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Correction of hemifacial atrophy using free anterolateral thigh adipofascial flap Li Teng, Xiaolei Jin*, Guoping Wu, Zhiyong Zhang, Ying Ji, Jiajie Xu, Jianjian Lu, Bo Zhang, Gang Zhou Cranio-Maxillo-Facial Surgery Department 2, Plastic Surgery Hospital of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, PR China Received 19 September 2008; accepted 8 June 2009 KEYWORDS Hemifacial atrophy; Anterolateral thigh adipofascial flap; Microsurgery Summary Treatment of hemifacial atrophy presents a challenge for reconstructive surgeons. Previous studies have described numerous methods for the correction of facial asymmetry. We present our experience with treatment of hemifacial atrophy using a microsurgical antero- lateral thigh adipofascial flap procedure and other adjunctive measures. This method is similar to that used for the free anterolateral thigh flap, but only the deep fascia of the anterolateral thigh and subcutaneous fatty tissue above the fascia were harvested. This flap procedure was used in 32 patients with moderate or severe hemifacial atrophy. In the first stage, the antero- lateral thigh adipofascial flap procedure was used in all the patients, of whom eight accepted a porous polyethylene implant along with the anterolateral thigh adipofascial flap to recon- struct the skeleton. In the second stage, ancillary procedures including porous polyethylene implantation, liposuction debulking, fat injection and flap re-suspension were performed to refine the outcome in 28 patients. The anterolateral thigh adipofascial flap is advantageous in that it can provide a reliable vascular pedicle with relatively thin, pliable soft tissue and direct primary closure of the donor site. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Romberg’s disease manifests as a progressive hemifacial atrophy of the skin and underlying soft tissues, cartilage and bone. The cause of the disorder is unknown, although many theories of its pathogenesis have been proposed. Foremost among these are infection, trigeminal peripheral neuritis, scleroderma and cervical sympathetic loss. 1 Recently, autologous vascularised adipose tissue has become the natural choice for craniofacial contour correction of moderate or severe hemifacial atrophy. Numerous free flaps have been used for restoration of facial contour deformities in patients with Romberg’s disease, including the deltopectoral, 2,3 groin, 4,5 omentum, 6e8 scapular and parascapular flaps 9e13 ; a latissimus dorsi * Corresponding author. No 33, Badachu Road, Shijingshan District, Beijing 100144, PR China. Tel.: þ86 1088772343; fax: þ86 1088961829. E-mail address: [email protected] (X. Jin). 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.06.009 Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1110e1116

Correction of Hemifacial Atrophy Using free Anterolateral Thigh Adipofascial Flap

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Page 1: Correction of Hemifacial Atrophy Using free Anterolateral Thigh Adipofascial Flap

Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1110e1116

Correction of hemifacial atrophy using freeanterolateral thigh adipofascial flap

Li Teng, Xiaolei Jin*, Guoping Wu, Zhiyong Zhang, Ying Ji, Jiajie Xu,Jianjian Lu, Bo Zhang, Gang Zhou

Cranio-Maxillo-Facial Surgery Department 2, Plastic Surgery Hospital of Peking Union Medical College,Chinese Academy of Medical Sciences, Beijing, PR China

Received 19 September 2008; accepted 8 June 2009

KEYWORDSHemifacial atrophy;Anterolateral thighadipofascial flap;Microsurgery

* Corresponding author. No 33,District, Beijing 100144, PR Chinfax: þ86 1088961829.

E-mail address: [email protected]

