Craniofacial Surgery

INTRODUCTION

Craniofacial trauma is a blanket term that refers to an injury of the face or skull. This can refer to skin, bone and teeth injuries as well parts of the mouth, neck and sinuses. Maxillofacial trauma is another name for injuries that primarily affect the facial features.

Craniofacial trauma can range from a minor scrape to lifetime disfigurement. Pediatric craniofacial trauma is treated differently than adult facial trauma, as normal growth and development of the skull and face can be impacted.

CAUSES

• Assault (most common; domestic violence is an important cause; alcohol may be involved).
• Road traffic accidents (midface fractures can occur).
•  
• Sporting accidents. Common activities such as contact sports and gymnastics can increase the likelihood of receiving a craniofacial injury.
• Guns shot wounds

SYMPTOMS

Facial trauma is often recognized by swelling, bruising and skin lacerations (cuts). Widening of the distance between a child’s eyes and movement in the upper jaw even when the head is stabilized are signs that bones within the face are broken. Abnormal sensations around a face and bleeding from the ears, nose or mouth can also indicate severe craniofacial trauma.

COMPLICATIONS OF CRANIOFACIAL TRAUMA

Immediate

• Airway compromise.
• Aspiration
• Haemorrhage
• Infection

Longer-term

• Scars and permanent facial deformity.
• Chronic sinusitis.
• Nerve damage leading to loss of facial sensation, movement, smell, taste or vision.
• Malocclusion of the teeth.
• Non-union/malunion of fractures.
• Malnutrition and weight loss.
• Facial disfigurement.

DIAGNOSTIC TESTS

• Panormaic Xrays
• CT scans of the facial structures with 3D reconstruction
• MRI of the head and neck

LEGEND: CT scan with 3D reconstruction showing a displaced fracture of the zygomatic bone (tripod fracture) because of a sports injury. The arrow shows the broken zygomatic bone.

LOCATION

Surgery to correct craniofacial trauma can only be performed in the hospital and usually requires hospitalization for a number of days depending on the severity of the trauma. The patient after surgery may need to recover for a day or so in the Intensive Care Unit, especially if the injuries are multiple.

ANESTHESIA

Anesthesia for Craniofacial trauma is usually General Anesthesia and needs to be administrated by anesthetists experienced in these type of injuries. 

TREATMENTS

The treatment for craniofacial trauma depends on the area of the skull or face affected:

1. Soft Tissue Injuries

Most soft tissue injuries result are treated with antiseptic and a bandage, however, bad cuts often also require sutures to close the wound. Doctors will also examine the injury to ensure that the nerves, glands and ducts were not damaged by the injury.

1. Bone Injuries

Bone fractures in the face are treated in a similar manner to fractures that occur in other parts of the body. Very minor fractures may not need treatment and can heal normally on their own. More serious fractures require the bones to be stabilized in order to heal properly. In these cases, surgery along with implants such as wires, plates and screws may be necessary.

• Frontal bone fractures 

• These usually follow a severe blow to the forehead.
• A dural tear should be considered if the posterior wall of the frontal sinus is fractured.
• There may be tenderness, crepitus or disruption of the supraorbital rim. Look for subcutaneous emphysema and reduced sensation of supraorbital and supratrochlear nerves.
• Surgery is needed if the nasofrontal duct is blocked.
• Non-displaced fractures are sometimes managed by observation.

 

• Orbital floor fractures

This usually follows a blow from an object >5 cm (eg, a tennis ball). The force may be transmitted along the orbital rim or through the orbit, compressing the globe, which pushes into the orbital floor (‘blowout’ fracture). Clinical features vary with the severity of the trauma and the time between trauma and presentation. Look for:

• Periorbital bruising, oedema, surgical emphysema.
• Vertical diplopia (double vision, especially on looking up) with restriction of upgaze.
• Enophthalmos (the eye is sunken).
• Infraorbital anaesthesia (lower lid, cheek, side of nose, upper lip, upper teeth and gums).
• It is worth noting that children may have a ‘greenstick’ fracture with significant muscle entrapment but minimal bruising (a ‘white-eye blowout’). They may have nausea and vomiting, especially on upgaze.

