The Risk of Conducting Overgrafting of Fat for Treating Facial Atrophy Induced by Localized Scleroderma

Localized scleroderma is a rare autoimmune connective tissue disorder leading to serious long-term aesthetic impairment in patients who need surgical treatment to gain facial improvement. However, it lacks a deep understanding of the difference between localized scleroderma patients and normal people in fat grafting surgery for improving facial atrophy.

A 25-year-old man with localized scleroderma induced atrophy of the chin sought surgical treatment to improve the facial deformity ([Fig. 1A]). Under local anesthesia, he received 9-mL fat grafting to the chin lesion. Two days postoperatively, he visited for a consultation, complaining that the skin at the lesion turned dark. Physical examination showed dark red blood slowly flowing out after an acupuncture test, suggesting a poor local skin blood supply. Ultrasound examination showed no signs of hematoma and induration at the injection site but revealed that the thickness of the skin on the lesion was only 40% of his normal skin thickness. In the next few weeks, part of the grafted fat was removed to reduce pressure, and the bacteriological examinations showed no bacterial infection. He also received hyperbaric oxygen treatment five times, but parts of the skin on the lesion were still necrotic and shed ([Fig. 1B]). At the follow-up at 6 months after the operation, the atrophy of the patient's chin was significantly improved compared with preoperatively, but a scar was left on the necrotic skin ([Fig. 1C]).

Fig. 1 (A) The patient had chin atrophy induced by localized scleroderma. (B) Parts of the skin on localized scleroderma lesion was necrotic. (C) At the follow-up at 6 months postoperation, the atrophy of the patient's chin was significantly improved, with a scar left on the necrotic skin site.

Regarding the cause of skin necrosis, it was assumed that the skin of the scleroderma lesion was too thin to withstand the increased tension after fat injection. Since only part of the grafted fat can retain, the conventional fat grafting procedures recommend conducting overgraft 20 to 30% fat of the target volume, with multipoint, multilayer, and multitunnel injection method. Unlike normal people, patients with localized scleroderma have various degrees of skin damage, including decreased skin thickness, severe skin fibrosis, poor skin mobility, and decreased skin elasticity. The excessive fat will exert great tension on the skin may result in skin ischemia and necrosis if the skin is too thin. Such procedures must be cautiously performed especially in the localized scleroderma patients undergoing fat graft for the first time.

More research and understanding of fat graft treatment for patients with localized scleroderma are needed, who are likely to require a different fat graft strategy in comparison to normal people. It is not advisable to care only about the improvement of the volume of soft tissue while ignoring the bearing capacity of the skin. We recommend as a routine that patients with scleroderma should undergo an ultrasound examination before surgery, assessing the severity of skin atrophy. The amount of fat graft should be comprehensively weighed between the skin thickness/tension test results and the volumetric measurement results. Though it may be less acceptable for the patients at very first, a formulation of the course of multiple consecutive grafts to achieve the target improvement of the soft tissue volume is also recommended for better safety and stable outcome.

Publication History

Article published online:
01 June 2021