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Direct Autogenous Fat Implantation for Augmentation of the Vocal Folds
Journal of Voice Vol. 15, No. 4, pp. 565-569 © 2001 The Voice Foundation
Direct Autogenous Fat Implantation for Augmentation of the Vocal Folds Harvey M. Tucker Department of Otolaryngology/Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
Summary: This report examines the results of autogenous fat implantation into paralyzed or flaccid vocal folds in 23 patients. No complications were encountered in any of these patients and very satisfactory voice improvement was achieved in every case. The voice improvement achieved initially has been sustained for one to four years in all patients but one, whose underlying disease process progressed and worsened the voice. Key Words: Fat implantation— Paralyzed vocal folds.
tion Meeting in 1995, to determine (1) if this approach could be clinically useful in achieving voice improvement in patients with unilateral vocal fold immobility or flaccidity, and (2) if implanted rather than injected autogenous fat would survive more predictably.
INTRODUCTION There has been much interest in recent years regarding injection of autogenous fat, usually obtained by liposuction, to augment paralyzed or flaccid vocal folds.1–3 Although this technique has gained some popularity, it has generally suffered from unpredictable absorption of the injected fat, resulting in deterioration of what may have been initially satisfactory improvement in voice parameters.3,4 More recently, direct implantation of surgically harvested autogenous fat has been suggested,5 not only to achieve similar voice improvement, but perhaps to provide better long-term survival of the fat and, thus, reduced deterioration of voice. A prospective study was undertaken by the author at the suggestion of Robert T. Sataloff, MD, DMA, at the Voice Founda-
MATERIALS AND METHODS From January 1, 1995 to December 31, 1999, all patients presenting to the author with either unilateral vocal fold immobility or vocal fold flaccidity were considered for this study. Those patients with immobile vocal folds who were judged to need more than 3–4 mm of medialization to achieve adequate glottic closure to allow good compensation were not included, since they were generally managed by open surgical medialization. A total of 23 such individuals were seen, of which 17 had unilateral vocal fold immobility that met the criteria for inclusion. Of these 17 patients, 3 had had previous surgical medialization with Silastic implant with insufficient glottic closure. Two others had undergone previous surgical medialization with good initial voice results, but had
Accepted for publication March 19, 2001. Presented at the 29th Annual Symposium: Care of the Professional Voice, Philadelphia, Pennsylvania, July 1, 2000. Send correspondence and reprint requests to Harvey M. Tucker, MD FACS, St Luke’s Medical Office Building, Suite 322, 11201 Shaker Boulevard, Cleveland, Ohio 44104. e-mail: [email protected]
565
566
HARVEY M. TUCKER
deteriorated because of further wasting of the unreinnervated paralyzed vocal fold. Twelve were previously untreated except for speech therapy. The remaining 6 patients suffered from bilateral vocal fold flaccidity of varying cause. Two were felt to represent myasthenia laryngis, one had bilateral superior laryngeal nerve palsy, and one suffered from amyotrophic lateral sclerosis (ALS). All of these patients had a preoperative voice assessment, including videostroboscopy and voice analysis by a speech and language pathologist. Most of them had similar postoperative voice assessment, although 5 did not undergo postoperative videostroboscopy. All patients provided a postoperative voice self-assessment and, at a minimum, high-quality tape recordings of their voices for review. SURGICAL TECHNIQUE Surgery is carried out under general endotracheal anesthesia to permit the use of suspension laryngoscopy and the precise microscopic control over fat implantation that is required. Fat is usually obtained through a small horizontal submental incision which is closed with subcuticular absorbable sutures. A rubber band drain is removed by the patient after twenty four hours. The earlobe might be a good alternative site, but would not offer enough fat in some cases and could result in unwelcome changes in the appearance of the lobule. Once obtained, the fat is placed in physiological saline until needed for implanation A suspension laryngoscope is inserted and the larynx exposed under the operating microscope. The false vocal fold is retracted as far laterally as possible to expose the entire superior surface of the immobile or flaccid true vocal fold in question (Figure 1). An incision is made parallel to the vocal ligament and as far laterally as possible in the mucous membrane of the superior surface of the vocal fold (Figure 2). A mucosal flap is developed by sharp and blunt dissection to reach the point at which fat implantation is desired (depending on pathology), either medial or lateral to the vocal ligament (Figure 3). When placed laterally, a pocket is created by blunt dissection made by opening a curved alligator forceps that has been inserted between muscle bundles or by using a right angle blunt hook, such that the anterior-posterior extent of the pocket is greater by about half than the Journal of Voice, Vol. 15, No. 4, 2001
FIGURE 1. Placement of laryngoscope for glottic exposure.
