Fat Injection From Filling to Regeneration

250
Part III • Clinical Applications • Skin
P osto p era ti ve C a re
A er at gra ing, the burn-scarred area is dressed with Steri-Strips all around; these remain in place or
1 week. T e patient is instructed to avoid placing signif cant pressure or rubbing on the area to limit dis-
location or migration o the injected at. T e incisions in the harvest and recipient sites are closed with
- nylon, and Reston sel -adhesive oam patches are applied to the harvest site.
C om p l i ca ti on s
We consider autologous at gra ing to be a sa e procedure with a low rate o immediate and late com-
plications, both at the local and systemic levels. We recently reviewed our case series o 1 patients
treated with at gra ing or di erent indications31 and ound no cases o intraoperative complications.
We encountered only one case o breast implant rupture in a patient who had undergone a previous mas-
tectomy and radiotherapy; this complication probably resulted rom direct trauma to the breast implant.
We did not f nd any cases o postoperative systemic complications, such as pulmonary embolism, sepsis,
deep venous thrombosis, or death.
With regard to local complications, among possible early donor site problems, only two hematomas oc-
curred. We recorded 83 cases o f brosis (local de ormation rom at harvesting, less than cm in diam-
eter) as late donor site complications.31 In the recipient site, our cases o in ection were noted, with no
skin necrosis observed. Our principle concern regarding the use o sharp needles was the potential or
accidental intravascular at injection, but this risk can be easily avoided by choosing the retrograde injec-
tion method. In our clinical experience using angiographic needles, we ound that edema and bleeding
o treated areas have been comparable to those detected using the standard technique, which are virtu-
ally nil.
We ound that hematomas could be managed with local compression. Local de ormities are more chal-
lenging to be addressed. In our experience, we observed only moderate cases that could be treated with
local massage to reduce deep f brosis and improve contour appearance. In three cases we observed a
more severe local de ormity in the donor site that required additional at gra ing to correct the contour
de ect. o prevent this complication, special caution should be exercised when harvesting adipose tis-
sue. Many radial movements should be used in an overall wide swath without passing repeatedly in the
same place to avoid causing a contour de ect. In thin patients or those who have previously undergone
liposuction, the typical donor sites may prove inadequate. T is can be overcome by a thorough clinical
examination to select a donor site that presents a more abundant adipose tissue reservoir.
S econ d a ry P roced ure
According to our protocol, this surgical procedure should be per ormed two to f ve times, with an inter-
val o 3 to 6 months between the operations, to renew the dermohypodermic layer.

251
Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
R esul ts
Fig. 18-2
At age 3 , this man had had second and third degree burns o the ace, upper arm, and trunk rom direct
f re exposure. At the time o his f rst lipostructure procedure, he was 3 years old.
Fig. 18-3
T ese sections were taken rom the patient’s le eyelids: the lower le lid (hematoxylin-eosin; magnif -
cation 4× ) and the upper right lid (hematoxylin-eosin; magnif cation 0× ) be ore his f rst lipostructure
treatment. T e staining shows the presence o f brous tissue in a reorganization phase, with no signif -
cant signs o regenerative activity. T e arrow indicates a hair section around which the supporting cell
activity seems necrotic.

252
Part III • Clinical Applications • Skin
Fig. 18-4
T e patient underwent three at gra ing treatments to le cheek, upper lip, le nasal ala, and le peri-
orbital region (a total o 17 cc was injected; 6 months later, cc was injected; 6 months later, 3 cc was
injected). He is seen 1 year a er the last treatment. T e improvement in skin color, consistency, pattern,
elasticity, and f rmness is evident. T e le nasal ala was repositioned downward by at gra ing alone,
without other surgical corrections.
Fig. 18-5
T ese tissue specimens were obtained 3 months a er the patient’s f rst at gra ing procedure. On the
le (hematoxylin-eosin; magnif cation 4× ), the skin is substantially normal, with rich vascularization.
T is rich vascularization is also shown on the right with a specif c stain (CD34, 4× ), which probably
indicates regenerative stimulation.

253
Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
Fig. 18-6
T ese sections were obtained during the same procedure. Above le (EE 0× ) shows clear, normal skin
sections and other skin sections with neoangiogenesis, and above right (EE; 0× ) one can see sweat
glands mixed with adipose tissue, indicating probable regeneration. Below, specif c staining highlights
the rich perigland vascularization (CD 4; magnif cation × ).
Fig. 18-7
When she was 0 years old, this woman had sustained second- and third-degree trunk burns rom direct
f re exposure. At the time o at gra ing treatment (lef ), she was 4 years old. She underwent two at
gra ing procedures (in which a total o 4 and cc was injected). Six months a er the second proce-
dure (right), one can see the improvement in color and retraction o the scars.

254
Part III • Clinical Applications • Skin
Fig. 18-8
When she was 9 years old, this woman received second- and third-degree burns o the ace, neck, trunk,
and upper arm rom direct f re exposure. At her f rst at gra ing treatment, the patient was 3 years old
(lef ). She underwent two treatments in the perioral region, cheek, and mandibular region (in the f rst
session, 1 cc was injected; months later, 10 cc was injected). T ree months a er the second treatment
(right), one can see the improvement in skin color and texture, lip retraction, cervical cords.
Fig. 18-9
When she was 1 year old, this woman sustained second- and third-degree lower limb burns rom ex-
posure to hot water. At the time o at gra ing, the patient was 18 years old (lef ). She underwent at
gra ing to the lateral side o her right thigh (1 cc was injected). wo months later (right), one can see
the improvement in skin color and texture.

255
Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
Fig. 18-10
When this patient was years old, she had second- and third-degree neck and thorax burns rom direct
f re exposure. At the time o treatment, the patient was 3 years old (lef ). She underwent at gra ing to
the cervical and thoracic region ( 9 cc was injected). Four months later (right), improvement in skin
color and homogeneity is evident, with a decrease in scar retraction.
Fig. 18-11
When she was 6 years old, this woman had direct f re exposure resulting in second- and third-degree
trunk burns. At the time o her f rst treatment, the patient was 7 years old (lef ). She underwent at
gra ing to the le lateral thoracic region (63 cc was injected; 3 months later, 3 cc was injected). T ree
months a er the second treatment (right), the improvement in skin color and homogeneity is evident, as
is the decreased scar retraction.

256
Part III • Clinical Applications • Skin
Fig. 18-12
When she was 17 years old, this woman sustained second- and third-degree burns in the dorsal area
rom direct f re exposure. At the time o her f rst at gra ing treatment, she was 31 years old (lef ). She
underwent three at gra ing sessions. Two months a er the last treatment (right), the improvement in
scar retraction and texture is evident.
Fig. 18-13
When she was years old, this woman sustained second- and third-degree thoracic burns rom hot
water exposure. At the time o her f rst treatment, she was 9 years old (lef ). She underwent at gra ing
to the right mammary region ( 0 cc was injected; months later, 1 cc was injected). One month a er
the second treatment (right), one can see the improvement in skin texture and homogeneity, as well as
in nipple position.3

257
Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
Fig. 18-14
When she was 33 years old, this woman had a acial burn on the le side rom a hot iron exposure and
no wounds on the right side. At the time o her f rst at gra ing procedure, the patient was 36 years old.
T ese MR images were obtained be ore and 3 months a er the f rst treatment. A er treatment (right),
the subcutaneous at o the le cheek is more homogeneous than be ore treatment (lef ). A er treatment,
the subcutaneous at o the le cheek is also more similar to the contralateral cheek. T ese f ndings may
suggest some structural rearrangement at this level. T e patient underwent three lipostructure treat-
ments (initially 3 cc was injected; months later, cc was injected; 9 months later, 4 cc was injected)
Clinically, 6 months a er the third treatment, improvement was evident in skin texture, so ness o the
subcutaneous at, elasticity, and in mimicry and acial expression on the a ected side. No signif cant
improvement was seen in skin color.

258
Part III • Clinical Applications • Skin
D i scussi on
Table 18-1 Data From Our First Case Series
Number o patients

160
Sex

1 4 emales, 36 males
Age at the time o injury

Average years (range 6 months to 6 years)
Age at the time o f rst injection

Average 3 . years (range to 67 years)
Vancouver Scar Scale (VSS) score at the time o f rst
injection (0-14)
Average 1 . years (range 10 to 14 years)
Number o treatments

Average 1.37 (range 1 to )
otal amount o harvested at

Average 3 cc (range to 0 cc)
Injected at

Average 4. cc (range 4 to 1 0 cc)
Follow-up

1 week, 1 month, 3 months, 6 months, and 1 months
Data rom our f rst case series are summarized in the table. At the last ollow-up, all patients agreed
that there was an improvement both in their subjective perception and in the actual appearance o the
burn scarred areas. T ey reported that they were pleased with their postoperative results because o the
improved so ness, elasticity, thickness, and pliability o the skin (see Figs. 1 - , 1 -4, and 1 -7 through
1 -13). Conf rming our clinical observations, the histologic sections o the burn scarred areas a er the
structural at gra ing procedure showed deposits o new collagen, an increase o local vascularization,
and hyperplasia o the skin layer. T e adnexal structures were almost like those o a normal tissue (see
Figs. 1 -3, 1 - , and 1 -6). MR showed the regeneration o skin and subcutaneous layer, with only
slight asymmetries and hypotrophy o so tissues in burned areas, i compared to the healthy side (see
Fig. 1 -14). No increase in signal or extra buildup o contrast agent a er injection o gadolinium was
ound. All patients treated with autologous at gra ing showed clinical and histologic improvement in
the damaged subcutaneous tissue.
Table 18-2 Clinical Scar Hardness Measured by Durometer (p Value < 0.05)
Durometer Mean Value
(preoperative)
Durometer Mean Value
(postoperative)
Case group

40.91 (DS 11. )

31.67 (DS 9.46)
Control group

33.7 (DS 10.94)

30.7 (DS 10.77)
In our subgroup we detected that scar hardness measured using a durometer showed a signif cant re-
duction between preoperative and postoperative values in the study group at 3 months o postoperative
ollow-up, whereas no signif cant reduction was observed in the control group (see the table above).

