Fat Grafting to Hemifacial Microsomia

INTRODUCTION
Le Fort I osteotomy, Bilateral Sagittal Split
Osteotomy (BSSO) and genioplasty have been
traditionally combined for treating hemifacialmicrosomia
cases. While correction of the lower two
thirds of the face contour asymmetry is achievable
through simple fat grafting, correction of the slanting
anterior occlusal plane and lips is attainable
through the relatively less aggressive segmental
osteotomy.
CASE PRESENTATION
Nine patients with hemifacialmicrosomia had
fat grafting for treating their facial lower 2/3 defective
contours. Five of them refused any maxillofacial
osteotomy (Figs. 1,2), two had fat transfer
associated with segmental anterior maxillary occlusal-
corrective osteotomy (Fig. 3) and one had
it combined with reduction tilting symmetryameliorative
genioplasty. One patient had the facial
fat grafting for reinforcing lower facial contours
after she had had the traditional osteotomies combining
Le Fort I and BSSO.
Fat was collected with a 50 cc syringe and a 2
or 3mm diameter liposuction blunt cannula from
the submental and neck areas and 4mm from trunk
or limbs. Aspirate was left to sediment for 10
minutes and or centrifuged at the lowest rotation
speed for 10-20 seconds. Fat cells were injected
through blunt 2mm cannulas. The amount of transferred
fat was predetermined for each recipient
face side and site according to the magnitude of
its contour deficiency; it measured 15 to 80ml for
each face side. At least half of the amount was put
in dissected subperiosteal pockets and or deeply
under the muscles whenever possible and the remaining
was injected in rows intra-muscularly and
subcutaneously. Minced bone grafts (when available
from contemporary osteotomies) were mixed with
the subperiosteally transferred fat graft.
Follow-up ranged between 2 months and 8
years and structural results were satisfactory with
maintained volume in all cases. Grafted face areas
showed bulging few years later concomitant with
body weight over-gain in three patients. These
were retouched through liposuction of the overstaffed
recipient areas and the suctioned previously
grated fat was recycled in the temporal areas and
retained volume there as followed-up to 30 months
[1].
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DISCUSSION
The term HemifacialMicrosomiais synonymous
to the older terms Oto-Mandibular Syndrome,
OtomandibularDysostosis or First and Second
Brancheal Arch Syndrome. The combination of Le
Fort I, BSSO and genioplasty used to be the classic
justifiable approach to correct patients' malocclusion
and hemifacial atrophy. In its mild form, the
Vol. 42, No. 2 / Fat Grafting to Hemifacial Microsomia
real main complaint of the patients is usually the
defective asymmetric contours of the lower two
thirds of the face and this is adequately answerable
with a simple fat grafting procedure. The slanting
occlusion and chin are correctable with a segmental
bone move.
The need for bone or cartilage grafts and muscle
flaps or prosthetic materials for treatment of facial
Fig. (2): Macrostomia and bilateral hemifacialmicrosomia (A) Preoperative and (B) 2 years aftermaxilla-mandibular
clefts closure in 3 layers, central upper lip vermilion muscle re-arrangement and a mucosal V-Y advancement
and 50ml fat grafting to each side of the face: 40ml to the mandibular angle and 10 to the maxillary
regions.
Fig. (3): Bilateral hemifacial atrophy more manifest on the left side (A) Preoperative and (B) 6 months post
incisive-canine tilting osteotomy with left first premolar extraction and fat grafting to the mandibular
angle regions 20ml on the left and 30ml on the right side.
Fig. (1): Right hemifacialmicrosomia (A) Preoperative and (B) 8 years post- 80ml centrifuged fat grafting to the
right mandibular side: 35ml injected supra-periosteal via an intra-oral approach and 45ml injected both
subcutaneous and intra-muscular through a tiny skin port below ear-lobule.
(A) (B)
(A) (B)
(A) (B)
defective contours in orthognathic surgery cases
has not ever been infrequent. Fat transfer may
efficiently enhance aesthetic facial osteotomy
results and may be as predictable and durable as
the older skeletal grafts and flaps. Fat grafting to
the maxillary areas in the case where the maxillary
sinus has been opened, should be deferred to a
secondary operation. When patients with acceptable
dental occlusion do not agree on cosmetically
intended facial osteotomy, fat transfer may be a
good alternative proposal. Fat grafts to the face
usually hypertrophy on subsequent overall body
weight gain. Facial grafted adipocytes match volume
changes that may happen to those in the
original donor site. Transplanted fat cells seem to
conserve genetic donor-site codes and hence volume
regulations equal to the donor site cells [2].
Facial fat grafting in orthognathic-surgery patients
has been shown over the past few years [3-7] as an
effective reliable tool.
In conclusion, fat grafting to the face treating
defective contours of hemifacialmicrosomia adult
cases may represent a satisfactory alternative to
the interruptive maxilla-mandibular osteotomies
when patient occlusion is acceptable. Combining
fat grafting with segmental osteotomies can effectively
address both contour deficiency and malocclusion.