A N C İLLA R Y PRO CED U RES O F M AXTT T O F A C I A I . SU RG ERY
B a h a t t m Ç e l i k ö z * , S e - M i n B a e k * *
* Departmcnl. of Plastic and Rocnnstructive Surgery ofGMMA
Instîf.ul e o f Flastic: ReconsUTictrv-c cnırıitifada.! Surgery of İt iUrıiversil.y Setıul/South Korea
ÖZET
H em ifasiyal atrofi, R om berg H astalığı, asim etrik yüz ve diğer sebeplerle oluşan yüz yumuşak doku eksildiklerinde görü n ü m ü düzeltm ek için bir çok değişik yöntem ler u y g u lan m aktad ır. B u u y g u lam aların a ra s ın d a y ağ enjeksiyonları, derm ofal grefiler ve dermofat j'ree jlep ler de kullan ılm aktadır.
Yüz görünüm leri bozuk olan 4 0 htm ifasiyal microsomiah, 14 asim etrik yüzlü, 2 Rom berg H astalıklı ve 3 0 deprese s k a n olan toplam 8 6 hastaya, 4 5 yağ enjeksiyonu, 2 1 dermofat greft ve 14 dermofat free flep girişimi uygulandı.
B u girişim lerin son u cu n da y ağ em ilim oranları, y ağ en jeksiy on ların d a % 30-40, derm ofat greftte % 2 0 r i0, dermofat free jlepte ise %5-10 olarak bulundu.
A n a h ta r K elim eler: Yağ enjeksiyonu, D erm ofat greft, Dermofat fr e e flep, Yağ emilimi.
A number o f procedures have beeıı utilİzed in an atteınpt to aciıieve reasonable facial con tou r in padents suffering from the distressing condition of hemifacial atrophy, Romberg’s Disease, asymmetric face and others facial anomalies. There are maııy tcchniques available for augm entation o f soft tissue contour in treatment o f facial anomalies. They raııge from the multistage tuh e p e di ele transfer o f tissues, to free tissue transfer of skin and fat, using ırıuscle and greater om enlum by m icrosurgical techııiques, to rotation of tem poralis fascia into the d efect and de-epithelialized flaps, dermiş, demi al fat, bone and cartilage grafts, free fat injection and ınjectable liquid silİcone^b^^hhöTAöhttıidS, 13,14,15,16,17,18,19,20,21,22,23,24^ Hlouz<25} had (he idea o f using liposuetion fat as graft. In fact fat in jectio n or transplantation is not a new technique, Neuınan and Peer are among some
SUMMARY
Many dijferent procedures have been utilized fo r correction o f fa c ia l contour in patients suffering from the distressing con dition o f h em ifa cia l atrophy, Romberg's Disea.se, asymmetric face, depressed scars and other fa c ia l anomalies.
Förtyfive fa t injections, twenty-seven derm ofat grafts an d fourteen dermofat fr ee fla p procedures inere perfornıed on 4 0 h em ifacial atrophy, 14 asym metric fa c e, 2 Romberg's Disease an d 3 0 depressed scars, total o f 86 cases. The absorbtion rates o f 30-40% in dermofat free flap cases.
Key Words: F a t injection, D erm ojat graft, D erm ofat free flap , Fal absorbtion.
of the pioneers who used fat for correcting deficiencies or soft tissue au gm e n ti on1-56,2 7 ■2 8).
After Illouz’s süeti on assisted lipectomy (SAL), the fat grafting techniques becanıe popular.
MATERIALS AND M ETH O D S
Eİghty-sİx patients who had facial defomıities were Lreated with fat injection, dermofat grafts and dermofat free flaps from 1988 to 1991. The age of the patients at the time of surgery ranged from 7 i.o 48 years. 30 of 86 patients were male and 56 were female. Maxiîlo - facial deformities were associated wîth 40 hemifacial mierosomia (46.6% ), 14 asymmetric face (16.3% ), 2 Romberg's disease (2.3%) and 30 depressed faces and scars (34.6%). These patients who had bony strueture di sor ders w ere opera te d on for bone correcdve surgery prior to these ancillary p rocedu res (19 cases, 23% ). A ncillary procedures were performed at the same or at a
Türk Plan Cer Derg (1994) Gik:2, Sayı: 3
Figüre 1: The fat aspiration and injection set
different session.
