Article

Retrobulbar Lipofilling to Correct the Enophthalmos

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Abstract

In this article, we describe an alternative procedure to restore the retrobulbar volume in enophthalmic patients. We report the case of a patient with a late enophthalmos we submitted to retrobulbar lipofilling to correct the defect. The preoperative assessment and the surgical technique are described in detail. The volume of fat injected was 3.2 mL, with a satisfying increase in exophthalmometry measurements. The procedure was well tolerated without complications. Retrobulbar lipofilling for enophthalmos appears to be a safe alternative technique for orbital volume enhancement. It avoids the use of alloplastic materials and allows to obtain good cosmetic results with an easy technique and minimal donor-site morbidity.

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... Autologous fat [27] Figure 4: Minimally invasive autologous fat injection: atraumatic suction, furification, and reinjection in the orbit using a cannula. Adapted from Cervelli et al. [50] transfer is minimally invasive, making it more acceptable for patients [ Figure 4]. [50] At present, the greatest inconvenience is the unpredictable long term outcome of the graft, related to the extremely variable rate of fat resorption. ...
... Adapted from Cervelli et al. [50] transfer is minimally invasive, making it more acceptable for patients [ Figure 4]. [50] At present, the greatest inconvenience is the unpredictable long term outcome of the graft, related to the extremely variable rate of fat resorption. [51][52][53] Many animal models have been tried to find the best process of lipofilling. ...
Article
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Posttraumatic orbital reconstruction has been a challenging mission for decades in craniomaxillofacial surgery. Complications like enophthalmos, diplopia and gaze obstacles emerge when orbital trauma occurs, affecting people’s daily life as well as their appearance. Advances in technology and research gained through years of experience has provided us with a greater understanding of the changes following trauma, as well as providing us with a variety of filling materials that we can choose from to handle the deformities. However, the best type of material for repair of orbital deformities remains controversial. This paper reviewed approximately 60 articles discussing materials used in orbital reconstruction or soft tissue defect filling in the past years, with the aim of giving a comprehensive overview of the advantages and disadvantages of materials used in this field so as to help surgeons to make a better choice.
... Although it is accepted that the enlargement of the orbital bone walls is the main culprit in the pathogenesis of late-term enophthalmos, lately many authors have been preferring the method of increasing the orbital or periorbital soft tissues for fixing the deformities or preventing enophthalmos [8][9][10][11][12]. Nishi et al [9] used costal cartilage sliced from posterior to equator in the subperiosteal plan, while Lee [10] preferred using cartilage after corrective osteotomies in order to increase the volume. ...
... Nishi et al [9] used costal cartilage sliced from posterior to equator in the subperiosteal plan, while Lee [10] preferred using cartilage after corrective osteotomies in order to increase the volume. Cervelli et al [11] indicated in their one-case study that retrobulbar fat tissue injection is a reliable and alternate method for the treatment of enophthalmos. Honda et al [12] used tissue expander for the treatment of an enucleated enophthalmos case. ...
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Post-traumatic enophthalmos is one of the late-term complications of the posttraumatic orbit, causing functional and cosmetic concern. In this study, the process, results, efficacy and reliability of the treatment of two young cases with late-term enophthalmos after blunt trauma to the orbit without any vision loss will be presented and discussed. Surgery for a balanced orbital volume increase was performed using porous polyethylene (Medpor) implants.
... Дефицит объёма мягких тканей орбиты может быть вызван различными причинами, такими как энуклеация, врождённый анофтальм/ микрофтальм, облучение, воспаление, синдром Парри-Ромберга, блефаропластика, а также декомпрессия орбиты и перелом её стенок [5,6]. В 1889 г. ...
