9,10
CRANIOFACIAL FAT GRAFTING SURGERY
Consensus is lacking regarding the best fat-grafting protocol for achieving successful overall symmetry in patients with craniofacial contour deformities.9–23 We have adopted craniofacial fat compartment–guided augmentation9,10,37–39 using Coleman’s structural fat-grafting technique.40 Instead of performing random craniofacial fat grafts, fat grafting focused solely on the center of the defect, or full-face fat grafting, our group9,10 performs standardized fat grafting of the core compromised regions (i.e., forehead, cheek, and/or chin). We can sequentially graft regions with no anatomical relationship with these core regions during a single fat-grafting procedure. We do not simultaneously graft neighboring regions as well because each fat compartment has an identifiable blood vessel that runs along its septal boundary.38 Grafting neighboring fat compartments in the same procedure may restrict blood flow because of the overall increase of interstitial fluid pressure and could compromise fat-graft outcomes as described in the “fluid accommodation model.”8,41
Some groups15,22 have adopted overcorrection as a strategy to compensate for anticipated fat graft loss. In the craniofacial fat-grafting literature,15,22 overcorrection of up to 20 to 30 percent has been reported, yet no established overcorrection parameter has provided consistent results. It has also been shown that postoperative overcorrection is unlikely to spontaneously resolve facial asymmetry in pediatric patients.15 Primary overcorrection requires removal of the grafted fat by means of lipoaspiration or direct excision, each of which may result in significant morbidity (e.g., unnecessary scars) and damage the facial neurovascular bundles.15 We believe that overcorrection may cause a “ripple effect,” namely that symmetry will be lost because of different fat-graft retention rates in specific areas of the fat compartments.9,10 Therefore, we restrict the volume required to achieve symmetry of each craniofacial unit to avoid large fat-graft volumes in a restricted recipient area.9,10 At some point, there is no additional space to inject fat because the volume increase is limited by a patient’s tight skin envelope. Recent publications8,41 have advocated that surgeons should not graft beyond what the recipient can physiologically accommodate. Patients with craniofacial deformities require higher fat volumes for each specific compartment, and their scarred and/or atrophic soft-tissue imposes a greater resistance to expansion,9–23 in contrast to patients who require fat grafting for aesthetic needs39 (Figs. 2 through 6).
Complementary Fat Graft Surgery
The need for complementary fat-graft sessions affects 20 to 100 percent of cases according to patient factors (i.e., patient age and diagnosis of craniofacial deformities), individual indication criteria, and adopted surgical techniques.9–23 However, there is no consensus on the ideal timing for complementary fat-graft sessions.9–23 It is difficult to assess the surgical outcome during the first 3 months, as the extent of edema and inflammation may act as confounding factors.42–44 In addition, the 3-month evaluation represents a critical time point in fat-graft outcomes, with volume and symmetry persistence at 3 months generally being maintained at future evaluations.9–11,42–46 Therefore, by analyzing the evidence available from experimental postoperative phases and clinical experience,9–23,42–46 it is possible to recommend new fat-graft sessions after the third postoperative month.
OUTCOME ASSESSMENT IN CRANIOFACIAL FAT GRAFTING
To date, there is no consensus in the fat-graft literature regarding the most appropriate method to accurately measure outcomes. Some craniofacial fat-graft studies9–23 have described improvements in patient- or family-reported satisfaction and surgeon perception of symmetry. Improvements in skin color, texture, and melanin index were seen after craniofacial fat grafting.17 In the photogrammetric symmetry analysis and three-dimensional measurement literature, some groups reported single or multiple fat-graft session–related symmetry or retention results, whereas other groups described using combined procedures (bone procedures and fat grafting) to obtain craniofacial symmetry.9–23 Overall, these studies showed a wide range of symmetry (79.8 to 99.3 percent) and fat-graft retention rates (32.8 to 94.1 percent).9–23
A recent systematic review47 confirmed that fat grafting is an effective approach for treating craniofacial soft-tissue deformities.9–23 Although fat grafting with supplements (e.g., platelet-rich plasma, stromal vascular fraction, bone marrow–derived mesenchymal stem cells, or cultured adipose-derived stem cells) may have great potential to alter the current treatment paradigm of craniofacial fat grafting, most of the available evidence is still based on nonenriched techniques9–23 (i.e., the Coleman technique40). Further well-executed randomized clinical trials or large comparative cohorts are necessary to define the real role of each technique in managing craniofacial contour deformities. Predictors of craniofacial fat-graft retention should be considered in the methodologic elaboration of these future studies because supplementary fat grafting may be more applicable to a subgroup of patients with unpredictable fat-graft retention rates, those older than 18 years, those diagnosed with Parry-Romberg syndrome, those who underwent previous bone surgical intervention at the site receiving fat grafting, and/or those who have frontal/temporal contour deformities.9 From a clinical perspective, plastic surgeons should consider these published outcomes to enhance preoperative evaluation and surgical planning (as described in previous sections) and to set realistic expectations for the patient and family when obtaining informed consent.
The successful correction of craniofacial contour deformities remains a major challenge faced by experienced plastic surgeons. The treatment plan and choice of surgical technique (bone and/or fat-graft operations) have depended on the specific diagnosis, patient age at presentation, and functional status. This article presents important concepts and strategies regarding craniofacial fat grafting. By adopting principle-based methods and the fat compartment theory, we are able to achieve craniofacial contour symmetry and other aesthetically pleasing outcomes without compromising function.
Patients provided written consent for the use of their images.
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