259
Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
Table 18-3 Clinical Preoperative and Postoperative Values, POSAS Parameters,
and p Values
Parameter

Mean (baseline)
Mean (at 3 month
follow-up)
p Value
Vascularization

.

.
< 0.0
Pigmentation
.

4.
< 0.0
T ickness

7

4.
< 0.0
Relie

4.

4.
< 0.0
Pliability

6.3

4.
< 0.0
Overall
.

4.
< 0.0
In the same subgroup, analyzing scores given to scars by both clinician and patient, we discovered a
reduction o a great deal o Patient and Observer Scar Assessment Scale (POSAS) parameters between
preoperative and postoperative values (see the table above).
T ese results depend on the raction o injected stem cells, representing the active regenerative com-
ponent in the transplanted tissue. T e almost complete regeneration and normalization o the skin
and o the subcutaneous tissue starts with the production o cytokines, angiogenic growth actors, the
ormation o new vessels, and the dif erentiation o stem cells in mature adipocytes. Hence, structural
at gra ing seems to improve the skin-hypodermic joint o the scar areas with an increase in the adi-
pose layer largely destroyed by burn injury and barely regenerated during the tissue repair process. T e
experimental observation o Brzoska et al33 on the epithelial dif erentiation o human adipose tissue-
derived adult stem cells is very interesting in the light o the clinical results o our study.
T ech ni ca l P ea rl s
• T e results o our experience are particularly promising and make the autologous gra ing o adipose
tissue, a minimally invasive and well-tolerated method, an e cient therapy in the treatment o burn
scars.
• T e high content o adult stem cells with dif erentiation potentialities on more cell lines and stimula-
tion o a neovascularization tissue could be the basis or the use o lipostructure also in the therapy o
pain ul hypertrophic scars and keloids.

260
Part III • Clinical Applications • Skin
REFERENCES
1. Willebrand M, Low A, Dryster-Aas J, et al. Pruritus, personality traits and coping in long-term ollow-up
o burn-injured patients. Acta Derm Venereol 84:375, 4.
. Malen ant A, Forget R, Papillon J, et al. Prevalence and characteristics o chronic sensory problems in
burn patients. Pain 7:493, 199 .
3. Shapiro Y, Epstein Y, Ben-Simchon C, et al. T ermoregulatory responses o patients with extensive healed
burns. J Appl Physiol Respir Environ Exerc Physiol 53:1 19, 198 .
4. Cole JK, Engrav LH, Heimbach DM, et al. Early excision and gra ing o ace and neck burns in patients
over years. Plast Reconstr Surg 1 9:1 , .
5. Carr-Collins JA. Pressure techniques or the prevention o hypertrophic scar. Clin Plast Surg 19:733, 199 .
. Carney SA, Cason CG, Gowar JP, et al. Cica-Care gel sheeting in the management o hypertrophic scar-
ring. Burns :1 3, 1995.
7. Boyadjiev C, Popchristova E, Mazgalova J. Histomorphologic changes in keloids treated with Kenakort. J
rauma 38: 99, 1995.
8. Alster CS, Williams CM. reatment o keloid sternotomy scars by the 585 nm ashlamp-pumped pulsed-
dye laser. Lancet 345(8959):1198, 1995.
9. Norris JE. Superf cial x-ray therapy in keloid management: a retrospective study o 4 cases and literature
review. Plast Reconstr Surg 95:1 51, 1995.
1 . Lawrence W . In search o the optimal treatment o keloids: report o a series and review o the literature.
Ann Plast Surg 7:1 4, 1991.
11. Harrop AR, Ghahary A, Scott PG, et al. Regulation o collagen synthesis and mRNA expression in normal
and hypertrophic scar f broblasts in vitro by inter eron-gamma. J Surg Res 58:471, 1995.
1 . Ehrlich HP. T e physiology o wound healing. A summary o normal and abnormal wound healing pro-
cesses. Adv Wound Care 11:3 , 1998.
13. Miller C. Cannula Implants and Review o Implantation echniques in Esthetic Surgery. Chicago: T e
Oak Press, 19 .
14. Lamme EN, Van Leuwen R , Brandsma K, et al. Higher numbers o autologous f broblasts in an artif cial
dermal substitute improve tissue regeneration and modulate scar tissue ormation. J Pathol 19 :595, .
15. Rigotti G, Marchi A, Galiè M, Baroni G, Benati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment
o radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived
adult stem cell. Plast Reconstr Surg 119:14 9, 7.
1 . Gimble JM, Katz AJ, Bunnell BA. Adipose-derived stem cells or regenerative medicine. Circ Res 1 :1 49,
7.
17. Hsu VM, Stransky CA, Bucky LP, et al. Fat gra ing’s past, present, and uture: why adipose tissue is
emerging as a critical link to the advancement o regenerative medicine. Aesthet Surg J 3 :89 , 1 .
18. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a source o multipotent stem cells. Mol Biol Cell
13:4 79, .
19. Strem BM, Hicok KC, Zhu M, et al. Multipotential di erentiation o adipose tissue-derived stem cells.
Keio J Med 54:13 , 5.
. ateishi-Yuyama E, Matsubara H, Murohara , et al. T erapeutic angiogenesis or patients with limb isch-
aemia by autologous transplantation o bone-marrow cells: a pilot study and a randomised controlled
trial. Lancet 3 (9331):4 7, .
1. Kocher AA, Schuster MD, Szabolcs MJ, et al. Neovascularization o ischemic myocardium by human
bone marrow–derived angioblasts prevents cardiomyocyte apoptosis, reduces remodeling and improves
cardiac unction. Nat Med 7:43 , 1.
. Otani A, Kinder K, Ewalt K, et al. Bone marrow-derived stem cells target retinal astrocytes and can pro-
mote or inhibit retinal angiogenesis. Nat Med 8:1 4, .

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Chapter 18 • Scar Remodeling With Fat Gra ting A ter Burn Injury
3. Patrick CW Jr. issue engineering strategies or adipose tissue repair. Anat Rec 3:3 , 00 .
4. Ibatici A, Caviggioli F, Valeriano V, Quirici N, Sessarego N, Lisa A, Klinger F, Forcellini D, Maione L,
Klinger M. Comparison o cell number, viability, phenotypic prof le, clonogenic, and proli erative poten-
tial o adipose-derived stem cell populations between centri uged and noncentri uged at. Aesthetic Plast
Surg 3 :9 5, 0 4.
5. Klinger M, Marazzi M, Vigo D, et al. Fat injection or cases o severe burn outcomes: a new perspective o
scar remodeling and reduction. Aesthetic Plast Surg 3 :4 5, 00 .
. Baryza MJ, Baryza GA. T e Vancouver Scar Scale: an administration tool and its interater reliability. J
Burn Care Rehabil :535, 995.
7. Hörl HW, Feller AM, Biemer E. echnique or liposuction at reimplantation and long-term volume eval-
uation by magnetic resonance imaging. Ann Plast Surg : 4 , 99 .
. Klinger M, Lisa A, Klinger F, et al. regenerative approach to scars, ulcers and related problems with at
gra ing. Clin Plast Surg 4 :345, 0 5.
9. Scherberich A, Beretz A. Culture o vascular cell in tridimensional (3-D) collagen: a methodological re-
view. T erapie 55:35, 000.
30. Caviggioli F, Forcellini D, Vinci V, Cornegliani G, Klinger F, Klinger M. Employment o needles: a di er-
ent technique or at placement. Plast Reconstr Surg 30:373e, 0 .
3 . Maione L, Vinci V, Klinger M, Klinger FM, Caviggioli F. Autologous at gra by needle: analysis o com-
plications a er 000 patients. Ann Plast Surg 74: 77, 0 4.
3 . Caviggioli F, Villani F, Forcellini D, Vinci V, Klinger F. Nipple resuscitation by lipostructure in burn se-
quelae and scar retraction. Plast Reconstr Surg 5: 74e, 0 0.
33. Brzoska M, Geiger H, Gauer S, et al. Epithelial di erentiation o human adipose tissue-derived adult stem
cells. Biochem Biophys Res Commun 330: 4 , 005.

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263
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St r uct ur al Fat Gr a t ing
or t he Regener at ion
o Ir r adiat ed issue
Alessandra Marchi, Alberto Marchetti, Gino Rigotti
263

264
Part III • Clinical Applications • Skin
generalized to the entire patient population; these e ects are now supported by long-term ollow-up.
Signif cant improvements were observed in patients with cutaneous ulcers and osteoradionecrotic com-
plications.
T e clinical results we achieved in these patients, combined with the extreme accessibility o lipoaspirate
obtained by minimally invasive procedures and the abundance o atty tissue in the body, indicate that
structural at gra ing or ischemic tissue regeneration is a particularly e ective technique, with great
potential or use in routine clinical practice.10
INDICATIONS
Fat gra ing is indicated or patients with progressive lesions a er radiotherapy. T ese patients are usu-
ally screened and objectively assessed based on the late e ects in normal tissues per subjective, objec-
tive, management, and the analytic (LEN -SOMA, or LS) scale,11,12 where grade corresponds to light
symptoms and grade corresponds to irreversible unctional damage. T ere are no specif c reasons or
patient exclusion rom therapy because o his or her LS score. T erapy is recommended when symptoms
are classif ed LS grade , including f brosis, atrophy, retraction, ulcers, and telangiectasias, accompanied
by itching and pain. T ere are no specif c limitations related to patient age and radiolesion site, but the
breast, with and without an expander or a prosthesis, is the most requent site. T ere ore the adminis-
tered radiation dose, time elapsed since radiation treatment, and the severity o symptoms associated
with the radiolesion (LS score) do not represent contraindications to at gra ing. T e elapsed time since
the end o radiotherapy and the f rst at gra ing session greatly varied in our series, rom months to
years. Fat gra ing to the irradiated breast should usually be per ormed at least to 8 months a er the
resolution o the immediate side e ects o radiation.
TECHNICAL GUIDELINES
Preparation
Preoperatively, the targeted area should be precisely identif ed and the number and locations o entry
points and direction o tissue injection tunnels def ned; these parameters can be ref ned during surgery.
T e goal is to achieve maximal uni ormity o distribution and to limit overlaps and gaps in tissue depo-
sition.
Harvest
A local anesthetic is used or harvesting atty tissue, with the patient under deep sedation. Antibiotics are
administered only once, minutes be ore the procedure. ypical donor sites include the medial aspect
o the knee, the abdomen, or the trochanteric areas, because these are requently a rich reservoir o atty
tissue. T e selected regions are inf ltrated with a cold saline solution, 5 ml with : , epineph-
rine and ml lidocaine .5%. Fatty tissue is harvested using a mm diameter blunt-tipped multihole
cannula, connected to a 5 cc Luer-Lok syringe. Aspiration must be done very gently, avoiding excessive
negative pressure. T e goal is to obtain very small clusters o lipoaspirate to improve the at take.13
Ref nement
When su cient tissue is harvested, the syringe is placed in a bowl or decantation.14 At the end o the
decantation, the upper layer o oil and the lower layer o residual liquid are discarded. T e at stored in
the 5 cc syringes is trans erred into a cc syringe or inf ltration.
Placement
With the patient under deep sedation, the lipoaspirate is injected with blunt cannulas to avoid per ora-
tion o veins and arteries. Vasoconstriction also minimizes the incidence o hematomas.

