Pursuing the Optimal Fat Grafting Technique for Cleft-Craniofacial Reconstruction: Toward a Physiologically and Anatomically Driven Surgical Approach.

Abstract

To the Editor: T he modern Coleman s structural fat graft principle revolutionized the care provided by plastic surgeons to augment the soft tissue envelope and improve the tissue quality of multiple congenital and acquired head-to-foot conditions. However, technical inconsistencies and variable volume retention remain. The author argues about a current transformation in fat grafting toward a more physiologically and anatomically driven approach, which would enhance cleft-craniofacial reconstruction. Fat harvesting, processing, and placement, followed by transient ischemia, is stressful to the fragile fat tissue and can lead to cell death and volume loss. Recent theoretical and mathematical modeling–, rheological simulation–, histopathological-, and clinical-based data have enriched our understanding of the mechanisms of fat graft survival and remodeling, that is, oxygen tension graft-to-recipient interface; graft-to-capacity ratio; recipient site preconditioning; and shear stress, flow speed, and pressure parameters. This physiological and anatomical information has constantly been incorporated into the surgical workflow for breast reconstruction, including percent augmentation of the recipient site, not percent graft survival. This information has only recently been integrated into the surgical rationale of cleft-craniofacial reconstruction, including microribbon and fluid accommodation models and fat placements in fat-specific recipient sites. However, no high-level evidence exists to support surgeons selection among the existing techniques. Importantly, the absence of consensus on a single harvesting, processing, and placement technique should not be interpreted as a random-based or principles-free environment of surgical planning and performance. Fat grafting is recurrently misguided as a simple procedure that can be easily completed in a few minutes, but this misperception acts as one of the major barriers to success. In fact, fat graft–related inconsistent results may be attributed to limited adherence to the fat survival process by adopting, for example, harvesting under high negative pressures and fat placements using multiple cannula passes within the same restricted recipient region with the risk of cavity formation. This scenario is well illustrated by a recent prospective study as fat grafting using a bolus technique yielded inferior results than those of hyaluronic acid for the treatment of postsurgical temporal hollowing. Deliberately, the bolus injection increases the fat necrosis and resorption rates because of the poor graft-to-recipient interaction. This previous investigation thus transmits a debatable message as either Coleman s principle or that the current fat survival–related data were not considered in the design of the study. Because attention to detail in each component and step of fat grafting is of paramount importance to properly embrace a fat-centered surgery, the implementation of an accurate technique requires patience and should be faced as a time-consuming procedure. Plastic surgeons managing cranio-orbito-facial-oral abnormalities should recognize the value of basic science and clinical principles, pursuing a truly “fat-friendly” surgical approach. Similar to breast reconstruction–related projects, there is a call for the insertion of well-delineated comparative studies of standardized fat grafting techniques in future research agendas. Level I and II data would compose the foundation for the decision-making process of the selection and execution of the optimal technique. The present time seems to be a good opportunity for multicenter international collaborative initiatives in the field of cleft-craniofacial surgery for the in-depth assessment of fat grafting outcomes, an essential procedure for the plastic surgery community with an ever-evolving culture of surgical improvement.