Monreal J.: Aesthetic and Functional Recovery of Congenital Muscular Torticollis Treated with Intramuscular Fat Grafting

Abstract

Congenital muscular torticollis is the third most common
congenital musculoskeletal disorder. The condition usually
presents as a result of contracture and shortening of the
sternocleidomastoid muscle. Skull and facial asymmetry
may occur in the presence of prolonged uncorrected head
tilt. Treatments include observation, the use of orthotics,
exercise programs, traction, and various forms of surgical
techniques. These include open or endoscopic transection or
release of one muscle insertion, bipolar release, and radical
resection of a sternomastoid tumor or the sternocleidomastoid
muscle. Some authors have stated that operative treatment
is of little value after the age of five, and the results are
even worse when the operation is done after puberty. All
the best known surgical techniques rely on the fact that the
muscle must be elongated in some form, but none of them
(if succeeded) provide a good combination of aesthetic and
functional improvement. Fat grafting has never been reported
as a technique to treat congenital muscular torticollis, and has
only been partially reported as surgical technique as a means
of replacing volume after a complete sternocleidomastoid
resection. The author reports a case of a 19 year old male
that presented with severe sequela of congenital muscular
torticollis unsuccessfully treated with open bi-polar release
in his infancy. The patient presented with a severe retraction
and thinning of his left sternocleidomastoid muscle associated
with ipsilateral craniofacial deformity and scarring at the level
of muscular release. Given that other muscle release, probably
could not improve the condition, the plan was to conduct
micromiotomies associated with fat grafting along the entire
length and thickness of muscle. Two fat grafting sessions
were performed over a period of six months. Eleven months
after the first session the patient has recovered almost all of
the aesthetics of the neck and muscle function without any
adverse effects or loss of grafted volume. Due to the extremely
good outcome of this patient, the author believes that fat
grafting should be considered as a more logical and less
invasive alternative for the treatment of congenital muscular
torticollis particularly in failed or neglected cases.

Full text

1
IFATS NEW YORK 2013 CONFERENCE
11TH ANNUAL MEETING
November 21-24, 2013
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75
A PHASE ONE, OPEN LABEL, SINGLE ARM STUDY
TO DEMONSTRATE THE SAFETY OF THE ANTRIA
CELL PREPARATION PROCESS DURING FACIAL FAT
GRAFTING ASSISTED WITH AUTOLOGOUS, ADIPOSE-
DERIVED STROMAL VASCULAR FRACTION (SVF)
Presenter: Shah Rahimian, MD, PhD
Authors: Rahimian S, Maliver L, Johns F, Bizousky D,
Gore R, Johnson T, McNitt D, Quist L
Antria Inc
Antria cell preparation process and its special reagent Adipolyx
may display a safe method of supplementing traditional
lipografts with adipose-derived stromal vascular fractions
(SVFs), which can be utilized in cosmetic or therapeutic
applications. Autologous transplantation of adipose tissue
is a common treatment for facial lipoatrophy; however,
treatment-result inconsistencies, regarding the sustainability
of the adipose engraftment, require identification of a more
efficacious treatment option according to Ersek et al. (1998)
and Shiffman et al. (2001). In addition, facial lipoatrophy has
been treated utilizing dermal fillers; however, dermal fillers
are a less advantageous treatment option due to composite
deterioration. Moreover, dermal fillers may induce allergic
responses, skin depigmentation, and/or nasolabial folds
according to Lowe et al. (2001).
Cellular components of the SVF have shown to secrete various
growth factors that sustain the lipograft. Imperative to the
function of SVF, in conjecture with lipoaspirate, is believed to
be adipose-derived stem cells (ADSCs). According to Puglisi
et al. (2010), Ichim et al. (2011), and Lu et al. (2011), ADSCs
possess the ability to differentiate into various tissue types,
inhibit inflammation, and stimulate angiogenesis. Thus,
the proprietary reagent and the methodology of extracting
and integrating the SVF with adipose tissue, utilized in
transplantation, may enhance graft retention. Ergo, Antria will
analyze the safety of SVF use in facial fat grafting via targeted
physical examinations, laboratory assessments and long term
follow ups concluding at 36 months post-op.
Antria has recently gained FDA and IRB approval to conduct a
phase I study, within the United States, verifying the safety of
SVF-enhanced lipografts within human subjects. Six subjects
will be enrolled. Analysis of the resultant data, documenting
whether Antria cell preparation process is a safe form of
treatment, will be available at the time of presentation.
76
AESTHETIC AND FUNCTIONAL RECOVERY OF
CONGENITAL MUSCULAR TORTICOLLIS TREATED
WITH INTRAMUSCULAR FAT GRAFTING
Presenter: Juan Monreal, MD
Author: Monreal J
Hospital San Rafael
Congenital muscular torticollis is the third most common
congenital musculoskeletal disorder. The condition usually
presents as a result of contracture and shortening of the
sternocleidomastoid muscle. Skull and facial asymmetry
may occur in the presence of prolonged uncorrected head
tilt. Treatments include observation, the use of orthotics,
exercise programs, traction, and various forms of surgical
techniques. These include open or endoscopic transection or
release of one muscle insertion, bipolar release, and radical
resection of a sternomastoid tumor or the sternocleidomastoid
muscle. Some authors have stated that operative treatment
is of little value after the age of five, and the results are
even worse when the operation is done after puberty. All
the best known surgical techniques rely on the fact that the
muscle must be elongated in some form, but none of them
(if succeeded) provide a good combination of aesthetic and
functional improvement. Fat grafting has never been reported
as a technique to treat congenital muscular torticollis, and has
only been partially reported as surgical technique as a means
of replacing volume after a complete sternocleidomastoid
resection. The author reports a case of a 19 year old male
that presented with severe sequela of congenital muscular
torticollis unsuccessfully treated with open bi-polar release
in his infancy. The patient presented with a severe retraction
and thinning of his left sternocleidomastoid muscle associated
with ipsilateral craniofacial deformity and scarring at the level
of muscular release. Given that other muscle release, probably
could not improve the condition, the plan was to conduct
micromiotomies associated with fat grafting along the entire
length and thickness of muscle. Two fat grafting sessions
were performed over a period of six months. Eleven months
after the first session the patient has recovered almost all of
the aesthetics of the neck and muscle function without any
adverse effects or loss of grafted volume. Due to the extremely
good outcome of this patient, the author believes that fat
grafting should be considered as a more logical and less
invasive alternative for the treatment of congenital muscular
torticollis particularly in failed or neglected cases.