Dermal Fat Grafts in the Management of Severe Craniofacial Infections
Craig R. Dufresne, MD, Ali Al-Attar, MD.
Georgetown University Hospital, Washington, DC, USA.
BACKGROUND: Infectious complications of craniofacial surgery are particularly difficult to manage because of the frequent use of plating and bone grafts, need for extensive debridement and explantation, and the resultant loss of domain. With increasingly aggressive craniofacial reconstructions during staged procedures and at times in irradiated or scarred beds, even the occasional infection can be a devastating setback. Current strategies to treat purulent infections surrounding foreign bodies include antibiotics, debridement, explantation, healing by secondary intent, and delayed attempt at reconstruction. At best, this approach leads to a scarred, retracted wound, often with compromised skeletal support, and almost always with severe loss of domain. We have found that placement of autologous dermal fat graft in the freshly debrided, irrigated wound (1) promotes resolution of infection, (2) allows immediate primary wound closure, (3) precludes the loss of domain that follows healing by secondary intent, and (4) provides soft tissue volume restoration.
METHODS: Fifteen craniofacial patients who developed purulent infections between 1986 and 2009 were treated with wound debridement, foreign body explantation, and immediate placement of autologous dermal fat grafts. A retrospective chart review was performed to evaluate patient clinical course, follow-up, outcome, and complications.
RESULTS: All fifteen patients who were treated with immediate placement of dermal fat grafts at the time of wound debridement had clinical resolution of their infections without loss of domain. The average follow-up time for these patients was approximately three years. The wound infections in all patients resolved without any recurrent or progressive infections. All fifteen patients were able to continue with their staged reconstructions, with either simultaneous or later placement of bone grafts and/or plating. Soft tissue volume was maintained in fourteen of the patients; one patient had atrophy of her dermal fat graft.
CONCLUSIONS: Infection in the craniofacial surgical patient is challenging and threatens the staged reconstruction. While autologous dermal fat grafts are devascularized, we have found that they can play a central role in the resolution of this clinical problem. Placement of dermal fat grafts at the time of initial wound debridement and foreign body explantation achieves multiple clinical goals, most importantly the sustained resolution of the infection and restoration of adequate soft tissue volume. We speculate that our successful experience with dermal fat grafting is due to several supportive factors in this clinical setting: well-vascularized blood supply of the face/scalp, inflammatory response associated with sub-acute or chronic wound infections, and adequate debridement of infected foreign body. However, we also speculate that the dermal fat graft might have biologic activity that promotes clinical resolution. The freshly-harvested, autologous dermal fat is a repository of lymphocytes and other immune cells that might contribute to wound sterilization, as well as of fibroblasts and adipocytes that might contribute to wound healing and tissue regeneration. Our sustained success with the dermal fat graft in the most contaminated of craniofacial wounds suggests both a clinical role as well as a foundation for future basic science investigation.
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