PEDIATRIC/CRANIOFACIAL

Craniofacial Microsomia Soft-TissueReconstruction Comparison: InframammaryExtended Circumflex Scapular Flap versusSerial Fat Grafting

Neil Tanna, M.D., M.B.A.Derrick C. Wan, M.D.Henry K. Kawamoto,

D.D.S., M.D.James P. Bradley, M.D.

Los Angeles, Calif.

Background: The authors investigated the use of serial autologous fat graftingto restore soft-tissue contour in craniofacial microsomia patients.Methods: Patients with moderate to severe craniofacial microsomia were dividedinto two groups. Microvascular free flap patients had reconstruction with infra-mammary extended circumflex scapular flaps at skeletal maturity (n � 10). Alter-natively, patients had fat grafting during multiple staged operations for mandibleand ear reconstruction (n � 21). Sex, age, severity of deformity [determined byOMENS (orbital deformity, mandibular hypoplasia, ear deformity, nerve involve-ment, and soft-tissue deficiency) classification], number of procedures, operativetimes, and augmentation volumes were recorded. A digital three-dimensional pho-togrammetry system was used to determine “final fat take” and symmetry (affectedside versus unaffected side). Physician and patient satisfaction were elicited.Results: Microvascular free flap and fat grafting groups had similar OMENSscores, 2.4 and 2.3, and similar mean prereconstruction symmetry scores, 74percent and 75 percent, respectively. Although the mean number of procedureswas less for the microvascular free flap group versus the fat grafting group (2.2versus 4.3), the combined surgical time was greater for the microvascular freeflap group. The complication rate for the microvascular free flap group was 12percent and that for the fat grafting group was 5 percent. The mean micro-vascular free flap volume implanted was 131 cc, with a final measured volumeof 106 cc. Mean fat grafting volume injected per case was 33 cc, with total fatinjections of 146 cc and a final measured volume of 121 cc. There was a meanfat loss of 25 cc and 83 percent fat take. Symmetry score was 121 percent for themicrovascular free flap group and 99 percent for the fat grafting group. Nostatistically significant difference in patient or physician satisfaction was noted.Conclusion: Serial fatgraftingprovidedausefulalternative tomicrovascular freetissuetransfer after skeletal reconstruction. (Plast. Reconstr. Surg. 127: 802, 2011.)

Craniofacial microsomia, or otomandibulardysostosis, is a spectrum of soft- and hard-tissue hypoplasia typically affecting the re-

gions of Tessier no. 6, 7, and 8 facial clefts on oneside.1,2 Serial examinations and retrospective re-

views of untreated patients demonstrate that thereis little growth on the affected side.3–5 Given thewidespread spectrum of facial deformities, thesepatients often require multiple operations to ad-dress the hard- and soft-tissue defects (Table 1).

The bony hypoplasia is corrected surgically atvarious time points and has been shown to im-prove secondary deformity and enhance body im-age development.5 For the treatment of mandib-ular hypoplasia, distraction has become the

From the Division of Plastic and Reconstructive Surgery,David Geffen School of Medicine, University of California,Los Angeles.Received for publication June 4, 2010; accepted August 26,2010.Presented at the 89th Annual Meeting of the AmericanAssociation of Plastic Surgeons, in San Antonio, Texas,March 20 through 23, 2010.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181fed6e4

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com802

mainstay of treatment in the growing patient, andorthognathic advancement is used in the skeletallymature patient.6–8 However, these modalities rarelycorrect the soft-tissue contour deformity.9–11

With craniofacial microsomia, the soft-tissuecover of the involved region is deficient. It is mul-tidimensional, with the skin, subcutaneous tissueof the cheek region, muscles of mastication, andparotid gland showing varying degrees of hypopla-sia. Microsurgical free tissue transfer has been of-fered as a treatment strategy to restore facial con-tour in craniofacial microsomia patients.12–21 Avariation of the parascapular flap, the inframam-mary extended circumflex scapular flap, hasproved to give good results.12,13 Free flap recon-struction is not, however, without morbidity orrisk. In addition, patient satisfaction and aestheticoutcome is not always optimal.17