265
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
Cannulas
Usually Coleman style II and III cannulas are used, because they pass easily through f brous or irradiated
tissues.
Level
Usually, the lipoaspirate is injected along any available plane rom skin to bone, starting rom the pe-
riphery and approaching the lesion. I possible, the at is injected underneath the plane o the ulcer.
When treating radiotherapy side e ects o breast-conserving therapy, the lipoaspirate is distributed in
the in rapectoral, retroglandular, and subcutaneous layers, but never inside the mammary gland. For
irradiated implants, the correct plane in which at should be injected is between the capsule and the skin.
T is procedure should be per ormed cautiously so the implant is not damaged.
Volumes
T e quantity o atty tissue to be injected is a crucial issue, orcing the surgeon to consider numerous ac-
tors, such as the sti ness o the subcutaneous and glandular tissues; skin contraction is a critical actor.
T e quantity o atty tissue to be inf ltrated is decided case by case, with care taken to preserve some elas-
ticity within the treated area at the end o the procedure.15 It is essential to avoid placing too much pres-
sure on the inf ltrated lipoaspirate. As previously mentioned in the preparation paragraph, the pattern o
lipoaspirate distribution within the targeted area is critically important, because it ultimately maximizes
the uni ormity o distribution and contact with the surrounding tissue to acilitate gra take.13
Number of Treatments
T e number o treatments strictly depends on the initial clinical picture and on the patient specif c re-
sponse to at gra ing. In our experience, three to six treatments are su cient.
KEY TO TECHNIQUE
o increase the quality o the result a er at gra ing, it is important to maximize the contact o the
aliquot o at with the host tissues. Placement o minuscule quantities o lipoaspirate in each tunnel is
crucial to obtain satis actory results.15 Injection o large parcels o at o en results in the ormation o
oily cysts and/or macrocalcif cations. Although these may generate undesirable suspicion o recurrence
on subsequent imaging, these neo ormations can easily be distinguished rom malignant tumors. It is
essential to release the lipoaspirate as the surgeon withdraws the cannula to minimize the risk o arterial
or venous emboli.
o release f brotic scar tissue or tight retracting f bers, rigottomies are per ormed with a 4-gauge needle.
T is surgical step should be made very care ully without extensive resections or detachments that would
lead to the ormation o oily cysts. Besides, an aggressive use o the technique may determine bleeding
with the subsequent melting o the transplanted at and the production o a uid collection that needs
to be drained.10,16
POSTOPERATIVE CARE
Immediately a er the at gra ing procedure, ice is placed over harvesting areas to limit the development
o hematomas. A so bandage is applied over these areas. Ice is maintained or to 8 hours, and the
pressure bandage in the donor site is kept in place as long as needed, normally not longer than days.
In the immediate postoperative period, ecchymoses and small hematomas are o en present, but nor-
mally they disappear within to weeks. Irregularities can be avoided by using small diameter cannulas
and proper liposuction techniques. Pain in the donor area is generally well tolerated and does not cause
any unctional limitation.

266
Part III • Clinical Applications • Skin
R esul ts
Fig. 19-1
A

B
C

D
E
F
G

H
T is 5-year-old woman had undergone radiation treatment af er right ovarian cancer 44 years be ore,
at the age o 1. She complained o the relatively sudden development o an ingrowing, pain ul, secreting
ulcer o the sacrum (A) within the year be ore she presented to our service. A at graf ing procedure was
planned.

267
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
An intraoperative biopsy conf rmed the osteoradionecrotic lesion. In the f rst at gra ing session a total
o 40 cc was placed around and deep to the ulcer (B).
wo weeks postoperatively, a local worsening in the biopsy site was present (C), but months later an
e ective improvement o the in ammatory perilesional aspect was evident (D).
A second gra o 40 cc and a third one o 50 cc were per ormed (E and F). T e local aspect o the tissues
improved but the f stulas were still secreting. In a ourth procedure, 0 cc was distributed widely in the
tissues around the ulcers and deep to the lesion. Eight months later, the f stulas were not yet completely
healed but were no longer secreting (G).
A def nitive and stable result was seen at her -year ollow-up (H). T ere has been no recurrence o the
radiolesions and the pain has totally resolved.
Fig. 19-2, A-D
A

B
C

D
T is -year-old woman presented with a late sequela o a radiation treatment per ormed 30 years be-
ore, a er a Halsted mastectomy. T e patient had a severe radiolesion, with di use so tissue necrosis
and osteoradionecrosis o the underlying ribs (LS scale grade 4) (A and B).
T e operation began with administration o deep sedation with a laryngeal mask, but intubation was
urgently needed—because o the presence o severe f brosis, the patient’s thorax did not expand properly.
T ere ore we strongly recommend general anesthesia and intubation in such patients.
An intraoperative biopsy was per ormed f rst; it conf rmed radiodamage and excluded cancer recur-
rence. T e necrotic tissues were removed and a f rst transplant o 50 cc o lipoaspirate was per ormed,
with a concentric distribution pattern rom the periphery toward the center o the lesion (C and D).

268
Part III • Clinical Applications • Skin
Fig. 19-2, E-J
E

F
G

H
I

J
A er the f rst treatment, the in ammation around the ulcer was improved and the patient’s pain re-
solved, the ulcer at the biopsy site had clearly worsened. She was seen 3 months a er a second at gra -
ing session in which 50 cc was placed, and the radionecrotic rib was debrided. T e lesion was still pres-
ent, but the f rst signs o spontaneous healing o the necrotic tissue were observed (E and F).
A er a third 0 cc at gra ing session, an accelerated, spontaneous healing process was evident (G and H).
At -year ollow-up, no recurrence o the ulcer or pain was observed, the skin o the gra ed area was
so , and the texture had improved over time. T e patient’s objective LS score is now 1 (I and J).

269
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
Fig. 19-3
A

B
C
D
E

F
T is young woman underwent a nipple-sparing mastectomy and immediate breast reconstruction with
a def nitive not variable volume implant. A er the histologic results, a course o therapeutic radiother-
apy was administered. T e radiation damage resulted in a secreting f stula (A and B). When the patient
presented to our service, the f stula had been present or 8 months.
It is essential to per orm a bacteriologic investigation to exclude any bacterial contamination, which
requires removal o the breast implant. In this case, no bacterial growth was detected, and there were no
contraindications to at gra ing treatment.
T e patient then underwent a f rst at gra ing session and direct closure o the f stula suturing skin edges
(C and D). T e at was distributed around the f stula as well as on the entire breast sur ace, in multiple
layers between the capsule and the skin.
Six months later, the patient underwent a second at gra ing procedure. T e treatment led to resolution
o the radiodamage (E). T e thickness o the subcutaneous adipose layer had increased, providing so ,
elastic tissue coverage o the implant. T is resulted in a more natural breast ptosis (F).

270
Part III • Clinical Applications • Skin
Fig. 19-4, A-H
A

B
C

D
E

F
G

H
T is 56-year-old patient had undergone a Madden mastectomy in or invasive ductolobular car-
cinoma. A er radiotherapy she developed a Baker III capsular contracture. Cranial dislocation o the
implant, attening o lateral quadrants, skin stif ness and pain were present (A and B).

271
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
T e patient underwent two at graf ing procedures; at the second operation the implant was removed (C
through F). T e patient reported total resolution o pain and elimination o the oreign body sensation
that she had complained o be ore at graf ing.
Subsequently a third and ourth at graf ing procedure resulted in improved volume and breast contour.
T e total amount o graf ed at was 55 cc; the reconstruction was completed in 8 months (G and H).
Fig. 19-4, I-L
I

J
K

L
Six years postoperatively (I through L), good shape and volume symmetry are evident. T e right breast is
as sof and ptotic as the contralateral breast. T e reconstructed breast has responded like a normal breast
as the patient’s weight has changed.

272
Part III • Clinical Applications • Skin
Fig. 19-5
A

B
C

D
E

F
G

H
T is patient presented a challenge; she presented with signif cant radiation sequelae and a f stula in the
submammary old a er a superior external quadrantectomy (A through D). It was evident that there was
signif cant volume asymmetry, cranial retraction o the gland and o the surgical scar, redness, telangiec-
tasias, and sti ness o the skin, or an LS o 3.

