Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1110e1116

Correction of hemifacial atrophy using free

anterolateral thigh adipofascial flap
Li Teng, Xiaolei Jin*, Guoping Wu, Zhiyong Zhang, Ying Ji, Jiajie Xu,
Jianjian Lu, Bo Zhang, Gang Zhou

Cranio-Maxillo-Facial Surgery Department 2, Plastic Surgery Hospital of Peking Union Medical College,
Chinese Academy of Medical Sciences, Beijing, PR China

Received 19 September 2008; accepted 8 June 2009

KEYWORDS Summary Treatment of hemifacial atrophy presents a challenge for reconstructive surgeons.
Hemifacial atrophy; Previous studies have described numerous methods for the correction of facial asymmetry.
Anterolateral thigh We present our experience with treatment of hemifacial atrophy using a microsurgical antero-
adipofascial flap; lateral thigh adipofascial flap procedure and other adjunctive measures. This method is similar
Microsurgery to that used for the free anterolateral thigh flap, but only the deep fascia of the anterolateral
thigh and subcutaneous fatty tissue above the fascia were harvested. This flap procedure was
used in 32 patients with moderate or severe hemifacial atrophy. In the first stage, the antero-
lateral thigh adipofascial flap procedure was used in all the patients, of whom eight accepted
a porous polyethylene implant along with the anterolateral thigh adipofascial flap to recon-
struct the skeleton. In the second stage, ancillary procedures including porous polyethylene
implantation, liposuction debulking, fat injection and flap re-suspension were performed to
refine the outcome in 28 patients. The anterolateral thigh adipofascial flap is advantageous
in that it can provide a reliable vascular pedicle with relatively thin, pliable soft tissue and
direct primary closure of the donor site.
ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Romberg’s disease manifests as a progressive hemifacial
atrophy of the skin and underlying soft tissues, cartilage
and bone. The cause of the disorder is unknown, although
many theories of its pathogenesis have been proposed.
* Corresponding author. No 33, Badachu Road, Shijingshan
District, Beijing 100144, PR China. Tel.: þ86 1088772343;
fax: þ86 1088961829.
E-mail address: jinyuyi@sohu.com (X. Jin).
Foremost among these are infection, trigeminal peripheral
neuritis, scleroderma and cervical sympathetic loss.1
Recently, autologous vascularised adipose tissue has
become the natural choice for craniofacial contour
correction of moderate or severe hemifacial atrophy.
Numerous free flaps have been used for restoration of facial
contour deformities in patients with Romberg’s disease,
including the deltopectoral,2,3 groin,4,5 omentum,6e8
scapular and parascapular flaps9e13; a latissimus dorsi