Many authors advocate that management of soft-tissue hypoplasia can be undertaken only after theunderlying facial skeleton has been addressed.12–15

After skeletal correction, microsurgical free-tissuetransfer of soft tissue may be used as a “finishingtouch.”15 This paradigm is likened to laying the foun-dation of a house before construction of the wallsand roof. The authors present a different model forconsideration of soft-tissue reconstruction.

As many patients with moderate or severe de-formity require multiple operations, serial autol-ogous fat grafting can be concomitantly per-formed simultaneously at the time of many of

these procedures. Staged operative interventionsfor mandibular distraction, ear reconstruction,and orthognathic surgery provide many opportu-nities for serial fat transfer (Table 1). Instead ofundertaking soft-tissue reconstruction after skel-etal correction, small gains in improving facialcontour can be made earlier. To study this alter-native soft-tissue treatment strategy, we performedvolumetric outcome comparison of patients whounderwent serial autologous fat grafting and/ormicrovascular free flap surgery.

PATIENTS AND METHODSCraniofacial microsomia patients who under-

went soft-tissue reconstruction with serial autolo-gous fat grafting or free flap reconstruction withan inframammary extended circumflex scapularflap at the University of California, Los Angeleswere included in this study (n � 31). Childrenincluded in the study were diagnosed by our mul-tidisciplinary craniofacial team between 1990 and2009. With institutional review board approval,the charts and records of all these patients werereviewed. Excluded from the study were patientswith incomplete records (examinations, photo-graphs, or documentation) and inadequate fol-low-up. All patients had at least 1-year follow-up.Sex, age, severity of deformity [as determined bythe OMENS (orbital asymmetry, mandibular hy-poplasia, ear deformity, nerve involvement, andsoft-tissue deficiency) classification], number ofprocedures, indications, and operative times forall interventions were recorded.22 Each patient wasassessed preoperatively, postoperatively, and infollow-up by the University of California, Los An-geles multidisciplinary craniofacial team.

Operative TechniqueAll operations were carried out under general

anesthesia. Before incision, intravenous Ancef(GlaxoSmithKline, Research Triangle Park, N.C.)was administered.

Group 1: Microvascular Free FlapFor patients who underwent microvascular

free flap surgery, an inframammary extended cir-cumflex scapular flap or modified parascapularflap was performed as described by Siebert et al.13

Soft-tissue deficiency was marked preoperativelywith the patient in the upright position. The pa-tient was placed in lateral oblique position and theflap was designed on a longitudinal axis of rota-tion, designed curvilinearly from the ipsilateralinframammary fold to the origin of the circumflex

Table 1. Potential Staged Corrective Procedures forPatients with Craniofacial Microsomia duringChildhood*

Early childhoodMacrostomia correctionRemoval of preauricular skin tagRepair of cleft lip/palate (if present)Mandibular distraction osteogenesis for tracheal

decannulation or delayed onset/recurrent OSAOrthodontic procedures

Late childhoodMandibular distraction osteogenesis for Pruzansky type

IIA to IIB (distraction device placement and removal)Rib graft for Pruzansky type IIIStaged microtia repair (framework fabrication, elevation,

canal reconstruction)Orthodontic procedures

Adolescence/adulthoodDouble-jaw surgery (Le Fort I osteotomy and bilateral

sagittal split osteotomy) for malocclusionOsseous genioplastyOrbital box osteotomy/facial bipartition

OSA, obstructive sleep apnea.*Potential staged corrective procedures for patients with craniofacialmicrosomia during childhood present multiple opportunities forserial autologous fat grafting. Procedures may vary depending on theinvolvement and severity of the deformity.

