Christina J. Tabit

Fat Grafting Versus Adipose-Derived Stem Cell Therapy: Distinguishing Indications, Techniques, and Outcomes

With adipose-derived stem cells (ASCs) at the forefront of research and potential clinical applications, it is important that clinicians be able to distinguish them from the fat grafting currently used clinically and to understand how the two approaches relate to one another. At times, there has been confusion in clinically considering the two therapies to be the same. This report is aimed at distinguishing clearly between fat grafting and ASC therapy with regard to the indications, harvesting, processing, application techniques, outcomes, and complications. Findings have shown that autologous fat transfer, a widely used procedure for soft tissue augmentation, is beneficial for reconstructive and cosmetic procedures used to treat patients with volume loss due to disease, trauma, congenital defects, or the natural process of aging. On the other hand, ASCs have been identified as an ideal source of cells for regenerative medicine, with the potential to serve as soft tissue therapy for irradiated, scarred, or chronic wounds. Recent advances in tissue engineering suggest that the supplementation of fat grafts with ASCs isolated in the stromal vascular fraction may increase the longevity and quality of the fat graft. Research suggests that ASC supplementation may be a great clinical tool in the future, but more data should be acquired before clinical applications.

Autologous Fat Transplantation in the Craniofacial Patient: The UCLA Experience

Abstract Patients with congenital craniofacial malformations present with complex challenges for reconstruction. Successful management requires individualized treatment often involving rebuilding the facial skeleton de novo, as well as correcting the overlying soft-tissue deficiencies in the final stages. At the University of California, Los Angeles (UCLA) Craniofacial Clinic, serial autologous fat transplantation performed during staged reconstruction is the preferred method. A total of 27 patients with a diagnosis of either craniofacial microsomia/Goldenhar (CM) (n = 19) or Treacher Collins syndrome (TC) (n = 8) were treated at the UCLA Craniofacial Clinic by autologous fat transfer between July 1999 and February 2009. Two-dimensional analysis was conducted on standardized preoperative and postoperative photographs to determine facial symmetry for every patient. Results was grouped based on pathology and analyzed by comparing adipocyte donor site (abdomen vs other). The mean ages at the time of first fat transfer were 17 years for the CM group and 15 years for the TC group. The average numbers of fat transfers per patient were 2.05 (CM) and 2.12 (TC). A mean of 3.74 procedures other than fat grafting was performed in each CM patient, whereas 4.38 other procedures were performed in each TC patient. In CM patients, less than 10.5 months between procedures resulted in improved symmetry. There was an average 6.63% improvement in facial symmetry in the CM group, and a 7.67% improvement in the TC group. Based on the UCLA experience, the durability of facial asymmetry and contour correction with fat transplantation is attainable in the craniofacial patient but may also require concomitant skeletal correction in the most severe cases.

Evaluation of plastic surgery training programs: integrated/combined versus independent.

Background: The authors aimed to differentiate between combined/integrated and independent (traditional) methods of plastic surgery training with regard to quality of trainees, caliber of graduates, and practice or career outcomes once graduated. Methods: To compare combined/integrated with independent residency program training, the authors conducted a Web-based survey of the American Society of Plastic Surgeons members looking at their experience and practice outcomes (n = 1056) and interviews of plastic surgery faculty looking at the quality of trainees (n = 72). The member survey evaluated background information, research credentials, pathway satisfaction, postgraduation activities, current practice, and academic affiliation. Faculty teacher interviews focused on knowledge base, diagnostic and treatment judgment, technical abilities, research capabilities, and prediction of future career success. Results: The member survey showed no difference (p > 0.05) between combined/integrated and independent trainees in practice type (cosmetic/reconstructive), practice volume, or academic achievements. Combined/integrated trained surgeons are three times more likely to recommend their training pathway and two times more likely to enter fellowship after residency. Alpha Omega Alpha Honor Medical Society membership correlated with a greater likelihood of having an academic practice at 5 and 10 years or more and higher professorship titles. Faculty evaluations showed that combined/integrated residents were superior in knowledge (49 percent versus 32 percent) but that independent residents were superior in technical ability (51 percent versus 20 percent) and research (57 percent versus 19 percent). Most faculty were unable to choose a pathway producing superior residents. Conclusions: Regarding future practice outcomes, there was not a superior training pathway. Regarding quality of trainees, there were differences in faculty evaluations, but there was no consensus on a better pathway.

Parry-Romberg reconstruction: beneficial results despite poorer fat take.