Management of orbital fractures

• Tell the patient not to blow their nose for 10 days.
• Arrange imaging as above; CT is particularly helpful. Liaise with ophthalmologists and maxillofacial surgeons (depending on local protocol).
• Some cases are managed conservatively with prophylactic broad-spectrum antibiotics (eg, co-amoxiclav) and outpatient monitoring.
• Surgery is required if:
  • This is a white-eye blowout in a child – surgery must be performed within 48-72 hours, as there is a high risk of necrosis of the entrapped ocular muscle.
  • There is symptomatic enophthalmos of >2 mm (this can easily be measured in the eye clinic).
  • There is greater than 50% of the orbital floor involved.
  • Diplopia fails to resolve after 2-3 weeks.

Complications

• Globe injury.
• Persistent diplopia requiring delayed surgery.
• Optic nerve damage.

 

• Nasal bone Fractures

Nasal injuries are the most common facial traumas. The nasal bones are the most commonly fractured bones of the face, as they occupy a prominent, exposed position and have little structural support. Changes in appearance and function can be prevented by prompt and appropriate management. Rhinoplasty and septoplasty procedures are often performed to correct untreated nasal fractures.

Symptoms of Nasal fractures

• Significant rhinorrhoea (evaluate for a CSF leak) or hemorrhage:
• Septal haematoma
• Deviation or malposition of the nose.
• Lacerations, swelling and bruising.
• Crepitus and instability.
• Facial / mandibular fracture.
• Facial anaesthesia.

 

Imaging
The diagnosis of nasal fracture is generally made on clinical grounds and imaging is usually unnecessary during the initial assessment.

Management

Patients without significant swelling or deformity may be discharged. For those with significant swelling:

• Give advice on using ice/simple analgesia. These will decrease the swelling and pain.
• Discharge – review in five days.
• Patients with significant nasal deviation should be seen again in a weeks time when the swelling has subsided.
• Adhesions to the surrounding soft tissue can occur in as few as 5-10 days. Fractured nasal bones usually heal in 2-3 weeks.
• Fracture reduction can be performed when it is possible to assess and manipulate the mobile nasal bones. This is usually within 5-10 days in adults and 3-7 days in children.
• Patients with little swelling may be suitable for immediate reduction.
• Closed reduction is preferred by most surgeons.

 

• Nasoethmoidal fractures

 

• These extend from the nose to involve the ethmoid bones.
• They can lead to damage of the lacrimal apparatus, canthus, nasofrontal duct or dural tear at the cribiform plate.
• If a dural tear is suspected, referral to a neurosurgeon is required.
• Ophthalmology, ear, nose and throat, maxillofacial and plastic surgery referral is required to manage other injuries.

 

• Maxillary fractures

 The two maxillae form the upper jaw, the anterior part of the hard palate, part of the lateral walls of the nasal cavities, and part of the floors of the orbital cavities. They meet in the midline at the intermaxillary suture and form the lower margin of the nasal aperture.

 Classification of Maxillary Fractures

• Le Fort I– a horizontal fracture across the inferior aspect of the maxilla. May result from a direct blow on the maxillary alveolar rim in a downward direction. The alveolar process and hard palate become separated from the rest of the maxilla.
• Le Fort II– a pyramidal-shaped fracture. It may result from a blow to the lower or mid-maxilla. It can present with facial edema, epistaxis, subconjunctival haemorrhage, CSF rhinorrhoea, a mobile maxilla.
• Le Fort III– a transverse fracture, also known as craniofacial dysjunction. It may follow a blow to the nasal bridge or upper maxilla. There is separation of all of the facial bones from the cranial base with simultaneous fracture of the zygoma, maxilla, and nasal bones.

