**4.3 Lipofilling procedure**

Different techniques exist for lipofilling injection [41]. There are many preparation techniques for adipose tissue. There is no universally accepted standard method. The Coleman technique, which was described in the early 1990s, is the most frequently used method. This technique aims to prevent damage to the fragile adipose cells as much as possible during transplantation and thus promote tissue survival [48]. The technique involves three steps and is described by Hsu et al. [41]. The first step consists of the harvest of fatty tissue from the upper abdominal wall or inner thigh using large- or small-volume liposuction (see **Figure 3a**). The upper abdominal wall or lateral thigh is very useful as donor sites because of the high amount of local fat cells. The donor site can be infiltrated with tumescence fluid (for instance, ringers lactate, adrenaline and lidocaine) just before the liposuction, but this can also be done after the suction. After liposuction, the second step involves the preparation of the adipose tissue. During the preparation phase, the fat sample is transferred in a 10 cc syringe for centrifugation (see **Figure 3b**). The syringe is centrifuged for 2– 3 minutes at 3000 rounds per minute (800 g) to separate out oils, debris, water (including lidocaine or adrenaline, saline and blood) and a layer of cell pellets/ residue from the cellular fraction. In the syringe, three layers will be visible: the oil layer at the top, cellular fraction in the middle, and cellular debris and red blood cells at the bottom (see **Figure 3c**). The segregated cellular fraction, composed of adipocytes and stromal vascular cells, is transferred to a small 1 cc syringe. The third and last step consists of the injection into the predetermined spots in the base of the tongue. Using a needle, the side of the tongue is perforated, and the injection cannula is introduced. The dominant hand is used, or the injection is performed on cannula retraction in a three-dimensional "fan pattern." The aim is to transfer small aliquots of fat with multiple passes at different depths. The non-dominant fingers can be placed behind the tongue to control the process. It is helpful if the assistant pulls on the tongue (see **Figure 3d**). The same procedure is usually performed separately on both sides of the tongue. In general, we inject 10–15 cc of fat per session.

The lipofilling procedure can be carried out under local anesthesia or general anesthesia. Because 30–50% of the injected fat might be resorbed, and not too much fat can be injected at the same time, it is recommended to repeat the assessments,

*Lipofilling in Post-Treatment Oral Dysfunction in Head and Neck Cancer Patients DOI: http://dx.doi.org/10.5772/intechopen.101824*

#### **Figure 3.**

*The procedure of a lipofilling injection. (a) Fat harvest from the abdomen, (b) fat substance, (c) syringe with fat after centrifugation, (d) injecting fat into the base of tongue.*

approximately 2–3 times. Preferably, between every injection procedure there is a period of 3 months to wait for the (positive) effect of the injection.

#### **5. Short-term outcomes**

In the last few years, different studies, primarily case reports, have been published about the use of lipofilling in patients with chronic dysphagia due to HNC (treatment) [38, 49, 50]. Navach et al. [49] reported about a 58-year-old patient with impaired swallowing after treatment for a nasopharyngeal carcinoma. This patient complained about dysphagia, the loss of body weight, aspiration pneumonia, and frequent episodes of bronchitis. A VFSS was conducted where a lack of bolus compression, asymmetry of the lingual movements, stagnation in the valleculae, lack of projection of the base of tongue, and more were visualized. The patient received 7 months of speech and language therapy to improve mobilization and strengthening of the swallowing muscles. The treatment improved the preparation and presentation of the bolus, although it was not sufficient enough. After 6 weeks, another VFSS showed a worsened bolus stagnation in the valleculae and at the base of tongue. This patient received a lipofilling injection in the base of tongue, which was performed following Coleman's procedure. In total, 5 cc of fat was injected into both sides of the base of tongue. After surgery, the patient experienced an improvement in swallowing, and minimal post-operative swelling was reported. A new VFSS was

made 1 month after surgery, showing an improved swallowing mechanism due to greater elevation of the base of tongue, the effective elevation of the larynx, and an improved closure of the larynx. After 3 months, the swallowing function was still stable, and the patient gained body weight.

In our institute, a study was performed by Kraaijenga et al., to investigate the feasibility and potential value of lipofilling in HNC patients with post-treatment oropharyngeal dysfunction [38]. This case series included seven patients. One patient dropped out of the study because of progression and therefore, he chooses a total laryngectomy procedure. Pre-assessment of the six remaining patients included VFSS, MRI, and the SWAL-QOL measurements. VFSS showed penetration and/or aspiration in all but one patient. Reduced or absent contact between the base of the tongue and pharyngeal wall was seen in all six patients. This reduced or absent contact resulted in residue above and below the hyoid bone. MRI showed volume loss or atrophy of the tongue in five patients. Two patients had reduced tissue of the tonsillar in the right tonsillar arch. The lipofilling session was performed using the Coleman technique. Patients received two to three injection sessions at 3-month intervals. In total, 20–35 cc adipose tissue was transplanted in all patients. No complications, such as necrosis, infection, swelling, or edema, were observed. The follow-up took place 1–3 months post-surgery. VFSS showed that four patients had improved swallowing function, and two of them were no longer feeding tube dependent. The MRI showed increased tongue volume with the injected fat spread out at the base of tongue. The SWAL-QOL showed improved quality of life in almost all patients.

Recently, Ottaviani et al. [50] published a case report about a 76-year-old patient with severe chronic dysphagia who had undergone a horizontal supraglottic laryngectomy and adjuvant radiotherapy. FEES showed a mobile right arytenoid and tissue loss in the base of tongue. VFSS demonstrated constant intra-swallowing aspiration and moderate pooling of food at the base of tongue with post-swallowing penetration and aspiration. The patient received 6 months of speech therapy focused on muscle strengthening and postural compensation techniques. The intervention turned out insufficient, and therefore, lipofilling injection was offered as a treatment option. The surgery was performed following the Coleman technique, and 5 cc was injected into the base of tongue. Intraoperatively, FEES was performed and demonstrated an improved swallowing function. However, trace aspiration for liquid textures and minimal residue was seen. After 1 week, FEES demonstrated only aspiration for liquids. After 1 month, the VFSS showed mild to moderate dysphagia. These results were also stable at 6 months post-surgery.

These three studies showed that lipofilling might be an effective treatment for HNC patients with chronic dysphagia. No complications were reported, and therefore, lipofilling seems safe [38, 49, 50]. Many patients showed improved objective and subjective swallowing function after lipofilling. Nevertheless, it remains difficult to predict how much fat will be resorbed and thus how long a therapeutic effect will persist. With the Coleman technique, absorption of fat seems to be reduced to some extent [32, 33]. In general, after 20–30 cc injections (in 2–3 procedures), positive effects are seen. However, sometimes repeated injections might be needed to achieve and hold a therapeutic effect. Hopefully, the injected tissue may also become less fibrotic, and no further injections are needed. Until now, there is no large data available yet, supporting this hypothesis.

#### **6. Case reports**

To give a better insight into lipofilling and how it can be used in post-treatment swallowing problems in HNC patients, three cases will be described in detail (see


*Abbreviations: M = male, F = female; TNM = classification of Malignant Tumors; RT = radiotherapy; CRT = chemo radiotherapy; No. = number of injections.*

#### **Table 1.**

*Characteristics of the three selected case reports.*

**Table 1**). Patients' pre lipofilling objective and subjective swallowing function are analyzed and compared with the swallowing function after the last lipofilling (short-term results) and between 2.5 years and 5.8 years after the last lipofilling treatment (long-term results).