1748-6815/$-seefrontmatterª2009Bridoi:10.1016/j.bjps.2009.06.009

Summary Treatment of hemifacial atrophy presents a challenge for reconstructive surgeons.Previous studies have described numerous methods for the correction of facial asymmetry.We present our experience with treatment of hemifacial atrophy using a microsurgical antero-lateral thigh adipofascial flap procedure and other adjunctive measures. This method is similarto that used for the free anterolateral thigh flap, but only the deep fascia of the anterolateralthigh and subcutaneous fatty tissue above the fascia were harvested. This flap procedure wasused in 32 patients with moderate or severe hemifacial atrophy. In the first stage, the antero-lateral thigh adipofascial flap procedure was used in all the patients, of whom eight accepteda porous polyethylene implant along with the anterolateral thigh adipofascial flap to recon-struct the skeleton. In the second stage, ancillary procedures including porous polyethyleneimplantation, liposuction debulking, fat injection and flap re-suspension were performed torefine the outcome in 28 patients. The anterolateral thigh adipofascial flap is advantageousin that it can provide a reliable vascular pedicle with relatively thin, pliable soft tissue anddirect primary closure of the donor site.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Romberg’s disease manifests as a progressive hemifacialatrophy of the skin and underlying soft tissues, cartilageand bone. The cause of the disorder is unknown, althoughmany theories of its pathogenesis have been proposed.

Badachu Road, Shijingshana. Tel.: þ86 1088772343;

(X. Jin).

tishAssociationofPlastic,Reconstruc

Foremost among these are infection, trigeminal peripheralneuritis, scleroderma and cervical sympathetic loss.1

Recently, autologous vascularised adipose tissue hasbecome the natural choice for craniofacial contourcorrection of moderate or severe hemifacial atrophy.Numerous free flaps have been used for restoration of facialcontour deformities in patients with Romberg’s disease,including the deltopectoral,2,3 groin,4,5 omentum,6e8

scapular and parascapular flaps9e13; a latissimus dorsi

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Page 2: Correction of Hemifacial Atrophy Using free Anterolateral Thigh Adipofascial Flap

Figure 1 Left. Intraoperative elevation of anterolateral thigh adipofascial flap. Right. The flap is laid out across the face with thefat side up and end-to-end anastomosis of the pedicle vessel with the recipient vessel is performed.

Correction of hemifacial atrophy 1111

musculocutaneous flapevascularised costochondral graft14;the transverse rectus abdominis muscle (TRAM) flap15; theradial forearm adipofascial flap16; and the free deep infe-rior epigastric perforator (DIEP) flap.17

In this article, we present our experience treating 32patients with hemifacial atrophy using the free antero-lateral thigh adipofascial flap and other adjunctivemethods such as porous polyethylene implantation, lipo-suction debulking, fat injection and flap re-suspension.

Patients and methods

The study protocol was approved by the Ethical Committeeof Plastic Surgery Hospital of the Peking Union MedicalCollege.

Patients

Between 1996 and 2008, a total of 32 free anterolateralthigh adipofascial flap microsurgical procedures were per-formed in 32 patients with moderate or severe progressivehemifacial atrophy deformities. Of these 32 patients,13 were male and 19 female, and their average age was23 years (range: 15e45 years). The average age at diseaseonset was 10.2 years. The average duration of atrophy was8.9 years. Fifteen lesions affected the left face, and 17affected the right. In 12 patients the lesion affected onlysoft tissue, while in 20 patients both soft tissue and bonewere affected.

Surgical techniques

All of the patients underwent computed tomography (CT)scanning and three-dimensional reconstruction of the skullto confirm the lesion preoperatively. When these lesionsencroach upon the facial skeleton or the temporozygomaticregion, their repair is complicated because of their irreg-ular three-dimensional curvature, and bone substituteshould be used to reconstruct the skeleton.

A Doppler flowmeter was used preoperatively to estab-lish the location of the perforator. A line was drawnbetween the anterosuperior iliac spine and the supero-lateral border of the patella on the donor thigh. With themidpoint of the line being the centre of a circle, most exitpoints for the perforator were identified within a circle

with a radius of 3 cm.18 The skin of the donor thigh wasmarked to match the defect of the recipient site, with theexit points for the perforator as the centre. After thesubcutaneous superficial adiposal tissue was bilaterallydissected through a T- or S-shaped skin incision, the desiredanterolateral thigh adipofascial flap from the descendingbranch of the lateral circumflex femoral artery washarvested in the standard manner (Figure 1, left).18,19

At the recipient site, when bone substitute was used toreconstruct the skeleton, the periosteum was elevated toexpose the affected bone (maxilla, zygoma, mandible,etc.) and porous polyethylene (Medpor, Porex Surgical,Newnan, GA, USA) was implanted into the subperiosteallayer through a gingivobuccal sulcus incision.