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Aim. Aesthetic rehabilitation of patients with secondary post-traumatic enophthalmos. Methods. From 2013 to 2018, 14 patients with secondary post-traumatic enophthalmos were treated at the maxillofacial surgery clinic of the Azerbaijan Medical University. All patients underwent reconstruction of the damaged orbital wall, so its bone volume was restored. However, in the postoperative period, a deficiency of the orbital soft tissue was noted. In preparation for the surgery, all patients underwent the following types of examination: three-dimensional computed tomography, photographic, anthropometric measurements with the determination of proportional indices and computer simulation. Based on the data obtained, the orbital proportion indices were calculated: intercanthal index (en-en)100/(ex-ex); orbital protrusion index (ex-ex)100/(ex-en,rl)+(en-en); orbital width index (ex-en,l)100/(en-en); eye fissure (palpebral) index (ps-pi, l)100/(ex-en,l); orbital index (os-or,l)100/(ex-en,l); eyebrow orbital height index (os-or,l)100/(sci-or,l); index of vertical orbital contour (os-or,l)100/(ps-os+pi-or)+(ps-pi); eyelid height index (pi-or,l)100/(ps-os,l). Microlipografting was performed according to the Coleman method with modification by T. Marten. Fat aspiration was performed with a blunt cannula with a diameter of 2.12.4 mm and a 10 ml syringe, without anesthetic administration. Prior to microlipografting, fibrotic cords between the skin and underlying tissues were dissected using a sharp needle and a V-shaped cannula. Microlipografting was performed using microcannulas of 0.71.1 mm. The fat microtransplant was introduced in two layers: under the circular muscle of the eye and subperiostally in the orbit. Results. In 11 cases, with an unexpressed form of secondary post-traumatic enophthalmos, a good aesthetic result was recorded. In 3 patients with a pronounced form of enophthalmos, a satisfactory aesthetic result was obtained; in these cases, repeated microlipografting was carried out. Conclusion. Microlipografting based on the calculation of the orbit proportions indices during rehabilitation of patients with secondary post-traumatic enophthalmos is a minimally invasive and effective procedure.
... Using a sharpened 16-gauge cannula, Hardy [26] reported success in a retrospective review of 13 orbits engrafted (3 with second injections) with a mean follow-up of 14.5 months, but without presenting any data. Some of these cases included sighted eyes as also described by Cervelli in a single case report [27] that only included 3 months of follow-up. In the current study, a 1-year threshold as a minimum criterion of success was deemed necessary to justify an OR procedure when compared to office-injectable soft tissue fillers. ...
Article
Background Orbital volume loss, early or late, is common after placement of an orbital implant or dermis fat graft, and there is currently no satisfactory long-lasting solution. Hyaluronic fillers are relatively easy to administer but are prone to migration and are temporary. Cannula-based orbital fat grafting has not gained the status of standard of care because of perceived low likelihood of success in the near term. This paper describes a technique for fat volume augmentation, its rationale, long-term follow-up, and a description of a complication unique to fat grafting in the orbit. Methods Ten consecutive subjects with acquired anophthalmic enophthalmos were enrolled in two IRB (institutional review board)-approved protocols (10.27 and 12.01) undergoing a single session of autologous fat grafting to the orbit using a closed blunt cannula technique. Preoperative photography and non-contrast MRIs (magnetic resonance imaging) were obtained prior, immediately after, and at 1 year after injection. Yearly postoperative photography was performed on subjects with successful results. Results Three of five subjects in IRB 10.27 clearly showed a clinically apparent increase in orbital volume at 1 year. One subject who failed to show improvement also sustained inadvertent injection into three extraocular muscles; she subsequently volunteered to enter IRB 12.01. Three of five subjects in IRB 12.01 did benefit, showing volume increase at 1 year, including the subject who had experienced intramuscular injection in 10.27. One subject in IRB 12.01 was lost to follow-up. Of the total of ten subjects enrolled, three showed no improvement and one was lost to follow-up; six subjects showed volume improvement at 1 year with two retaining the correction at 5 years and four showing variable diminution over 2–5 years. With the exception of the subject who sustained injection into extraocular muscles, none experienced complications. Conclusion A modified technique is recommended for orbital fat injection distinct from methods used elsewhere in the body. Theoretical limits of volumetric enhancement temper expectations in orbital fat grafting and should inform surgical planning. Cannula-based orbital fat grafting can be done safely and result in a gain of orbital fat volume at 1 year and in some cases up to 5 years. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
... Sir: I t was with interest that we read the Experimental article by Brown et al. published in the May issue of Plastic and Reconstructive Surgery, investigating the efficacy and safety of retroseptal lipotransfer in animal models. 1 This interesting study adds a solid scientific basis to few published works on enophthalmos correction in humans. [2][3][4][5] We would like to take the opportunity to report our experience with correcting posttraumatic enophthalmos of the amaurotic eye in nine patients treated at the Department of Maxillofacial Surgery of Florence between January of 2008 and December of 2013. Six patients were men and three were women, with a mean age of 37.3 years (range, 19 to 51 years), and all were free from further comorbidities. ...