Fat injection Teclınique : This proceclure İs based on Illouz's fat. grafting Lechnique.
Recipient pocket. was prepared with a spccial cannula and fat injection set. was used for obtaining small quantities of fat (Figüre 1). A s mail stab wound w as m ad e on both side of üıe lower abdomen after injection o f 0.5% lidocain with 1/200.000 epinephrine. Fat was aspirated vİa tlıis incision after washing wit.h antibiotic.
solution with insulin, fat was injected irıto the clefect site whiclı was readily nıarked with a skin marker.Stab wound was elosed with sutures and ınoderate c.ompressive dressing was done with elas toplaş t. Fat volüm es were used ranging from 2 Lo 25 cc. Moderate övere orreetion about 20% to 30% was aimed (Table I).
Tabie i: The volumes of the fat injection techniqııes.
Arnount Upper lid Lower lid Cheek Malar Preauricular Total
(cc) rt İt rt İt rt II rt II rt İt
0 - 5 2 4 3 2 3 2 1 t 2 1 21
5 - 1 0 - - - - 5 4 2 - - - 11
1 0 - 1 5 - i - - 4 3 - - - - 7
1 5 - 2 0 - - - - 3 : 1 - - - - 4
2 0 - 2 5 - - - 2 - - - - 2
lo ta ! 2 4 3 2 17 10 3 j 1
I
2 1 45
Derm ofat G raft Technİque : Seven o f twenty-seven patients’ grafts w ere harvested from lower abdomen. Twenty o f twenty-seven w ere harvested from groin area. The groin
areas were generally chosen as a donor site because o f resulting s car. D erıııofat graft volumes weı~e used ranging from 4 x 3 cm to 12 x 10 cm (Figüre 2), (Table 11). The moderate övere orreetion was aimed on tlıese pocedures.
The dermofat gınfts were de-epithelialized and washecl with antibiotic solution be for e inserting to the recipient area and grafts were fîxed witlı bolster sutures to prevent m igration and bulkiness.
Figüre 2: The view of the de-epithelized dermofat graft Table II: The sizes of the dermofat grafts
Size (cm) Che rt
ek İt
Forehead Tem rt
ple İt
Total
5x5 1 1 2 1 - 6
5x5 3 4 1 1 - 9
10x10 5 4 - - 9
15x10 2 1 - - - 3
Total 11 10 3 2 1 27
Dermofat Free Flap Tec.hniques: Fourteeıı of eigthy-six patients were operated on with dermofat free flap for correction of soft tissue deformities of maxillö-facial area. The dermofat free .flaps vvere also obtaiııed in the saırıe manner from groin areas. Flap sizes vvere ranged from 8x5 cm to 12 x 10 cm (Table III).
SURGICAL TECH N IQUES
General anesthesia was iııduced. The face was nıarked wİth the patient in supine position.
M A XILI, O-FACİAL SURGFRY
Table III: The sizes and the applicaîion regions of the dermofat free flaps
P a t ı . N o . Sex/A Preop.D * F lîç ı S iz e Donor Area R e c ip . Area A nasto. P re v e . Tx
1 f / 2 0 [I F M" 9 x 1 1 cm ( İt. O o r in R t.C h e e k S T A * Two Jsmb O p r. *
2 f / 2 0 H F M 7 x 1 0 cm R t " R t . " F A * Jawe Opr.
3 m/30 H F M 8 x 1 2 Cm R t . " R t . " S T A TMJ r e l + CCG
4 f / 1 7 H F M 9 x 7 cm L t . L t . " S T A Two ja w s o p r .