1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2009.06.009
Correction of hemifacial atrophy
Figure 1 Left. Intraoperative elevation of anterolateral thigh adipofascial flap. Right. The flap is laid out across the face with the
fat side up and end-to-end anastomosis of the pedicle vessel with the recipient vessel is performed.
musculocutaneous flapevascularised costochondral graft14;
the transverse rectus abdominis muscle (TRAM) flap15; the
radial forearm adipofascial flap16; and the free deep infe-
rior epigastric perforator (DIEP) flap.17
In this article, we present our experience treating 32
patients with hemifacial atrophy using the free antero-
lateral thigh adipofascial flap and other adjunctive
methods such as porous polyethylene implantation, lipo-
suction debulking, fat injection and flap re-suspension.
Patients and methods
The study protocol was approved by the Ethical Committee
of Plastic Surgery Hospital of the Peking Union Medical
College.
Patients
Between 1996 and 2008, a total of 32 free anterolateral
thigh adipofascial flap microsurgical procedures were per-
formed in 32 patients with moderate or severe progressive
hemifacial atrophy deformities. Of these 32 patients,
13 were male and 19 female, and their average age was
23 years (range: 15e45 years). The average age at disease
onset was 10.2 years. The average duration of atrophy was
8.9 years. Fifteen lesions affected the left face, and 17
affected the right. In 12 patients the lesion affected only
soft tissue, while in 20 patients both soft tissue and bone
were affected.
Surgical techniques
All of the patients underwent computed tomography (CT)
scanning and three-dimensional reconstruction of the skull
to confirm the lesion preoperatively. When these lesions
encroach upon the facial skeleton or the temporozygomatic
region, their repair is complicated because of their irreg-
ular three-dimensional curvature, and bone substitute
should be used to reconstruct the skeleton.
A Doppler flowmeter was used preoperatively to estab-
lish the location of the perforator. A line was drawn
between the anterosuperior iliac spine and the supero-
lateral border of the patella on the donor thigh. With the
midpoint of the line being the centre of a circle, most exit
points for the perforator were identified within a circle
1111
with a radius of 3 cm.18 The skin of the donor thigh was
marked to match the defect of the recipient site, with the
exit points for the perforator as the centre. After the
subcutaneous superficial adiposal tissue was bilaterally
dissected through a T- or S-shaped skin incision, the desired
anterolateral thigh adipofascial flap from the descending
branch of the lateral circumflex femoral artery was
harvested in the standard manner (Figure 1, left).18,19
At the recipient site, when bone substitute was used to
reconstruct the skeleton, the periosteum was elevated to
expose the affected bone (maxilla, zygoma, mandible,
etc.) and porous polyethylene (Medpor, Porex Surgical,
Newnan, GA, USA) was implanted into the subperiosteal
layer through a gingivobuccal sulcus incision.
A 4- to 5-cm incision was made below the mandible edge
to expose the facial vessel and create a subcutaneous
pocket for flap transfer. An adjunctive incision was used in
the temporal area if the fronto-temporal area was
affected. The flap was laid out across the face with the fat
side up and trimmed if necessary. End-to-end anastomosis
of the pedicle vessel with the recipient vessel was achieved
using anastomosis rings (Beijing Medical Instrument Co.,
Beijing) with a diameter of 1.5e2.5 mm, or a microsurgical
technique (Figure 1, right).
After blood circulation of the flap was confirmed, the
flap was transferred to the pocket with the fat side up and
some anchoring sutures were made between the adipofas-
cial flap and the pocket to fix the flap. The donor site was
closed directly. Adjunctive procedures were performed on
some patients 6 months to 1 year after the first surgery to
refine the facial contour. For patients who had flap bulki-
ness, liposuction was used to de-fat and thin the flap. For
patients who had flap sagging, the flap was re-suspended to
the fascia temporalis through the temporal incision. For
patients who had insufficient correction of the edge of the
skin flap, fat injection was performed according to Cole-
man’s approach to fill the local depression.13,20e22 In
addition, for some patients with bone defects who did not
have immediate skeletal reconstruction during the first
surgery, porous polyethylene was implanted.
Results
All 32 of the flaps survived completely, without flap
necrosis or other severe complications. The anterolateral
1112
Table 1 Summary of anterolateral thigh adipofascial flap used to correct hemifacial atrophy
Sex Side Flap size (cm)
Male Female Left Right
Number 13 19 15 17 11  6 w 20  11
thigh adipofascial flap ranged from 10 to 20 cm in length
and from 6 to 12 cm in width. During the first surgery,
porous polyethylene was used for immediate skeletal
reconstruction in eight patients. For the other 24 patients,
only anterolateral thigh adipofascial flap was transferred to
reconstruct the facial soft-tissue defect. Two cases of
haematoma and two cases of seroma were observed. The
haematoma and seroma disappeared after aspiration by
needle poking and fixation with bandaging (Table 1).
Secondary operations including liposuction debulking, fat
injection, flap re-suspension and porous polyethylene
implantation were performed for 28 patients (Table 2). All
patients received follow-up ranging from 6 months to 7
years. The facial shapes were relatively symmetrical, the
contours were satisfactory and no notable dysfunction of
the donor thigh was observed. The slight asymmetry of the
lower extremity and the scar at the donor site were
acceptable.
Case reports
Case 1
A 21-year-old woman suffered from progressive atrophy of
the left face and presented with obvious left-sided facial
deformity. In August 2003, the patient underwent the first
surgery, consisting of microsurgical anterolateral thigh
adipofascial flap transfer, to correct the deformity. The flap
measured 20  11 cm with a vascular pedicle that was 9 cm
long. An end-to-end anastomosis of the flap vessel with the
recipient facial vessel was performed. After trimming
the excessive superficial fat, the flap was transferred to the
pocket with the fat side up through a submandibular inci-
sion. The flap survived without any complications. Six
months later, the patient underwent liposuction to debulk
and re-suspend the flap. The facial contour deformity was
satisfactorily corrected (Figure 2).
Case 2
A 19-year-old woman suffered from progressive atrophy of
the left face that affected both the soft tissue and the
skeleton. The patient underwent microsurgical antero-
lateral thigh adipofascial flap transplantation in the first
stage of surgery to correct the soft-tissue deformity. The
flap measured 19  10 cm, with an 8-cm vascular pedicle.
Table 2 The adjunctive procedures
A B C D AþB AþC AþD
Number 0 0 11 2 3 2 2
Liposuction Z A; Fat injection Z B; Medpor implantation Z C; Flap Resuspension Z D; without adjunctive procedure Z E.
L. Teng et al.
Donor site complications Recipient site
Seroma Haematoma complications
2 2 0
An end-to-end anastomosis of the flap vessel with the facial
vessel was performed. The flap was transferred to the
pocket of the left face with the fat side up through
a submandibular incision. The flap survived without
any complications. One year later, porous polyethylene
(Medpor, Porex Surgical) implantation was used to augment
the zygoma through a gingivobuccal sulcus incision, and fat
injection was performed to correct the local depression of
the suborbital area and chin. The appearance of the
affected face was satisfactorily improved (Figure 3).
Discussion
Hemifacial atrophy is a complex craniofacial malformation.
Correction of this deformity presents a challenge because
deficiencies of both the facial skeleton and the overlying
soft tissue often must be addressed to achieve optimal
reconstructive results. Augmentation of the facial soft
tissue may be required for two reasons.23 First, adequate
soft tissue may be needed to protect and cover a planned
bone substitute to obtain a natural appearance. Second,
additional subcutaneous thickness is often needed to
substitute for the deficient subcutaneous fat, parotid and
muscle mass and create a symmetrical facial contour.
Microsurgical restoration of the facial contour has been
widely used for treatment of hemifacial atrophy, and many
authors have published their evaluations of the results.2e17
Microsurgical reconstruction focussing on the correction of
facial asymmetry and reconstruction of contour has
become the ‘gold standard’ of treatment.9 Many kinds of
free flaps have been used to correct Romberg’s disease, all
of which have had disadvantages. For example, the major
disadvantage of the vascularised groin dermalefat flap is
that the primary defatting can be difficult because the
pedicle vessel runs in a deeper layer from the proximal to
distal portion.3,4 With the omentum flap, its unpredictable
fat content and its need for a laparotomy and fascial sling to
prevent long-term sagging are the main disadvantages.6e8
The scapular or parascapular flap is a feasible option for
hemifacial atrophy, but some patients have hypertrophic
scarring at the donor site. In addition, simultaneous ele-
vation is difficult because of the donor site’s proximity to the
face, potentially necessitating a positioning change to obtain
the flap.9e13 Therefore, a consensus on the ideal method has
not yet been reached, and investigations to discover the
ideal flap continue.
BþC CþD AþBþC AþBþD E Total
3 2 2 1 4 32
Correction of hemifacial atrophy 1113