FIGURE 2. Mucosal incision is made as far lateral as exposure permits.
length of the intramuscular separation itself. This maneuver effectively creates anterior and posterior recesses within the muscular layers of the vocal fold (Figure 4). Fat is teased from the specimen previous-
FAT IMPLANTATION FOR AUGMENTATION OF THE VOCAL FOLDS
567
then inserted into the pocket and prodded with moistened blunt hooks and/or alligator forceps until it is retained within the pocket without undue protrusion. In this manner, the extension of the fat into the anterior and posterior recesses created in formation of the pocket retains it in position, without the need for sutures or tissue glue. The mucosal flap is returned to its original position, or at least far enough laterally so that none of the implanted fat is visible. No perioperative antibiotics are used. In consideration of such factors as age, condition of the airway, and other clinical or pathological issues, preoperative Decadron may be used and/or the patient may be observed overnight, depending on the judgment of the surgeon in such cases. RESULTS
FIGURE 3. A superior mucosal flap is developed as far medially as is required to properly place the muscular pocket to receive the fat implant.
FIGURE 4. The incision for the pocket is somewhat shorter than the pocket itself, so as to develop anterior and posterior recesses that help to retain the fat implant without sutures or tissue glue.
ly obtained to create a spindle-shaped piece that is estimated to be of the correct size to fill the pocket and its anterior and posterior recesses. The fat implant is
All 23 patients experienced quite significant voice improvement as a result of the procedure (Table 1). None of the patients were felt to be worse or lacking in improvement, either by their own self-assessment or by formal voice analysis three months after autogenous fat implantation. Voice improvement has been maintained without perceived worsening for one to four years, except for the patient with amyotrophic lateral sclerosis (ALS). Such parameters as loudness, sustainability, number of words possible on one breath, etc., were evaluated at various intervals by either the speech and language pathologist and/or the surgeon. Eighteen of these patients had postoperative videostroboscopy at least once following surgery, but none sooner than three months after. All of these demonstrated a straight, unbowed vocal fold with good mucosal wave. There were no immediate complications. One patient developed a polyplike protrusion on the superior surface of the implanted vocal fold which, although it was slightly pedunculated, did not interfere with the very good voice that had been achieved. Nevertheless, this was removed endoscopically approximately 6 months later without further sequelae. Another patient, who was suffering from ALS, eventually had significant worsening of his voice because of the progression of his disease. He eventually required a Silastic surgical medialization, which improved his voice until he succumbed to his underlying disease 3 years after the original fat implantation. Journal of Voice, Vol. 15, No. 4, 2001
568
HARVEY M. TUCKER TABLE 1. Voice Results after Autogenous Fat Implantation At Three Months N=23
Worse
Same
Improved
Normal
Unilateral vocal fold immobility = 17
0
0
14
3
Vocal fold flaccidity = 6
0
0
5
1
At One to Four Years N=23
Worse
Same
Improved
Normal
Unilateral vocal fold immobility = 17
0
0
13
4
Vocal fold flaccidity = 6*
1*
0
4*
1
* One patient succumbed to ALS with a worse voice.
DISCUSSION Although injection of alloplastic materials was the mainstay in management of vocal fold immobility for most of the past century, the search for better techniques has gone on almost from the beginning.6 The ability to inject autogenous fat has looked promising for some time, since it is the patient’s own tissue, is easily obtained, and seems to provide very good voice improvement in the majority of cases.1-3 Unfortunately, autogenous fat does not seem to reliably survive the liposuction and passage through a Bruning syringe which is required in order to inject it. It appears that enough of the individual fat cells are either ruptured or traumatized that they cannot retain necessary volume, or that the rupture of enough fat cells stimulates a more aggressive local inflammatory response in the recipient tissues.4 Thus, injected autogenous fat usually requires some degree of overcorrection to achieve satisfactory voice results. Direct implantation, on the other hand, appears to require little or no overcorrection, providing the fat is handled gently to minimize lysis of cells.7 Placement of implanted fat either medial or lateral to the vocal ligament depended on the author’s clinical judgment. In those cases where there was notching or significant atrophy of the free margin of the vocal fold and when only limited (1–2 mm) correction seemed to be necessary, the implant was placed medially. When greater correction (2–4 mm) seemed necessary, the fat implant was usually placed lateral to the vocal ligament. Journal of Voice, Vol. 15, No. 4, 2001
Using the “extended pocket” technique described above, it has not been necessary to use either sutures or tissue adhesives to reliably retain the implanted fat. Although it can be challenging to manipulate the spindle-shaped piece into the pocket and recesses and manage to have it remain there, once it has been successfully placed it appears that blood and tissue fluids are sufficient for purposes of retention. It was not generally feasible to do in-depth voice analysis both preoperatively and postoperatively in this series of patients. Such issues as cost, distance to facilities, general health, etc., did not always allow rigorous scientific analysis, but perceptive evaluation certainly suggested that the initial voice results were not only comparable to those achieved with injected materials, but that there was little or no deterioration over the times available for follow-up in this study. Clearly, a prospective, comparative study between fat injection and implantation might answer these questions, as well as provide an opportunity for more rigorous long-term voice analysis. CONCLUSIONS Direct implantation of autogenous fat has resulted in voice improvement comparable to that achieved with other injection techniques in a group of 23 patients suffering from vocal fold flaccidity or unilateral vocal fold immobility. The voice improvement achieved has persisted for one to four years without evidence of significant deterioration.
