Introduction
Autologous fat grafting AFG is used both in aesthetic and reconstructive surgery. Neuber described fat transfer in retractile scarring and published successful outcomes (1). In recent decades this technique has been used increasingly since the development of modern liposuction techniques in the 1980s by Illouz (2, 3). The technique of harvesting and processing, expanded applications and fat transfer is now commonly used in the head/face and neck.(4, 5) Coleman provided a comprehensive description of techniques in the 1990s, and in recent years the scientific basis of the regenerative effects of fat grafts is progressing (6, 7).
Adipose tissue has notable plasticity and has endocrine function.(8) A lipoaspirate of fat tissue contains an aqueous fraction, the stromal vascular fraction (SVF), which is a combination of pre-adipocytes, endothelial precursor cells, endothelial cells, macrophages, smooth muscle cells, lymphocytes, pericytes, and adipose-derived stem cells ASCs.(9) The latter have the potential to differentiate into numerous cell lines comparable with mesenchymal stem cells (9, 10). ASCs are involved in biologic pathways of inflammation and tumour environment.(7) ASCs have been ascertained to promote angiogenesis and further showed elevated pro-oncologic behaviour in xenografts (10, 11). The applications also have expanded beyond physical ‘contouring and space-filling’ to regenerative applications that address radiation injury, abnormal scarring, improving aged skin and managing varieties of skin injury such as burns(2, 9, 12).
The worldwide incidence of head and neck cancer (HNC) is more than 550,000 cases with around 300,000 annual deaths. About 90% of all head and neck cancers are squamous cell carcinomas (HNSCC). HNSCC is the sixth leading cancer by incidence worldwide.(13, 14) About one third of these patients present with low stage disease (T1-2, N0), therefore radiation or surgery protocols are available for treatment. Higher stage disease in HNC requires postoperative chemoradiotherapy (13) resulting in treatment sequelae like a cosmetic burden (15), trismus, radiotherapy-induced neck fibrosis (16) and radiodermatitis, further skin irregularities, and lymphedema (17). AFG can address these complications after successful treatment. The safety of AFG is largely accepted, but attitudes differ where and the anatomical region to be treated has previously been ablated for cancer(8).
Unlike breast surgery, it is not clear what current attitudes and trends are in facial fat grafting in the post-cancer treatment patient, for example, post-radiation injury, contour defect, or chronic neck lymphedema. We aimed to try ascertaining attitudes in this respect and whether these attitudes are reflected in the evidence base for these procedures. We recognize there are no English or German published guidance, healthcare system based or otherwise, to guide the treating teams.