THE U S E OF D E R M A - F A T G R A F T S IN THE F A C E

By G. BOERING and A. J. C. HUFFSTADT

From the Departments of Oral Surgery and Plastic Surgery of the University Hospital of Groningen, The Netherlands

THE use of derma-fat grafts to correct soft tissue defects in the face remains contro- versial. The first publication was written by Eitner (192o). In 1931 the method was described in America by Figi. In the opinion of many authors derma-fat grafts establish a blood circulation sooner than do fat grafts.

According to Peer (1959) the derma-fat graft is the most satisfactory tissue to correct soft tissue defects. On the other hand, Stark (1962) writes : " The significant shrinkage in size of fat grafts (45 per cent.) makes them virtually valueless in reconstruct- ive surgery ". Bouman (1966) states that, according to his experiments with fat and derma-fat grafts in pigs, both types of grafts show the same chance of survival. The good results in mammaplasties encouraged us to use them also in the face.

Indications.--Traumatic defects.--Our first case was treated in 1957, when a 17- year-old girl asked for correction of a supra-orbital depression caused by a horse-kick at the age of 3. A derma-fat graft was taken from the abdominal wall. The skin over the depression was undermined and the graft was inserted with the dermal side turned outwards. Figure I shows the appearance before operation and Figure 2 the same patient about one year after the correction. In 1965, eight years after the operation, she returned. This time she wanted another scar on her forehead near the hairline corrected (Fig. 3). Tiffs was done with a zig-zag procedure. We could not resist the temptation to take a small biopsy of the eight-year-old derma-fat graft. Our pathologist reported that he could see fat cells and fibrotic dermal tissue with sweat glands still recognisable.

After this first success we have used derma-fat grafts in the face in 2o cases for all kinds of depressions.

Unilateral mandibulo-facial dysostosis. A most interesting deformity to mask with a derma-fat graft turned out to be the asymmetrical face in mandibulo-facial dysostosis. The most characteristic signs of this syndrome are unilateral flattening, a curving of the lower part of the face and a deviation of the chin towards the affected side. Malformations of the ear and a macrostomia on the affected side are common findings. Epibulbar dermoids are often present.

X-ray examination shows a unilateral hypoplasia of the mandible, especially of the ascending ramus. In most cases a hypoplasia of the malar bone and arch, and sometimes of the maxilla, exists as well.

Figure 4 shows a typical case of unilateral mandibulo-facial dysostosis. The derma- fat graft for correction, taken from the abdominal wall, is shown in Figure 5 ; the epidermis has already been removed. One year later there is still too much bulging of the graft (Fig. 6). This excess was corrected. The condition of the face five years after the original grafting operation is shown in Figures 7 and 8.

Another case of severe unilateral mandibulo-facial dysostosis before and after correction is shown in Figures 9, IO and I I. In the photos showing a smile it is especi- ally clear that derma-fat grafts are natural grafts as far as softness and mobility are concerned.

I72

THE USE OF DERMA-FAT GRAFTS IN THE FACE I73

FIG. z FIG. z

Fig. i

A I7-year-old girl with a supra-orbital depres- sion caused by a horse-kick at the age of 3.

Fig. z

The patient in Figure I, one year after correc- tion with a derma-fat graft.

Fig. 3

The correction of a scar on the forehead made it possible to take a biopsy of the 8-year-old

derma-fat graft.

FXG. 3

174 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 4

FIG. 6 FIG. 7

Fig. 6 .--One year after the correction there is still too much bulging of the graft. Figs. 7 and 8 . - -The condition of the face at rest and while smiling, 5 years after the original operation.

T H E U S E O F D E R M A - F A T G R A F T S I N T H E F A C E 175

Hemimandibulectomy and unilateral neck-dissection.--Recently we came across another group of deformities in which the use of derma-fat grafts seems to be very favourable. In cases of oral carcinoma, in which a radical resection is performed, and in which reasonable oral function exists as far as eating and drinking are con- cerned, correction of the very obvious depression in the operated area with a derma- fat graft is a simple method, far less complicated than reconstruction of the mandible with a bone-graft. An example of such a case is given in Figures 12 and 13. The same patient four months after the correction is shown in Figures 14 and 15.

FIG. 8

Our experience with this last group is only short, but we hope for similar long term results as in the other cases of derma-fat grafts in the face.

Technical details.--The skin over the depressed area is undermined through one or two incisions as far as its limits. Meticulous hmmostasis is essential. The graft (skin and subcutaneous fat) is usually taken from the abdominal wall and the epidermis is then removed with a Humby knife. The derma-fat graft is shaped to fit snugly into the prepared cavity. We prefer to make a slight overcorrection. Fixation of the graft is very important because it has a tendency to curl up, and for this reason transcutaneous fixation at the most cranial border of the graft is carried out with silk sutures which remain in place for lO-14 days. The caudal border of the graft is fixed by catgut sutures to the underlying tissues. No drains are used. A pressure dressing with adhesive plaster completes the operation.

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FIG. 9 FIG. I0

Fig. 9 . - - A I9-year-old girl wi th severe unilateral mandibulo-facial dysostosis.

Figs. IO and I r . - - T h e same patient about one year after the correction.

FIG° I I

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FIGS. 12 AND 13

An example of a facial deformity after a hemimandibulec tomy and a unilateral neck-dissection.

FIGS. 14 AND 15

The same patient 4 months after the correction.

2 E

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RESULTS

Up till now the results of the 20 cases of derma-fat grafts in the face are very encouraging. Of course it is necessary to continue the follow-up of all these patients for ten years after the operation.

Of these 20 cases, one was a failure due to infection (primarily ha:matoma ?). In three cases a secondary reduction had to be done. In one patient, when correcting a depression in the forehead the graft was too thin and one year later a second graft was placed on top of the first.

T h e great advantage of the use of derma-fat grafts in the face is that only a simple operation, with very little stress to the patient, is necessary, while very satisfactory results are obtained.

REFERENCES

BOUMAN, F. G. (I966). Thesis, State University of Groningen, The Netherlands. EITNER~ E. (I920). Med. Klin., i6, 93. FIGI, F. A. (1931). Surg. Clins N. Am., 4, 831. PEER, L. A. (1959). " Transplantation of Tissues." Baltimore : Williams & Wilkins. STARK, t . B. (1962). " Plastic Surgery." New York : Harper & Row.