... Lee [17] has advocated the use of autologous, diced-cartilage graft to augment the orbital-tissue volume in addition to the standard fracture-reduction methods in the acute setting. In a recent case report, Cerveli et al. [18] demonstrated the use of retrobulbar lipofilling for correction of enophthalmos and suggested its use as a safe alternative technique for orbital volume enhancement. Bernardino [19] suggested the correction of late posttraumatic enophthalmos by using a tissue expander. ...
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Management of posttraumatic enophthalmos can present as a challenge to the reconstructive surgeon, particularly in cases of late presentation. This article reviews the pertinent anatomy of the orbit, diagnostic modalities, indications for surgery, and surgical approaches as they relate to the treatment of posttraumatic enophthalmos. Internal orbital reconstruction has evolved to an elegant procedure incorporating various biologic or alloplastic implants, including anatomical pre-bent implants. Successful repair of late enophthalmos has been demonstrated in multiple recent studies and is likely related to the precision with which orbital anatomy can be restored.
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In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually includes the prolapse of orbital tissues into the sinus or compression by the surrounding bone structures. Although the retro-orbital fatty tissue, orbital fascia, and the muscle tissue can be reduced to the original place after being incarcerated into the maxillary space, it is obvious that the procedure can lead to significant fibrosis in these structures. The authors have aimed to carry out a quantitative evaluation of the fatty tissue volumes in patients with repair delayed for more than two weeks. The preoperative and postoperative fatty tissue volumes and the changes in total orbital volume were evaluated by using CT on the patients (n = 9) who were consulted to the authors' clinic from other health centers. Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retro-orbital fatty tissue was statistically significant. Evaluating postoperative retro-orbital fatty tissue volumes may have implications for surgical intervention in the future.
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Post-traumatic enophthalmos is challenging and incompletely understood clinical problem. Careful preoperative planning based on the results of the physical examination and thin-section CT scan should direct the operative reconstruction. A stepwise approach to the management of soft tissue and bony defects is required. Through the application of these principles, the aesthetic and functional sequelae of post-traumatic enophthalmos can be improved greatly with minimal complications.
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Retro-orbital fat volume reduction has been reported in patients with enophthalmos but could be restored by a suitable fat autograft. Buccal and subcutaneous adipose tissues were identified as possible donor sites. Samples of these and of orbital fat were obtained from fresh cadavers, and the relative volumes of collagen and of endothelial cells and the numerical density of mast cells were compared since these might influence graft survival. The results demonstrated strong similarities between orbital and buccal fat which were significantly different from subcutaneous fat. It was concluded that the buccal fat pad would be a more suitable donor site than subcutaneous adipose tissue to replace orbital fat loss and that its use merits further investigation.
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To evaluate the effects of retro-orbital intramuscular cone injection of fat in the treatment of posttraumatic enophthalmos in both patients with intact globes and those patients who have had globes removed. Case series. Private practice involving an otolaryngologist and an ophthalmologist. Three groups of patients were treated: group 1 included those patients with an intact globe; group 2, patients with an orbital implant following enucleation; and group 3, patients with no orbital implant following enucleation. Autogenous fat was harvested from the abdomen using a microsuction lipectomy technique. The fat was injected into the intramuscular cone in the retrobulbar or retroimplant space using a 14-gauge needle. Sustained improvement of enophthalmos measured by Hertel's exophthalmometry in those patients with an intact globe. Subjective appearance of prosthesis by physician and patient were used for end points in patients whose globes were removed. In group 1, all patients were able to maintain a correction to within 1 mm of the normal eye. In groups 2 and 3, all patients had a subjective improvement in appearance, but they had development of enophthalmos if the prosthesis was decreased in size. Seven patients (64%) required multiple injections. Retro-orbital injection of fat autografts allows correction of persistent posttraumatic enophthalmos.
