Repair Revolution: Surgeons use fat grafts to address extensive facial deformities

Larger Defects Require More than Fat

Other plastic surgeons echoed Dr. Lam’s contention that the cases for which such an approach might work are limited.

“There really aren’t a lot of clinical situations where surgeons are successfully injecting large volumes of fat into those types of defects,” said Craig D. Friedman, MD, FACS, a facial plastic surgeon with a private practice in Wilton, Conn., and a visiting surgeon at Yale-New Haven Hospital in New Haven, Conn. According to Dr. Friedman, the general trend in such cases, at least in the past decade, has been to use free flaps that not only contain fat, but also include some combination of blood vessels, tissue, muscle and fascia. These grafts “come with their own blood supply and achieve much better peripheral tissue integration” than would an injection of lipo-aspirated abdominal fat, he said.

There are instances where fat grafts can work, with some limitations, in moderately larger defects. “In the lateral parotid mandible area, where you’ve done a radical extirpation of malignant tissue or congenital/traumatic defect, fat grafts are still a viable corrective approach,” Dr. Friedman said. “But it’s by no means a perfect solution. There will be volume resorption of the fat, so repeat procedures could be needed.”

When faced with more moderate soft tissue defects, Dr. Friedman said he relies primarily on processed tissues and adjunctive biomaterial fillers such as Alloderm, which is made from donated human cadaver skin. In fact, the logic of using a fat graft even for these moderate-sized defects “eludes me,” he said. In such cases, “you have to overtransplant with the fat graft, because it’s hard to predict how much volume you’re going to end up with. If that’s the case, why not use processed tissue? It’s much more predictable, it vascularizes nicely, it’s a terminally sterilized substance and it does a good job of preserving all of the extracellular matrixes, microvessel structures and other types of tissue architecture that are important for the tissue to be incorporated into the defect and yield an optimal cosmetic result.”

“With our approach, we’re not using a flap at all; we simply excise a volume of fat with a layer of its overlying dermis attached.”

—James L. Netterville, MD

A Combined Approach

James L. Netterville, MD, director of head and neck surgical oncology at Vanderbilt University Medical Center, in Nashville, Tenn., advocates a combined approach for repairing extensive soft tissue defects. His procedure of choice uses free dermal fat grafts (FDFG), which contain not only fat, but also an overlying layer of dermis. According to Dr. Netterville, the grafts can be used to fill in large facial defects following parotidectomies and other extensive head and neck surgeries, “with excellent cosmetic results and long-term outcomes.”