5 f / 2 0 A s y m .F a c e 9 x 1 2 cm R t . R t . " F A Two ja w s o p r .
6 f / 1 7 R o m b e rg ’ s D 1 0 x 1 2 cm R t . R t . " S T A -
7 f / 2 8 D ep . F a c e 9 x 1 2 cm L t . L t . " F A H e m a n .E x c i s i o n
8 m/27 A s y m .F a c e 1 0 x 1 2 cm R t . R t . " S T A Two ja w s o p r
9 m/16 H F M 8 x 7 cm L t . " L t . " F A Two j+ T M J rel+CO G
1 0 m/1 9 A sy m .F a c e 8 x 1 1 cm R t . R t . " S T A Two J+-TMJ r e l+ ( X G
1 1 m/25 H F M 7 x 1 0 cm L t . L t . " F A Two j aw s o p r
12 f / 3 0 H F M 9 x 7 cm R t . R t . " S T A Two j aw s o p r
.13 f/ 1.5 H F M 8 x 6 cm L t . " L t . " S T A Two ja w s o p r
1 4 f / 2 0 H F M 8 x 1 2 cm L t . *' L t . " S T A Two j aw s o p r
S T A : Superficial temporal artery F A : Facîal artery H F M : Hemifacıal microsomia Local anesthetic solulion witlı 1/200 000
epinephrine were infiltrated int.o the disseclion area. Patients who had bohy disorders such as m alo cclu sio n , TM J ankylosis ot' bo n e asymmetry, the boııy reconstructions were ıındertaken prior to ancillary procedures (two jaw operations, TMJ ankylosis releasing +
costochondral grafl).
R lıytidectorny İn cisions were used.
Subcutaneous disseclion s were perforıned to elevate the cheek skin. The pocket was prepared with meticulous bleeding control, The dermofat grafts were harvested from donor sites af ter preparing recipierıt pocket.. The grafts were de-epithelized before transporling to the ch eek and in sertio n into the pocket.
Approximately 7 or 9 bolster sut.ures were put över the grafts for stabilizaüon purposes.
İn the dermofat free flap opera ti on, facial arteries and vekA 5), and temporal arteries and veinsi0^1 were dissected out in the recipient area.
In the donor site, groin area, the flaps were outlined. The femoral art.eries were exposed and the superficial ciıxumflex iliac vessels were identified. The flaps were transferred and
inserted into the pocket after de-epithelization.
Microvaseular anastomoses w ere perform ed uncler operating m icroscope. Patency o f anastomoses were confirmed and flaps were fixed with b o ls te r su tu re s. B u lk y, non-compressive dressings were done. Donor sites were closed primarily.
RESU LTS
The mean follow-up period in our patients were 11 months (ranging from 3 months to 20 months). In fat injection cases, at monthly follow-ups, absorbtion o f the in jected fat material w ere observed ranging from 30% to 40%. Tlıere was progressİve absorbtion of fat mostly during the first three months and it eontinued even after the fır s t 3 months. The absorbtion proccss slowed down after tlıis period. (Figüre 3,4)
Twenty of forty-five patients required re-fat injection at the end of one ye ar. Rest o f the patients were saüsfied with the results. The patients who ne ede d re-fat in jection were undergone another operation under local anestlıesİa. After these operations, patients were
Türk Flast Ger Derg (1994) Ci1r.:g, Sayı: 3
Figüre 3a: Fat injection: Preoperaîive view of depressed scar Figüre 3b: Fat injection: Postoperative view after 9 monîhs
Figüre 4a: Derrnofat graft: Preoperaîive view
satisfied with tlıc results and had no other complaints. în t.his series, we had only local inflamation signs as a conıplication İn 7 cases.
These patieııts receiöed anti inflamatory and cordcosteroid trcatınent.
We observed insufficient facial contour correction in 9 o f 27 derinofat cases. These
Figüre 4b: Derrnofat graft: Postoperative view after 10 months paüents w ere suggestecl another fat injection and the surgeries were performed under local anesthesia. The results were satisfactory after these procedures (Figüre 5,6). We had infecdon in one c.ase, local inflammation İn 4 cases.