273
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
T e patient underwent three at gra ing procedures in which a total o 5 0 cc was placed; a rigottomy
was also per ormed, and contralateral reshaping was per ormed to improve symmetry.
Six years postoperatively, the reconstructed breast has a natural appearance, skin texture and color are
almost normal, ptosis is reduced, and a satis actory elongation o the surgical scar is evident (E through
H). T e downward shi o the breast and elongation o the scar were produced by the rigottomy pro-
cedure. Resolution o pain occurred immediately a er the f rst two gra ing procedures. T e patient
reported that no pain or itching has recurred. Over time, an almost normal sensation o the breast has
been restored. Improvement o the telangiectasias is also evident. T e secreting f stula in the in ramam-
mary crease healed completely, with no recurrence.
C om p l i ca ti on s
T e complication rate associated with at gra ing o irradiated tissue is very low. In ection is very un-
common; the incidence is less than 0.5%. T is is probably a result o the antiin ammatory properties o
lipoaspirates, which have been shown to avor the blocking o -lymphocytes. Nevertheless, we strongly
advise prophylactic administration o an intravenous antibiotic 0 minutes be ore surgery begins.
Damage to veins or small arteries may result in ecchymosis and occasionally hematomas. o reduce the
incidence o these problems, the use o sharp needles in the breast should be avoided, even or injection
o a local anesthetic.
Oily cysts may occur in breast reconstruction with at gra ing; these can readily be corrected by direct
aspiration.
Radiologic imaging usually shows new calcif cations present, whether in total breast reconstruction or
breast-conserving therapy. T e morphologic aspect o calcif cation related to at gra ing is always clas-
sif ed as Bi-Rads and Bi-Rads , which indicates benign calcif cation and cannot be con used with the
linear, amorphic microcalcif cations typical o breast cancer.
D i scu ssi on
In our practice, the most requent application o structural at gra ing is in the treatment o breasts with
complications arising rom radiotherapy. Serious sequelae may occur even many years a er radiation.
We have encountered complications even 5 or 40 years a er a patient underwent radiotherapy. T is
conf rms the slow but progressive ischemic role o tissue damage rom radiotherapy. Common signs and
symptoms are ulcerative lesions o the thoracic wall, osteoradionecrosis o the underlying ribs, itching,
pain that is o en resistant even to morphine, unctional limitation o the upper limb, and a strong smell
that impairs the patient’s social li e.
In our patients, healing was complete a er an average o three sessions o at gra ing. T e quality o the
skin as well as the unctional capability improved over time. T e perilesional in ammatory aspect o the
ulcers and the pain decreased a er the f rst gra . Gradual debridement o the necrotic tissue or ribs was
per ormed during each surgical session when needed. In our series, all patients undergoing at gra ing
showed clinical improvement according to the LEN -SOMA scale.
Radiotherapy in breast reconstruction with both expanders and def nitive implants always a ects the ul-
timate outcome, resulting in various degrees o capsular contracture. In more severe cases, radiotherapy
can lead to so tissue thinning, wound dehiscence, or skin necrosis, with implant extrusion.

274
Part III • Clinical Applications • Skin
Breast-conserving therapy signif cantly benef ts rom adjunctive at gra ing treatment to restore breast
contour irregularities, correct residual gland retraction, o set breast volume def cits, and enhance skin
texture quality.
Although in our protocol an average o three at gra ing sessions are per ormed, the number o surgical
sessions may increase. Fibrosis generated by radiotherapy makes tissues tough and sti , and the amount
o gra ed at that can be injected at each session is low when compared with injection in nonirradiated
tissues. T e injection o a small quantity o at in ischemic tissue improves the at take. T e number o
surgical procedures is related to the severity o the radiation damage.
At the initial consultation, all patients are in ormed o the need or multiple sessions o at gra ing (typ-
ically three to six), and this should be rein orced be ore and a er each procedure. Sometimes a higher
resorption rate o the at occurs a er the f rst session. However, in an unpredictable way, at some point
the percentage o engra ment increases dramatically. It is as i the body is using the regenerative proper-
ties o the injected at in a f rst step, and only a er the tissue begins to regenerate is it possible to obtain
a permanent volume increase.
In all the breasts totally reconstructed with at even a er radiotherapy, one o the most striking e ects
is the recovery o skin sensation. T is is one o the most surprising aspects o the regenerative capacities
o gra ed at. Even many years a er mastectomy, patients report restoration o a sensitive breast a er
a series o at gra ing procedures. T is aspect, more than restoration o a symmetrical breast, tells the
patient that her reconstruction is complete.
At the beginning o our clinical experience, we processed at by centri ugation, but or the past years
we have transitioned to decantation. With both techniques we obtain three di erent layers in the har-
vested at: the oil on top, the purif ed lipoaspirate in the middle, and anesthetic/blood uids at the bot-
tom. T e lowest raction contains a pellet with the stromal vascular raction. We always discharge the oil
and the uids when they exceed 0% o the total amount, but we always keep the pellet, which is added
back to the viable lipoaspirate.
We believe that the onnard technique is very e ective in the treatment o the aging skin. In radiodam-
aged tissues, this technique is help ul when the skin is extremely thin, retracted, and adherent to the
thoracic wall, making it impossible to inject lipoaspirate. We inject nano at in retracting or hypertrophic
scars to so en and enhance the tissue quality.
In more severe cases associated with breast-conserving therapy or in delayed reconstruction a er total
mastectomy, we recommend the use o the external vacuum expansion system. T is device, when used
with correct patient compliance, produces tissue enlargement and increases vascularity in the recipient
site, improving scar retraction and reducing the total number o surgical/ at gra ing sessions necessary.17
When possible, we try to per orm a complete breast reconstruction with at without placing a breast
implant. T is technique has no substantial contraindications; its limits are the quantity o available atty
tissue and the patient’s willingness to undergo multiple surgical procedures and use the external expan-
sion system.

275
Chapter 19 • Structural Fat Gra ting or the Regeneration o Irradiated issue
C oncl usi on
Our enthusiasm or structural at gra ing is ever increasing. We routinely o er our patients the option o
at gra ing to resolve the late sequelae o radiotherapy and ischemic-based pathologies.
When patients are compliant with the necessary multiple surgical steps, we per orm total breast recon-
struction with at gra ing, without the use o implants or matrices or o invasive surgery with aps. T e
latest published reports conf rm the oncologic sa ety o the procedure.18-22
T ech ni ca l P ea rl s
• Fatty tissue is an abundant source o raw material or tissue regeneration through autologous trans-
plantation.
• Purif cation o atty tissue by centri ugation/decantation aims to enhance the action o multipotent
adipose stem cells present in the lipoaspirate.
• T e surgical procedure is simple and does not require special preoperative and postoperative patient
preparation or care.
• T ere are no specif c limitations to the number o procedures; the number o sessions can be estab-
lished based on clinical improvement.
• T ree to six sessions are normally su cient to obtain signif cant clinical results.
• It is crucial or the tissue deposition pathways to be geometrically uni orm within the targeted area to
achieve aesthetic results.
• T e homogeneous placement o minimal quantities o tissue along each tunnel minimizes the orma-
tion o oily cysts and/or calcif cations.
• T e external vacuum expansion system is a use ul tool or reconstruction o complex de ects.
• Rigottomies are o paramount importance. T ey help to release scar contracture, create space or the
at to be injected, acilitate repositioning o the in ramammary old, and create adequate breast ptosis
as needed.
REFERENCES
. Coleman SR. Hand rejuvenation with structural at gra ing. Plast Reconstr Surg 0: 3 ; discussion
4 , 00 .
. Billings E Jr, May JW Jr. Historical review and present status o ree at gra autotransplantation in plastic
and reconstructive surgery. Plast Reconstr Surg 3:36 , .
3. De Ugarte DA, Morizono K, Elbarbary A, et al. Comparison o multi-lineage cells rom human adipose
tissue and bone marrow. Cells issues Organs 4: 0 , 003.
4. Rydén M, Dicker A, Götherström C, et al. Functional characterization o human mesenchymal stem
cell-derived adipocytes. Biochem Biophys Res Commun 3 :3 , 003.

276
Part III • Clinical Applications • Skin
5. Gimble J, Guilak F. Adipose-derived adult stem cells: isolation, characterization, and di erentiation po-
tential. Cytotherapy 5:3 , 003.
. Rehman J, raktuev D, Li J, et al. Secretion o angiogenic and antiapoptotic actors by human adipose
stromal cells. Circulation 109:1 9 , 004.
. Cao Y, Sun Z, Liao L, et al. Human adipose tissue-derived stem cells di erentiate into endothelial cells in
vitro and improve postnatal neovascularization in vivo. Biochem Biophys Res Commun 33 :3 0, 005.
8. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment o radiotherapy tissue damage by lipoaspirate
transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 119:1409;
discussion 14 3, 00 .
9. Bentzen SM, T ames HD, Overgaard M. Latent-time estimation or late cutaneous and subcutaneous
radiation reactions in a single- ollow-up clinical study. Radiother Oncol 15: , 1989.
10. Rigotti G, Marchi A, Khouri RK. Minimally invasive autologous mastectomy incisionless reconstruction;
external expansion at gra ing and percutaneous scar release: a multicenter experience. Presented at the
Eighty-eighth Annual Meeting and Symposium o the American Society o Plastic Surgeons, Seattle, Oct
009.
11. Pavy JJ, Denekamp J, Letschert J, et al; EOR C Late E ects Working Group. Late e ects toxicity scoring:
the SOMA scale. Int J Radiat Oncol Biol Phys 31:1043, 1995.
1 . LEN SOMA scales or all anatomic sites. Int J Radiat Oncol Biol Phys 31:1049, 1995.
13. Khouri RK, Khouri RK Jr, Rigotti G, et al. Aesthetic applications o Brava-assisted megavolume at gra -
ing to the breasts: a 9-year, 4 -patient, multicenter experience. Plast Reconstr Surg 133: 9 ; discussion
808, 014.
14. Khouri RK, Rigotti G, Cardoso E, Khouri RK, Biggs M. Megavolume autologous at trans er: part II.
Practice and techniques. Plast Reconstr Surg 133:13 9, 014.
15. Rigotti G. Discussion: T e volumetric analysis o at gra survival in breast reconstruction. Plast Reconstr
Surg 131:19 , 013.
1 . Khouri RK, Smit JM, Cardoso E, Pallua N, Lantieri L, Mathijssen IM, Rigotti G. Percutaneous aponeurot-
omy and lipof lling: a regenerative alternative to ap reconstruction? Plast Reconstr Surg 13 :1 80, 013.
1 . Khouri RK, Rigotti G, Khouri RK Jr, et al. issue-engineered breast reconstruction with Brava-assisted at
gra ing: a -year, 488-patient, multicenter experience. Plast Reconstr Surg 135: 43, 015.
18. Rigotti G, Marchi A, Stringhini P, et al. Determining the oncological risk o autologous lipoaspirate gra -
ing or post-mastectomy breast reconstruction. Aesthetic Plast Surg 34:4 5, 010.
19. Rigotti G, Marchi A, Micciolo PR, et al. On the sa ety o autologous at gra ing or breast reconstruction.
Plast Reconstr Surg 130: 0 e; author reply 08e, 01 .
0. Klopp AH, Gupta A, Spaeth E, et al. Concise review: Dissecting a discrepancy in the literature: do mesen-
chymal stem cells support or suppress tumor growth? Stem Cells 9:11, 011.
1. Petit JY, Maisonneuve P, Rotmensz N, et al. Sa ety o lipof lling in patients with breast cancer. Clin Plast
Surg 4 :339, 015.
. Kronowitz SJ, Mandujano CC, Liu J, et al. Lipof lling o the breast does not increase the risk o recurrence
o breast cancer: a matched controlled study. Plast Reconstr Surg 13 :385, 01 .