A 4- to 5-cm incision was made below the mandible edgeto expose the facial vessel and create a subcutaneouspocket for flap transfer. An adjunctive incision was used inthe temporal area if the fronto-temporal area wasaffected. The flap was laid out across the face with the fatside up and trimmed if necessary. End-to-end anastomosisof the pedicle vessel with the recipient vessel was achievedusing anastomosis rings (Beijing Medical Instrument Co.,Beijing) with a diameter of 1.5e2.5 mm, or a microsurgicaltechnique (Figure 1, right).

After blood circulation of the flap was confirmed, theflap was transferred to the pocket with the fat side up andsome anchoring sutures were made between the adipofas-cial flap and the pocket to fix the flap. The donor site wasclosed directly. Adjunctive procedures were performed onsome patients 6 months to 1 year after the first surgery torefine the facial contour. For patients who had flap bulki-ness, liposuction was used to de-fat and thin the flap. Forpatients who had flap sagging, the flap was re-suspended tothe fascia temporalis through the temporal incision. Forpatients who had insufficient correction of the edge of theskin flap, fat injection was performed according to Cole-man’s approach to fill the local depression.13,20e22 Inaddition, for some patients with bone defects who did nothave immediate skeletal reconstruction during the firstsurgery, porous polyethylene was implanted.

Results

All 32 of the flaps survived completely, without flapnecrosis or other severe complications. The anterolateral

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Table 1 Summary of anterolateral thigh adipofascial flap used to correct hemifacial atrophy

Sex Side Flap size (cm) Donor site complications Recipient sitecomplicationsMale Female Left Right Seroma Haematoma

Number 13 19 15 17 11� 6 w 20� 11 2 2 0

1112 L. Teng et al.

thigh adipofascial flap ranged from 10 to 20 cm in lengthand from 6 to 12 cm in width. During the first surgery,porous polyethylene was used for immediate skeletalreconstruction in eight patients. For the other 24 patients,only anterolateral thigh adipofascial flap was transferred toreconstruct the facial soft-tissue defect. Two cases ofhaematoma and two cases of seroma were observed. Thehaematoma and seroma disappeared after aspiration byneedle poking and fixation with bandaging (Table 1).Secondary operations including liposuction debulking, fatinjection, flap re-suspension and porous polyethyleneimplantation were performed for 28 patients (Table 2). Allpatients received follow-up ranging from 6 months to 7years. The facial shapes were relatively symmetrical, thecontours were satisfactory and no notable dysfunction ofthe donor thigh was observed. The slight asymmetry of thelower extremity and the scar at the donor site wereacceptable.

Case reports

Case 1

A 21-year-old woman suffered from progressive atrophy ofthe left face and presented with obvious left-sided facialdeformity. In August 2003, the patient underwent the firstsurgery, consisting of microsurgical anterolateral thighadipofascial flap transfer, to correct the deformity. The flapmeasured 20� 11 cm with a vascular pedicle that was 9 cmlong. An end-to-end anastomosis of the flap vessel with therecipient facial vessel was performed. After trimmingthe excessive superficial fat, the flap was transferred to thepocket with the fat side up through a submandibular inci-sion. The flap survived without any complications. Sixmonths later, the patient underwent liposuction to debulkand re-suspend the flap. The facial contour deformity wassatisfactorily corrected (Figure 2).

Case 2

A 19-year-old woman suffered from progressive atrophy ofthe left face that affected both the soft tissue and theskeleton. The patient underwent microsurgical antero-lateral thigh adipofascial flap transplantation in the firststage of surgery to correct the soft-tissue deformity. Theflap measured 19� 10 cm, with an 8-cm vascular pedicle.