FAT IMPLANTATION FOR AUGMENTATION OF THE VOCAL FOLDS REFERENCES 1. Mikaelian DO, Lowry LD, Sataloff RT. Lipoinjection for unilateral vocal fold paralysis. Laryngoscope. 1991;101:465– 468. 2. Shindo ML, Zaretsky LS, Rice DH. Autologous fat injection for unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol. 1996;105:602–606. 3. Hsiung MW, Woo P, Minasian A, Mojica JS. Fat augmentation for glottic insufficiency. Laryngoscope. 2000;110:1026– 1033.
569
4. Mikus JL, Koufman JA, Kilpatrick SE. Fate of liposuctioned and purified autogenous fat injections in the canine vocal fold. Laryngoscope. 1995;105:17–22. 5. Wexler DB, Jiang J, Gray SD, Titze IR. Phonosurgical studies: fat-graft reconstruction of injured canine vocal cords. Ann Otol Rhinol Laryngol. 1989;98:668–673. 6. Lewy RB. Experiences with vocal cord injection. Ann Otol Rhinol Laryngol. 1976;85:440–450. 7. Jiang JJ, Wexler DB, Titze IR, Gray, SD. Fundamental frequency and amplitude perturbation in reconstructed canine vocal folds. Ann Otol Rhinol Laryngol. 1994;103:145-148.
Journal of Voice, Vol. 15, No. 4, 2001
Direct Autogenous Fat Implantation for Augmentation of the Vocal Folds Harvey M. Tucker Department of Otolaryngology/Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
Summary: This report examines the results of autogenous fat implantation into paralyzed or flaccid vocal folds in 23 patients. No complications were encountered in any of these patients and very satisfactory voice improvement was achieved in every case. The voice improvement achieved initially has been sustained for one to four years in all patients but one, whose underlying disease process progressed and worsened the voice. Key Words: Fat implantation— Paralyzed vocal folds.
tion Meeting in 1995, to determine (1) if this approach could be clinically useful in achieving voice improvement in patients with unilateral vocal fold immobility or flaccidity, and (2) if implanted rather than injected autogenous fat would survive more predictably.
INTRODUCTION There has been much interest in recent years regarding injection of autogenous fat, usually obtained by liposuction, to augment paralyzed or flaccid vocal folds.1–3 Although this technique has gained some popularity, it has generally suffered from unpredictable absorption of the injected fat, resulting in deterioration of what may have been initially satisfactory improvement in voice parameters.3,4 More recently, direct implantation of surgically harvested autogenous fat has been suggested,5 not only to achieve similar voice improvement, but perhaps to provide better long-term survival of the fat and, thus, reduced deterioration of voice. A prospective study was undertaken by the author at the suggestion of Robert T. Sataloff, MD, DMA, at the Voice Founda-
MATERIALS AND METHODS From January 1, 1995 to December 31, 1999, all patients presenting to the author with either unilateral vocal fold immobility or vocal fold flaccidity were considered for this study. Those patients with immobile vocal folds who were judged to need more than 3–4 mm of medialization to achieve adequate glottic closure to allow good compensation were not included, since they were generally managed by open surgical medialization. A total of 23 such individuals were seen, of which 17 had unilateral vocal fold immobility that met the criteria for inclusion. Of these 17 patients, 3 had had previous surgical medialization with Silastic implant with insufficient glottic closure. Two others had undergone previous surgical medialization with good initial voice results, but had
Accepted for publication March 19, 2001. Presented at the 29th Annual Symposium: Care of the Professional Voice, Philadelphia, Pennsylvania, July 1, 2000. Send correspondence and reprint requests to Harvey M. Tucker, MD FACS, St Luke’s Medical Office Building, Suite 322, 11201 Shaker Boulevard, Cleveland, Ohio 44104. e-mail: [email protected]
565
566
HARVEY M. TUCKER
deteriorated because of further wasting of the unreinnervated paralyzed vocal fold. Twelve were previously untreated except for speech therapy. The remaining 6 patients suffered from bilateral vocal fold flaccidity of varying cause. Two were felt to represent myasthenia laryngis, one had bilateral superior laryngeal nerve palsy, and one suffered from amyotrophic lateral sclerosis (ALS). All of these patients had a preoperative voice assessment, including videostroboscopy and voice analysis by a speech and language pathologist. Most of them had similar postoperative voice assessment, although 5 did not undergo postoperative videostroboscopy. All patients provided a postoperative voice self-assessment and, at a minimum, high-quality tape recordings of their voices for review. SURGICAL TECHNIQUE Surgery is carried out under general endotracheal anesthesia to permit the use of suspension laryngoscopy and the precise microscopic control over fat implantation that is required. Fat is usually obtained through