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scapular artery. The degree of facial deformityguided the width of the flap and inclusion of fascialextensions of the dorsal thoracic fascia. Flap widthvaried from 4 to 10 cm. Flaps were contoured grosslyafter harvest, but final sculpting was performed afterinset into the deficient soft-tissue bed. The donor sitewas closed in layers over a drain.

A limited preauricular rhytidectomy incisionwas performed and a subcutaneous pocket wasmade to just beyond the preoperative markings.Superficial temporal vessels were exposed andprepared. The flap’s pedicle and deep surfacewere oriented away from the skin. Permanent su-ture fixation of the flap’s fascia was performed tomultiple sites around the infraorbital rim and zy-goma periosteum. Soft-tissue bolsters were placedfrom the flap through the skin to ensure that theflap was positioned properly in the pocket. Skinwas closed over a drain. Routine postoperative flapmonitoring was performed by serial Doppler andclinical examination. Patients were typically dis-charged on day 5 and soft-tissue bolsters were re-moved in the office at 10 days.

Group 2: Serial Fat GraftingThe specific details of our fat harvest, prepa-

ration, and grafting are documented in a previousarticle.23 The methodology used at our institutionis very similar to that described by Coleman.24 Fatwas typically harvested from the abdomen or flank.If a sufficient amount of fat could not be obtainedfrom these depots, as in some of our young pa-tients, other sites including the medial thigh andbuttock were used. After fat was harvested usingmanual suction with a 10-cc syringe and a 3-mmblunt cannula, the aspirated fat was centrifugedfor 3 minutes at 3000 rpm. After the supernatantwas removed, fat was transferred into 1-cc syringesand injected immediately into the affected regionsof the face. Multiple access sites and a “fanning-out” technique were used to transfer small aliquotsof fat into various depths of the soft tissue.

Outcome AnalysisThe number of soft-tissue reconstruction pro-

cedures performed for patients undergoing serialfat grafting was compared with that for patientsundergoing microvascular free flap surgery. Theseincluded any flap revisions. For serial fat grafting,the amount of fat injected (in cubic centimeters)was recorded for each procedure. In addition, themean for all procedures and the final volume werecalculated. For the microvascular free flap group,the volume of fat/fascia grafted based on water

displacement in the operating room was recorded.During revision surgery, the volume of fat re-moved was recorded so that the final volume couldbe determined. All complications or adverseevents for each group of patients were noted. Theoperating surgeon documented perioperativecomplications, including but not limited to wounddehiscence, bleeding, infection, hypertrophicscarring, contour irregularities, flap failure, anddonor-site complications.

In both groups of patients, volume determi-nations were made with a digital three-dimen-sional photogrammetry system (MU-4 imaging sys-tem; 3dMD, Atlanta, Ga.). This high-resolution,digital, three-dimensional photography systemhas been used by our institution and other authorsfor reliable volumetric analysis.25–29 The distancefrom the patient to the camera was consistent andstandardized throughout the duration of thestudy. We cross-referenced two methods of volu-metric analysis: (1) radial region and (2) surfacelandmarks. Three independent users selected thecenter of the radius or surface landmarks andrecorded volumetric measurements based on thesystem software.

Volumetric augmentation was noted for eachpatient by comparing the preoperative, postoper-ative (6 weeks), and follow-up (1 year) reconstruc-tion volumes of the affected side. Fat take wasconsidered the difference between postoperativevolume and preoperative volume. Final fat takewas considered the fat preservation at 1 year or thedifference between the follow-up volume and pre-operative volume. Fat loss over time was the fattake minus the final fat take.

Volume symmetry was evaluated by comparingthe affected side to the unaffected side. Each in-dependent evaluator attempted to match radialand landmark surface points between the sides.Symmetry score was determined both preopera-tively and at follow-up and calculated as follows:symmetry percent � (affected side volume/con-tralateral unaffected side volume) � 100.