Figure 2 Case 1. A 21-year-old woman with left-sided hemifacial atrophy. (Above left) Preoperative frontal view. (Above right)
Postoperative frontal view after subcutaneous anterolateral thigh adiposal flap transfer. (Centre left) Preoperative left oblique
profile. (Centre right) Postoperative left oblique profile. (Below left) Preoperative submental view. (Below right) Postoperative
submental view.

The anterolateral thigh flap procedure was first reported
by Song et al. in 198424 and has been widely used in
coverage of traumatic and chronic wounds, burn scars, soft-
tissue defects of the face and forehead after ablative
surgery for carcinoma, and reconstruction of the penis,
vagina, tongue, dura maters, foot surface, sole and skull
base.25e34 The anterolateral thigh flap has many advan-
tages18,23,24,34e38: it provides a large reliable skin flap with
a long vascular pedicle; it can be raised with neighbouring
tissues such as the vastus lateralis, rectus femoris, iliac
bone or tensor fasciae latae; no special positioning is
required; and a flow-through flap can be designed for
reconstruction of both soft-tissue and major vessel defects.
The anterolateral thigh adipofascial flap is one of the
applied forms of the anterolateral thigh flap. In cadaver
studies, the perforators could be dissected in the adipose
layer and were observed to extend almost perpendicularly
to the subdermal plexus.35 Because the perforating vessel
of the flap flows into the subdermal plexus almost
perpendicularly after passing through the deep fascia, it
can be shaped and thinned through trimming the fat of its
superficial layer, as desired, without injuring the delicate
circulation of the flap and jeopardising its viability.36
Bleeding from the edge of the deep fascial layer and its
adipose surface during flap harvesting confirms the viability
of the adipofascial flap. However, partial flap necrosis may
be caused by excessive defatting or inappropriate flap
design. Therefore, the initial trimming should be fairly
conservative. With the harvesting of the anterolateral thigh
adipofascial flap, the donor-site defect can be directly
closed without tension, minimising donor-site
morbidity.37,38 This approach not only provides a thinner
1114 L. Teng et al.

