Facial contour problems arise from a variety of reasons including birth defects, traumatic injuries, cancer, certain diseases such as HIV, the aging process and certain aesthetic concerns. Provided that the underlying bone structure is normal, treatments are directed at the concept of adding volume. Volumetric addition today is often done by fat grafting. Transplanted fat offers a natural soft tissue solution that has even been shown to have a regenerative effect on the facial recipient.
The vexing problem with fat grafting is that it is not consistent. Its survival is not completely predictable despite improved methods of harvesting and processing. A lot of plastic surgeons have also had the experience that different parts of the face may fare better than others.
The influence of the facial recipient site on fat grafting was evaluated and published in the August 2009 issue of the journal Plastic and Reconstructive Surgery. They specifically looked at this issue in reconstruction cases of facial volume loss due to traumatic or congenital deformities. They analyzed 100 such patients who had structural fat grafting to the face with patient satisfaction surveys and objective assessment by a five-member panel. What they found was a highly variable rate of success based on different facial areas. The cheeks, lateral facial areas and chin was highest while the lips and temple areas were the poorest. The forehead, eyebrows, and nose had intermediate success. Equally significant was the eight cases of before and afters that was impressive, particularly the burn patients.
This report is significant in that it shows overall that fat grafting is useful, even in difficult reconstructive cases. The concept that it somehow changes the quality of the abnormal tissue beds is not only appealing but may well be true. Despite the lack of any scientific evidence to date for why this would occur, it is likely that the stem cells from the fat graft can differentiate into different connective tissue lines. This has certainly been demonstrated in cell cultures.
The intriguing questions from this study is why do the results vary in different parts of the face and how does this translate to cosmetic applications. The most likely explanation for the variances of results is that the recipient beds differ. The cheeks, side of the face and chin naturally have fat and fat grafts will do better when put into such a natural scaffold. The lips and temple area have little to no fat and the grafts are being put into non-like sites where growth and conversion of fat cells is not well supported. As for the cosmetic patient, it would be fair to say that the results would be just as good if not better than in reconstructive cases. The differences in success, however, would see the same variability as we have observed clinically.
In my Indianapolis plastic surgery practice, I occasionally will add PRP (platelet-rich plasma) to smaller volume fat grafts as a growth factor booster. Whether this would improve the results seen in this study is unknown, but remains theoretically appealing with no downside. The use of PRP with fat grafting is most relevant in the face due to the limited volume of PRP obtainable and the volume of fat being injected. The volumetric ratios would lead one to believe it would be more successful with a 1cc PRP:10 – 20cc fat mix ratio being possible.
Dr. Barry Eppley
Indianapolis, Indiana