These , complicated cases were treated with antibiodcs and/or corticosteroİds. We observed
M AXI Ll .O-FAGIAL SURGERY
Figüre 5a: Dermofat graft: Preoperaîîve view
approximatelly 20% to 30% absorbüon rate in tlıis group.
İn dermofat free flap cases, the results were sa tisfa cto ry (Figü re 7). W e had no co m p lica tio n s e x ce p t one h em atom a formation. Hematoma was evacuated. Another case had in su fficien t paten cy in early pos top er atiye pcriod and patency was corrected in reoperation. The absorbüon rate was very little in this group (5% to 10%) but 8 of 14 cases neecled nıore correction at the encl o f the follow-up period. Fat injection proeedures were performed under local anesthesia.
D ISC U SSIO N
The developrnent o f subcutaneous adipose tissue starts with the primitive organs which appear in the subcuüs from tlıe 3rd - 4th fetal month on. These are small retikuloendothelial struetures, the basis for the indîvidual fat lobules develop later. After birth, the primitive fat organ goes into full differentadon under the influence of hormones and in dependence on
Figüre 5b: Dermofat graft: Postoperative viewafter8m onths
food supply^9’3(0. Their num ber varies in different. regions of the body. There are also regions in which no fat organs are based^-A This means that the subcutis has a spesific disposidon to develop adipose tissue which is gen ede in origin and shows local variation. This view has found confirmation in tlıe practise of plastic surgcry^27 A characteristic example İs abdoıninal llaps ü'ansplant to distant region that were found to increase in thickness wlıen the patient gained weight. The flaps clearly retain the fat disposition o f the d onor site.
Experimental studies on rats have shown that primitive fat organs can be transplanted and will develop such as the external car and evelids(33k
Whcn composite grafts are transplanted tlıe concept of "take" depends on the size o f the graft and tlıe rıature of the transplanted tissue.
IVithin certain limits, if a composite graft is well perfused from the perİphery it will survive and be viable. In the under certain limits the graft m ay be lost through lack of vascularity(29*30h
Türk Plast Çer Uerg (1994) Cilt:2, Sayı: 3
Figüre 6a: Dermofat free fiap: Preoperative view Figüre 6b: Dermofat free flap: Postoperaîive view after 11 months
Th e facial region has ahundan t blood circulatioıı, tlıerefore fat graft can survive and large volurnes of fat can he trans pl ant e d to the face.
Accordiııg to the study hy Briglıt, Thacker and B ru îîn e r^ ^ circulation o f the free nonvascularized fat graft was reestablishecl by means of blood vessel to vessel reanastomosis also known as inoseulation. These grafts if failed to becoıne revascularized, it was often replaced by fibrous Lissue and bone ingrowth caused by osteogenesis.
Fat transplantation is not a ncw technique (sephhsy İnjection technique is a very simple and easy techniqne with no secondary defects to the donor and recipient area and minör disability o f paüent. The patieııt is able to resume his/lıer activity very s o on after surgeıy.
The maiıı disadvantage has been the instance degree of resorptiond>2>6, i6,26y This is diffİcult to evaluate but we estiınated that this was mor e tlıan 30 % for s om e area. över five or six
months. The resorption reaches il s hîghest level İn the fir s t three months after hıjection. W e performed moderate overcorrection (ab ou t 20%
to 30%) and İt is available to do same degree of overcorrection at the time of injection and wait more tlıan six montlıs before touclıing up. In o ur e xp eri ence the fat İnjection must. be done after correction of facial bony coııtour and tlıen moderate overcorrection and slight pressure dressing is applied about oııe week. Prevention of infeetion is necessary with routine antibiotics
( 3 5 ,3 6 J3 I7,38)_ y p e is pretreated with insuline.