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In 23 patients with traumatogenic enophthalmos and diplopia autologous (rib cartilage, iliac crest bone), heterologous (lyophilized dura), and alloplastic (Silastic, P.D.S., HA-blocks) material was implanted into the orbit in a late secondary intervention. The results were encouraging as for the improvement of the diplopia as well as the enophthalmos. If rib cartilage should not or cannot be used a hydroxyapatite ceramic block is the best alloplastic implant material due to its stability, inertia, and availability.
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To document the amount and rate of re-absorption of fatty tissue transplanted using the author's technique, the author initiated controlled studies in 1987. A selected crease was infiltrated with autologous fatty tissue using a nearby crease as control. At specific time intervals the infiltrated crease was compared to the nearby control crease to evaluate percentage of recurrence. Photographs were taken in the first week, then at least yearly over six years. All views, all positions of the mouth, and all lighting situations demonstrated the continued absence of any crease in the area of infiltration. In contrast, the nearby control crease remained unchanged or deepened from its preoperative condition, giving every indication of a permanent correction. This experiment demonstrates the potential lasting nature of corrections performed with the transplantation of fatty tissue and is supported by over 400 infiltrations into the nasolabial folds in the author's practice.
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The potential of CT to facilitate preoperative planning of reconstructive maxillofacial surgery by orbital volume quantification was analysed in 11 patients with traumatic enophthalmos as a late sequela of zygomatic fractures. We carried out biplanar CT examination of the orbits, and calculated total orbital and fat volumes for the healthy and enophthalmic sides. Displacement of the orbital floor and lateral wall was present in 11 and 7 cases respectively. Indentation of the medial wall was noted in 9 cases. Quantitative evaluation of the orbital cavity revealed a significant increase (P < 0.0188) in total volume on the enophthalmic side, the difference between the two sides ranging from 9.2% to 36.4%, mean 17.9%. The degree of enophthalmos, measured radiologically as 2.5-5 mm, correlated with the increase in orbital cavity volume (P = 0.000076). Enophthalmos was 2.5-3 mm in 7 cases (63.6%) and 3.5-5 mm in 4 (36.4%). This corresponded with a mean increase in orbital volume of 3.4 ml (12.3%) and 7.1 ml (27.8%) respectively. Fat atrophy was not an aetiological factor in the production of post-traumatic enophthalmos.
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Lipostructure is a natural, long-lasting method of filling and supporting the face using intricate layering of infiltrated autologous tissue. This method allows the tissues to be sculpted to enact three-dimensional augmentation of facial elements. Because the grafted fat becomes integrated into the host tissues, it is almost undetectable after transplantation, except by photography. To successfully use fatty tissue as such a graft, attention must be paid to the nature of fatty tissue; to the methods of harvesting, transfer, and placement; and to the preparation of the patient. Fatty tissue is a complex, delicate structure that is easily damaged by mechanical and chemical insults. Successful fat transplantation demands that every step be practiced with attention to this fragile nature of fatty tissue. Precision is an important consideration in the augmentation of millimeters of facial elements. The true volume of infiltration is difficult to judge if too much blood, lidocaine, or oil is present in the tissue being placed. Fat is living tissue that must be in close proximity to a nutritional and respiratory source to survive. Therefore, placement of small amounts of fatty tissue in multiple tunnels assumes the utmost importance in the quest for both survival of fatty tissue and an aesthetically appropriate correction. Successful, three-dimensional sculpting requires attention to patient preparation, meticulous planning, and fastidious photographic evaluation. The potential applications in aesthetic and reconstructive surgeries of this new tool are profound. Lipostructure represents an important advance in plastic surgery: a safe, long-lasting method of recontouring the face with autologous tissue.
