Facial Soft Tissue Augmentation Using Lateral Thoracic–Based Free Flaps in Autoimmune-Related Facial Lipoatrophy

BACKGROUND: Facial soft tissue atrophy secondary to autoimmune disease poses a unique reconstructive challenge. Conventional methods such as fat grafting and alloplastic augmentation often yield unsatisfactory results in this population owing to chronic inflammation, immunosuppressive therapy, and progressive tissue destruction. This study presents clinical outcomes of facial soft tissue augmentation using lateral thoracic-based free flaps-specifically the serratus anterior muscle (SAm) flap and the thoracodorsal artery perforator (TDAP) flap-in patients with autoimmune-related facial lipoatrophy. METHODS: A retrospective review was performed of 7 consecutive patients who underwent facial soft tissue augmentation using SAm or TDAP flaps between 2012 and 2025. All patients had autoimmune disease-related facial lipoatrophy. Flap selection was guided by the presence of a skin defect, required volume, and pedicle length. Demographic data, operative details, complications, secondary procedures, and follow-up outcomes were analyzed. RESULTS: All 7 patients were female (mean age, 53.4 y). Underlying diagnoses included systemic lupus erythematosus with lupus panniculitis (n=3) and rheumatoid arthritis-associated panniculitis (n=4). The SAm flap was used in 4 patients and the TDAP flap in 3. The superficial temporal and facial vessels served as recipient vessels in 3 and 4 cases, respectively. The mean operative time was 150 minutes (range, 120-210 min). No flap-related complications were observed. Two patients developed mild brow ptosis, which was subsequently corrected. Secondary procedures were performed in 3 patients to address residual contour irregularities in areas adjacent to the flap. At a mean follow-up of 18.9 months (range, 12-36 mo), all patients demonstrated stable volume maintenance and satisfactory facial symmetry. CONCLUSIONS: Lateral thoracic-based free flaps offer a reliable and efficient approach for facial soft tissue augmentation in patients with autoimmune-related lipoatrophy. The SAm flap is well-suited for smaller defects without skin involvement, while the TDAP flap is preferable when a skin paddle, greater volume, or longer pedicle is required. Both techniques can be performed in the supine position with a concealed donor site and acceptable operative times.