This may inerease the survival percentage. The advantage of this injection technique appears to be in the viability to transfer minute amount of ti s su e without interrupting the vascularity o f recipient side^39T0,4i)_
Free fat grafts sometimes do not give satisfactory r e s u lts ^ h h 44) _ considerable reduetion in the volüme of Üre graft İs to be expecl.ed. Exp erim en Lal studies have shown tîıat revasculaıization is only partial with fat grafts.
MAXILLO-FAGIAL SURGERY
Figüre 7a: Dermofat free flap: Preoperative view
Oil cysts clevelop İti area that have not been revascularized and dıc fal is gradually rcsorbed.
It is probable that hypervascularizaüon caused by thc healing process further encourage depledon o f thc survivıng fat cells. Failure wit.h Llıe free grafts slıould n o f however, be ascribed entirely to the proper des o f adipose tissue (30;33)_ success of a fal. grafl depends on the İndividual combination of number o f factors atul every fat graft İs therefore in a sense unrepetable. These problems are also reflected in the rhn i rai dalah5-1.
In one respect, fat grafts dearly hold a special position and that is when they becoıne necrotic, it is knowıı that fat is not simply reso rb ed bu t nıusL be Laken up by macrophages. A fat graft is therefore a potendal foreign bodv. The foreign body reaction is chroııic in dı araç t er and degradation o f the fat tends to take years. But in expemııental stucly, ın ic r o s c o p ic a lly e ig h t m on th a f ter tr an s p 1 an la ti o n , üıe grafts appear like normal adipose tissuel29’33dfi).
Figüre 7b: Dermofat free fiap: Postoperative view after 9 months Derrnal fat grafts are preferred for technical reason. The view that these grafts lose less in volüme is not one that is geııerally shared, however, extensive experinrental studies were carried ou t with derin al fat grafts and it w as unable to dernonstrate appreciable advantages for reconstructİorı. The dermiş offers excellent.
conditİons for the developrnent o f vascular anastoınosis. The cutaneous plexus which provides a common bas e for blood supply to the dermiş as well as the subcutis is preserved in the graft. Fat layer on one o f iıs m ajör surfaces is not 1raumatized(l2f
Adipose tissue transplantadon can be free using a skin flap witlı ın icro su rgical anastoınosis. The fırst reported use o f a buried fre e d erm o fat flap by mi cr o vascu lar aııastomosis was by Fujin o'd). To o ur knotvledge the folloıving is the second reported case done by this method and application o f the technicpıe to pat.ients with severe Romberg's Disease deformitv. Excellent descripdon o f the anatomy o f the groin flap have provided
Türk Plast Cer Derg (1994) Çil t: 2, Sayı: 3
sig n ifican t guidelİncs for this ırıethod
( 1 1 , 2 1 , 3 4 , 3 5 , ^ buried dermofat free tlap has been described ofteıı with a 20 veav follow up showing nıuch inıproved reten tion of the trans fere d volüme. However, this procedure may require 3 operations for the transfer pltıs secondary operation to finish the tailoring.
Fat in je ctio n tech niqu e has many advantages. This procedure can be done several time s uııder local atıesthesia in out-patient c.linic without hospitalization.
Seıııiliquid autologous fat may be used in a multitude of situadon in which s of t tissue filliııg mateıial is required<38k it will correct contour deformities secondary to trauma or surgery, pitted acne scars, depressİon deform ities associated wİth facial hemiatroplıy, or purely aesthetic deform ities treated adjunctİvely during or after r h y t i d e c f o m y { 2 ’ 4,6 T G 2 ;> ,3*638,4Q)_
For surgeon, it is a very easy procedure. It has no serious complication. Results are hİglıly satisfactory and cost factor is very reasonabîe for patients. Th er efor e, this procedure is applicable for minör defects. Large defects can be corrected by building up the desired arca in stages.
Children who have not conıpleted the ir facial growt.h should probably be excluded until the effects o f this procedure on facial growth can be judged adequately and sufficieııt tissue is available for correction. The snıall size o f the vessels in children al s o inak e microvascular anastomosis mor e diffucult.
