Autologous Adipose Tissue Grafting



Autologous Adipose Tissue Grafting


Richard A. Gangnes



INTRODUCTION

The ability to enhance facial contour and structure using autogenous adipose tissue has been one of the most important adjuncts in the facial plastic surgeon’s armamentarium to have been popularized in the last 20 years. I now use adipose tissue to provide volume and shape to the aging face during facial surgery and as a stand-alone procedure. It is used to restore traumatic or iatrogenic soft tissue defects; it is used for acquired or congenital facial contour abnormalities or asymmetries; to improve the quality and texture of severely actinically damaged skin; and to help restore facial shape, symmetry, and eyelid closure after facial nerve dysfunction secondary to eighth cranial nerve tumor surgery. The ability to graft adipose tissue to the face precisely, easily, and effectively should be in every facial plastic surgeon’s skill set, along with the knowledge of its benefits, limitations, and risks.

Aesthetic surgery of the aging face has traditionally focused on excisional techniques. Surgery was aimed at counteracting the natural descent of facial structures and removing redundant soft tissue. In recent years, however, the concept of volume restoration has increasingly become recognized to be of vital importance in treatment of the aging face. A look back into history reveals that plastic surgeons of the previous century understood the need of volume restoration. Reports from the literature of the early 20th-century describes efforts to augment tissues with a wide array of injectable substances, such as paraffin, petroleum jelly, latex, gold, silver, ivory and cow horn.

Different types of face-lifts were popularized and promulgated as ways to lift and elevate with the consequence of thinning and flattening the face. As we have learned more about the aging face, we know that the changes involve more volume changes than a falling or laxity, particularly after the recognition that part of the aging process involves a shrinking of the underlying bony skeletal framework. What appears as facial laxity is not just intrinsic laxity of the soft tissue and the skin envelope but it is having the envelope reside over a shrinking skeletal support. With the realization that volume restoration alone, as Dr. Coleman demonstrated in the early nineties with structural adipose tissue grafting, achieved in many cases a remarkable youthful enhancement without the tightening, elevation, or tissue removal, we began to see the value of volume restoration as an important adjunct to surgery of the aging face. What began as an either-or proposition evolved into a simultaneous operation with ever-improving results and with greater patient and surgeon satisfaction. Now, volume restoration is an important part of the surgical and nonsurgical treatment of both the aging face and other facial abnormalities. In fact, with the increasing numbers of injectable fillers with varying characteristics that have been brought to the cosmetic market in the last 10 years, both surgeons and nonsurgeons have seen the volumizing of the face as an increasingly important part of their practice. With that, however, we are seeing an increasing number of patients “overvolumized” as patients, surgeons, and nonsurgeons choose to use volume enhancers instead of surgery for a variety of reasons, when the best outcomes are more often achieved with a blend of both volumizing and surgery. It is clear that the medical profession has recognized the importance of volume restoration in the treatment of the aging face, and now the dilemma is to choose the most appropriate way to achieve those soft,
round, energetic, and beautiful contours of the youthful face. After using nearly all of the facial fillers including injectable collagen introduced over 20 years ago, adipose tissue remains one of the most valuable volume- and contour-enhancing materials that we use both as an adjunct to surgery and as a procedure by itself.

A review of the past efforts to rejuvenate the aging face reveals that excisional-based surgery has not provided sufficiently good results for facial rejuvenation. These traditional excision-only approaches do little to improve cheek or temporal hollowing. Indeed, the tightening and lifting procedures may accentuate volume loss by flattening facial contours. Adipose tissue and skin removal during a blepharoplasty may even worsen the hollowed-out, aged appearance of the eyes. Many contemporary aesthetic surgeons now routinely employ adipose tissue transfer or injectable fillers to enhance their outcomes. Several types of commercial fillers have been used with varying degrees of success and longevity. On the other hand, adipose tissue grafting has demonstrated excellent availability and biocompatibility as well as improved overall skin quality in treated areas for reasons that are unknown. Early criticisms of adipose tissue grafting were the variable and seemingly high degrees of adipose tissue graft loss. However, today, with more experience and improved understanding of atraumatic tissue handling and refined harvest and injection techniques, graft retention has improved significantly. Autologous adipose tissue transfer is now well regarded as an invaluable tool in the plastic surgeon’s armamentarium that can be used either alone or in combination with traditional excisional techniques in facial rejuvenation.

Volume loss has been studied by many and is understood to be a fundamental component of the aging process. Coleman, one of the most influential pioneers of adipose tissue grafting, regarded atrophy of adipose tissue as the primary factor in aging. He also proposed that a significant amount of volume loss was due to colloidal fluid loss with aging. Gonzalez-Ulloa described facial aging as volume loss involving all the structures of the face, including the muscles, bone, skin, and adipose tissue. Lambros singled out specific areas (the brows, the tear trough, the cheeks), and demonstrated how the addition of volume may give results better than traditional methods. A radiologic study by Pessa demonstrated the effect of bony changes on volume loss in the aging process. More recently, the anatomic cadaver work by Rohrich and Pessa illustrated the loss of adipose tissue in specific compartments of the face. While the mechanism for age-related volume loss continues to be investigated, the role of volume restoration in facial rejuvenation is well accepted.

As more research and study has been conducted into the basic science, biology, and technique of grafting over the last 20 years, autologous adipose tissue grafting has assumed an important role in nearly every facial plastic surgeon’s practice. Just as the explosion in popularity of liposuction of the body and the face in the early eighties resulted in many patients having contour irregularities that subsequently required correction with adipose tissue and other techniques, we will be seeing problems related to autologous adipose tissue grafting because of the marked increase in the number of procedures performed in the last few years. Just as we saw in the eighties the increasing numbers of complications that tempered our enthusiasm for liposuction and forced a critical look at the science and technique behind this new procedure, we are beginning to see similar problems with adipose tissue grafting as the techniques have become more commonly used by plastic surgeons. It is now more important than ever to adopt a judicious approach to structural adipose tissue grafting; learn what has worked, what problems we have seen, and where this valuable procedure benefits our patients; and learn about ideal facial shape and contour in both the youthful face and the aging face so that we can bring both science and art to the benefit of those entrusted to our hands.


HISTORY

As with any surgical procedure, a history of previous surgery, medical problems, medications, previous fillers, cosmetic surgery, and allergies, must be obtained. It is also important to ask questions about expectations, goals, and, if previous surgery was performed, whether the patient was satisfied with the results. Expectations and psychological suitability are important parts of the assessment based on history and are explained additionally later. The patient’s age and body habitus as well as the degree of regular physical activity has a direct impact on the long-term results of adipose tissue grafting, the degree of overcorrection that one should consider, how to counsel the patient with regard to expectation, and the location and amount of donor adipose tissue. The patient’s menstrual history in the case of female patients and whether they are pre-, post-, or perimenopausal will impact one’s decisions as to patient suitability and the volume of adipose tissue to be used at any one time.




Oct 7, 2018 | Posted by in OTOLARYNGOLOGY | Comments Off on Autologous Adipose Tissue Grafting

Full access? Get Clinical Tree

Get Clinical Tree app for offline access