Management of Maxillary Fractures

• Maxillary fractures are usually managed by open reduction and fixation.
• Patients with higher Le Fort injuries have more severe injuries and more frequently need a surgical airway. Those with Le Fort III injuries have a higher chance of needing neurosurgical intervention or experiencing vision-threatening trauma.

 

• Mandibular fractures

When a blow to the mandible causes a fracture there are often other fractures too and these must be sought:

• Trauma to one side often produces an ipsilateral body fracture and a contralateral subcondylar fracture.
• A heavy blow to the symphysis produces a symphyseal fracture and bilateral subcondylar fractures.
• It is also important to exclude damage to the cervical spine and to ascertain that the airway is not compromised.

 

Symptoms of mandible fractures

• Abnormality in facial contour and shape of the mandible as well as tenderness, swelling, redness, lacerations or haematoma
• Malocclusion of the teeth.
• Loose and fractured teeth
• Bruising inside the mouth
• Paresthesia or anesthesia of the chin and teeth
• Spasm of the muscles of mastication can produce trismus (difficulty opening the mouth)

Management

General measures

Treatment is usually surgical but a conservative approach may be acceptable for children with a greenstick fracture or the elderly edentulous patient with minimal displacement. Support to the jaw may relieve discomfort. Chewing should be minimised or avoided with a liquid or puréed diet.

Surgery for mandible fractures

A surgical approach is often advocated nowadays where a conservative line may have been acceptable before. A variety of wires, plates and screws are used to reduce the fractures. Incisions are made usually inside the mouth.

RISKS

• Wound Infection
• Hematoma
• Delayed union of fractures or non union of fractures
• Malocclusion
• Infection of hardware (screws and plates)
• Extrusion of screws and plates
• Ugly scars
• Diplopia
• Hypesthesia
• Necessity to reoperate

 RESULTS

If the there are no complications the results of the reconstructions are permanent. The swelling and bruising takes a few weeks to disappear. Sometimes secondary surgery needs to be done in order to optimize the results.

CASE 1

PANFACIAL INJURIES

LEGEND: Patient with panfacial trauma (soft tissues, bones and dentition) due to an accidental  gunshot wound The patient had lost almost all of the mandible, major part of the left maxilla, the left side of the nose, all of the lower lip and floor of the mouth, his tongue was always outside the mouth, he was unable to eat regular food and he was constantly drooling. He had minimized also his activities due to his appearance. He underwent elsewhere initially salvage surgery, with coverage of the defect of the mouth with a pectoral muscle flap from the chest (arrow). He had no bone reconstruction

LEGEND: He underwent secondary reconstruction of the mandible with a free fibula flap, bone grafts to reconstruct the upper jaw (maxilla) and multiple surgeries with local and distant flaps to reconstruct the nose, the lower and upper lip and the chin

LEGEND: 3D CT- scan and Panorex of the reconstructed mandible

LEGEND: After multiple surgeries the patient had also prosthetic dentition placed. Now he has excellent occlusion, he eats regular food, he has no tracheostomy, he is not drooling and has resumed all his activities

 

CASE 2

ORBITAL FLOOR FRACTURE

LEGEND: Left orbital floor fracture (upper left photo arrow). Reconstruction with placement of Medpore implant (right upper left photo arrow). CT scan after the reconstruction showing the implant in place (bottom left photo arrow). Type of Medpore implant used (bottom right photo)

 

CASE 3

MANDIBLE FRACTURE

LEGEND: Patient with right sided mandible fracture (arrow of left photo). After the surgery with plates and screws with incision inside the mouth the patient has excellent occlusion of the teeth

INTRODUCTION

Cranioplasty is a surgery done to improve the symmetry and shape the head. It involves the repair of irregularity or imperfection in the skull. It is a complicated procedure. It requires the cooperation of a plastic surgeon and a neurosurgeon.Cranioplasty is both a cosmetic surgery and also protective for the brain.

