Fat Transplants - Olney, MD

Facial deformity due to buccal fat pad loss is a rare but significant complication of dentoalveolar surgery, such as sinus augmentation. We present a case that was referred for correction of facial soft tissue asymmetry in the left submalar region of unknown etiology. The patient, however, states that the soft tissue depression happened following a sinus augmentation procedure that was done by another surgeon. She denied having any trauma or other dental/ facial-related procedure to that area. This asymmetry happened possibly secondary to loss of a section of the buccal fat pad. Whether this was related to the sinus lift procedure could not be ascertained by our investigation. To treat this asymmetry, purified abdominal fat graft was used in multiple small volume injections. The three-year follow-up showed no relapse of the soft tissue facial defect. Fat grafting to correct facial deformity is a safe and reliable treatment with few complications that can replace more invasive surgical procedures.

Buccal fat pad (BFP) is an encapsulated, well-vascularized fatty tissue that consists of a body and four processes. The body has three distinct lobes—anterior, intermediate and posterior—which are located behind the zygomatic arch. There are four processes that extend from the body to buccal space, deep infra-orbital space, pterygomandibular space, and infra-temporal fossa.1 Buccal fat pad functions as a deep and superficial facial space filler, a gliding path for adjacent muscle movement and a cushion to surrounding neurovascular structures during facial and masticatory muscles extension and contractions.1,2,3 Dentoalveolar surgeries, such as upper 3rd molar extraction or sinus augmentation for dental implants, can cause unwanted exposure or release of BFP. The buccal extension of the BFP is the most superficial segment and contains roughly one-third of the BFP volume. This is the main part of BFP, which may become exposed unwantedly during dentoalveolar surgeries, or on purpose for facial recontouring by reducing buccal fullness.3 Over the past several decades, there has been a number of studies that have shown the use of BFT to correct oral and facial deformities by means of extension pertaining to a part of BFP as a pedicle flap to close a defect, or removal of specific lobe(s)/extension of BFP to recontour the face.3-6 This signifies the importance of BFP as facial filler to maintain facial contour and the devastating consequence of its loss on facial appearance. Fat grafting or fat transplant is the removal of excess fat from a donor site with the intention of re-implanting the fat graft in the defect area. It can be used as filler around the lips, nasolabial fold, periorbital area, cheek and chin. It has been shown to successfully correct cosmetic deformity due to trauma, acne, facial hemiatrophy, lipoatrophy, etc.7,8 Autogenous fat transplant was first documented in 1893 by Neuber, who used it to correct facial deformity due to tuberculosis, and then in 1911 by Bruning, who used fat transplant to correct facial asymmetry post-rhinoplasty.9,10 In 1985, Fournier introduced a new harvest technique to the existing liposuction method by aspiration of fat with low-pressure syringe. He called it “ LipoSculpture” and showed that the viability and integrity of adipose tissue is much better preserved with this technique.11 It was not until the 1990s that Coleman added centrifugation to the previous fat liposuction technique, a new fat transfer technique that he described in a series of publications and trademarked as “LipoStructure” for the successful harvest, transport and transplantation of fatty tissue. Coleman centrifuged the harvested fat tissue and injected a specific volume of purified fat, as needed for the defect, in a small volume “parcel of fat” in repeated injections. This technique helps to place the desired volume of fat in a condensed small volume, while keeping the “fat parcels” as separate as possible from each other to provide maximal space between each injected fat tissue. This will help the recipient site to re-vascularize the fat tissue by optimal exposure of graft to blood flow and, hence, survival and regeneration of the transplanted tissue.12,13 In 1994, Carpaneta and Ribeiro showed that smaller injected fat volume, less than 3 mm, had the most survival rate, which confirmed the results of Coleman regarding his fat transfer technique. 14,15 Today, literature shows surgeons using the same main principles as set forth by Coleman, but different steps and procedures have been introduced with successful outcomes and are being used worldwide depending on the surgeon’s experience and comfort level.