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The surgical correction of post-traumatic enophthalmos is among the most challenging problems for the surgeon. A thorough understanding of orbital anatomy and the purposed mechanisms of enophthalmos is crucial to the ultimate success or failure of the procedures. The successful orbital reconstruction begins with a careful physical examination of the patient that is attentive to ocular function, soft-tissue position, and visible or palpable defects of the facial skeleton. The physical examination combined with thin section CT scanning in the axial and coronal planes provides the basis of the operative plan. The anatomy of the deformity should dictate the anatomy and shape in the surgical correction. In many cases, multiple surgical incisions will be required; therefore, care must be taken to maximize exposure and minimize the cosmetic problems associated with large incisions. We advocate a step-wise approach consisting of mobilization of the soft tissues in the area of the fracture, repositioning of the anterior and middle sections of the bony orbit, and reattachment of the soft tissue to the bone at the proper location. The approach to reconstruction of the bony orbit that we advocate is to first sequentially reposition each segment of the rim, carefully examining each articulation. Once rim reconstruction is complete, reconstruction of the internal wall is performed. Recall that the largest source of error is in inadequate reduction of the orbital rim, owing to the fact that this error is "squared" (according to the model) in the computation of the orbital volume. Through the application of these principles, the cosmetic and functional sequelae of post-traumatic enophthalmos can be improved greatly with minimal complications.
Article
Thirty-two cases of orbital blowout fracture, excluding those of linear fracture with trap-door variety, were selected to study the changes of the eyeball position: posterior displacement or enophthalmos, medial and inferior displacement. Two-millimeter slices of computed tomographic scans were taken, and the eyeball positions were measured with the contralateral eye as a control. Intraorbital edema, if present, at least 10 days after injury had little effect on the position of the eyeball, nor was there any evidence to suggest the late onset of enophthalmos. Enophthalmos remains around 1 mm before total orbital enlargement reaches 2 ml in volume, thereafter increases proportionally with total orbital enlargement until 4 ml, then remains on a plateau. Enophthalmos increases proportionally with the increase of medial orbital wall enlargement when the inferior orbital wall enlargement is less than 2 ml. With inferior wall enlargement more than 2 ml, 3 to 4 mm of enophthalmos is seen irrespective of the increase of medial wall enlargement. The medial displacement of the eyeball increases proportionally with the increase of medial wall enlargement when inferior wall enlargement is less than 2 ml. The inferior displacement of the eyeball has little proportional relationship with medial or inferior wall enlargement when the former exceeds 2 ml. Relatively good proportional relationship is found between the enophthalmos and the medial displacement of the eyeball, but not between the enophthalmos and the inferior displacement of the eyeball.
Article
When using free fat autologous grafts as a filling material was first proposed in 1893 by Neuber, the idea rapidly gained enthusiasm and endorsements. Our early experience with autologous fat transplantation was disappointing, but even then it was clear that fat could be transferred with partial success. Since then, further clinical works by Guerrerosantos, Coleman, and others have shown that it is possible, by careful handling of transplanted fat, to improve the survival of this tissue. We have reviewed our recent experiences and have found several patients with whom autologous fat transplant has been successful with up to an 8-year postoperative follow-up.
Article
The author has used fat transfer, including pearl fat grafts and fat injections, for almost 18 years in practice. Techniques for pearl fat grafting and fat injections are described. Pearls are limited to eyelids and small depressions. Fat injections can be used to augment various facial areas, including chin, cheekbones, nasolabial folds, lips, labiomandibular folds, glabella, forehead, and nose.
Article
In this retrospective study, we evaluated isolated blowout fractures of the orbital floor by region-of-interest measurements from coronal computed tomography (CT) scans and their relationship to ophthalmologic findings. Fracture area and volume of displaced tissue of blowout fractures in 38 patients were measured from coronal CT scans. Measurement was performed by identifying distances (for area calculation) of the fracture and identifying areas (for volume calculation) of the displaced tissue in each CT slice. The calculated data were then compared with the amount of enophthalmos, presence of diplopia, and limitation of ocular motility. Orbital floor area (mean +/- SD) was 5.72 +/- 1.07 cm(2); fracture area, 2.63 +/- 1.20 cm(2); and the volume of displaced tissue, 1.15 +/- 0.91 mL. The average proportion of the fracture within the orbital floor was 45.3 +/- 17.6%. Fracture area and volume of displaced tissue were significantly positively correlated with enophthalmos and diplopia and not correlated with the limitation of ocular motility. For enophthalmos of 2 mm or greater, mean fracture area (mean +/- SD) was 4.08 +/- 1.09 cm(2) and volume of displaced tissue was 1.89 +/- 1.19 mL; for less than 2-mm enophthalmos, 1.98 +/- 0.83 cm(2) and 0.83 +/- 0.58 mL, respectively. Enophthalmos of 2 mm can be expected with 3.38 cm(2) of fracture area and 1.62 mL of displaced tissue. Region-of-interest measurement from coronal CT scan has an application in the assessment of patients with pure blowout fractures of the orbital floor and adds useful information in posttraumatic evaluation of orbital fractures.