Dr. BahaMin Çeliköz
GATA Plastik Cerrahi Kliniği ABD 06018 E tlik/ ANKARA
KEFEREN CES
1. Bircoll, M,, No vak, B.H. : Autologous fat transplantation employing liposuction techniques.
Ann Plast Surg. 18;327-329, 1987.
2. Ghajchir, A., Benzaqueıı, I.; Liposuction fat grafts in face wrinkles and lıenıifacial atrophy. Acsth Plast Surg 10; 115-117, 1987.
3. Daniel, R.K., Taylor, G.I.,: D is tan t transfer of an island flap by microvascular anastomoses Plast Reconst S u rg 5 2 ;lll, 1973.
4. De la Fuente, A., Tavora, T.: Fat injection for correction of facial lipodistrophies; A prelitni- nary report. Aesth Plast Surg 52,12:39-43, 1977.
5. Edgerton, M.T., Wells, J.E.: Gorrectİon of severe hemifacial atrophy with a free dermiş fat Hap fronı tlıe lower abdomen. Plast Reconst Surg 59:223, 1977.
6. Ellenbogcn, R; Free aut.ogeneous pcarl fat grafts in face-A preliminary report of a rediscovered technique technique. Ann Plast Surg 16;3, 179-194, 1986.
7. Fujino, T., Tanino, R., Sugiınoto, C., : Microvascular transfer of free delltopectoral dermal flap. Plast Reconst Surg 55;428, 1975.
8. Loeb, R., Tat pad sliding and fat graftiııg for leveling lid depreşsions: Glinics in Plast Surg 8:4, 757-776, 1981.
9. Shintomi, Y„ Ohura, T., Honda, K., Lida, K: The reco n stru ctio n o f progressive facial hemiatrophyby free vascularised dermis-fat flaps:
Br J Plast Surg 34, 398-409, 1981.
10. Tweed, a.E.T., Manktelow, R.T.,2Tıke.r, R.M.; Facial contour recontructionwith free flaps. ann Plast Surg 12:313-320,1984.
11. Harashina, T., Nakajima, T., Yoshimura, Y: A free groin flap recontruction in progressive facial hemiatroplıy. Br j Plast Surg 30;315, 1977.
12. Neunıann, G.G.: The use of large buried pedicled flaps of der miş and fat: Glinical and pathological evaluation in tlıe treatment of progressive facial hemiatroplıy Plast Reconst Surg 11:315, 1953.
13. Wellsj.IT., Edgerton, M.T.: Correction of severe hemifacial atrophy with a free dermis-fat flap fronı lovver abdomen. Plast Reconst Surg 32:15, 1977.
14. Wİİliam, H.B., Grepeau, R.J.: Free dermal fat flaps to tlıe face. Ann Plast Surg 3:1, 1975.
15. Jurkevdcz, M.J., Nahai, F.: The use of free revascularized grafts in the aıııelioration of hemifacial atrophy. Plast Reconst Surg 76:44, 1985.
16. Moscoııa, R., Ullma, Y: et. ala.: Free fat injection for the correction of hemifacial atrophy. Plast Reconst Surg 84: 3, 501-506.
17. Leaf, N.,H.A.ı correction of contour defects of the face with dermal and fat graft. Ardı Surg 105:715, 1972.
18. Edgerton, M.T., Wells, J.E.: Indications for and pitfallsof soft tissue augmcntation with lİquİd Silicon e. Plast Reconst Surg 58, 157,1976:
19. Asley, F.L., Thompson, D.P., lleııderson, T.:
Augmentation o f surface contour by subcutaneous injection of Silicon e fluid. Plast Reconst Surg 51.8, 1973.
20. Eııdo, T., Nakayama, Y., Matsuııra, E., Natsui, H., Soeda, S.: Paddle dermis-fat radİal forearm free flap. Ann Plast Surg 32:1,93-96.1994.