Scl er oder ma
and Fat Gr a t ing
Guy Magalon, Aurélie Daumas,
Jéremy Magalon, Nolwenn Sautereau, Julie Veran,
Florence Sabatier, Brigitte Granel
S ys s s s (SS ) s ph sys u u s s h z by p s-
s v v s u p hy f b s s h b h bu s f y b y -
y. P v SS Eu p , p h s s us , s s b
. 6 .58 s s/ 0,000. SS s s y u s qu y w , w h s x
pp x y 3: . T p k s usu y u h f h .
T v s u p hy su s h v s b v s s ,
h , p v v s u p hy, p y s u , v f b s s,
w h subs qu u b . I sp s h v s u p hy, pp p v ss
p s u . T v s u s SS p s v s h
y sp s f b p ss w h p f b b s s
y f b b s s s h h u s x u x p s. T f b p ss
v v s y sk bu s s, u .1
R s h s h v b p v - h p s h
s h s SS h s, p u y pu y hyp -
s (PAH), pu y f b s s, s s.
I , v s s su h s u h b k s, s, PDE5 h b s
s f s - h py. O h v s u s su h s h p s s
(ERAs) p s s ( p s , p s y ) b us R y u ph -
wh f s - s , bu us s f s - pu y
hyp s . I s u s s /pu y f b s s, u supp ss v u s
, u y ph sph , y ph (MMF) z h -
p . F s - h py s s s (SRC) s b s s - v
zy h b s (ACE ).2
C h a p t e r 2 0
277

278
Part III • Clinical Applications • Skin
As a consequence, mortality in SSc disease has dramatically decreased in recent years. T us patients now
request treatment o the lesions o the ace and hands that are almost always present. T ese are a source
o social discom ort and disability, and they are not improved by drugs. o date, therapeutic interven-
tions in this disease are mainly based on the use o vasodilators or Raynaud phenomenon and digital
ulcers. Bosentan ( racleer), an ERA, may be prescribed to prevent ischemic digital ulcers. Unlike other
autoimmune diseases, steroids and other immunosuppressive drugs have limited clinical benef t in SSc.
No therapy has been shown to reverse or slow the progression o tissue f brosis or substantially modi y
the natural progression o the disease.3-8
Signif cant renewal o interest in the use o at gra ing or the restoration o all volume de ects was
observed a er the initial description o the LipoStructure®
technique by Coleman (see Chapter ). In
this chapter, we present the literature and our clinical approach using autologous adipose tissue in the
treatment o the ace and hands in patients with SSc.
F a t G ra f ti n g : A P romi si n g O p ti on f or T rea tment
o f th e F a ce i n S S c P a ti ent s
Involvement o the ace with associated oral complications, aesthetic changes, and impairment o the
patient’s sel -image is ound in more than 0% o patients with SSc.9-12 T e ace becomes amimic, cu-
taneous wrinkles disappear on the orehead, vertical urrows develop around the mouth as a result o
retraction o the skin, and the nose becomes sharp. Face and mouth changes also include lip thinning,
reduction o both the width o the mouth (microcheilia) and opening (microstomia), and xerostomia.
T ese changes inter ere with eating, speaking, and oral hygiene measures. Dental problems are common
in people with SSc or a number o reasons: tightening o the acial skin can make the mouth opening
smaller and narrower, which makes it hard to care or the teeth; dry mouth caused by salivary gland
damage speeds up tooth decay; and damage to connective tissues in the mouth can lead to loose teeth.
Facial mani estations are disf guring and lead to unctional, aesthetic, and social discom ort. T e high
requency o these mani estations, as well as the unctional disability and aesthetic burden they induce
in patients, underscore the need to o er therapeutic options that have been crucially lacking to date. Fat
gra ing has been used or the treatment o other sclerotic conditions, including localized scleroderma.
In 0 5 Del Papa et al13 f rst reported the benef t o at gra ing using the classic Coleman method to treat
f brotic perioral changes in 0 SSc patients with a cutaneous di use orm. A er at harvest and centri -
ugation, cc o processed lipoaspirate was injected in di erent sites around the mouth using a blunt
cannula. T is minimally invasive surgical procedure was reported to have a good sa ety prof le. T ree
months a er treatment, both the interincisive teeth distance and oral perimeter signif cantly increased
in these patients.
T e special context o SSc requires some modif cations to this approach, in particular the use o harvest
and implantation o smaller parcels o adipose tissue.14 T us microgra ing represents an evolution o the
art. Fat is harvested with a mm ( -gauge) cannula with openings o less than mm, which harvests
at lobules o about 600 microns. Processed lipoaspirate is then injected using a 0. mm ( -gauge)
placement blunt-tipped cannula. T e entire procedure is per ormed with the use o local anesthesia
(supplemented with conscious sedation i needed) and can be per ormed either on an outpatient or
inpatient basis.

279
Chapter 20 • Scleroderma and Fat Gra ting
SURGICAL TECHNIQUE
Fig. 20-1
C
D
E

F
A
B
T e steps o at microgra ing or the treatment o SSc o the ace are shown. Local inf ltration is done, in
this case, in the inner aspect o the knee (a pre erred site or harvesting) (A). A er an interval in which
the lidocaine takes e ect, microharvesting is per ormed with a closed system (B). T e lipoaspirate is
processed (as described under Purif cation). A local anesthetic is injected in the a ected areas o the ace
(C), and the entry point is punctured with a 1-gauge ( .8 mm) needle (D). Microgra ing is per ormed
with a 1 cc syringe and a 1-gauge ( .8 mm) cannula (E). T e at placement and quantities in this patient
(total 1.5 cc) are shown (F).
Sampling and Inf ltration
T e f rst step is anesthesia o the entry point with a 3 cc syringe and a 3 -gauge needle. An incision
is then made with a 14-gauge needle be ore inserting the inf ltration cannula o the same diameter
(14-gauge, mm). For inf ltration, we use a modif ed Klein solution containing 8 mg o lidocaine and
epinephrine 1:1, , with a wet technique. ypical harvesting areas include the abdomen, hips, and
inner knees; our pre erred location or small quantities is the inner side o the knees. Aspiration is per-
ormed using a 1 cc syringe with less than 1 cc o vacuum (less than 3 mm Hg).

280
Part III • Clinical Applications • Skin
Purif cation
wo techniques can be used or purif cation o the product:
• T e standard or at gra processing has or a long time been based on centri ugation. For mi-
cro at gra ing technique, we recommend 1 or minutes o centri ugation at 1 g. T e lower
raction containing the inf ltration liquid is removed. In our experience, there will be minimal oil
rom disrupted at cells.
• Filtration with the PureGra closed membrane f ltration system (PureGra , Solana Beach, CA)
can be used as an alternative. umescent uid, blood cells, debris, and oil are removed by this
system, leaving f ltered, purif ed, living at.
With both techniques, the pure atty tissue is trans erred through a Luer-Lok adapter rom the 1 cc
syringe into multiple 1 cc syringes or gra ing. o prevent air bubbles, a connector is f rst placed on the
1 cc syringe and primed with tissue be ore connecting to the 1 cc syringe.
Placement
T e entry points are anesthetized. T e skin barrier is punctured with a 1-gauge needle ( . mm diam-
eter) in the same direction in which the mini-cannula will be introduced ( 1-gauge, . mm). Adipose
tissue can be injected in all areas, but especially in the superf cial plane, as close to the skin level as can
be achieved without risk o irregularities. T e tissue can be implanted in several planes and in di erent
directions. T e microgra s are approximately 5 microns and contain only a ew hundred cells.
RESULTS
A
B
C
D
Fig. 20-2, A-D
T e results or three SSc patients who underwent micro at gra ing are shown at 6-month ollow-up. In
this 47-year-old patient with a di use cutaneous orm o the disease, micro at gra ing improved her
ability to open her mouth (A and B). A 5 -year-old patient with a limited cutaneous orm o the disease
(C and D).