Figure 3 Case 2. A 19-year-old woman with left-sided hemifacial atrophy affecting both the soft tissue and the skeleton. An
anterolateral thigh adipofascial flap (19  10 cm) was used to restore the soft tissue of the left face. In the second surgery, a porous
polyethylene implant was used to augment the zygoma, and fat injection was performed to correct the local depression of the
suborbital area and chin. (Above left) Preoperative frontal view. (Above right) Postoperative frontal view. (Below left) Preoperative
left oblique profile. (Below right) Postoperative left oblique profile.

and more pliable tissue flap but also eliminates the need for
a skin graft for the donor-site defect. The presence of deep
fascia of the flap allows adequate fixation to facial fascia
and avoids sagging after reconstruction.23
One of the disadvantages of the anterolateral thigh
adipofascial flap is that a minority of patients have
anatomical blood vessel variation, and a small minority lack
blood vessel perforators. Therefore, it is very important to
detect perforators precisely by the Doppler flowmeter
before surgery. If flap dissection reveals a lack of perfora-
tors, an anteromedial thigh adipofascial flap can be used as
an alternative to the anterolateral thigh adipofascial flap.
Another disadvantage of the flap is that the musculocuta-
neous perforators of some flaps course a long distance
inside the muscle before going into the flap, making the
dissection relatively difficult and tedious.
In the present study, adjunctive procedures such as
porous polyethylene implantation to reconstruct the skel-
eton, liposuction to debulk the flap, fat injection to fill the
edge of the flap and flap re-suspension to correct the
gravitational sag were employed. Porous polyethylene is
the most widely used implant material and is moderately
pliable and relatively easy to shape. It has an ‘open-pore’
structure that is relatively resistant to collapse and allows
some degree of tissue in-growth. It enhances the effect of
restoration on the facial contour in three dimensions
and avoids sagging and bulkiness of the flap postoperatively
in cases with serious skeletal deformity. Coleman’s
Correction of hemifacial atrophy
lipoinjection technique was used to modify the free ante-
rolateral thigh adipofascial flap contour, to restore adja-
cent atrophic areas and to treat the remaining small or
moderate defects. In our experience, the injected fat can
survive without total resorption or dissolution, and a rela-
tively symmetrical appearance can be expected. A bulky
flap can be improved through liposuction, a simple and
effective method with minimal morbidity. Because of the
loose fat of the flap, liposuction can be performed easily.
The fat from the liposuction can also be used to fill the
facial depressions, and a perfectly symmetrical appearance
can be achieved. For patients who have sagging of the flap
after the first stage, the flap is re-suspended to the fascia
temporalis or the zygoma periosteum through the temporal
incision or the inferior orbital margin incision. In short,
a perfectly symmetrical appearance can be achieved by
using the above-mentioned adjunctive methods either
solely or jointly to correct the various defects after the first
stage.
In conclusion, we have found the anterolateral thigh
adipofascial flap to be ideal for facial contour restoration in
moderate or severe hemifacial atrophy because it can be
successfully harvested and transferred with a microsurgical
technique and it allows tissue matching. Combined with
auxiliary methods, the anterolateral thigh adipofascial flap
can provide an ideal treatment for facial asymmetry in
hemifacial atrophy.
Acknowledgements
The authors are indebted to Mr. Zhang Chao, Ms. Pei Yue,
and Mr. Mark Levien for their assistance and proofreading.
Conflict of interest
None.
Funding
None.
The research protocol in the manuscript was approved
by the Ethical Committee of Plastic Surgery Hospital of
Peking Union Medical College.
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