|Year : 2017 | Volume
| Issue : 2 | Page : 412-419
Improving esthetic outcome of facial scars by fat grafting
Fouad Ghareeb1, Dalia M Elsakka1, Yahia Alkhateep2, Hossam M Zayed3
1 Department of Plastic Surgery, Menoufia Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Menoufia Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Plastic Surgery, Benha Teaching Hospital, Benha, Egypt
|Date of Submission||01-Jan-2017|
|Date of Acceptance||09-Apr-2017|
|Date of Web Publication||25-Sep-2017|
Hossam M Zayed
Tala, 32627, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the effects of different techniques of fat grafting on improving the esthetic outcome of facial scars.
Control of facial scarring is one of the most difficult challenges in surgical practice, and represents a difficult therapeutic problem facing plastic surgeons to achieve good results. To date, no gold standard exists for the treatment of scar tissue. Autologous fat grafting has been introduced as a promising treatment option for scar tissue-related symptoms. However, the scientific evidence for its effectiveness remains unclear.
Patients and methods
This study was conducted on 30 patients with obvious facial scars. Patients' age ranged from 8 to 48 years. Patients were selected randomly to be treated with fat grafting. The abdomen and thigh were the most commonly chosen donor sites. Fat was processed to be injected at the dermohypodermal junction (microfat grafting) or intradermal injection (nanofat grafting) was used.
Fat grafting proved to have a significant role in scar remodeling. This was measured clinically by the Vancouver Scar Scale. Regarding patient satisfaction with cosmetic appearance, 15 cases were evaluated as excellent, eight cases were evaluated as good, and five cases were evaluated as fair.
Autologous fat grafting has a significant role in facial scar remodeling and provides a beneficial effect on facial scar tissue and scar-related conditions with not only esthetic results but also functional results. Significant improvement in scar appearance, skin characteristics, and restoration of volume and three-dimensional contour is reported.
Keywords: esthetic outcome, facial scars, fat graft
|How to cite this article:|
Ghareeb F, Elsakka DM, Alkhateep Y, Zayed HM. Improving esthetic outcome of facial scars by fat grafting. Menoufia Med J 2017;30:412-9
|How to cite this URL:|
Ghareeb F, Elsakka DM, Alkhateep Y, Zayed HM. Improving esthetic outcome of facial scars by fat grafting. Menoufia Med J [serial online] 2017 [cited 2019 Jun 17];30:412-9. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/412/215476
| Introduction|| |
Throughout history, facial scars have represented a problem, where most of the solutions are unsatisfactory. The search for a more successful method with long-term, better results for different skin types remains the main challenge facing plastic surgeons .
Every injury to the dermis heals to form a scar. Dermal scars vary considerably with regard to appearance, form, stiffness, and contour, depending on the injury and the characteristics of the wound-healing process. Although scar tissue is necessary for the final stage of wound healing, it can have several adverse consequences. Scars can be cosmetically disfiguring, and severe scarring can cause emotional, social, and behavioral problems. For instance, Levine et al.  concluded that patients with facial trauma report higher levels of depression and anxiety and they feel dissatisfied with their body image.
Scars can also induce chronic pain, which may develop after acute pain, a symptom of normal wound healing. Another symptom is itchiness, producing severe discomfort and causing patients to scratch, which in turn threatens the healing process. Furthermore, hypertrophic or keloid scars, contractures, and adhesion formation can cause functional limitations. A survey by Young and Hutchison  showed that many patients are unhappy with a scar that results from surgery, and more than 90% would appreciate any improvement of this scarring.
Current treatment options for facial scars include topical or intralesional corticosteroid injections, intralesional bleomycin or 5-fluorouracil, silicone gel sheets, pressure therapy, radiotherapy, cryotherapy, laser, and surgery. Other strategies including the use of transforming growth factor-b, collagen synthesis inhibitors, nonsteroidal anti-inflammatory agents, minocycline, angiotensin-converting enzyme inhibitors, and gene therapy are still under study. These methods vary in efficacy, and their use is limited by high recurrence rates and side-effects including pigmentary changes, skin atrophy, and pain .
Although the development of cosmetic lasers and other light-based devices has allowed the effective treatment of many cosmetic disorders that were previously not treatable, the undesired complications are a reality with their clinical application .
