return to: Facial Plastics

Last update: before 2017

GENERAL CONSIDERATIONS:

1. Dermal fat grafting has been used for over a hundred years (McNichols et al) and provides an autologous tissue source.

PREOPERATIVE PREPARATIONS

1. Evaluation
   1. Pre-operative photography
   2. Pre-operative electromyography if indicated
   3. Consent for Surgery should include discussion of realistic goals, benefits, and the need to overcorrect for expected wound contraction, as well as a scar on the abdomen
2. Speak with Anesthesia team prior to case to ensure that no long-lasting paralytic is administered if you will be stimulating facial nerve branches

NURSING CONSIDERATIONS

1. Room Setup
   1. Turn either 90 or 180 degrees to allow access to the abdomen and area of head and neck of interest
2. Instrumentation and Equipment
   1. Not necessary, but useful: facelift scissors, lighted retractors
3. Medications (specific to nursing) 
   1. Plain epinephrine 1:100,000
4. Prep and Drape
   1. Iodine prep, blue towels with staples over abdomen with umbilicus visible at a minimum. Some staff prefer Ioban over towels with no staples. Then a "marking" towel with clamp followed by medium drape. Lastly over this, an oto split drape.
5. Drains and Dressings
   1. Pressure dressings for face: kerlix rolls over fluffs for modified mastoid dressing or Barton's dressing, or an elastic facelift (Jaw Bra) over fluffs to face. Pressure dressing on abdomen: with fluffs and large tegaderm or Elastoplast tape,+/- penrose

ANESTHESIA CONSIDERATIONS

1. Consider use of an oral rae if needed
2. The need for nerve stimulation (i.e. for parotid defect) will necessitate use of only short-term paralytics throughout the case

Modified Operative Note

Attention was directed to the abdomen where a 10 cm x 4 cm elliptical incision was planned. The incision was made but only carried through the epidermis. The epidermis over the ellipse was then dissected off and deepithialized. The resulting elliptical area of dermis was then resected free from the skin, along with the adipose tissue deep to the dermis, resulting in a dermal/adipose graft. The defect was closed with deep vicryls and a subcuticular Monocryl, after careful hemostasis was obtained with bipolar. Facial reconstruction of the tissue deficit was then undertaken. The graft was trimmed and was placed into the defect in the left cheek. It was sized and resized to fit the given defect. Numerous times the graft was removed and trimmed and resized. Graft was slightly (20-30%) oversized with the anticipation of atrophy over time. It was secured in place with Monocryl sutures. Fine adjustments were made to the contour by trimming the graft, as well as adding additional dermis to help hide skin thickness irregularities. A round drain was placed and hooked to a hemovac. The deep layers of the incision lines were closed with Monocryl and the skin was closed with 5-0 nylon.

References

Coleman SR. Plast Reconstr Surg. 2006 Sep;118(3 Suppl):108S-120S.Structural fat grafting: more than a permanent filler.

Kumar NG¹, Thapliyal GK.J Maxillofac Oral Surg. 2012 Sep;11(3):319-22. doi: 10.1007/s12663-012-0358-6. Epub 2012 Apr 25.Free dermal fat graft for restoration of soft tissue defects in maxillofacial surgery.

McNichols CH¹, Hatef DA, Cole P, Hollier LH, Thornton JF. J Craniofac Surg. 2012 May;23(3):e234  Contemporary techniques for the correction of temporal hollowing: augmentation temporoplasty with the classic dermal fat graft.