281
Chapter 20 • Scleroderma and Fat Gra ting
Fig. 20-2, E-F
E
F
A 5 -year-old patient with a dif use cutaneous orm both show a decrease in the vertical urrows around
their mouths caused by retraction o the skin and trophic ef ects (E and F). T e aesthetic improvement
is evident in each woman.
Table 2 - Outcome Af er Fat Micrograf ing in the Faces o Patients With SSc
Inclusion
(baseline)
Months
(n = )
Change
( months / baseline)
p value*
6 Months
(n = 2)
Change
(6 months / baseline)
p value†
Mouth Handicap in Systemic Sclerosis Scale (MHISS) score/48
Mean (± SD)
Median [Q - Q ]
. (± . )
.5 [ 9 - ]
5. (± . )
4. [ 4 - 5]
– . (± . )
– . [– 4 - ]
.
. (± .9)
.5 [ 4.5 - ]
– . (± 5. )
– .5 [– 4.5 - – .5]
< .
Rodnan Skin Score on Face/3
Mean (± SD)
Median [Q - Q ]
.4 (± . )
. [ - ]
.9 (± . )
. [ - ]
– .5 (± . )
– . [– - ]
. 9
.9 (± . )
.5 [ - ]
– . (± .5)
– . [– - ]
.
Mouth Opening (mm)
Mean (± SD)
Median [Q - Q ]
. (± . )
5. [ . - . ]
. (± 5. )
. [ 4. - . ]
. (± . )
. [ . - 5. ]
. 4
. (± 5. )
. [ 4. - .4]
. (± 4.4)
.4 [ . - 5. ]
. 5
Xerostomia Inventory Questionnaire/55
Mean (± SD)
Median [Q - Q ]
4. (± .5)
9. [ - 45 ]
.4 (± .9)
. [ 9 - ]
– 5. (± . )
– 5. [– - – ]
. 5
. (± . )
4.5 [ - 4 ]
– 5. (± 4.9)
– 5. [– .5 - – . ]
. 4
Sugar Test (min:sec)‡
Mean time (± SD)
Median [Q - Q ]
:54 (± : 4)
: [ : - : ]
:45 (± : 4)
: 5 [ : 5 - 5: 5]
– : (± : )
– : [– :5 - – : ]
.5
(NS)
:45 (± :5 )
: [ :59 - : ]
– : (± : 9)
– :5 [– : - – : ]
.
Visual Analog Scale for Facial Pain/100
Mean (± SD)
Median [Q - Q ]
5. (± . )
.5 [9 - 5 ]
. (± .5)
. [ - 5 ]
– .5 (± 9. )
– . [– - ]
.44
(NS)
5. (± . )
. [ - ]
– 5. (± .5)
– .5 [– 45.5 - – 9.5]
.
*p value rom baseline to 3 months.
†p value rom baseline to 6 months.
‡Sugar cube test (time required to melt a sugar cube—27 mm long, 17 mm wide, 11 mm high—without crunching it).

282
Part III • Clinical Applications • Skin
T e minimally invasive at gra ing technique was used to treat the aces o 4 patients with SSc ( with
limited cutaneous orms) with acial handicaps def ned by the Mouth Handicap in Systemic Sclerosis
Scale (MHISS) with a score equal to or greater than 0, a Rodnan Skin Score o the ace equal to or
greater than , and maximal oral opening o less than mm. T e outcomes are summarized in the ta-
ble.15 No in ectious complications related to the procedure were recorded. A er liposuction, small areas
o bruising at the zones o at harvest were observed in patients and local pain reported in 3 patients.
Concerning the perioral at injection, small areas o bruising were observed (n = 3), pain (n = 3), peri-
oral sensitive mani estation (n = ) and trigeminal neuralgia (n = ), which spontaneously resolved in
a ew days. We observed a signif cant decrease in the mouth handicap score (MHISS) at 3 and months
a er the procedure. Secondary e cacy parameters evaluating perioral skin sclerosis with the Rodnan
Skin Score applied to the ace, maximum oral opening, sicca syndrome (assessed with the xerostomia
inventory questionnaire and the sugar test), and acial pain (assessed with a Visual Analog Scale) also
signif cantly improved at 3 and at months. T us this minimally invasive approach o ers new hope or
treatment o the ace in SSc patients.
A d i p ose T i ssue– B a sed T h era p y f or T rea tment
o f th e H a n d i n S S c P a ti ent s
Most SSc patients complain o disability in daily activities related to their hands, leading to social and
pro essional impairment. Hand disability has a multi actorial origin, with microvascular lesions, skin
sclerosis, tendon retractions, bone and articular involvement, and subcutaneous calcinosis. All these
lesions cause pain, unctional impairment, and aesthetic and psychological distress.16-18
VASCULAR INVOLVEMENT OF THE HANDS
Vascular dys unction, including Raynaud phenomenon, acrocyanosis (permanent ischemia), and sub-
sequently digital ulcers, with their potential complications (in ections, digital necrosis, autoamputation)
are a signif cant component o the pathogenesis o SSc. Raynaud phenomenon occurs in almost all pa-
tients with SSc (9 %). Digital ulcers, def ned as necrotic lesions that develop either at the distal aspects
o the digits or over bony prominences, occur in up to 0% o patients and are o en recurrent.
SKIN INVOLVEMENT OF THE HANDS
Skin involvement is characterized by the variable extent and severity o skin thickening and hardening.
T e f ngers, hands, and ace are generally the earliest areas o the body involved. As the disease pro-
gresses, however, the skin loses its ability to stretch and becomes shiny as it tightens across the underly-
ing bone. Eventually, in severe cases, the f ngers may lose the ability to move, and it can become di cult
to extend the f ngers, leading to claw de ormities.

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Chapter 20 • Scleroderma and Fat Gra ting
BONE AND JOINT INVOLVEMENT OF THE HANDS
Distal phalangeal resorption with bone loss (acroosteolysis) can be observed in SSc. Arthralgia and ar-
thritis are observed in about % o cases. Metacarpophalangeal and proximal interphalangeal arthritis
are also requently present. T is joint destruction is not as severe as it is in rheumatoid arthritis, but it
can lead to f nger de ormities and disability.
T ere is little available in terms o medical therapy to improve hand unction. In view o the current
disappointing status o available pharmacological agents mainly based on vasodilator drugs, cold and
trauma protection, and physiotherapy, regenerative medicine represents an alternative option.19,20
Bank et al21 reported the use o at gra ing or the treatment o re ractory Raynaud phenomenon in
patients, o whom had SSc. welve patients had previously received botulinum toxin injections, and
patients had undergone prior sympathectomies. Abdominal at was harvested using the Coleman
technique. A er processing, approximately cc o purif ed at was injected with blunt cannulas: to
cc in the dorsum o the hand, to cc in the snu
ox, to cc in each dorsal webspace, to cc
along the superf cial palmar arch, to cc in the volar webspace, and to cc and to cc in the f rst
webspaces. T e average postoperative ollow-up was 7. months (range . to . months). Postoper-
ative f ndings included reduced pain, a decrease in the number, duration, and severity o Raynaud phe-
nomenon attacks, and a decrease in the number o ulcerations. T ree patients had no changes, and the
procedure was later repeated. wo patients had minor complications: one developed a cellulitis requiring
antibiotics and the other a transient numbness o the f ngers. For one patient, the second injection was
complicated by carpal tunnel syndrome.
Del Papa et al22 reported the e cacy o at gra ing or the treatment o chronic, poorly responsive
SSc-related ischemic digital ulcers. Fi een patients were enrolled in the study; each had a long-lasting
digital ulcer (at least months) in one f ngertip that was unresponsive to intensive systemic and local
treatment. Fat was harvested through liposuction rom subcutaneous abdominal adipose tissue under
local anesthesia and was then centri uged. A total o . to cc o the processed lipoaspirate was injected
at the base o the a ected f nger by sequential introduction o small aliquots in di erent directions rom
the injection site under local anesthesia. Ulcer healing was observed in all patients a er an average o
. weeks (range to 7 weeks) a er the procedure. T e result lasted during the 6-month period o
ollow-up. A signif cant reduction o pain intensity was observed; each patient also received analgesics.
No side e ects were observed.
Because o skin f brosis and skin tightening, we considered micro at gra ing in the f ngers to be too risky
because the potential or ischemia related to the volume e ect. T us we proposed the use o adipose-
derived stromal vascular raction cells (ADSVF) cells, obtained through enzymatic digestion o adipose
tissue with the Celution System (Cytori T erapeutics, San Diego, CA),23,24 which allows isolation o a
uid- and cell-enriched solution. Data rom in vitro and in vivo experimental models and rom early
clinical trials in diseases with vascular involvement and/or immune dys unction show combined proan-
giogenic, antiin ammatory, antif brotic, and immunomodulatory e ects o the ADSVF. We per ormed
the f rst-in-humans open label clinical trial using ADSVF or the treatment o hand disability on SSc
patients using the technique described above.25

284
Part III • Clinical Applications • Skin
SURGICAL TECHNIQUE
A

B

C
D

E

F
G

H

I
J

L
K
Fig. 20-3
Our surgical technique using ADSVF or the treatment o the hands is illustrated. Local anesthetic is in-
jected at the entry points (A), in this case, in the inner aspect o the knee (B). T e guidance hole is made
with a 1 -gauge needle (C). Microharvesting is per ormed with the closed Celution closed system in the
knee (D and E). en doses o 1 cc each (one or each f nger) o diluted ADSVF is prepared (F). T e entry
point is punctured with a 5-gauge needle (0.5 mm) (G). T e injection point or the thumb is located
at the level o metacarpophalangeal joint (H). With a 5-gauge (0.5 mm) rein orced cannula, 0. 5 cc o
ADSVF is injected into the subcutaneous tissue in contact with the neurovascular pedicles using a retro-
tracing technique (I through L), in which the cannula is inserted to 3 cm, depending on f nger length,
in the subcutaneous plane, and the injection o the SVF is made when the cannula is removed. T e in-
jection point or long f ngers is located at the union o palmar and dorsal sur aces at the level o the PIP
joints. As in the thumb, 0. 5 cc o ADSVF is injected using a 5-gauge (0.5 mm) rein orced cannula into
the subcutaneous tissue, using a retrotracing technique.