Article
Autogenous fat transfer with lipoinjection for soft-tissue augmentation is a commonly used technique without a universally accepted approach. The high percentage and variable amount of fat resorption reduce the clinical efficacy of this procedure and often result in the need for further grafting. The purposes of this study were to evaluate the effect of different harvesting and preparation techniques on human fat tissue viability and to determine fat tissue viability rates among the different fat preparations transplanted into a severe combined immune deficiency mouse model at 3 months. Using standard liposuction and syringe aspiration, fat was removed from patients (n = 3) undergoing elective body contouring. Tissue was prepared by six different combinations of centrifugation and/or washing the cells with lactated Ringer's solution or normal saline. Metabolic activities of fat cell viability were monitored to assess overall cell viability. To analyze viability over 3 months, freshly harvested tissue specimens (minimum n = 5) were prepared by a combination of various procedures (wash, centrifugation, and different solutions) and subsequently injected under the dorsal flank skin of severe combined immune deficiency mice in two experiments. Mice were monitored for 12 weeks and the fat xenografts were removed for mass and histological evaluations. Metabolic analyses showed improved cell viability in tissue specimens undergoing minimal manipulation. No significant differences in fat cell viability, as assessed by graft weight maintenance or histologic evaluations, were observed with regard to harvesting or preparation techniques. Improved viability of freshly harvested but untreated fat specimens may be expected as compared with grafts that have undergone additional manipulations. No unique combination of preparation or harvesting techniques appeared to be more advantageous on transplanted fat grafts at 3 months. This study also demonstrated a reliable animal model for future investigation into examining novel applications for augmenting fat graft survival.
Article
The efficacy of sliced costal cartilage chip grafts for the treatment of late posttraumatic enophthalmos was investigated. Surgery was conducted based on the method reported by Matsuo et al. in 1989. After making an incision in the lower eyelid, dissecting the subperiosteum of the medial orbital wall, orbital floor and lateral orbital wall was performed to the posterior of the orbit, and then costal cartilage chips were gradually grafted in a step-like configuration to the subperiosteum from a location posterior to the equatorial plane of the eyeball. At this time, as well as to the area of concave depression in the orbital bone caused by the fracture, grafts were made to the subperiosteum of the non-deformed medial and lateral orbital wall, to move all of the orbital tissue, including the eyeball, forward. This was performed for five cases of severe late posttraumatic enophthalmos. Among the five cases, there were four cases of severe orbital fracture and one case for which malignant orbital tumor extirpation and radiation therapy had been performed. Following surgery, although mild enophthalmos remained in three of the five cases, esthetically satisfactory results were obtained for all cases. Costal cartilage chip grafts were shown to be an effective method for the treatment of late posttraumatic enophthalmos.
Article
Grafted fat has many attributes of an ideal filler, but the results, like those of any procedure, are technique dependent. Fat grafting remains shrouded in the stigma of variable results experienced by most plastic surgeons when they first graft fat. However, many who originally reported failure eventually report success after altering their methods of harvesting, refinement, and placement. Many surgeons have refined their techniques to obtain long-term survival and volume replacement with grafted fat. They have observed that transplanted fat not only adjusts facial and body proportion but also improves surrounding tissues into which the fat is placed. They have noted not only the improvement in the quality of aging skin and scars but also a remarkable improvement in conditions such as radiation damage, chronic ulceration, breast capsular contracture, and damaged vocal cords. The mechanism of fat graft survival is not clear, and the role of adipose-derived stem cells and preadipocytes in fat survival remains to be determined. Early research has indicated the possible involvement of more undifferentiated cells in some of the observed effects of fat grafting on surrounding tissues. Of particular interest is the research that has pointed to the use of stem cells to repair and even to become bone, cartilage, muscle, blood vessels, nerves, and skin. Further studies are essential to understand grafted fat tissue.