a small horizontal submental incision which is closed with subcuticular absorbable sutures. A rubber band drain is removed by the patient after twenty four hours. The earlobe might be a good alternative site, but would not offer enough fat in some cases and could result in unwelcome changes in the appearance of the lobule. Once obtained, the fat is placed in physiological saline until needed for implanation A suspension laryngoscope is inserted and the larynx exposed under the operating microscope. The false vocal fold is retracted as far laterally as possible to expose the entire superior surface of the immobile or flaccid true vocal fold in question (Figure 1). An incision is made parallel to the vocal ligament and as far laterally as possible in the mucous membrane of the superior surface of the vocal fold (Figure 2). A mucosal flap is developed by sharp and blunt dissection to reach the point at which fat implantation is desired (depending on pathology), either medial or lateral to the vocal ligament (Figure 3). When placed laterally, a pocket is created by blunt dissection made by opening a curved alligator forceps that has been inserted between muscle bundles or by using a right angle blunt hook, such that the anterior-posterior extent of the pocket is greater by about half than the Journal of Voice, Vol. 15, No. 4, 2001
FIGURE 1. Placement of laryngoscope for glottic exposure.
FIGURE 2. Mucosal incision is made as far lateral as exposure permits.
length of the intramuscular separation itself. This maneuver effectively creates anterior and posterior recesses within the muscular layers of the vocal fold (Figure 4). Fat is teased from the specimen previous-
FAT IMPLANTATION FOR AUGMENTATION OF THE VOCAL FOLDS
567
then inserted into the pocket and prodded with moistened blunt hooks and/or alligator forceps until it is retained within the pocket without undue protrusion. In this manner, the extension of the fat into the anterior and posterior recesses created in formation of the pocket retains it in position, without the need for sutures or tissue glue. The mucosal flap is returned to its original position, or at least far enough laterally so that none of the implanted fat is visible. No perioperative antibiotics are used. In consideration of such factors as age, condition of the airway, and other clinical or pathological issues, preoperative Decadron may be used and/or the patient may be observed overnight, depending on the judgment of the surgeon in such cases. RESULTS
FIGURE 3. A superior mucosal flap is developed as far medially as is required to properly place the muscular pocket to receive the fat implant.
FIGURE 4. The incision for the pocket is somewhat shorter than the pocket itself, so as to develop anterior and posterior recesses that help to retain the fat implant without sutures or tissue glue.
ly obtained to create a spindle-shaped piece that is estimated to be of the correct size to fill the pocket and its anterior and posterior recesses. The fat implant is
All 23 patients experienced quite significant voice improvement as a result of the procedure (Table 1). None of the patients were felt to be worse or lacking in improvement, either by their own self-assessment or by formal voice analysis three months after autogenous fat implantation. Voice improvement has been maintained without perceived worsening for one to four years, except for the patient with amyotrophic lateral sclerosis (ALS). Such parameters as loudness, sustainability, number of words possible on one breath, etc., were evaluated at various intervals by either the speech and language pathologist and/or the surgeon. Eighteen of these patients had postoperative videostroboscopy at least once following surgery, but none sooner than three months after. All of these demonstrated a straight, unbowed vocal fold with good mucosal wave. There were no immediate complications. One patient developed a polyplike protrusion on the superior surface of the implanted vocal fold which, although it was slightly pedunculated, did not interfere with the very good voice that had been achieved. Nevertheless, this was removed endoscopically approximately 6 months later without further sequelae. Another patient, who was suffering from ALS, eventually had significant worsening of his voice because of the progression of his disease. He eventually required a Silastic surgical medialization, which improved his voice until he succumbed to his underlying disease 3 years after the original fat implantation. Journal of Voice, Vol. 15, No. 4, 2001
568
HARVEY M. TUCKER TABLE 1. Voice Results after Autogenous Fat Implantation At Three Months N=23
Worse
Same
Improved
Normal
Unilateral vocal fold immobility = 17
0
0
14
3
Vocal fold flaccidity = 6
0
0
5
1
At One to Four Years N=23
Worse
Same
Improved
Normal
Unilateral vocal fold immobility = 17
0
0
13
4
Vocal fold flaccidity = 6*
1*
0
4*
1
* One patient succumbed to ALS with a worse voice.