Table 2 The adjunctive procedures

A B C D Aþ B Aþ C Aþ D

Number 0 0 11 2 3 2 2

Liposuction Z A; Fat injection Z B; Medpor implantation Z C; Flap R

An end-to-end anastomosis of the flap vessel with the facialvessel was performed. The flap was transferred to thepocket of the left face with the fat side up througha submandibular incision. The flap survived withoutany complications. One year later, porous polyethylene(Medpor, Porex Surgical) implantation was used to augmentthe zygoma through a gingivobuccal sulcus incision, and fatinjection was performed to correct the local depression ofthe suborbital area and chin. The appearance of theaffected face was satisfactorily improved (Figure 3).

Discussion

Hemifacial atrophy is a complex craniofacial malformation.Correction of this deformity presents a challenge becausedeficiencies of both the facial skeleton and the overlyingsoft tissue often must be addressed to achieve optimalreconstructive results. Augmentation of the facial softtissue may be required for two reasons.23 First, adequatesoft tissue may be needed to protect and cover a plannedbone substitute to obtain a natural appearance. Second,additional subcutaneous thickness is often needed tosubstitute for the deficient subcutaneous fat, parotid andmuscle mass and create a symmetrical facial contour.

Microsurgical restoration of the facial contour has beenwidely used for treatment of hemifacial atrophy, and manyauthors have published their evaluations of the results.2e17

Microsurgical reconstruction focussing on the correction offacial asymmetry and reconstruction of contour hasbecome the ‘gold standard’ of treatment.9 Many kinds offree flaps have been used to correct Romberg’s disease, allof which have had disadvantages. For example, the majordisadvantage of the vascularised groin dermalefat flap isthat the primary defatting can be difficult because thepedicle vessel runs in a deeper layer from the proximal todistal portion.3,4 With the omentum flap, its unpredictablefat content and its need for a laparotomy and fascial sling toprevent long-term sagging are the main disadvantages.6e8

The scapular or parascapular flap is a feasible option forhemifacial atrophy, but some patients have hypertrophicscarring at the donor site. In addition, simultaneous ele-vation is difficult because of the donor site’s proximity to theface, potentially necessitating a positioning change to obtainthe flap.9e13 Therefore, a consensus on the ideal method hasnot yet been reached, and investigations to discover theideal flap continue.

Bþ C Cþ D Aþ Bþ C Aþ Bþ D E Total

3 2 2 1 4 32

esuspension Z D; without adjunctive procedure Z E.

Page 4: Correction of Hemifacial Atrophy Using free Anterolateral Thigh Adipofascial Flap

Figure 2 Case 1. A 21-year-old woman with left-sided hemifacial atrophy. (Above left) Preoperative frontal view. (Above right)Postoperative frontal view after subcutaneous anterolateral thigh adiposal flap transfer. (Centre left) Preoperative left obliqueprofile. (Centre right) Postoperative left oblique profile. (Below left) Preoperative submental view. (Below right) Postoperativesubmental view.

Correction of hemifacial atrophy 1113

The anterolateral thigh flap procedure was first reportedby Song et al. in 198424 and has been widely used incoverage of traumatic and chronic wounds, burn scars, soft-tissue defects of the face and forehead after ablativesurgery for carcinoma, and reconstruction of the penis,vagina, tongue, dura maters, foot surface, sole and skullbase.25e34 The anterolateral thigh flap has many advan-tages18,23,24,34e38: it provides a large reliable skin flap witha long vascular pedicle; it can be raised with neighbouringtissues such as the vastus lateralis, rectus femoris, iliacbone or tensor fasciae latae; no special positioning isrequired; and a flow-through flap can be designed forreconstruction of both soft-tissue and major vessel defects.The anterolateral thigh adipofascial flap is one of theapplied forms of the anterolateral thigh flap. In cadaverstudies, the perforators could be dissected in the adipose

layer and were observed to extend almost perpendicularlyto the subdermal plexus.35 Because the perforating vesselof the flap flows into the subdermal plexus almostperpendicularly after passing through the deep fascia, itcan be shaped and thinned through trimming the fat of itssuperficial layer, as desired, without injuring the delicatecirculation of the flap and jeopardising its viability.36