285
Chapter 20 • Scleroderma and Fat Gra ting
In the operating room, the harvesting o at and ADSVF injection were conducted with the use o con-
scious sedation; harvesting areas were anesthetized.
Sampling and Inf ltration
T e entry points are anesthetized with a 3 cc syringe and a 3 -gauge needle. For inf ltration, we use a
modif ed Klein solution containing mg o lidocaine and epinephrine 1:1, , with a wet tech-
nique. A er puncturing the guidance hole with a 14-gauge needle, inf ltration is per ormed with a mm
cannula in the knees, abdomen, and hips, and, i necessary, in the back. For collection we use a Khouri
1 -hole cannula, . mm long by 1. mm wide, or a standard Coleman harvesting cannula. Harvesting
was per ormed with a 1 cc syringe in a closed circuit with terminal 4 mm by mm openings with a
two-way nonreturn valve, sterile tubing, and a cc collection bag. Lipoaspirate is harvested using a
low vacuum. When the bag is f lled, it is placed in a sterile double pack and transported to the cell ther-
apy laboratory.
Purif cation
ADSVF was obtained within hours a er lipoaspiration using the Celution automated processing sys-
tem. issue is trans erred into the canister, then washed and rinsed with Ringer’s lactate at 37° C a er
which the processing enzyme is prepared and injected. On completion o digestion, the system auto-
matically washes and concentrates the ADSVF cells. A er centri ugation, . cc o ADSVF is collected
rom each side o the centri uge or a total o cc. T e cc is diluted into 11 cc o Ringer’s lactate, then
trans erred in 1 doses (1 cc), one or each f nger. otal viable nucleated cell recovery and viability per-
centages were determined using an automated cell counter. Cellular components were identif ed by ow
cytometry analysis with a panel o cell sur ace markers.
Placement
T e ADSVF cells were transported in a controlled ashion to the operating room. T e injection points
were marked on the edges o each f nger, at the junction o palmar and dorsal aces. Entry points
were per ormed using a -gauge needle ( . mm). ADSVF cells were then injected using a -gauge
( . mm) rein orced cannula placed into the subcutaneous tissue adjacent to the neurovascular pedicles:
. cc o the solution was injected into each lateral side o each digit, using a retrotracing technique,
rom distal to proximal. Entry points were positioned at the metacarpophalangeal joint or the thumb,
and the proximal interphalangeal joint where the palmar and dorsal skin joins or the long f ngers. T e
procedure continues on all f ngers o the f rst hand be ore proceeding with the same injections to the
other hand. Both hands were treated over approximately minutes.
o have maximal visibility when introducing the cannula, it is essential that a magni ying glass be used.
We have pre erentially used neuroleptanalgesia, which has been associated with a straight orward and
unremarkable postsurgical recovery.
Postoperative Period
Patients were discharged rom the hospital a ew hours a er the procedure. No dressing was required.
T e resumption o normal activities is possible immediately a er at gra ing.

286
Part III • Clinical Applications • Skin
RESULTS
100
90
80
70
60
50
40
30
20
10
0
Cochin Hand Function Scale (CHFS)
Hand pain: visual analogue scale (VAS)
Raynaud’s Condition Score (RCS) S4
Scleroderma Health Assessment
Questionnaire (SHAQ)
1,8
1,6
1,4
1,2
1,0
0,8
0,6
0,4
0,2
0
S
H
A
Q

(
/
3
)
C
H
F
S

(
/
9
0
)
,

h
a
n
d

p
a
i
n

V
A
S

(
/
1
0
0
)

a
n
d

1
0
×
R
C
S
S
4

(
1
/
1
0
)
Baseline (day 0)

2 months

6 months

12 months
Fig. 20-4
12-month follow-up for SSc patients receiving ADSVF injection
We conducted a phase I, open-label, single arm, and single study site clinical trial with a -month
ollow-up (SCLERADEC).25 In this study, SSc patients were enrolled rom December 0 through
May 0 3. All subjects had previously received an optimal treatment or digital vasculopathy, according
to the EULAR 009 recommendations. Patients were eligible i they were more than years old and
had a Cochin Hand Function Scale (CHFS) o more than 0/90. Subjects receiving regular physiother-
apy o the hands were asked to continue without any change during the trial. T e extended -month
ollow-up data have been published.26
olerance a er ADSVF gra ing into the 0 f ngers o SSc patients was good, with only minor adverse
events potentially related to the procedure: abdominal bruises induced by the lipoaspiration, tran-
sient paresthesia on the lateral side o the le f h f nger, and pain located on the lateral side o the
le thumb. T ese events spontaneously resolved in a ew days. Abdominal lipoaspiration sample points
healed in less than days a er the procedure, and the points o entry or ADSVF gra ing healed as soon
as day . ADSVF gra ing did not cause any digital ischemia or in ectious complication.
T e CHFS is a unctional disability questionnaire about daily activities validated in rheumatoid arthritis
and osteoarthritis, and recently in SSc.17 A er ADSVF gra ing into the 0 f ngers, a signif cant decrease
o the CHFS at , , and months was observed. Raynaud’s Condition Score (RCS) evaluated how
much the condition a ected patients’ use o their hands during the preceding week in terms o intensity
and requency o Raynaud phenomenon crises, pain, numbness, or other symptoms (scale 0 = no pain
or no unctional impact to 0 = maximum pain or unctional impact). A signif cant reduction o the
RCS rom baseline was observed at , , and months a er the procedure. Similarly, hand pain showed
a signif cant improvement o VAS or pain (0 to 00) at and months. T e VAS or pain remained
lower at -month ollow-up in comparison to baseline and approached statistical signif cance.
Grip strength, as assessed with a Jamar dynamometer, increased at and months a er the procedure.
Similarly, an increase in pinch strength “key pinch” at and months was observed. T e Kapandji
score did not change rom baseline to months but improved at months o surgery (p = 0.00 ). Lat-
eral range o motion o the f ngers increased at and months a er ADSVF injection.

287
Chapter 20 • Scleroderma and Fat Gra ting
Table 2 -2 Main Results and Outcome From Baseline to 6 and 12 Months Af er ADSVF Injection Into the
Fingers o SSc Patients
Baseline

6 Months
Change
(6 months - baseline)
p
Value*
2 Months
Change
( 2 months - baseline)
p Value†
CHFS Total/90
Mean ± SD
Median [min - max]
4 .5 ± .
4 .5 [3 . - 9. ]
. ± 5.4
. [ . - 4 . ]
– .3 ± .
– 3 . [– 5 . - . ]
.
4.3 ± 9.
.5 [ . - . ]
– 4. ± .
– .5 [– 5 . - . ]
< .

RCS/10
Mean ± SD
Median [min - max]
. ± .9
.5 [ .5 - . ]
.9 ± .4
3. [ .5 - 3. ]
– 4.3 ± .
– 4.5 [– . - – .5]
.
.5 ± .4
3. [ .5 - 4.5]
– 4.5 ± .
– 4.5 [– .5 - – .5]
< .

Hand Pain VAS/100
Mean ± SD
Median [min - max]
59.4 ± .
5 .5 [5 . - .5]
. ± 5.3
3. [9. - . ]
– 4 . ± .
– 44. [– . - . ]
< . 3 .9 ± .
4 . [ . - 9 . ]
– .5 ± 3 .
– 4. [– . - 5. ]
. 5
Jamar Score (kg)
Dominant hand
Mean ± SD
Median [min - max]
. ± 5.
5. [9. - .5]
9.4 ± .4
. [5. - 3 . ]
4. ± .4
3. [– . - . ]
. 33
.9 ± .4
9.5 [ . - 3 . ]
5. ± 5.
5. [ . - . ]
. 4
Non-dominant hand
Mean ± SD
Median [min - max]
4.9 ± .
4. [ . - 3 . ]
. ± .
. [3.5 - 9. ]
4. ± 3.5
3. [ . - 3. ]
.
9.3 ± .
. [ . - 3 . ]
5 ± 4
4. [ . - 4. ]
.
Pinch Score (kg)
Dominant hand
Mean ± SD
Median [min - max]
.3 ± .
.9 [ . - 4. ]
.3 ± .3
. [ .9 - 5.4]
. ± .
.9 [– . - 3.4]
. 9
5. ± .
5. [ . - 9. ]
. ± .9
. [– .5 - .5]
. 3
Non-dominant hand
Mean ± SD
Median [min - max]
.3 ± .9
.9 [ . - 3. ]
. ± .
. [ . - 3. ]
. ± .
.5 [– . - 3.4]
. 5
4. ± .
4. [ . - .5]
. ± .4
. [– .5 - . ]
. 3
Mean Circumference of Fingers (ring size) With Jeweler’s Rings
Dominant hand
Mean ± SD
Median [min - max]
.9 ± .
. [5 . - . ]
59. ± .4
. [5 . - 4.4]
– . ± .
– .3 [–4. - – .4]
< .
59. ± .
59. [5 . - 4]
– . ± .3
– . [– . - . ]
.
Non-dominant hand
Mean ± SD
Median [min - max]
. ± .3
. [5 . - 4. ]
5 . ± .
5 . [54. - . ]
– .5 ± .5
– .5 [– 4. - .4]
< . 5 . ± .9
5 .3 [55.4 - . ]
– .5 ± .
– . [– . - – .4]
< .

mRSS Applied to the Hands/ 8
Mean ± SD
Median [min - max]
.9 ± 4.9
.5 [3. - . ]
9.9 ± .
. [ . - . ]
– . ± .
– . [–5. - 4. ]
. 4
.4 ± 5.5
.5 [ . - . ]
– .5 ± 3.
– 3. [– . - 3. ]
. 4
SHAQ Score/3
Mean ± SD
Median [min - max]
.4 ± .3
.4 [ . - . ]
. ± .4
. [ . - .5]
– . ± .4
– . [– .5 - – . ]
.
. ± .
. [ . - .5]
– . ± .5
– . [– .5 - – .4]
.
*p value rom baseline to M6.
†p value rom baseline to M12.
p values were determined by paired Student’s t-test.
CHFS, Cochin Hand Function Scale; mRSS, Modif ed Rodnan Skin Score applied to both hands; RCS, Raynaud's Condition Score; SD, Standard Deviation; SHAQ, Scleroderma
Health Assessment Questionnaire; VAS, Visual Analog Scale.