Although clinicians and researchers have described a variety of protocols for the treatment of scar tissue, limited data about the effectiveness are derived from well-designed, prospective, randomized controlled clinical trials. To date, no gold standard exists for the treatment of scar tissue. Treatments are mostly based on the individual experience of clinicians, with varying degrees of success .
A relatively new option for the treatment of scar tissue is the use of autologous fat grafting, first described by Neuber in 1893 and later refined by Coleman. Autologous fat grafting has a volume-increasing effect and is thought to stimulate the neosynthesis of collagen fibers, which therefore increases dermal thickness, resulting in an improvement in skin quality . It has also shown improvement in different types of pain. The hypothesis is that mesenchymal cells of the graft provide prolonged analgesia by changes in the microenvironment and secretion of substances .
The use of autologous fat grafting has increased in common practice, but to date there is a lack of scientific evidence regarding the effects on scar tissue .
The purpose of this study was to evaluate the effects of different techniques of fat grafting on improving the esthetic outcome of facial scars.
| Patients and Methods|| |
This study was carried out at the plastic surgery departments of Menoufia University Hospital and Benha Teaching Hospital from July 2015 to November 2016.
This study included 30 patients with unpleasant, obvious facial scars of different etiological factors. Patients were fully informed about the procedure, and written consents were obtained from all patients. The study was approved by Ethical Committee of Menoufia Faculty of Medicine. The ages of patients varied between 8 and 48 years (mean age was 25.3 years). Sixteen patients were males and 14 were females. Sixteen patients had atrophic scars, 10 had depressed scars, and four had textural scars.
All patients with facial scars of different etiological factors (post-traumatic, postburn, and postinflammatory scars) were eligible.
Patients with severe chronic illnesses (chronic renal failure, chronic liver disease, etc.), mentally or psychologically disoriented patients, patients who had undergone previous chemotherapy and radiotherapy, pregnant women, presence of active infection, and patients with hypopigmented scars and recent (within the past month) treatment of targeted study sites by steroid injections or other scar-management modalities were excluded.
All patients selected for the procedure underwent clinical assessment, routine preoperative examinations, and routine laboratory investigations.
The harvesting sites were selected keeping in mind convenience of access and enhancement of the patient's contour. The abdomen was the most commonly chosen site. General anesthesia was commonly used, but local anesthesia with intravenous sedation was used for small areas. To each 1000 ml of 0.9% saline solution, one ampoule of adrenaline 1 mg/ml, and 15 ml of lidocaine hydrochloride 2% without adrenaline were added.
The tumescent solution was infiltrated, and fat was harvested with a liposuction 3-mm cannula (Hipro Dent Instruments Pvt Ltd, Sialkot, Pakistan) on a 50-ml syringe (Lifelong Meditech Ltd, Haryana, India).
The aspirated fat was transferred to 10-ml syringes and then centrifuged at 3000 rpm for 3 min using an 80-1 Electric Centrifuge (Jiangsu Jinyi Instrument Technology Company Limited, Jiangsu, China) toconcentrate fat particles and separate them from fluids and debris, which were then discarded. The purified fat was then transferred to 3-ml Leur-lock syringes (Lifelong Meditech Ltd) that were ready for injection.
After centrifugation, the lipoaspirate was mechanically emulsified by shifting the fat between two 10-ml syringes connected to each other by a female-to-female Luer-Lock connector (Hipro Dent Instruments Pvt Ltd). After at least 30 passes, the fat changed into an emulsion. At the end of the fragmentation process, the fat liquidized and took on a whitish appearance – 'nanofat'.
A 3-ml Luer-Lock syringe with a 2-mm fat-injection blunt cannula (Hipro Dent Instruments Pvt Ltd) attached to its nozzle was used. Through a small skin incision, the cannula was used to release the adherences of the scar in all its planes and create subcutaneous tunnels in a fan-shaped manner and multiple levels into which the fat cells were deposited when the cannula withdrawn. In cases of important fibrosis, scar subcision was initiated with a sharp needle.
The amount of fat grafted depended on the extension of scar that needed treatment. Overcorrection of about 25–30% was performed.
