Fat Grafting for Treatment of Burns, Burn Scars, and Other Difficult Wounds

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Key points

  • The use of fat grafting has changed our practice dramatically, mainly in relation to our previous routines of using immediate excision and grafting in burns of the hands and in relation to our early (practically the immediate day after admission) use of muscle flaps for exposed bone fractures in patients who were traditionally referred (6–8 weeks after the original injury) from a local state hospital with subacute wounds and open fractures of the middle or lower third of the leg.

  • Fat grafting

Overview

Fat grafting has been used worldwide taking advantage of the benefits of adipose-derived stem cells (ADSC's) for regenerative purposes and their ability to differentiate in fat, bone, cartilage, muscle, and possibly other tissues. They also have a great variety of regenerative and metabolic properties, and growth factors (eg, epidermal growth factor, transforming growth factor-β, hepatocyte growth factor, platelet-derived growth factor, basic fibroblast growth factor). Fat on the lipoaspirate

Treatment goals and planned outcomes

The use of fat grafting as an adjuvant treatment in acute and subacute burn wounds and in chronic vascular wounds (venous insufficiency or diabetic arterial disease) takes advantage of fat’s benefits: a variety of metabolic and regenerative properties, increasing vascularization, and enhancing the tissue regeneration process. When these wounds are treated with repeated fat grafting (15–21 days apart), healing is the planned outcome.13, 14, 15

When treating burn scars, the objective is to

Preoperative planning and preparation

Patients with subacute burn wounds (more than 3 weeks in our Service without apparent progression to healing), open fractures of the tibia, associated to nonhealing or poorly healing wounds, chronic venous insufficiency, or diabetic arterial disease wounds are selected for adjuvant treatment with fat injection. In open wounds, injections are performed under general anesthesia, in 15- to 21-day intervals.

Patients with hypertrophic scarring after healing of a burn or keloids of any origin are

Patient positioning

Patients are supine when using the abdomen or thighs as donor areas or on lateral decubitus when obtaining fat from the lateral upper thighs. Fat is usually injected while the patient is supine.

Procedural approach

Fat harvesting and fat injection are sterile surgical procedures and should be performed only in accredited operation rooms under rigorous, completely sterile technique. In patients with scars (healed wounds), the donor area and recipient area are individually prepared and draped in the usual manner. In patients with open, nonhealed wounds, the recipient area is prepared only after the planned amount of fat is obtained, while it is being centrifuged and distributed in various syringes.

Fat is

Infection

Although infection is a common complication in burn and other trauma wounds, we have experienced no complications related to infection, even with injections through burn and other wounds and with fat deposited over the wound. We recommend, however, in wounds that are heavily contaminated, a debridement 2 days before the fat injection procedure.

Fat Grafting Technique or Procedure

Complications in fat grafting may be related to the procedure or technique themselves, mostly because of physical trauma to underlying structures by the

Postprocedural care

In wounds, a closed dressing is applied with a first layer of petroleum jelly gauze, followed by several layers of fine mesh gauze that are soaked with double-strength Dakin solution (Henry Drysdale Dakin, 1880–1952, English chemist). A bandage finishes the dressing. Dressings are changed every 2 days. In scars, a piece of paper tape is placed on the puncture sites (Fig. 7).

Rehabilitation and recovery

During treatment, patients are followed by the entire dedicated team. Support from all related paramedical specialties is constantly provided. In most of the burn sequelae cases, fat grafting is used as a measure to bring relief in scar hypertrophy and restriction. It has proved to be very efficient, occasionally avoiding and frequently postponing scar removal reconstructive procedures.

As part of their rehabilitation and our goal to attain full patient recovery, reconstructive procedures aiming

Outcomes

All 240 patients with burn or trauma wounds treated with this technique healed. Of the 42 patients with venous or diabetic ulcers, 40 healed. The two unhealed patients were a 68-year-old woman with an 8-year-old venous ulcer on the right leg who lost the skin graft 15 days after the procedure while at another institution (she had two successful injections, which led to a initially successful skin grafting; see Fig. 5); and, a 72-year-old man with diabetes with one wound in the plantar area and

Clinical results in the literature

Several studies indicate that the SVF within the collected fat is richer in ADSC's, and some have warranted that the enrichment of fat grafting with cells from the SVFequals cell-assisted lipotransfer. Although there are apparent advantages in doing that, we believe that there are enough stem cells on the centrifuged fat to warrant the obvious benefits we have noticed on our patients who were treated with the Coleman technique.21, 22, 23, 24, 25

Enriching fat grafting with platelet-rich plasma

Summary

Fat grafting as an adjuvant treatment of burn and other wounds favors healing, while decreasing the usual healing time and fostering lesser to practically no hypertrophic scarring. When used under scars or immediately over joint spaces it diminishes fibrosis, diminishing scar thickness and allowing for more pliability of the skin and for recovery of the joint normal spaces. It may also favor bone formation aiding in bone fractures and segmental bone loss recovery.

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