To assess satisfaction, physician and patientsurveys were used that have been validated forintrarater and interrater reliability in previousstudies.6 Physician satisfaction with the outcomebased on symmetry, volume, and overall appear-ance was recorded in both the perioperative andfollow-up periods using a five-point scale (0, dis-satisfied or no improvement; 1, only partially sat-isfied or 25 percent improvement; 2, half satisfiedor 50 percent improvement; 3, mostly satisfied or75 percent improvement; and 4, totally satisfied or100 percent improvement). A patient satisfaction

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assessment (0, dissatisfied or no improvement; 1,only partially satisfied or 25 percent improvement;2, half satisfied or 50 percent improvement; 3,mostly satisfied or 75 percent improvement; and 4,totally satisfied or 100 percent improvement) wasalso collected in both the perioperative and fol-low-up periods.

Statistical AnalysisAn unpaired t test was used to determine any

significant differences between the two groups ofpatients. To compare patient and physician satis-faction scores between the two groups, a Mann-Whitney-Wilcoxon test was performed. A value ofp � 0.05 was considered statistically significant.

RESULTSDuring the study period, 31 patients with

craniofacial microsomia underwent correction ofsoft-tissue hypoplasia and had complete recordsand imaging necessary for comparative analyses.Ten patients in group 1 (Fig. 1) underwent mi-crovascular free flap surgery with an inframam-mary extended circumflex scapular flap (Table 2).Serial autologous fat grafting was performed in 21patients (Figs. 2 and 3) in group 2 (Table 3).Preoperatively, both groups had similar soft-tissuedeficiencies, as determined by the OMENS clas-

sification, with a mean soft-tissue deficiency scoreof 2.4 � 0.5 for group 1 (microvascular free flap)and 2.3 � 0.7 for group 2 (serial fat grafting)(Table 4). In addition, the mean prereconstruc-tion symmetry score for groups 1 and 2 was 74 �7.1 percent and 75 � 5.0 percent, respectively.Neither difference was statistically significant.

Patients who underwent soft-tissue reconstruc-tion with microvascular free flaps (group 1) had astatistically significantly lower number of proce-dures than those children who received serial fatgrafting (p � 0.05). The average number of pro-cedures for the patients who underwent infra-mammary extended circumflex scapular flap sur-gery (group 1) including take-backs or flaprecontouring revisions was 2.2 � 0.6. The meannumber of autologous fat grafting procedures(group 2) performed was 4.3 � 1.0. A mean num-ber of only 0.3 cases of fat grafting was performedwithout a simultaneous procedure such as stagedear reconstruction. The total surgical time or netsurgical time was 490 minutes for group 1 and 228minutes for group 2. However, the average oper-ative time per case was 232 minutes for group 1and 48 minutes for group 2.

The complication rate in group 1 was 12 per-cent, including a hematoma and partial flap losswith fat necrosis. In group 2, there was a 5 percent

Fig. 1. Craniofacial microsomia microvascular free flap (group 1) patient. (Left) Preoperative frontal image shows facial asymmetrywith right hypoplasia before skeletal or soft-tissue correction. (Center) After double-jaw (Le Fort I/bilateral sagittal split osteotomy)surgery but before soft-tissue correction of skeletal midline was seen. (Right) Postoperative frontal image following soft-tissuereconstruction with an inframammary extended circumflex scapular flap shows improved facial symmetry (note that the patientalso had orbital dystopia correction with right orbital box osteotomy/downward movement and septorhinoplasty).

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complication rate, with infection and surface ir-regularities. One patient from the microvascularfree flap group had a prolonged seroma, but therewas no donor-site morbidity in the serial fat graft-ing group.