Contour irregularities were minimized using digital pressure immediately after placement.
Superficial intradermal and subdermal injection of nanofat was performed using sharp needles (up to 27 G) mounted on a Luer-Lock syringe. Injection was performed until yellowish discoloration of the skin showed up.
The treated area was covered with dressing for 1 week, and the patients were instructed not to apply pressure or friction to the recipient sites to limit displacement of fat infiltration.
External pressure with elastic compressive dressing was applied to the donor sites to minimize postoperative edema and to prevent hematoma formation.
All patients received antibiotics for 7 days, antiedematous drugs, and analgesics.
Follow-up and assessment
Results were assessed by clinical examination and postoperative photographs obtained 5 days and 2 weeks postoperatively and then at 1, 3, and 6 months postoperatively.
The postoperative outcome was evaluated according to the esthetic appearance of the scar, patient satisfaction with regard to overall improvement of scars, and complications of the procedure.
Therapeutic response was determined according to the scores on the Vancouver Scar Scale (VSS).
Vancouver Scar Scale
It is a quantitative objective scale that seeks to provide a standard for analyzing scar tissue. The VSS evaluates redness, height, pliability (contracture and elastic texture), and pigmentation. The four categories are scored between 0 and 3 or 4. The scores range from 0 to 14 [Table 1] .
Results were collected, tabulated, and statistically analyzed using an IBM personal computer and statistical package for the social sciences (SPSS, version 20 for Windows; SPSS Inc., Chicago, Illinois, USA). Descriptions of quantitative variables are provided as means, SDs, and ranges. Descriptions of qualitative variables are provided as numbers and percentages. The χ2 test was used to compare qualitative variables between groups. A P value of less than 0.05 was considered statistically significant.
| Results|| |
The present study found a significant improvement in patient satisfaction after injection (76%) in comparison with the preinjection state, and this is a good indicator of the effect of fat injection with regard to a significant change in the scar.
In this study, both microfat (as a filler) and nanofat (as a skin rejuvenation agent) were used for depressed and atrophic scars (26 cases). For textural scars (four cases), only nanofat was used for skin rejuvenation and to improve the quality of the skin.
Regarding the VSS, there was significant improvement in vascularity and pliability of scars with improvement in scar pigmentation. There was also reduction in the degree of pain and itching as assessed by the self-assessment score [Table 2],[Table 3],[Table 4].
Regarding the degree of pruritus, as estimated by the self-assessment score, the patient was asked to verbally indicate the level of pruritus, which was represented as none, mild, moderate, or severe, and numbered 0–3 as shown in [Table 5].
Regarding the degree of pain as estimated by the self-assessment score, the patient was asked to verbally indicate the level of pain, which was represented as none, mild, moderate, or severe, and numbered 0–3 as shown in [Table 6].
Patient satisfaction level was documented on a scale from 0 to 10 (10, highly satisfied) as shown in [Table 7] depending on the esthetic appearance of the scar after the procedure, scar color and pliability, relief of associated pain and pruritus, and complications of the procedure.
With regard to complications in treatment of facial scars using fat grafting, resorption of fat graft occurred in six cases. All complicated cases had no associated medical disorders [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7].
