Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Autologous Free Fat Grafting for Management of the Facial Contour Asymmetry Rafael Denadai, MD, Cesar Augusto Raposo-Amaral, MD, Celso Luiz Buzzo, MD, MSc, and Cassio Eduardo Raposo-Amaral, MD, PhD Background: The purposes of this study were to report autologous free fat grafting as the workhorse procedure to augment the facial soft- tissue envelope and restore facial contour symmetry of patients with asymmetric facial malformations; to detail the SOBRAPAR Hospital algorithm for soft-tissue reconstruction of patients with facial contour asymmetry; and to assess facial symmetry after fat grafting. Methods: A retrospective analysis of consecutive patients (n ¼ 178) who underwent fat grafting to restore the facial contour symmetry according to the SOBRAPAR Hospital algorithm between 2009 and 2016 was conducted. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed. Results: There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement, with a mean fat graft procedures per patient of 1.6  0.7, ranging of 1 to 3. Conclusion: A significant improvement of facial contour symmetry was obtained in a subset of patients using fat grafting according to the SOBRAPAR Hospital algorithm. Key Words: Facial contour asymmetry, free fat grafting, symmetry (J Craniofac Surg 2018;00: 00–00) F acial contour asymmetry is a frequent condition characterized by a wide clinical spectrum including malformations of the skeletal structures and/or surrounding soft tissues in any combination of dimensions. 1 Treatment of these patients is challenging as often it requires multiple surgical interventions since early childhood to address hard- and/or soft-tissue defects. 1–10 Although different protocols adopting various surgical techniques have been applied for facial contour asymmetry reconstruction worldwide, no treat- ment consensus has been established regarding the ideal protocol including the optimal timing for the procedures and/or type of surgery. 1–10 The purposes of this study were to report autologous free fat grafting as the workhorse procedure to augment the facial soft- tissue envelope and restore facial contour symmetry of patients with asymmetric facial malformations; to detail the SOBRAPAR Hospital algorithm for soft-tissue reconstruction of patients with facial contour asymmetry; and to assess facial symmetry after fat grafting. METHODS A retrospective observational study was performed on consecutive patients diagnosed with facial contour deformities by the SOBRA- PAR multidisciplinary craniofacial team, and who underwent autol- ogous free fat grafting between 2009 and 2016. Demographic data (age, gender, race, and body mass index [kg/m 2 ]), disease-related data (diagnosis and previous craniofacial bone surgery at the site that received fat grafting), surgical-related data (donor site, recipi- ent site, and grafted volume), and outcome data (computerized photogrammetric facial symmetry analyses and complications) were collected through medical records, clinical photographs, and interviews with all patients. National body mass index cut off points 11 were adopted to divide pediatric patients into under- weight, normal weight, or overweight according to their age and gender, whereas the widely used World Health Organization cut off points of 18.5 and 25 kg/m 2 were adopted for adult stratification. Patients with previous craniofacial soft-tissue augmentation and/or incomplete medical records/follow-up (< 12 months after the reported surgeries) were excluded. All subjects were enrolled upon a consent form signed by the patients or their parents, in accordance with the Helsinki Declara- tion of 1975, as amended in 1983. Institutional review board approval was granted for this study. The SOBRAPAR Hospital Algorithm for Soft-Tissue Reconstruction of Facial Contour Asymmetry In the 38 years of the SOBRAPAR Hospital, craniofacial bone and soft-tissue surgeries have been routinely performed according to strict selection criteria, patient expectations, and always respecting the limits of reconstruction. We act as a reference center for the treatment of patients with a broad spectrum of craniofacial deformities from numerous regions of Brazil, including underprivileged areas. We treat patients with different ages at the presentation with (or with no) previous surgical treatments according to different protocols. This poses challenging obstacles as our surgical approach should be adapted to each particular clinical situation. As new challenging clinical situations appear, we modify/adapt the algorithm to incorpo- rate such patients into our therapeutic rationale, always trying to keep the individuality of each clinical presentation. In addition, our reconstructive treatment algorithm has been shaped as the knowledge and the technical modifications have arisen and their effectiveness has been proven. The protocol described here should therefore not be regarded as single or absolute. Based on our previous experiences 12–15 and evidence-based data, 1–10,16–20 the SOBRAPAR algorithm has been focused on the achievement of facial contour symmetry as early as possible with no From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil. Received October 3, 2017. Accepted for publication December 20, 2017. Address correspondence and reprint requests to Rafael Denadai, MD, Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, Sa ˜o Paulo CEP: 13084-880, Brazil; E-mail: denadai.rafael@hotmail.com The authors report no conflicts of interest. Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004369 ORIGINAL ARTICLE The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 1