Bleeding from the edge of the deep fascial layer and itsadipose surface during flap harvesting confirms the viabilityof the adipofascial flap. However, partial flap necrosis maybe caused by excessive defatting or inappropriate flapdesign. Therefore, the initial trimming should be fairlyconservative. With the harvesting of the anterolateral thighadipofascial flap, the donor-site defect can be directlyclosed without tension, minimising donor-sitemorbidity.37,38 This approach not only provides a thinner

Page 5: Correction of Hemifacial Atrophy Using free Anterolateral Thigh Adipofascial Flap

Figure 3 Case 2. A 19-year-old woman with left-sided hemifacial atrophy affecting both the soft tissue and the skeleton. Ananterolateral thigh adipofascial flap (19� 10 cm) was used to restore the soft tissue of the left face. In the second surgery, a porouspolyethylene implant was used to augment the zygoma, and fat injection was performed to correct the local depression of thesuborbital area and chin. (Above left) Preoperative frontal view. (Above right) Postoperative frontal view. (Below left) Preoperativeleft oblique profile. (Below right) Postoperative left oblique profile.

1114 L. Teng et al.

and more pliable tissue flap but also eliminates the need fora skin graft for the donor-site defect. The presence of deepfascia of the flap allows adequate fixation to facial fasciaand avoids sagging after reconstruction.23

One of the disadvantages of the anterolateral thighadipofascial flap is that a minority of patients haveanatomical blood vessel variation, and a small minority lackblood vessel perforators. Therefore, it is very important todetect perforators precisely by the Doppler flowmeterbefore surgery. If flap dissection reveals a lack of perfora-tors, an anteromedial thigh adipofascial flap can be used asan alternative to the anterolateral thigh adipofascial flap.Another disadvantage of the flap is that the musculocuta-neous perforators of some flaps course a long distance

inside the muscle before going into the flap, making thedissection relatively difficult and tedious.

In the present study, adjunctive procedures such asporous polyethylene implantation to reconstruct the skel-eton, liposuction to debulk the flap, fat injection to fill theedge of the flap and flap re-suspension to correct thegravitational sag were employed. Porous polyethylene isthe most widely used implant material and is moderatelypliable and relatively easy to shape. It has an ‘open-pore’structure that is relatively resistant to collapse and allowssome degree of tissue in-growth. It enhances the effect ofrestoration on the facial contour in three dimensionsand avoids sagging and bulkiness of the flap postoperativelyin cases with serious skeletal deformity. Coleman’s

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Correction of hemifacial atrophy 1115

lipoinjection technique was used to modify the free ante-rolateral thigh adipofascial flap contour, to restore adja-cent atrophic areas and to treat the remaining small ormoderate defects. In our experience, the injected fat cansurvive without total resorption or dissolution, and a rela-tively symmetrical appearance can be expected. A bulkyflap can be improved through liposuction, a simple andeffective method with minimal morbidity. Because of theloose fat of the flap, liposuction can be performed easily.The fat from the liposuction can also be used to fill thefacial depressions, and a perfectly symmetrical appearancecan be achieved. For patients who have sagging of the flapafter the first stage, the flap is re-suspended to the fasciatemporalis or the zygoma periosteum through the temporalincision or the inferior orbital margin incision. In short,a perfectly symmetrical appearance can be achieved byusing the above-mentioned adjunctive methods eithersolely or jointly to correct the various defects after the firststage.

In conclusion, we have found the anterolateral thighadipofascial flap to be ideal for facial contour restoration inmoderate or severe hemifacial atrophy because it can besuccessfully harvested and transferred with a microsurgicaltechnique and it allows tissue matching. Combined withauxiliary methods, the anterolateral thigh adipofascial flapcan provide an ideal treatment for facial asymmetry inhemifacial atrophy.

Acknowledgements

The authors are indebted to Mr. Zhang Chao, Ms. Pei Yue,and Mr. Mark Levien for their assistance and proofreading.

Conflict of interest

None.

Funding

None.The research protocol in the manuscript was approved

by the Ethical Committee of Plastic Surgery Hospital ofPeking Union Medical College.

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