|Figure 1: A 25-year-old male patient presented with a postinflammatory (abscess) atrophic scar over the right cheek, which was treated with fat grafting using abdominal fat (one session) (a) Preoperative right lateral view. (b) Six-month postoperative view after one session of fat grafting showing excellent results.|
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|Figure 2: A 22-year-old male patient presented with a post-traumatic, atrophic, hyperpigmented scar over the left cheek treated with fat grafting using abdominal fat (two sessions with a 3-month interval). (a) Left lateral preoperative view. (b) Three-month postoperative view after the second session showing good results.|
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|Figure 3: An 8-year-old female patient presented with a post-traumatic depressed scar over the forehead treated with fat grafting using thigh fat (one session). (a) Preoperative anterior view. (b) Six-month postoperative anterior view after one session of fat grafting showing excellent results. (c) Preoperative left lateral view. (d) Postoperative left lateral view of the same patient.|
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|Figure 4: A 23-year-old male patient presented with postacne atrophic scars over the right and left cheek, treated with fat grafting using abdominal fat (one session). (a) Preoperative right lateral view. (b) Six-month postoperative view after one session of fat grafting showing excellent results. (c) Preoperative left lateral view. (d) Postoperative left lateral view of the same patient.|
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|Figure 5: A 36-year-old female patient presented by postburn hyperpigmented scar over the chin treated with nanofat grafting using abdominal fat (two sessions). (a) Preoperative anterior view. (b) Six-month postoperative view after two sessions of nanofat grafting (with 3 months interval) showing good results.|
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|Figure 6: A 15-year-old male patient presented with a post-traumatic depressed scar over the forehead treated with fat grafting using thigh fat (one session). (a) Preoperative view. (b) Four-month postoperative view after one session of fat grafting showing good results.|
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|Figure 7: An 18-year-old male patient presented with a post-traumatic, depressed, hyperpigmented scar over the left cheek treated with fat grafting using abdominal fat (one session). (a) Preoperative left lateral view. (b) Six-month postoperative view after one session of fat grafting showing excellent results.|
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| Discussion|| |
Scaring is a particularly distressing phenomenon and is most unwelcome when it occurs on the face. Facial scars may appear to be only a cosmetic concern and can be considered less important than other types of life-threatening diseases, but these treatment-resistant disorders can have significant impact on quality of life and sometimes are life-threatening by making the host suicidal .
Various treatments have been developed to improve the appearance of scars and to address these adverse effects, including silicone gel sheets, pressure garments, corticosteroid therapy, dermabrasion, surgical excision, chemical peels, multiple filling agents, and laser treatments .
Autologous fat transfer has been used to fill defects in soft tissues caused by trauma, deep burns, or surgery. Adipose tissue has been shown to be an accessible source rich in mesenchymal stem cells (MSCs). These present an innovative therapeutic opportunity in many clinical fields including plastic and reconstructive surgery, especially for their ability to enhance mechanisms of repair in many tissues . MSCs are particularly interesting because they have the ability to self-renew and differentiate into many different cell types when cultured, particularly into cells of mesodermal origin, such as fibroblasts, osteoblasts, chondrocytes, and adipocytes .
Fat grafts should be considered as the ideal fillers, providing autologous and completely biocompatible tissue. Fat is available in sufficient quantities in the majority of patients, even very thin individuals, with low associated donor site morbidities. It integrates naturally into the recipient site, can be removed if necessary, and is potentially permanent .
The major advantages of autologous fat grafting are as follows: minimally invasive operation, short hospital stay, ease of harvest and implantation, low donor site morbidity, availability of fat and autologous nature, easy to learn and practice, and minimal complications in competent hands .
Fat grafting is technique dependent, and not all techniques, surgeons, and patients will experience the same longevity or effect of grafted fat .
Fragen  found that transferring fat under skin grafts, scars, and on top of semirigid or rigid surfaces improves the viability of fat transfer. Placing it under burn scars will increase the padding of the burn scar and make the skin grafts over it more pliable and flexible .
In this study, males were affected more than females – 16 (53.33%) males and 14 (46.66%) females. Post-traumatic scars represented 22 (73.33%) cases.
In this study, the mean age of patients was 25.3 years with 93% of patients aged below 40 years, which reflects the domination of youngsters in the study population. This could be explained by the psychological trauma caused by scars in young patients compared with older ones.
On the contrary, Cervelli et al. showed a mean age of 40 years as they were concerned with fat injection in chronic lower extremity ulcers, which mostly occur in old age. Fontdevila et al.  showed a mean age of 45 years as they were concerned with fat injection for rejuvenations.
The volume of injected fat ranged from 2 to 50 ml, with a mean of 25.75 ml. Guyuron and Majzoub  stated that the volume of injected fat ranged between 1 and 4 ml per site in their study as they were working with facial augmentation of small areas. Cervelli and Gentile  stated that they injected about 120-ml fat mixed with platelet gel as they were treating progressive hemifacial atrophy.
The donor site in 70% of the studied patients was the lower abdomen, in 16.66% thighs, and in 13.33% the buttocks. This shows that most of the candidates had abundant abdominal fat, which made harvesting easier. Patients whose donor sites were the thighs and the gluteal region were mostly children and thin muscular patients with little fat in their lower abdomen.