Article
Facial hemi atrophy is seen after trauma, Parry-Romberg syndrome and on other rare occasions. Since the aesthetic deficit is very obvious and irritating, facial reconstruction is often requested by these patients. In most cases the only option for sufficient reconstruction is free flap reconstruction, which represents the standard treatment. Recently in plastic surgery, various new techniques have been developed with the potential for multiple applications. Lipofilling has been presented primarily for the correction of cosmetic lesions or the reconstruction of minor soft tissue defects, but even reconstruction of larger soft tissue deficits is possible. The concept of using 3-D technology in facial reconstruction has multiple advantages. Primarily, the ideal final aesthetic outcome can be simulated by virtual reconstruction. Mathematic calculations deliver exact numbers in volume deficits, enabling precise planning of soft tissue substitution especially in lipofilling, ideally avoiding unnecessary corrections. Since autologous soft tissue reconstruction represents a dynamic process with periods of swelling as well as atrophy, quality control is required for achieving optimal results. Use of 3-D scanning has the advantage of reliable visualisation in soft tissue reconstruction without the limitations of harmful side effects. We present the history of a female suffering from the posttraumatic consequences of head injuries related to a car accident and the successful correction of her hemi facial atrophy by autologous lipofilling. Technical details and the potential of 3-D scanning in plastic surgery are discussed.
Article
Clinical use of autologous fat grafts for facial soft-tissue augmentation has grown in popularity in the plastic surgery community, despite a perceived drawback of unpredictable results. The authors' review of the literature and their current techniques of autologous fat transfer focused on (1) the donor site, (2) aspiration methods, (3) local anesthesia, (4) centrifugation and washing, (5) exposure to cold and air, (6) addition of growth factors, (7) reinjection methods, and (8) longevity of fat grafts. Clinical experience and basic science data showed a slight preference for the following: harvesting abdominal fat with "nontraumatic," blunt cannula technique, preparation by means of centrifugation without washing or addition of growth factors, and immediate injection of small amounts of fat by means of multiple passes. Quantitative evidence of clinical fat survivability and predictability of volume restoration does not exist, yet reports of patient satisfaction with this procedure do. Clinicians report the need for revisionary procedures to optimize results. Although there is an increased trend in replacement of soft-tissue volume with autologous fat transfer, the literature fails to provide definitive evidence of fat survival. A large-scale clinical assessment using three-dimensional volumetric imaging would provide useful outcome data.
Article
The purpose of this study is to present an alternative procedure for rehabilitation of the volume deficient anophthalmic or enophthalmic socket. A retrospective review of clinical and photographic records of 12 patients with either an anophthalmic or enophthalmic orbit (14 orbits) undergoing volume augmentation by micro-fat grafting, or lipostructure, as initially described by Coleman. Patients with orbital volume deficiency seen in the oculoplastic clinic at Chelsea and Westminster Hospital, London, UK, were invited to participate in the study. The technique is discussed in detail. The volume of fat injected ranged from 0.8 mL to 4.5 mL (median, 3.05 mL) per orbit, with a median increase in exophthalmometry measurements (available in 9 patients) of 2 mm (range, 0-7.5 mm). Subjective improvement in cosmetic outcome was experienced in all patients. Repeat grafting was required in 1 patient, and will be required in another patient. There were no embolic complications. The procedure was well tolerated in all patients. Median follow-up was 14.5 months (range,12-30 months). Micro-fat grafting to the anophthalmic or enophthalmic socket appears to be a safe alternative technique for orbital volume enhancement. It has the advantages of avoiding alloplastic infectious complications, ease of technique, minimal donor site morbidity, acceptable graft take rate, low embolic complication rate, and good cosmetic outcome.
Article
After more than a century of use, fat grafting is firmly entrenched in the skill set of plastic surgeons. While macrofat grafting is relatively predictable and reliable, microfat grafting by injection is still in the stages of technical evolution. Review of the current literature suggests that revascularization may take up to 21 days to reach the center of a microfat graft. We recommend harvesting by excision (or gentle aspiration), processing by short and gentle centrifuge to separate the layers, and reinjection of the lower layer via a fine cannula (for example, 17 gauge for the face) and a 1-mL syringe with multiple passes, injecting only a tiny amount with each pass as the needle is withdrawn, to obtain the most reliable clinical outcome.
  • Ramieri