Volume AugmentationVolume augmentation for group 1 patients,

based on volume at the time of inset of the infra-mammary extended circumflex scapular flap, wasa mean of 131 � 16.5 cc; after revisions, whichincluded soft-tissue debulking, the mean final vol-ume was 106 � 13.4 cc. The three-dimensional

imaging using radial recording and surface land-marks showed an initial mean fat take in the post-operative period of 124 � 10.4 cc. The meanfinal fat take using three-dimensional imagingafter 1-year follow-up and revision procedureswas 101 � 9.3 cc.

Volume augmentation for group 2 patientswas based on the amount of fat injected (mea-sured in cubic centimeters) during each proce-dure. The mean for all fat grafting procedures was33 � 3.2 cc. The final mean volume of fat injectedbased on the total of fat injected during all pro-cedures was 146 � 9.2 cc. Three-dimensional im-aging using radial recording and surface land-

Table 2. Characteristics of Craniofacial Microsomia Patients Who Underwent Microvascular Free Flap or anInframammary Extended Circumflex Scapular Flap

Patient OMENSNo. of

Procedures

Volumeof Initial

Flap(cc)

FinalVolume

(cc)Prereconstruction

Symmetry (%)Postreconstruction

Symmetry (%)Physician

SatisfactionPatient

Satisfaction

1 O0M2AE2N72S3 2 129 104 74 122 3.6 3.4

2 O0M2AE2N72S3 3 145 110 76 124 3.3 3.4

3 O0M2AE2N72S2 2 137 124 84 110 3.2 3.3

4 O0M2AE2N72S2 3 138 98 71 117 3.7 3.6

5 O0M2AE2N72S3 1 95 95 88 139 2.8 3.6

6 O1M2AE2N72S2 3 144 115 68 114 3.3 3.0

7 O0M2AE2N72S3 2 150 131 71 122 3.8 3.6

8 O0M2AE2N72S2 2 115 95 73 120 3.6 3.3

9 O0M2AE2N72S2 2 122 90 64 116 3.3 3.5

10 O0M2AE2N72S2 2 135 102 73 126 3.9 3.8

Mean O0M2AE2N72S2 2.2 131 106 74 121 3.5 3.5

Fig. 2. Craniofacial microsomia fat grafting (group 2) patient. (Left) Preoperative frontal image shows facial asymmetry with righthypoplasia before skeletal or soft-tissue correction. (Center) After right mandibular distraction and staged ear reconstruction sur-gery with serial fat grafting (two times). (Right) Postoperative frontal image following soft-tissue reconstruction with serial fatgrafting (four times) showed improved facial symmetry.

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marks showed an initial mean fat take for eachprocedure in the postoperative period of 35 � 3.5cc. The mean final fat take using three-dimen-sional imaging measurements after 1-year fol-low-up was 121 � 8.1 cc (83 percent). The meanfat loss was 25 � 3.0 cc.

There was a higher amount of volume augmen-tation achieved with less fat loss in the microvascularfree flap group compared with the serial fat graftinggroup (p � 0.05). For three-dimensional imaging,radial recording volumes differed from surface land-mark volumes by less than 3 percent, and interratererror was less that 2 percent.

Volume SymmetryAfter soft-tissue reconstruction, group 1 pa-

tients had a symmetry score of 121 � 7.9 percentand patients in group 2 had a symmetry score of99 � 5.4 percent. When comparing final volumesof the affected to the unaffected sides, a value of100 percent is ideal. Patients in group 2 had apostreconstruction symmetry score significantlycloser to 100 percent (p � 0.05).

SatisfactionWhen considering patient and physician sat-

isfaction, no statistically significant difference was

noted betweens groups 1 and 2 (p � 0.05). On afive-point scale, the mean physician satisfactionscore for groups 1 and 2 was noted to be 3.5 � 0.3and 3.6 � 0.2, respectively. The average score forpatient satisfaction was 3.5 � 0.2 for group 1 and3.7 � 0.5 for group 2.

