Autologous fat transplantation: a good option for treatment to facial deformity after head trauma

Correcting facial deformities is still a significant challenge for the dermatological surgeon. The therapeutic options may vary depending on the etiology, location, costs, and attending physician’s experiences of the. Although some studies have shown controversies regarding the results of using autologous fat transplantation (AFT) to treat facial depression, we report a case with good aesthetic results after two sessions of AFT in a male patient with a depressed facial fracture after head trauma.


INTRODUCTION
Depending on the facial deformity and its etiology, it is possible to use several methods, from less invasive ones (such as botulinum toxin 1 and filling with hyaluronic acid 2 ) to more complex surgeries (such as silicone implants or acrylic resin prostheses 3 ). Autologous fat transplantation (AFT) is a surgical alternative, especially in cases of lipodystrophy. [4][5][6][7][8][9][10] We report a case of a patient with complaints of depressed facial scars ( Figure 1) after a head injury, which is considered ideal for AFT for treatment, with satisfactory aesthetic results. Although this technique has cost-benefit advantages, the literature describes the unpredictability of the results due to the possibility of absorption with consequent loss of volume and the need for new uses. 5,6,7 This case report aims to demonstrate this technique's effectiveness, low cost, easy performance, and patient and surgical team's good satisfaction level.

METHODS
A 15-year-old man, student, had a motorcycle crash, with a consequent head injury and frontal, parietal, and temporal bone fractures on the right side. He underwent neurosurgical interventions, such as bone graft and insertion of a platinum plate, to correct depressed scars and fractures. After days of induced coma and intensive care, the patient evolved without motor sequelae at hospital discharge (only local paraesthesia) but with aesthetic deformity (he referred to a local depressed scar) that bothered him. He was 16 years old when he underwent neurosurgery for dermatological assessment.
As it was only an aesthetic correction, the mother and the patient were informed about the procedure. They signed the Patient Photo Release and Informed Consent forms.

RESULTS
The patient responded well in the immediate postoperative period, without infection of the surgical sites or hemorrhages. Six months after the intervention, he presented good aesthetics and no functional impairment of the face, although partial resorption of local fat occurred ( Figure 5). We recommended a second AFT with the consent of the patient and his mother.
The second intervention was conducted without complications. After nine months, the patient presented a very good aesthetic result (Figure 6).

DISCUSSION
The correction of facial deformities, whatever their etiology, is still a significant challenge for the dermatological surgeon. In more straightforward cases, such as post-traumatic chin deformities, botulinum toxin can be used. 1 However, for lipodystrophy or depressed facial scars, autologous fat grafting (AFT), hyaluronic acid, or poly-L-lactic acid are recommended. 2 For cases of cartilage and bone loss, acrylic resin prostheses can be used. 3 AFT is very interesting in correcting facial deformities, considering that the adipose tissue is relatively abundant on the skin surface, has an ideal texture and modeling, in addition to an almost zero tissue rejection index. 6,8,10 Although it has been proposed since the end of the 19th century, some studies present controversies regarding the procedure given the effectiveness of the results. 6,8 The hypothesis for no improvement would be fat absorption or low tissue viability transferred. 6 With the neurosurgery team's permission, in the case of an aesthetic procedure, we opted to perform the AFT in the present case, considering the low cost, tissue rejection rate, and risk of complications.
The patient evolved with good aesthetic results, and after six months of the first surgery ( Figure 5), there was a significant improvement in the local depressed scar. Even so, we conducted a second intervention to correct the possible absorption of some areas. Nine months later, the patient achieved an excellent result ( Figure 6). Some studies have also noticed a significant improvement with AFT, especially after the second intervention. 5.6 This study hypothesizes that the procedure's effectiveness is higher on the second session due to the remaining adipocytes' presence from the first intervention. It hinders the absorption of this new injected fat tissue and, somehow, also stimulates fibroblasts.
Another therapy option is poly-L-lactic acid (PPLA). PPLA is a biocompatible, resorbable, and immunologically inert polymer. Its mechanism of action consists of the stimula-   tion of fibroblasts in their subclinical inflammatory response. It can be used in cases of facial deformities, including plates and screws. 2. 6 We opt for not using it due to the extent of the depressed scar, costs, and risk of papules, nodules, and granulomas formation.
Although some studies have shown controversial results, the AFT technique used in the case has proved to be entirely satisfactory. The deformity that the patient called "sinking" was solved and provided an improvement in his self-esteem.

CONCLUSION
AFT is a technique that is easy to perform, well-tolerated, has low cost, and presents good cosmetic results ( Figures 5  and 6).