INDICATIONS FOR CRANIOPLASTY

Conditions that Cranioplasty treats

• Premature close of the cranial sutures (craniosynostosis)
• Some hereditary conditions that can cause children to be born with skull irregularities (cranium bifida, encephaloceles, cutis aplasia, etc).
• Persistent damage to the skull as a result of trauma
• A hole in the head following previous neurosurgical procedures (after removal of a tumor).
• The defect in some places that leaves the brain exposed that could cause severe damage.

LEGEND: CT scan image of a defect (hole) of the side of the skull, after trauma to the head

Reasons to have a Cranioplasty

Cranioplasty might be performed for any of the following reasons:

• Protection: In certain places, a cranial defect can leave the brain vulnerable to damage.
• Function: Cranioplasty may improve neurological function for some patients.
• Aesthetics: A noticeable skull defect can affect a patient’s appearance and confidence.
• Headaches: Cranioplasty can reduce headaches due to previous surgery or injury.

CONSULTATION

During the preliminary consultation the Plastic Surgeon will:

• Take a thorough medical history, as well as assess the patient’s mental and emotional attitudes toward the surgery. Because a realistic attitude is crucial to the success of the surgery, the surgical procedure and realistic expectations will be discussed.
• Take photographs so he can study your facial features and chin.
• Discuss individual risks, especially those related to medical situations such as high blood pressure, a tendency to scar, smoking, and any deficiency in blood clotting.

An MRI and a 3D-CT scan of the skull and facial bones will be necessary to determine the proper procedure for you.

LEGEND: 3D- CT scan of the head, showing a defect of the frontal bone

PREPARATION FOR THE SURGERY

• Stop smoking at least six weeks before undergoing surgery to promote better healing
• Avoid taking aspirin, certain anti-inflammatory drugs, and some herbal medications that can cause increased bleeding
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery.

LOCATION

A Cranioplasty is done in a hospital. During a Cranioplasty, you’ll typically be comfortable with the aid of a general anesthetic — which renders you unconscious.

ANESTHESIA

In most cases, we use general anesthetic so that you will sleep throughout the procedure.

 THE SURGERY

 Cranioplasty is a procedure that replaces a portion of the skull with either original bone tissue or plastic (SYNTHETIC)  implants.

• The patient is given general anesthetic and is positioned with the bone defect uppermost.
• The area of incision is shaved and prepared with antiseptic.
• The patient is covered in drape in such a way only the incision can be viewed.
• Local anesthetic is injected and then the area is cut.
• The scalp is cut apart from the ‘dura’, the underlying covering of the brain, and the edges of the surrounding bone are cleaned to let the graft to stick.
• The surgeon will decide on the source of the graft. The iliac bone bounding the pelvis, ribs and even a part of adjacent skull bone can be used.
• It is also possible to fix a gap in the skull by using synthetic material. Materials such as silastic, titanium plate, rib graft, prefabricated acrylic, synthetic bone substitute, and other similar material manufactured for the fast use of implantation into the body can also be used.
• The original bone or a replacement that is kept ready is placed in the defect area and secured with screws, plates or with special discs.
• If the graft is not available, the patient is treated from the chosen material.
• This is shaped to fit.
• This is also fixed to the surrounding area.
• Once plated everything is repositioned.
• The skin is then closed either with nylon suture or with special staples.

 

TYPES OF COMMON MATERIALS USED FOR CRANIOPLASTY

• Autogenous bones
• Part of the skull
• Ribs, scapula (shoulder blade), sternum, pelvic bones
• Non-metal allografts
• Methyl-metacrylate
• Hydroxyapatite

