Parry-Romberg syndrome is a poorly understood entity consisting of a slowly evolving atrophy primarily of the subcutaneous and adipose tissue of one side of the face. Progressive facial hemiatrophy produces great emotional disturbance to the patient. There is no treatment for it; rather the challenge for the plastic surgeon is to restore the volume and contour of the face, achieving symmetry. Various methods have been proposed for hemifacial atrophy treatment. For mild to moderate cases with no bone atrophy, filling the defect can achieve satisfactory results. There is a major call nowadays for minimally invasive procedures with almost no downtime and satisfactory results. Autologous fat transplantation is one of them and enables the plastic surgeon to rejuvenate the face and to fill acquired or congenital soft tissue defects.

Hemifacial atrophy has been treated with autologous fat transplantation for a long time, as described by many authors [1, 4, 5]. It seems to be the ideal filler because of its plentifulness, biocompatibility, natural feel, minimal trauma, quick recovery, and less cost. In the 1990s, Coleman developed his technique which was accepted and used worldwide. It includes gentle removal and handling of aspirated fat and injection techniques using small volumes of fat and multiple passes. Although autologous lipotransfer has been widely accepted as a successful technique to address facial volume loss, a frequent criticism of this procedure is the uncertainty regarding the longevity of its results necessitating two or three stages of fat grafting at about 3–6 months interval to accomplish the desired result. Disparity exists in the literature regarding long-term outcomes, with rates of survivability of transplanted fat varying from 10 to 90 %. ASAPS concluded that 30 % of the transferred adipose tissue remains viable after 1 year, recommending overcorrection. Thus, the results are unpredictable and the Parry-Romberg syndrome patient should be followed indefinitely. The surgery should be performed at a time when the atrophy has been stable at least for a couple of years. If there is underlying skeletal atrophy, then this should be corrected first. The transplanted fat may increase or decrease in volume with the patient’s weight fluctuations. The most resistant to weight fluctuations seem to be the outer buttocks, flanks, and inner knee fat. The outer thigh fat was found by some authors to have lower resorption rate due to the relative avascularity [6], while others did not find any difference in resorption rates among various sites [7]. According to Guerrerosantos [8], fat injected under the SMAS, into the muscle, and next to the periosteum survives better. Intramuscular injection allows longer-term survival [9].

The most atraumatic technique in handling the fat tissue should be used in order to ensure cells’ viability. Controversies exist regarding which method of fat harvest and preparation yields the greatest number of viable fat cells. The Coleman technique is very well known and used worldwide. The fat is harvested manually with a blunt-tipped cannula connected to a 10-mL Luer-Lok syringe. After harvest, the fat is centrifuged at 3,000 rpm for 3 min, both upper and lower levels of components are removed and the remaining fat grafts are injected with different Coleman cannulas [3]. Studies performed by Pu et al. [10] showed that fat grafts harvested with the Coleman technique have a greater number of viable adipocytes and a more optimal cellular function than fat grafts obtained with conventional liposuction, although fat grafts obtained by both methods maintain normal histologic structure. In contrast, Smith et al. found no significant difference in adipocyte viability between the two techniques [11]. Their studies also showed that minimal preparatory manipulation (no washing, no centrifuge) was associated with increased graft survival. Minn et al. [12] found no significant difference in fat cell survival between grafts prepared by centrifugation and open cotton gauze technique, in contrast to metal sieve concentration method which has the lowest fat cell viability due to the traumatic handling.

Improved methods of fat preparation have been recently described [13, 14], such as the addition of adipose-derived stem cells (ADSCs). Adipose tissue is considered to be an ideal source of uncultured stem cells [15]. Several authors successfully treated Parry-Romberg syndrome with only one session of ADSC-enriched lipoinjection [4, 16]. ADSCs are to be found in the SVF (stromal vascular fraction) which contains cells with great proliferative capacity. ADSCs are isolated from the SVF by enzymatic digestion, filtration, and centrifugation. The addition of stem cells to the aspirated fat converts ADSC-poor fat to relatively ADSC-rich fat improving the efficacy of fat transfer [17

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