DISCUSSIONCraniofacial microsomia represents a wide

spectrum of bony and soft-tissue hypoplasia. Tocorrect these deformities, patients often undergomultiple operations. These are staged and per-formed at various time points, beginning as earlyas the neonatal period and extending into adult-hood (Table 1). This presents a unique opportu-nity for early soft-tissue reconstruction with serialautologous fat grafting.

With craniofacial microsomia, mandibular ab-normality is most evident and occurs to some de-gree in 89 to 100 percent of patients.1,2 The man-dible can be operated on at all stages of the child’slife, depending on the necessity of the operation.Mandibular distraction is considered in the neo-natal period only to treat significant airwayobstruction.7 Mandibular distraction may then bereconsidered during midchildhood (between theages of 6 and 12 years) for delayed onset/recur-rent obstructive sleep apnea, to facilitate trache-

Fig. 3. Craniofacial microsomia fat grafting (group 2) patient. (Left) Preoperative frontal image shows left facial hypoplasia and righttorticollis before ear, mandibular, or soft-tissue correction. (Center) After right sternocleidomastoid release for torticollis, left costalcartilage graft for Pruzansky type III mandibular deformity, subsequent rib graft distraction, and fat grafting (two times). (Right)Postoperative frontal image following staged ear reconstruction and soft-tissue reconstruction with serial fat grafting (four times)shows improved facial symmetry.

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Tab

le3

.C

har

acte

rist

ics

ofC

ran

iofa

cial

Mic

roso

mia

Pat

ien

tsU

nd

erg

oin

gSe

rial

Fat

Gra

ftin

g

Tot

alV

olum

epe

rFa

tIn

ject

ion

Pro

cedu

re(c

c)

Pat

ient

OM

EN

SN

o.of

Pro

cedu

res

Firs

tSe

cond

Thi

rdFo

urth

Fift

hSi

xth

Tot

alFa

tIn

ject

edpe

rC

ase

(cc)

Pre

reco

nstr

ucti

onSy

mm

etry

(%)

Pos

trec

onst

ruct

ion

Sym

met

ry(%

)P

hysi

cian

Sati

sfac

tion

Pat

ient

Sati

sfac

tion

1O

0M2A

E2N

70S

24

3035

4234

144/

3576

105

3.7

42

O0M

2BE

2N7

2S3

435

3840

2513

8/35

7295

3.5

43

O1M

2AE

3N7

2S2

634

3533

3830

2819

8/33

8197

3.7

34

O0M

1E0N

70S

13

3525

2888

/29

7410

73.

64

5O

0M3E

1N7

1S3

542

3436

3035

177/

3566

103

3.4

46

O0M

2BE

2N7

0S2

440

3633

2513

4/34

7796

3.4

37

O0M

1E0N

72S

13

3532

2592

/31

6910

13.

73

8O

0M2A

E2N

72S

36

3038

2635

3830

197/

3378

923.

74

9O

0M2A

E2N

73S

34

2736

3035

128/

3282

109

3.5

410

O0M

2BE

3N7

3S3

540

2835

3022

2818

3/31

7310

23.

84

11O

0M2B

E2N

72S

25

3840

3533

3718

3/37

6594

3.7

412

O0M

1E2N

71S

23

3835

3010

3/34

7196

3.8

313

O0M

2AE

2N7

2S2

533

2735

2830

153/

3179

103

3.6

414

O0M

1E3N

70S

24

4538

3538

156/

3976

923.

43

15O

0M2B

E2N

73S

34

3532

2830

125/

3176

983.

74

16O

0M3E

3N7

2S3

636

3435

2839

3020

2/34

7389

3.4

417

O0M

1E2N

70S

13

3735

3510

7/36

8410

33.

64

18O

0M2A

E2N

72S

34

4435

3735

151/

3874

107

3.2

319

O0M

1E0N

70S

24

3025

3035

120/

3071

993.

84

20O

0M2B

E2N

73S

35

3835

3532

2516

5/31

7510

03.