ObjectiveFor the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied the volume retention and skin changes after autologous fat grafts within diseased regions. Summary Background DataThe long-term survival and volume retention of fat grafts used in soft tissue reconstruction of Parry-Romberg syndrome is still unknown, as are skin changes after fat grafting. MethodsSex, age, severity of deformity, number of procedures, operative times, and augmentation volumes were recorded. Preoperative/postoperative 3-dimensional computed tomographic scans were also reviewed. A digital 3-dimensional photogrammetry system was used to determine “final fat take” and symmetry. Romberg fat grafting volumes were compared to nonaffected, cosmetic fat-grafted patients. For skin changes, a spectrophotometer was used to quantify percent improvement in melanin index. Physician and patient satisfaction surveys (5-point scale) were elicited, including overall outcome and skin color/texture. ResultsThe mean number of procedures correlated to the severity of deformity: mild, 1.8 procedures; moderate, 3.4; and severe, 5.2. With Romberg patients, fat grafting injected: per case, 48 mL; total, 188 mL; and final measured volume, 101 mL. Romberg patients had less “fat take” than nonaffected grafted patients (final take, 41% vs 81%). Skin color/texture showed 3-fold improvement after fat grafting procedures. The mean melanin index improvement seen in the diseased regions of Romberg patients after fat grafting was 42% (+3%). Skin color and texture improvement was also shown in patient surveys (preoperative = 2.4 + 0.06 to follow-up = 3.4 + 0.09) and physician (preoperatively = 2.1 + 0.1 to follow-up = 3.6 + 0.1). ConclusionsDespite poorer fat graft take within the disease region of Romberg patients, fat grafting resulted in long-term improvement in hypoplasia and skin hyperpigmentation.

Parry-Romberg reconstruction: optimal timing for hard and soft tissue procedures.

AbstractFor the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied 3 controversial issues: (1) optimal timing, (2) need for skeletal reconstruction, and (3) need for soft tissue (medial canthus/lacrimal duct) reconstruction. Patients with Parry-Romberg syndrome (>5 y follow-up) were divided into 2 groups: (1) younger than 14 years and (2) 14 years or older (n = 43). Sex, age, severity of deformity, number of procedures, operative times, and augmentation fat volumes were recorded. Physician and patient satisfaction surveys (5-point scale) were obtained, preoperative and postoperative three-dimensional computed tomographic scans were reviewed, and a digital three-dimensional photogrammetry system was used to determine volume retention. Our results indicate that the younger patient group required more procedures compared with the older patient group (4.3 versus 2.8); however, the younger group had higher patient/family satisfaction scores (3.8 versus 3.0). Skeletal and soft tissue reconstruction resulted in improved symmetry score (60% preoperatively to 93% final) and satisfaction scores (3.4 preoperatively to 3.8 final). Patients with Parry-Romberg syndrome required multiple corrective surgeries but showed improvements even when beginning before puberty. Soft and hard tissue reconstruction was beneficial.

Necessity of latency period in craniofacial distraction: Investigations with in vitro microdistractor and clinical outcomes

BACKGROUND To determine the need for latency period in membranous bone distraction, we performed 1) in vitro comparison of preosteoblasts suspended in a 3D microdistraction model and 2) a clinical study comparing mandibular distraction cases with/without latency. METHODS In the In Vitro study, Preosteoblasts polymerized in 3D-collagen gel were placed in a microdistractor and separated into three groups: 1) distraction with latency, 2) distraction without latency, and 3) static. After 2, 4, 6, and 8 days, cell proliferation, total protein levels, alkaline phosphatase activity, and osteogenic gene expression were assessed through RT-PCR. In the clinical study, patients underwent mandibular distraction in two groups: 1) latency and 2) no latency (n = 45). The rest of the distraction protocol was identical. Outcome was based on clinical examination, radiographs at six months, and 3D CT scans. RESULTS In the In Vitro study, The distraction without latency group compared to the latency group had delays in: proliferation, total protein count, alkaline phosphatase activity, osteogenic gene expression in CBFA-1 (fourfold vs. eighteenfold), and in osteocalcin (twofold vs. sixfold). The distraction without latency group had higher apoptotic levels during the first four days compared to the latency group (68% vs. 14%). For the clinical study, similar perioperative complications (5% vs. 6%), X-ray mineralization (93% vs. 94%), bone volume, (8.6 vs. 9.1 cc) and bone density of central distraction zone (78% vs. 81%) were observed with or without latency. CONCLUSIONS In vitro studies showed poorer results in cell survival, proliferation and osteogenic activity compared to distraction with latency; yet, clinically, there were no differences in distraction with latency versus without.