MAXİ_LLO-FAClAL SURGERY
21. Shintonıi, Y., Ohura, T., Honda, K, et al : The Reconstruction of progressivc facial hemiti’oplıy by free vascularized dermiş fat flaps. Br J Plast Surg 43:398-409, 1981.
22. Upton, J., Mulliken, J.B ., Hicks, P.1Y, et al:
Restoration of facial contour using free vascularized omental transfer. Plast Surg 66:560-567,1980.
23. Spcar, S.L., Oldham, R.J.: A Lcngtlıcned omental pedicle in facial reconstruction. Plast Reconst Surg 77:828-831. 1986.
24. Robinson, J.K., Hanke CAV.: Injectabl collogen implant; Histopathologic Identification and longevity of correction. J Ucrmatol Surg One ol
11; 124,1985.
25. Mouz, Y.G.: The fat celi "graft" : A new technique to fiil depressiotıs. Plast Reconst Surgery 78:122,1986.
26. Peer, L.A.: Loss of weighl and volüme in human fal.. Plast Reconst Surg 5:217. 1950.
27. Peer, L.A.: Transplantation of tissue, transplantation of fat. Baltimore, VVilliam and Wilkins, 1959.
28. Neriman, C.G.: The us e of 1ar ge beıried pedicled flaps of dermiş and fat: Glinical and patlıological evaluation İn treatıııent of progressive hemiatrophy. Plast Reconst Surg 11:315. 1953.
29. Rossaltİ, B.: Revascularization and phagocytosis İn free fat autografts: an experimentl study. Br J Plast Surg 13:35 1990
30. Horibe, K., P s illaki s, j., Spira, V.: Derrnal fat transplantation; experimental study of blood vascularization. Glin Tlıera 3:117, 1974.
31. lllouz, Y.G.: Studious of subcutaneous fat. Aesth Plast Surg. 14; 165-175. 1990.
32- Jiri S.: Adipose tissue in plastic Surgery . Ann Plast Surg 16:5, 444-452, 1986.
33. Sawhney, C.P., Banerjee, T.N., chakravarti, R.N.:
Behavior of derrnal fat transplants Br J Plast Surg 22: 169, 1989.
34. Bright, R.M., Thacker, ITT., Brunner, R.D.: Fate of autogenous fat implant s İn t lıe frontal sinüs es of cats. Am J. vet Re. 44:22- 1982.
35. Regnault, P., Daniel, K.R.: Ûepressed scars and soft. tissues: ann Plast. Surg 10:427-430, 1983.
36. lan, R.M.,Yu, R.G., Park, B.Y.: Simultaneous total correction of TM] ankylosis and fasla! asymmetry.
Plast Reconst Surg 13:35, 1990.
37. Kilaİıı, R.G., Dartoıı, c., Bzowski, A.: Use of dcrmal fat flaps İn treating abdominal scars in abdominoplasty and in subtrochanteric lipectomy. PlastReconst Surg 60:876, 1977.
38. Hurwitz, P.J., Sarel, R.: Facial reconstruction in partial lipodistrophy. Ann Plast Surg 8:253-257, 1981.
39. Barret, II.O., Ball, E.G.: Morphologic and metabolic changcs in procedures in rat. adipose tissue in vit.ro by insulin. Science 129:1282, 1959.
10. Soloman, S.S., Turpİn, B.P., Duckworth, W.C.:
Gomparative studies of tlıe antilipolytic effect. of insulin and adenosine İn tlıe perfuscd isolated fat celi. Hor Metab Res 12:601, 1980.
41. Smith, U., Bostrom, S., Johanson, R, et ala:
Human adipose tissue iıı cuiture. Studies on tlıe metabolic effects of İnsulin. Diabetologia 112:137, 1976
42. Smith, R.J.,Foley, B., Mc Gregor, La., Jackson, I.T.: The anatoıııical basis of the groin flap. Plast Reconst. Surg 49;41, 1972.