44

21O

0M1E

0N7

0S2

430

3435

3313

2/33

8298

3.9

4M

ean

O0M

2AE

2N7

2S2

4.3

146/

3375

993.

63.

7

Plastic and Reconstructive Surgery • February 2011

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ostomy decannulation, or to treat significant andsevere mandibular ramal asymmetry.8 In additionto lengthening the mandibular bone, distractionalso lengthens the regional muscles of mastica-tion, nerves, and soft tissue.9 However, it rarelyresolves the soft-tissue deficiencies.10,11 ForPruzansky type III mandibles, a costal cartilage orrib graft may be required (between 5 and 8 yearsof age).

Throughout childhood, patients may undergodental rehabilitation and orthodontic proceduresto improve occlusion.30 Often, at skeletal maturity,an orthognathic procedure is required. A double-jaw procedure or Le Fort I osteotomy with simul-taneous bilateral sagittal split osteotomy of themandible is used to correct the dental midline andan occlusal cant. Osseous genioplasty may be usedsimultaneously or on its own for final chin pointcorrection. In addition, vertical orbital dystopiacan be addressed with orbital box osteotomy orfacial bipartition. With craniofacial microsomia,microtia is present in 66 to 99 percent of patients.1These children benefit from staged total ear re-construction between 5 and 10 years of age.

For final correction of soft-tissue deficiency, amicrovascular free tissue transfer has been usedwidely.14,15 Many flaps have been described for themicrosurgical restoration of facial contour, in-cluding groin, parascapular, rectus abdominis, su-

perficial inferior epigastric artery, latissimus dorsi,deltopectoral, radial forearm, and anterolateralthigh flaps.12–21 Although free tissue transfer is ef-fective, it is not without increased risk and mor-bidity in this patient population. A majority ofthese patients have had multiple previous recon-structive procedures, making microvascular flapreconstruction arduous. Scarring and tethered tis-sue from previous dissection is common. The su-perficial temporal vasculature is not always avail-able as recipient vessels because of previoustemporal incisions and the harvesting of tem-poroparietal fascia for ear reconstruction.31 In ad-dition, flap revision is routinely advocated 6months postoperatively for flap debulking, reeval-uation, recontouring, and resuspension. Patientswho received the inframammary extended cir-cumflex scapular flap (group 1) had overcorrec-tion, as evidenced by their 121 percent postrecon-struction symmetry score. These patientsunderwent an average of 2.2 procedures. Scarring,proximity to critical structures, and flap contrac-ture made it difficult to contour the flaps to matchthe contralateral unaffected side.

With microsurgical reconstruction, it has beenreported that patient satisfaction is not alwaysoptimal.17 Inigo et al. reported that 23 percent of118 conventional free flap cases for severe defor-mity indicated a poor result.17 However, in ourstudy, patient satisfaction was high, with a score of3.6 of 4.0. Finally, despite the flap delivering vol-ume to the affected area, the aesthetic result is notalways ideal. The flap can sag because of its weight,affecting nearby structures such as the lower eye-lid. At times, flap contracture can cause irregu-larity of the skin and a hard texture with palpationof the surface.

Considering the multiple staged operative in-terventions craniofacial microsomia patients un-dergo and recognizing the morbidity of free tissuetransfer, we performed serial fat grafting for soft-tissue correction of craniofacial microsomia pa-tients and undertook a comparative study. Ourdata showed that serial fat grafting throughoutchildhood was a viable alternative to free tissuetransfer after skeletal correction for addressingcraniofacial microsomia soft-tissue deformities.