Correction of hypertelorbitism: evaluation of relapse on long-term follow-up.

Background Hypertelorbitism has been associated with a variety of congenital deformities. Appropriate timing for surgical correction remains controversial. We present our long-term experience of 33 patients with hypertelorbitism undergoing facial bipartition or orbital box osteotomy. Methods Patients with hypertelorbitism treated with either facial bipartition or orbital box osteotomy and repositioning who had long-term follow-up were studied (n = 33). Age at the time of first surgery, preoperative interdacryon distance, and immediate postoperative interdacryon distance were recorded. Relapse was determined on postoperative follow-up, and the need for secondary correction was noted. Physician satisfaction score (range, 0–4) was also assessed. Results Patients had a mean total follow-up of 14.0 years. With regard to age at the time of initial procedure, patients younger than 6 years were all noted to have relapse, and 83% underwent revision surgery. In patients 6 years or older, only 11% had relapse and required a second operation. Yet, satisfaction scores were similar (3.2 versus 3.5). With regard to the severity of hypertelorbitism, there was no relapse noted among patients with mild hypertelorbitism (interorbital distance [IOD], 30–34 mm). Among those with moderate hypertelorbitism (IOD, 35–40 mm), 29.4% developed relapse. By contrast, all patients with severe hypertelorbitism (IOD, >40 mm) were noted to have relapse requiring repeat correction. Satisfaction scores were similar (3.4 versus 3.3 versus 3.1). Conclusions Relapse after surgery for hypertelorbitism is related to the age of the patient at correction and the preoperative severity. When possible, surgical repositioning of the orbits should be delayed until later childhood.

The Sarnat studies in craniofacial biology.

Abstract Dr. Bernard Sarnat is one of plastic surgery’s greatest laboratory investigators. His contributions to our understanding of modern craniofacial molecular biology are immense. His landmark studies continue to influence the way we approach and treat patients today. This article outlines his classic investigations of the craniofacial skeleton, with particular interest in lower face, midface, and upper face development; cranial suture and cranial base biology; and tooth and dental development. In this article, a brief summary of Dr. Sarnat’s investigations are followed by how these data have had an important clinical impact.

Abstract 100: Nager Syndrome Dental Pulp Stem Cells Have Osteogenic Potential

Purpose: Our laboratory is developing a regenerative peripheral nerve interface (RPNI) device. RPNI construction includes a light wrap of decellularized small-intestine submucosa (SIS) as a scaffold upon which an ionic/electrical conductive material is polymerized. However, the porosity of SIS and SIS with polymer is unknown. The purpose of this study is to determine RPNI revascularization, vitality, and reinnervation when SIS contains poly 3,4 ethylene dioxytheophene (PEDOT).

Staged reconstruction of the lower eyelid following tri-lamellar injury: A case series and anatomic study

PURPOSE Lower eyelid scaring and malposition following violation of all three lamellae pose a significant ophthalmologic reconstructive challenge. The purpose of our study was to document a staged approach for this problem using: 1) transconjunctival scar release followed by palatal graft below the tarsal plate and subciliary scar release followed by full-thickness skin graft superficial to the tarsal plate and 2) subsequent autologous fat grafting to the lower eyelid. METHODS Cadaveric anatomic dissections were performed. Post-traumatic and post-surgical lower eyelid deformities requiring reconstruction were reviewed and outcome assessment was based on symptomatic improvement, perioperative complications, reoperations and long-term follow-up (> 1 year). RESULTS Cadaver dissections demonstrated consistent lower eyelid tarsal plate and lamellar anatomy for the use of palatal graft and skin grafting. Clinically, 75% cases resulted from full thickness traumatic laceration of the lower eyelid or malar region and 25% of cases occurred after transconjunctival incisions were made for zygomatic maxillary repositioning following partial lower eyelid laceration. Preoperative symptoms of: epiphora, tearing, redness, blurry vision and dryness improved in all patients and complete resolution was seen in 63% of patients. Thirty-seven percent of patients had complications: Redundancy of palatal graft, Partial FTSG loss, cellulitis after fat transfer. CONCLUSIONS We describe an approach for the scarred and displaced lower eyelid following injury to all three lamellae that provided symptomatic improvement after lower lid scar tissue release, lengthening of the contracted septum, support of the posterior lamellae with a palatal graft and a replacement of anterior lamella with full thickness skin graft.