LEGEND: Methylmethacrylate (medpore) implant

• Metal allografts
• Titanium

LEGEND: Titanium plate implant

RECOVERY

Operations on the head do not often hurt much, but you may have a headache and will have pain relief pills and injections to ensure you’re comfortable. Most cranioplasty patients spend two to three days in the hospital after surgery. When your care team determines you can get around, shower, and dress yourself, you will get a repeat CT scan of your head. If the surgical site looks okay, you will be released and can go home. Depending on how quickly you recover from any pre-operative disability, you may require rehabilitation. The sutures are removed 5-10 days after the surgery. You can shower usually one week after the surgery. You may have to wear a protective helmet for a few weeks if needed

RISKS

The most common risks (however they are rare) include:

• Post operative hematoma necessitating drainage.
• Infections (sometimes the implant has to be removed).
• Inflammation
• Failure to incorporate the implants
• Brain injury
• Prolonged recovery time.
• Recurrence
• Seizure
• Clot in the legs (which rarely can travel to the lungs)

RESULTS

Provided that the implant used (either bone or synthetic) is well accepted by the body, then the results are permanent.

LEGEND: Preoperative photo of skull of patient with svere contour irregularities after a neurosurgical operation for removal of a tumor

LEGEND: Intra-operative photo of the skull defect reconstructed with a Medpore (synthetic) implant (LEFT). Right photo after two months shows a smooth regular contour

INTRODUCTION

A well defined chin helps give balance to the face and creates a major part of one’s profile. Mentoplasty, or chin augmentation, is used to enhance the profile and/or facial contours and balance.

INDICATIONS – IDEAL CANDIDATES

The goal of chin surgery is to bring balance to the face as described above. Chin surgery/genioplasty corrects receding chins, chin misalignment or chin excess.

A chin that seems too small in proportion to other facial features can make the nose appear overly long. Plastic surgeons frequently use chin implants to balance the features of a younger patient or may use genioplasty in conjunction with another cosmetic procedure in a more mature patient.

A sliding Genioplasty is reserved for more complex chin deformities, such as those caused by genetics, trauma, or disease. This procedure can resolve problems related with chin deformities, such as airway obstruction. Since this is a sliding surgery, no bone grafting procedure is required.

CONSULTATION

Important factors to discuss with your surgeon include:

• Skin type
• Ethnic background
• Individual healing rate
• Age

Your surgeon can also provide information on new medical techniques for chin surgery and offer recommendations for supplementary surgery that can ensure the greatest improvement.

During the preliminary consultation the Plastic Surgeon will:

• Take a thorough medical history, as well as assess the patient’s mental and emotional attitudes toward the surgery. Because a realistic attitude is crucial to the success of the surgery, the surgical procedure and realistic expectations will be discussed.
• Take photographs so he can study your facial features and chin.
• Discuss individual risks, especially those related to medical situations such as high blood pressure, a tendency to scar, smoking, and any deficiency in blood clotting.
• A Panoramic X-ray or a CT scan of the facial bones may be necessary to determine the proper procedure for you.

PREPARATION FOR THE SURGERY

Your surgical team will instruct you on how to prepare. You should arrange for someone to drive you home after your surgery. You may also want to make arrangements for someone to help you for a day or two while you heal. In advance of your procedure, your surgeon will ask you to:

• Stop smoking at least six weeks before undergoing surgery to promote better healing
• Avoid taking aspirin, certain anti-inflammatory drugs, and some herbal medications that can cause increased bleeding
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery.

LOCATION

A Genioplasty is done in a hospital or an outpatient surgical facility.

ANESTHESIA

In most cases, we use general anesthetic so that you will sleep throughout the procedure. Local anesthesia with intravenous sedation is also an option for some patients.

THE PROCEDURE

1. AUGMENTATION GENIOPLASTY WITH IMPLANTS

• To augment the chin, the surgeon begins by making an incision either in the natural crease line just under the chin or inside the mouth, where gum and lower lip meet.
• By gently stretching this tissue, the surgeon creates a space where an implant can be inserted. This implant, made of synthetic material that feels much like natural tissue normally found in the chin, is available in a wide variety of sizes and shapes. This allows custom fitting of the implant to the configurations of the patient’s face.