With our comparative study, before interven-tion, both groups of patients had similar degreesof soft-tissue deficit based on the mean OMENSsoft-tissue score and prereconstruction symmetryscores. As expected, group 2 (fat grafting) patientshad a statistically greater number of proceduresthan those in group 1 (microvascular free flap);however, the total time in the operating room for

Table 4. Mean Outcome Values for MicrovascularFree Flaps and Serial Fat Grafting

MVFF(group 1)

Serial Fat Grafting(group 2)

No. 10 21OMENS soft-tissue

deficiency score 2.4 � 0.5 2.3 � 0.7No. of procedures† 2.2 � 0.6 4.3 � 1.0Operative time, min

Per case 232 48Total 490 228

Complications, % 12 5Volumetric

augmentation, ccCase 131 � 16.5 33 � 4.1Total† 106 � 13.4* 146 � 24.8

Prereconstructionsymmetry, % 74 � 7.1 75 � 5.0

Postreconstructionsymmetry,† % 121 � 7.9 99 � 5.4

Physician satisfactionMean � SD 3.5 � 0.3 3.6 � 0.2Range 2.8–3.9 3.2–3.9

Patient satisfactionMean � SD 3.5 � 0.2 3.7 � 0.5Range 3.0–3.8 3–4

MVFF, microvascular free flap.*For MVFF flaps, volumetric case fill represents flap volume at insetand total represents initial volume minus the fat removed at revision.†p � 0.05.

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fat grafting patients (228 minutes) was less thanfor microvascular free flap patients (490 minutes).Microvascular free flap patients were overcor-rected, with postreconstruction symmetry scoresof 121 percent (�100 percent, which is ideal). Bycontrast, patients undergoing serial fat graftingachieved a symmetry score closer to 100 percentand were found to have 82 percent fat retentionat follow-up. There was no statistically significantdifference in patient or physician satisfactionnoted in either group. In short, groups 1 and 2achieved similar results, with the latter foregoinga free flap transfer procedure with increased do-nor-site morbidity and benefiting from earlier soft-tissue improvement.

For the craniofacial microsomia patient whopresents in adolescence with significant soft-tissuehypoplasia, an inframammary extended circum-flex scapular flap is still considered by us to be theappropriate management. This procedure has theadvantage of large volume correction with one ortwo procedures. For the growing child who willrequire multiple reconstructive procedures in thefuture, we plan serial fat grafting throughout theirreconstructions.

Fat transfer is generally regarded as a safe pro-cedure, with isolated reports of severe morbidity.23

Although rare, aphasia, hemiparesis, hemiplegia,and blindness have occurred secondary to fatembolism.32–37 No patients in this series developedsigns or symptoms consistent with fat embolism.The authors believe that retrograde injection offat can minimize the risk of intravascular transfer.More common complications include hematoma,cellulitis, and contour irregularities.

Survival rates of fat grafts vary tremendously inthe literature.23 In addition, these clinical assess-ments fail to objectively assess outcomes. Instead,the results of these studies are based on subjectiveevaluations, such as preoperative and postopera-tive photographs. Although initially patients whoreceived fat injections (group 2) had a postsym-metry score of 99 percent, the mean fat take in ourstudy group measured by three-dimensional pho-tographic imaging was 82 percent. These data con-firm that overcorrection may be necessary whencorrecting soft-tissue deficiency with fat grafting.As survival and retention of fat varies among in-dividuals, it is difficult to ascertain exactly howmuch overcorrection is appropriate. The use ofautologous fat grafting to improve craniofacialcontour will become increasingly important as ad-vancements in tissue engineering improve survivalof cells and predictability.38,39

CONCLUSIONSPatients with craniofacial microsomia require

multiple operations and procedures for the cor-rection of hypoplasia. By combining serial autol-ogous fat grafting at the time of these operativeinterventions, the craniofacial contour can be im-proved markedly. Fat grafting is safe and effective,and often alleviates the necessity and added mor-bidity of microvascular free tissue transfer.

James P. Bradley, M.D.200 UCLA Medical Plaza, Suite 465

Box 956960Los Angeles, Calif. 90095-6960

bradley.research@gmail.com

PATIENT CONSENTParents or guardians provided written consent for

the use of patient images.

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