Roerich et al.  compared harvests from the abdomen, thigh, flank, and medial knee and all produced a statistically equivalent number of viable cells. In contrast, Padoin et al.  found that the lipoaspirate cell concentration from the lower abdomen and inner thighs were significantly higher than other sites as these sites might be sources of adult mesenchymal cells. This could improve the viability of the injected fat. In agreement with these findings, Guyuron and Majzoub  used the same donor sites most probably because of the same reasons – easy accessibility and abundant fat.
As there is no clear correlation between donor site location and longevity of the implanted tissues, we do not consider that any donor area is better. The harvesting sites should be easily accessible in the supine position, the position used for almost all facial fat grafting procedures. Therefore, the abdomen and medial thighs are most commonly used as donor sites.
During the fat grafting injection, it is important to release the adherences of the scar in all its planes, and thus we break the hard fibrous tissue with the lipofilling cannula. At the beginning of the infiltration, the scar offers high resistance to pass the cannula, but when the procedure progresses the fibrosis relaxes and fat injection becomes easier. In this study, a blunt cannula was used for scar release. However, in cases of important fibrosis, the release could be started with a sharp needle.
In the present study, fat injection was performed using a 2-mm blunt cannula. Fat harvesting was performed using a 3-mm blunt multiperforated liposuction cannula, to obtain a lipoaspirate with small fat particles to provide a smooth injection through the fine lipofilling cannula. If the fat particles are too large, passage through the injection cannula would be difficult and disrupted injection will follow, which may result in an unequal lipofilling with irregular fat deposits. Trepsat  used a multiperforated liposuction cannula of 3-mm in diameter with 2-mm side holes to harvest fat for injection in different parts of the face.
In this study, 'nanofat grafting' was combined with microfat grafting where the nanofat was layered in an intradermal level to enhance skin quality rather than building up a significant fat volume.
In this clinical study, autologous fat grafting accomplished preoperative expectations. Regarding the VSS, there was improvement in the vascularity and pliability of scars with improvement in scar pigmentation. There was also reduction in the degree of pain and itching as assessed by the self-assessment score. Patient satisfaction was achieved in 76% of cases.
In agreement with these results, Klinger et al.  concluded that injection of processed autologous fat seems to be a promising and effective therapeutic approach to scars of different origin, and they affirmed that the treated areas regain characteristics similar to normal skin and are clinically assessable, with not only esthetic but also functional results. The treated skin becomes more elastic and softer, allowing even in the case of facial scars a gradual recovery. Durometer evaluation data showed a significant reduction in skin hardness after autologous fat grafting, which demonstrates efficacy in scar treatment.
It was found that fat injection was superior in depressed atrophic scars because of its filling character. In management of acne sequelae, the fatty tissue is injected homogenously under the dermis to release the fibrosis instead of achieving a local volumizing effect. The aspect of the face improves with fat grafting, which helps hide the small cutaneous depressions caused by acne.
The study witnessed a significant improvement in personal satisfaction after injection (76%) in comparison with the preinjection state, and this is a good indicator of the effect of fat injection in bringing about a significant change in the scar. Jakson et al.  stated that patient satisfaction was 96%, although the volume 'take' was not always sufficient in the observer's opinion, as recontouring involved postradiation subcutaneous defects in the lower limbs, which are not obvious like the face.
The precise mechanism by which fat graft leads to tissue improvement is still unclear. These results may be achieved through MSCs rather than adipocyte-derived products, stromal growth factors, hormones, tissue macrophage components, or all these. The exact role of stem cells in the scar release process remains to be determined. Probably, at the basis of the tissue remodeling process, there is local action of cytokines, growth factors, angiogenic factors, enzymes, and cellular components contained in lipoaspirates, leading to the formation of new blood vessels with fibrotic tissue remodeling and a new inflammatory response .
| Conclusion|| |
This clinical study concluded that autologous fat grafting has a significant role in facial scar remodeling and provides a beneficial effect on facial scar tissue and scar-related conditions with not only esthetic but also functional results. Significant improvement in scar appearance, skin characteristics, and restoration of volume and three-dimensional contour is reported. Associated pruritus and pain were also improved.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]