Many types of implants are available, manufactured from a variety of materials, including silicone or other substances. There is no available evidence to suspect that silicone implants cause any disease. Your surgeon will consult with you and discuss recommendations for the type of implant to use.

• After implantation, the surgeon uses fine sutures to close the incision. When the incision is inside the mouth, no scarring is visible. If the incision is under the chin, the scar is usually imperceptible.

1. AUGMENTATION GENIOPLASTY WITH SLIDING OSTEOTOMY

• A sliding genioplasty is the most well known of all the facial osteotomies and also the most commonly performed. It is done for various chin augmentation and reshaping purposes.
• The incisions are usually made in the inside of the mouth

• The advantage of a sliding genioplasty is that it is very versatile in terms of dimensional changes of the chin. The bone cuts can be devised to bring the chin forward, make it vertically longer, widen or narrow it or almost any combination thereof.

• With the use of today’s plate and screw designs, the genioplasty no longer just as to ‘slide’ forward to make for a stable dimensional change to the chin.

1. CHIN REDUCTION SURGERY

• In chin reduction surgery, incisions are made either in the mouth or under the chin. The surgeon sculpts the bone to a more pleasing size.
• For this surgery, the surgeon will make an incision inside the mouth and reposition the facial bones. The procedure, depending on the extent of the work, takes from less than an hour to approximately three hours.
• He may use plates and screws to achieve that.

 

1. OTHER PROCEDURES TO ENGANCE THE RESULT

Submental liposuction in which excess fatty tissue is removed to redefine the chin or neckline

Performing a facelift and neck lift, with tightening of the muscles of the neck.

When there is a contributing problem of dental malocclusion, or birth defects in the structure of the jaw itself, surgery of the jaw can improve the form and function of the lower face and greatly enhance appearance.

The plastic surgeon may also recommend chin augmentation in conjunction with rhinoplasty, as when the nose is changed the entire balance of the face changes as well. 

RECOVERY

• Immediately after surgery, the surgeon usually applies a dressing that will remain in place for two to three days. You will experience some tenderness. Post-operative discomfort can be controlled with prescribed medications.
• Chewing will probably be limited immediately after chin surgery, and a liquid and soft food diet may be required for a few days after surgery. Most patients feel a stretched, tight sensation after the surgery, but this usually subsides in a week.
• After approximately six weeks, most swelling will be gone, and you can enjoy the results of your procedure. Rigorous activity may be prohibited for the first few weeks after surgery. Normal activity can be resumed after approximately ten days.

RISKS

• Pain for which you will be given painkillers afterwards
• Bleeding
• Swelling
• Antibiotics are prescribed to minimize that risk. In rare cases that the implant gets infected then it may have to be removed
• Numbness to the lower lip and chin and sometimes the front teeth because the nerve that supplies those areas can be stretched during the surgery. Usually it recovers completely but there’s a small chance of permanent altered sensation.

RESULTS

The results of a genioplasty are permanent.

CASE EXAMPLES

LEGEND: 43 year old lady with small chin. Correction with silicone implant

LEGEND: 45 year old male with small chin. Correction with horizontal sliding osteotomy

INTRODUCTION

Parry-Romberg syndrome, also known as Romberg’s disease or progressive hemifacial atrophy, is a rare atrophic disorder characterized by a progressive deterioration of the skin and soft tissues of half the face.

 CAUSES

Parry-Romberg syndrome is overall more common in girls. The cause of this disease is still unknown. Some factors thought to cause this disease include:

• Viral or bacterial infections
• Autoimmune diseases
• Nervous system abnormalities
• Inflammation of the brain or meninges (lining of the skull)
• Physical trauma

 

SYMPTOMS

Symptoms of Parry-Romberg syndrome include loss of tissue in any region of the face. It generally begins as a subtle change and may progress to severe deterioration of the soft tissues with pigment changes in the skin.

