Grafting of autologous adipose tissue can be recommended in some cases of facial plastic surgery to correct the
congenital and traumatic alterations. However, some authors have reported
unpredictable results about both the resorption rate of adipose tissue grafts
and the quantification of the consequent surgically increased volume loss [1,2].

Besides, many authors have studied the behavior of adipose grafts in the areas
treated with radiation therapy; these studies agree in considering these areas
as being unsuitable for grafting of autologous adipose tissue [1,2].

Rhabdomyosarcoma is a type of cancer that can also affect the orbit. It is not a
common neoplasm and has an estimated annual incidence of approximately 4?5 new
cases per million children below 15 years of age. There is a slight prevalence
in males, with a male/female ratio of 1.5:1.
Sarcomas of the soft tissues, the most frequent of which is rhabdomyosarcoma,
represent 7% of all pediatric malignant tumors [3].

Although the 5-year survival rate of patients with orbital unilateral
rhabdomyosarcoma is beyond 85%, the extent of eradication therapy and of the
subsequent radiation therapy has a destructive impact on the treated area [4-6].

As a matter of fact, destructive surgery is not followed by rehabilitation.
These patients often present with adipose tissue atrophy associated with
deforming fibrotic conditions; these biological manifestations result from the
radiations affecting that area [6,7].

Enucleation of the eye, especially in small children, can cause atrophy of the
corresponding hemiface and decreased orbital growth, which create reluctantly
accepted aesthetic conditions [6].

The aim of this work is to describe a new surgical approach to atrophies in the
zygomatic region of patients with previous oncological surgery and ocular
radiation therapy: we discuss about a rationale for the use of dermal-fat
grafts.

This is a new technique which has never been described before in the literature
and it is innovative compared to the traditional techniques. This technique has
the advantage of a natural final result; moreover, we can rule out any
possibility of rejection. When we perform the surgery on irradiated tissues,
which are therefore more vulnerable, we have the possibility of using autologous
tissue causing no local reaction and providing an adequate tissue thickness.

This technique represents an excellent opportunity for treatment of this
atrophies, but the only disadvantage is the need to remove tissue from a
different region of the body.

The alternative surgical procedures may be the mobilization of closeness flaps,
or the microsurgery or the lipofilling: the first could create more scarring, so
it is not the most aesthetic alternative; the second is a much more invasive
surgical technique and it has a duration longer operating with a poor
predictability of results; in the third case, a good result requires more
surgical sessions to achieve a stable result.

CASE REPORT
We report a case of a 32 years old female patient, clinically healthy, with a
medical history of surgical enucleation of the right eyeball, who had received
rhabdomyosarcoma radiation therapy in her youth.
The patient presented with a depression in the right zygomatic region, upper
eyelid asymmetry, and a slight right hemiface dimorphism, as compared to the
left hemiface (Figures 1,2).

Fig. 1 Pre-operative picture.	Fig. 2 Pre-operative picture.	Fig. 3 Incision in the sovrapubic region.
Therefore, we decided to proceed with autologous tissue grafting in that region. Subject to incision in the sovrapubic region, we took a dermal-fat flap from the abdominal region, which had been previously treated (Figures 3, 4).
Fig. 4 A dermal-fat flap taken from the abdominal region.	Fig. 5 Design of the operative area.	Fig. 6 A slightly oversized dermal-fat flap.
The collected tissue, slightly oversized than the surrounding area, was grafted in a skin bag. The bag was detached around the right zygomatic region affected by tissue loss; we used vascularization of the orbicularis oculi muscle to perform the graft (Figures 5, 6, 7, 8, 9).
Fig. 7 The bag detached around the right zygomatic region affected by tissue loss.	Fig. 8 Dermal-fat flap positioned into the bag.	Fig. 9 Dermal-fat flap filled into the bag.
Fig. 10 One month follow-up picture.

A small graft was also placed in
the right superior palpebral sulcus. Besides, blepharoplasty of the left upper
eyelid was also performed; in this way, we corrected the palpebral asymmetry
that the patient complained.

RESULTS
The surgical outcome, 48 hours after the surgery, revealed that the right
zygomatic region had returned to its proper anatomical shape, although there
were still signs of postoperative edema (Figure 10).

The tissue graft adhered properly, and there were no evident signs of necrosis
or superinfections. The 1 month after follow-up showed that the palpebral areas
appeared symmetric and well-proportioned, with patient satisfaction and with no
signs of necrosis or superinfections (Figure 10).

DISCUSSION
The treatment of tissue loss with grafting of autologous adipose tissue in the
aesthetic areas is not a widely used technique in plastic and reconstructive
surgery; [1,2] as a matter of fact, general literature reports conflicting
studies on the use of this procedure for tissue replacement [8-18].

Very damaged tissues, like those exposed to radiation therapy, are generally not
suitable for grafting [18,19] of adipose tissue, presumably due to compromised
vascularization of the receiving bed caused by prolonged release of cytokines
(such as Transforming Growth Factors), which in turn cause fibrosis and
angiogenesis with neoformations of the aberrant vascular tissue [10,16].

However, other studies have achieved good results with grafting of autologous
adipose tissue in areas previously exposed to radiation therapy, although they
reported that resorption was slightly superior to normal tissues [1]. In order
to reduce the aesthetic impact resulting from tissue resorption, it is advisable
to plan a 20?50% hypercorrection of the grafted tissue [7].

Particular attention should be paid to hemostasis to prevent clot formation at
the receiving site; this allows proper vascular anastomosis between the graft
and the receiving bed [8].

The orbit has a relatively high fat content, usually in the periorbital region,
and is a richly vascularized area; experimental studies have shown how grafting
of adipose tissue should be performed where it is particularly present under
physiological conditions [1,2,8,12,13]. Besides, it was also demonstrated that
graft survival is higher in case of muscle placement [14-21].

CONCLUSION
In the described case, we achieved a technically and aesthetically satisfying
result despite the patient’s medical history involving several perplexities
about the use of autologous dermal-fat tissues, because of prior radiation
therapy exposure. The clinical case shows that even a region exposed to
radiation therapy can be a valid receiving bed for dermal-fat grafting; it is
necessary to evaluate the anatomical characteristics of the surgical site to
verify vascularization and local compatibility to the presence of adipose tissue
in situ. A good hemostasis makes graft vascularization more predictable, thanks
to the increased presence of vascular anastomosis between the receiving bed and
the graft. One should consider the possibility to graft an oversized dermal-fat
flap compared to the volume of the region in order to minimize the aesthetic
impact of the adipose tissue, which tends to get reabsorbed over time.

AUTHORS

Francesco Inchingolo, Marco Tatullo, Andrea Pacifici,
Marco Gargari, Alessio D Inchingolo, Angelo M Inchingolo, Gianna Dipalma,
Massimo Marrelli, Fabio M Abenavoli and Luciano Pacifici

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