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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.
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Fat grafting
Fat Grafting for Treatment of Burns, Burn Scars, and Other Difficult Wounds
Section snippets
Key points
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.
References (34)
- et al.
Neural differentiation of adipose-derived stem cells isolated from GFP transgenic mice
Biochem Biophys Res Commun
(2005) - et al.
Minimal criteria for defining multipotent mesenchymal stromal cells, the International Society for Cellular Therapy position statement
Cytotherapy
(2006) The technique of periorbital lipoinfiltration
Operat Tech Plast Reconstr Surg
(1994)Structural fat grafts: the ideal filler?
Clin Plast Surg
(2001)- et al.
Wound healing effect of adipose-derived stem cells: a critical role of secretory factors on human dermal fibroblasts
J Dermatol Sci
(2007) - et al.
La lipostructure dans les sequelles de brulures facials
Ann Chir Plast Esthet
(2012) - et al.
Fat grafting accelerates revascularization and decreases fibrosis following thermal injury
J Plast Reconstr Aesthet Surg
(2012) - et al.
Improvement of facial scar appearance and microcirculation by autologous lipofilling
J Plast Reconstr Aesthet Surg
(2014) - et al.
Playdoyer en faveur de la greffe adipocytaire de S.R. Coleman
Ann Chir Plast Esthet
(2001) - et al.
Development of micro-injection as an innovative autologous fat graft technique: the use of adipose tissue as dermal filler
J Plast Reconstr Aesthet Surg
(2012)
Multilineage cells from human adipose tissue: implications for cell based therapies
Tissue Eng
Human adipose tissue is a source of multipotent stem cells
Mol Biol Cell
Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose derived adult stem cells
Plast Reconstr Surg
Adipose-derived stem cells for regenerative medicine
Circ Res
Non-cultured autologous adipose-derived stem cells therapy for chronic radiation injury
Stem Cells Int
Basic science review on adipose tissue for clinicians
Plast Reconstr Surg
Long term survival of fat transplants: controlled demonstrations
Aesthetic Plast Surg
Cited by (69)
Use of autologous adipose tissue in acute burn wound management: A systematic review
2024, Annales de Chirurgie Plastique EsthetiqueComparison between platelet-rich plasma (PRP) and mechanically emulsified fat grafts in management of chronic wounds
2023, Asian Journal of SurgeryComparison of Conventional and Platelet‐Rich Plasma-Assisted Fat Grafting: A Systematic Review and Meta-analysis
2021, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :Among its advantages are an abundant source, ease of accessibility and harvesting, versatility, and nonimmunogenicity.1,2 Studies have highlighted the widespread use of fat grafting,2 including for tissue defect contouring, scar softening,3-5 and improving fibrosis.6 Despite its versatility and other advantages, the most challenging issue limiting autologous FG is its unpredictable survival rate.7
Adipose-derived stem cells for wound healing and fibrosis
2021, Scientific Principles of Adipose Stem Cells