The tongue, roof of the mouth and gums may also be affected, and in some children the eyes or cheeks may appear sunken. Facial hair may turn white and fall out. The skin can also become darkly pigmented or show patches of unpigmented skin.

The signs and symptoms of Parry-Romberg are very different from person to person and range from mild to severe.

Because it is a progressive condition, the symptoms worsen over time before entering a stable phase.

The evident physical changes may include:

• The appearance that the mouth and nose are shifting or leaning toward one side
• A sunken-in appearance of both the eye, as well as the cheek, on the affected side of the face
• Changes in skin color (pigmentation), including darkening (hyperpigmentation) or lightening (hypopigmentation)
• Facial hair may turn white and fall out (alopecia)
• Facial bone or muscle loss

LEGEND: 32 year old female with Romberg’s syndrome affecting the right side of the face. Note the empty right cheek and the deviated nose.

DIAGNOSIS

The typical onset of the disease is in the first or second decade of life (ages 5-15) and involves a slow progressive loss of skin, subcutaneous fat, muscle and occasionally bone.

The period of atrophy may last 5-10 years or more, and then is typically followed by a period of no active disease, called the burnout period.

DIAGNOSTIC TESTS

• MRI of the head and brain
• CT SCAN of the facial bones
• Opthalmologic examination
• Neurologic examination

TREATMENT

The treatment of true Romberg’s disease is symptomatic. The timing of any surgical intervention is generally agreed to be the best following exhaustion of the disease course and completion of facial growth.

Medical treatment has been largely unsuccessful, and surgery remains the mainstay of treatment for Parry-Romberg syndrome. Most surgeons favor waiting until the disease has “burned out” before initiating treatment.

Types of treatment

Facial contour restoration employing a myriad of reconstructive techniques, have been described including fat grafts, dermis fat grafts, lipo injections, pedicle flaps, bone and cartilage grafts, microvascular free tissue transfer, orthognathic corrective maxillary surgery and alloplastic implants. For muscle spasm associated with Rombergs disease, Botox has been used with success.

• Fillers

Hyalorunic acid injections has been used with success as an office based procedure but it is not permanent and needs to be performed on a yearly basis.

• Fat Grafts and Dermal Fat grafts

Fat auto grafts are said to vascularise at day 4 and after a process of inflammation and fibrosis, resorption occurs until roughly 40 to 70% of the graft remains in patients followed from 1 to 3 years. Dermis fat grafts have also been employed with excellent contour restoration and survival. Fat and dermis fat grafts would appear to be appropriate for mild to moderate contour deformities.

• Lipoinjection and Lipofilling

Microlipoaspiration and lipoinjection is a process by which fat is harvested from one area of the body (usually the belly button region, thigh or buttock) through a thin cannula and injected into the region contour deformity. Sometimes, various hormones or proteins have been added to the fat in the hope that this will give a better take. Fat grafts transferred by lipoinjection are subject to the same local resorbable factors as those described by standard fat grafts and a resorption rate of up to 50% has been noted. A limitation of these techniques is that a small to moderate volume of fat only can be injected into any given spot, as large volumes will jeopardize revascularisation. The benefits however, are that the process can be repeated multiple times and there is minimal donor site morbidity.

• Free tissue transfer (see the FREE FLAP SECTION for more information)

Unlike fat grafting before them, the free vascularised flaps transferred for facial contour reconstruction provided large volumes of reliable tissue. Disadvantages of the free tissue reconstruction include donor site scarring and morbidity, recipient site scars, longer operative times and hospital stays, plus a definite incidence of flap loss. The more commonly used flaps are the groin flap. These have the advantage of including relatively large volumes of subcutaneous tissue and fascia whilst leaving relatively acceptable donor site scars.

• Orthognathic Surgery

In some cases, constriction of growth by the atrophy process in younger patients lead to considerable deformity of the jaws in the long term. Orthognathic surgery can be of great benefit in correcting the underlying skeletal abnormality before soft tissue flaps are added.