DISCUSSION Although injection of alloplastic materials was the mainstay in management of vocal fold immobility for most of the past century, the search for better techniques has gone on almost from the beginning.6 The ability to inject autogenous fat has looked promising for some time, since it is the patient’s own tissue, is easily obtained, and seems to provide very good voice improvement in the majority of cases.1-3 Unfortunately, autogenous fat does not seem to reliably survive the liposuction and passage through a Bruning syringe which is required in order to inject it. It appears that enough of the individual fat cells are either ruptured or traumatized that they cannot retain necessary volume, or that the rupture of enough fat cells stimulates a more aggressive local inflammatory response in the recipient tissues.4 Thus, injected autogenous fat usually requires some degree of overcorrection to achieve satisfactory voice results. Direct implantation, on the other hand, appears to require little or no overcorrection, providing the fat is handled gently to minimize lysis of cells.7 Placement of implanted fat either medial or lateral to the vocal ligament depended on the author’s clinical judgment. In those cases where there was notching or significant atrophy of the free margin of the vocal fold and when only limited (1–2 mm) correction seemed to be necessary, the implant was placed medially. When greater correction (2–4 mm) seemed necessary, the fat implant was usually placed lateral to the vocal ligament. Journal of Voice, Vol. 15, No. 4, 2001
Using the “extended pocket” technique described above, it has not been necessary to use either sutures or tissue adhesives to reliably retain the implanted fat. Although it can be challenging to manipulate the spindle-shaped piece into the pocket and recesses and manage to have it remain there, once it has been successfully placed it appears that blood and tissue fluids are sufficient for purposes of retention. It was not generally feasible to do in-depth voice analysis both preoperatively and postoperatively in this series of patients. Such issues as cost, distance to facilities, general health, etc., did not always allow rigorous scientific analysis, but perceptive evaluation certainly suggested that the initial voice results were not only comparable to those achieved with injected materials, but that there was little or no deterioration over the times available for follow-up in this study. Clearly, a prospective, comparative study between fat injection and implantation might answer these questions, as well as provide an opportunity for more rigorous long-term voice analysis. CONCLUSIONS Direct implantation of autogenous fat has resulted in voice improvement comparable to that achieved with other injection techniques in a group of 23 patients suffering from vocal fold flaccidity or unilateral vocal fold immobility. The voice improvement achieved has persisted for one to four years without evidence of significant deterioration.
FAT IMPLANTATION FOR AUGMENTATION OF THE VOCAL FOLDS REFERENCES 1. Mikaelian DO, Lowry LD, Sataloff RT. Lipoinjection for unilateral vocal fold paralysis. Laryngoscope. 1991;101:465– 468. 2. Shindo ML, Zaretsky LS, Rice DH. Autologous fat injection for unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol. 1996;105:602–606. 3. Hsiung MW, Woo P, Minasian A, Mojica JS. Fat augmentation for glottic insufficiency. Laryngoscope. 2000;110:1026– 1033.
569
4. Mikus JL, Koufman JA, Kilpatrick SE. Fate of liposuctioned and purified autogenous fat injections in the canine vocal fold. Laryngoscope. 1995;105:17–22. 5. Wexler DB, Jiang J, Gray SD, Titze IR. Phonosurgical studies: fat-graft reconstruction of injured canine vocal cords. Ann Otol Rhinol Laryngol. 1989;98:668–673. 6. Lewy RB. Experiences with vocal cord injection. Ann Otol Rhinol Laryngol. 1976;85:440–450. 7. Jiang JJ, Wexler DB, Titze IR, Gray, SD. Fundamental frequency and amplitude perturbation in reconstructed canine vocal folds. Ann Otol Rhinol Laryngol. 1994;103:145-148.
Journal of Voice, Vol. 15, No. 4, 2001