288
Part III • Clinical Applications • Skin
ADSVF gra ing induced a signif cant reduction in the circum erence o the f ngers at , 6, and
months in both hands (measured with jeweler rings). T e assessment o skin involvement included
semiquantitative estimation (Modif ed Rodnan Skin Score applied to hand) o skin thickness, pliability
(hardness), and f xation to underlying structures (tethering). A decrease o skin sclerosis was observed
a er months o surgery. Among subjects having at least one digital ulcer (DU) at inclusion, total
number o DU decreased, rom 5 DUs at baseline, 0 at months, 7 at 6 months, and 9 at months.
Patients perceived their general health status also to be improved as shown by a reduction o hal o the
Scleroderma Health Assessment Questionnaire (SHAQ, score rom 0 = no handicap to = severe hand-
icap) at , 6, and months a er surgery, which was expected given that hand handicap plays a major
role in quality o li e.
D i scussi on
Micro at gra ing to the ace o SSc patients is a sa e and reliable procedure that reduces the disabilities
associated with the condition and improves the quality o the skin, mouth opening, xerostomia, and
acial pain.
Del Papa et al13 demonstrated the sa ety and easibility o at gra ing or SSc patients. T ey obtained a
signif cant improvement o the mouth opening capacity at months a er the procedure. In comparison
with our study, these investigators injected a similar mean quantity o purif ed at, and the statistically
signif cant increase o the maximum interincisive distance at months in the study o Del Papa et al
(mean + .6 mm) was very close to the one observed in ours (+ .7 mm). In our study, with a longer
ollow-up, the increase in mouth opening persisted at 6 months, with a clinical benef t elt by the patients
in their ability to speak and eat and in easier access or dental care.
We per ormed the microgra ing protocol, whereas Del Papa et al22 used the classic Coleman technique.
PureGra f ltration technique o ers a better at quality by reducing blood cell and ree lipid content,
with greater adipose tissue viability when compared with gravity separation and centri ugation methods.
T e improvement o acial handicap assessed by the MHISS questionnaire included the three domains:
reduction in mouth opening, sicca syndrome and aesthetic concerns (data not given). Interestingly, the
sicca syndrome decreased as illustrated by the improvement o the xerostomia inventory questionnaire
as well as the time to melt a sugar cube on the tongue. A long-term ollow-up o the unctional and aes-
thetic benef t o the lipof lling needs to be assessed. In addition, data would be use ul or determining
whether a second at gra ing session would urther increase benef ts.
Implantation o autologous reshly isolated ADSVF into the f ngers o patients with SSc has a avorable
sa ety prof le, with encouraging e cacy results. Single subcutaneous at gra ing has shown long-term
benef ts ( months) in reduction o hand disability, in Raynaud phenomenon severity, and sclero-
dactyly, and increases in strength and motion, consequently leading to improved quality o li e. Most
e cacy parameters were improved rom months a er the procedure, with benef ts lasting at least
months. It is notable that some scores (Kapandji, Modif ed Rodnan Skin Score applied to the hands)
that were not statistically signif cant at 6 months, became signif cant at months. T is suggests a possi-
ble continuous and progressive e ect o the cell-based therapy on skin f brosis.
ADSVF appears to counterbalance various pathological mechanisms involved in hand damage, particu-
larly ischemia and skin f brosis. Due to their pleiotropic e ects, ADSVF seems to be a promising therapy
or the hands o scleroderma patients. o conf rm these results, two randomized placebo-controlled
trials in a larger population o SSc patients are ongoing—SCLERADEC II (C NC 0 55 54 ) in France
and the S AR rial (C NC 0 96 ) in the United States.
T e clinical benef t could not be attributed to a specif c subpopulation o cells within the ADSVF; how-
ever, the dataset is insu cient to draw def nitive conclusions regarding attribution. Additional pheno-

289
Chapter 20 • Scleroderma and Fat Gra ting
typic and unctional characterizations o the ADSVF will help understanding the mechanisms support-
ing the clinical e ects o ADSVF.
Although at gra ing into the f ngers remains considered a risk or adverse events in the context o
SSc disease, Del Papa et al22 reported the sa ety and e cacy o at gra ing into the base o f ngers with
re ractory digital ulcers. T e authors attributed the benef t to the adipose tissue–derived cell raction
containing both adipose stem cells (reparative mesenchymal cells) and ADSVF.
In the uture it will be interesting to evaluate the combination o at gra ing with ADSVF or platelet-rich
plasma (PRP) or both f lling and correcting trophic e ects. By combining the LipoStructure technique
with the regenerative cell therapy tissue, gra longevity and positive e ect could be enhanced. In SSc
disease, applications could concern both hands and ace— or hands, the association o both ischemic
mani estations and mechanic ulcers related to skin tightening on bone relie , and or ace, optimization
o the regenerative e ect and a better survival o the gra ed at.
C oncl u si on
Oro acial mani estations and hand involvement resulting rom SSc disease lead to disability and im-
paired quality o li e or which current treatment options have limited e cacy. Micro at gra ing or the
ace and ADSVF injection or the f ngers are both easible and can be per ormed sa ely in SSc patients
with disability. Although still preliminary in terms o evidence-based medicine, data reported in the
literature and our own experience suggest that SSc can benef t rom at gra ing. Micro at gra ing into
the ace improves mouth opening and skin quality, with aesthetic benef t. Microinjection o ADSVF in
f ngers o ers a unctional and trophic e ect. T ese results support the use o at microgra ing or SSc
patients with acial handicap and autologous ADSVF in treatment o hand disability in patients with SSc.
Further placebo-controlled studies on a larger population o patients are ongoing and will help deter-
mine the place o ADSVF in SSc therapeutic approach.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
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C h a p t e r 2 1
T g g b p g p g
w g p b b f p - v (ADSC ) g v
p p b y , b g , p b y
. T j ( p ) g v y g v b
p p , w g w EGF, GF-b , HGF, PDGF, BFGF.1-4
T p b g g v by p q .
T p p b by p y by b b ,
p g b y, g g , w b
j / p b .
Ov y , w v p g v y g p b w
x w g g x w g g, y -
y w k g g. W p , yp y p w
g w w xp b , w w . I p , w w
p v ( ) b g y; y, w j y
w j v y. T v w v y y .
S y, w v g g g p ( b ),
p , w g v f b
. O p p f g g g
g g g yp p g
g g p , g g v p yp p y
w g .
r eat ment o Di icult Wounds
and Scar s Wit h Fat Gr a t s
Nelson Sarto Piccolo, Mônica Sarto Piccolo,
Maria T ereza Sarto Piccolo
291

292
Part III • Clinical Applications • Skin
I n d i ca ti on s f or F a t G ra f ti n g f or th e T rea tment
o f D i f f i cul t W
oun d s a n d S ca rs
Candidates or adjuvant treatment with a at gra ing procedure at our service are those with:
• Deep second- or third-degree burns o the hand or the oot
• Burn wounds that have had no apparent progression toward healing or or more weeks
• Subacute burns or other wounds within more than 6 weeks a er the accident, with or without
open wounds or ractures
• Hypertrophic scars that are not improving a er 6 or more weeks with the use o pressure gar-
ments or devices, or that are causing unctional de ormities
• De ormities around joints and their consequences resulting rom the development o f brosis
• Partial scar resections, when at is injected under the suture line, immediately a er the resection
is per ormed
• Filling o decubitus ulcers, avulsion injuries, and void spaces, with or without ap repair (elimi-
nating the use o suction drains)
M
a teri a l a n d M
eth od s
We use the Coleman technique in all procedures (see Chapter ). We repeat injections in wounds every
to weeks until healing or a def nitive procedure is per ormed, such as skin gra ing, a ap, or some
other operation. A er these wounds are healed, procedures using at gra ing through injections under
the scar and/or delivery to its sur ace are per ormed at -month intervals. In patients who present to us
when their wound is already healed, we also gra at to the hypertrophic scars that do not respond to
pressure; we per orm the gra ing at -month intervals, using similar techniques. In hypertrophic scars
that will lead to a unctional de ormity, at gra ing is per ormed as soon as the de ormity is diagnosed,
and these injections are repeated at -month intervals.5-7
OBJECTIVES OF TREATMENT
• Fat gra ing sessions to days apart are used in wounds to take advantage o at’s benef ts; the ob-
jective o treatment is to obtain healing o the wound.8-10
• When treating burns or other scars, the objective is to decrease the amount o hypertrophy (f brosis),
diminishing the scar thickness and increasing scar malleability. We also use this technique to decrease
f brosis around bone joints and to release tendon adhesions.11-13
ANESTHESIA
Procedures are per ormed with the patient under general anesthesia.

293
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
DONOR AREAS, INCISION SITES, AND VOLUME
We rotate among donor sites as needed. Fat is most requently obtained rom the abdomen, inner thighs,
or lateral upper buttocks. Incisions or introduction o the liposuction cannula are placed on the mid-
line, at the suprapubic crease, or medial to the emoral pulse, at the inguinal crease (with the patient
supine), or in the middle axillary line, at the upper border o the iliac bone (with the patient in the lateral
decubitus position).
T e actual volume o harvested lipoaspirate should be at least twice the anticipated volume that the
surgeon plans to inject, and at least our times this volume i the plan includes delivering at over the
wound. Fat is delivered by laying the prepared at directly over the wound or the scar that has been pre-
treated with a laser or microneedling. T e amount o at delivered or laid over the area is usually approx-
imately ml/ 0 cm2, and this at is covered with f ne mesh Vaseline®
gauze.
As an initial volume estimate, we consider that approximately cc o prepared (centri uged) at will
be needed or every 0 cm2 o wound area. One must also consider that on average, 0% to 40% o the
lipoaspirate is discarded as oily or aqueous ractions a er centri ugation.
PATIENT POSITIONING
Patients are placed supine when the abdomen or thighs are the donor areas or in the lateral decubitus
position when at is obtained rom the lateral upper thighs. Fat is usually injected while the patient is
supine.
PROCEDURE
Because at harvesting and gra ing are sterile surgical procedures, these should be per ormed only in
accredited operating rooms using rigorous, completely sterile technique. When necessary, shaving o
the pubic area or proximal thigh is per ormed in the operating room immediately be ore the procedure.
In patients with scars (healed wounds), the donor area and recipient area are individually prepped and
draped in the usual manner. In patients with open, nonhealed wounds, the recipient area is prepped
only a er the planned amount o at is obtained, while it is being centri uged and distributed in multiple
syringes.
Fat is harvested using a 0 cc Luer-Lok syringe attached to a mm cannula, with two mm side open-
ings distally. We use lengths o 0, 5, or 0 cm, depending on the harvesting site. T e cannula is intro-
duced through a No. 5 blade puncture incision.
In children weighing less than 5 kg, we pre er to use 0 cc syringes and multi (micro)–per orated can-
nulas, which will generate a higher negative pressure and a more even and e cient at harvesting, re-
spectively. Occasionally, in very small patients (our smallest patient weighed kg), it may be necessary
to harvest at rom more than one donor site.

294
Part III • Clinical Applications • Skin
Fig. 21-1
One or more distally plugged 10 cc syringes containing the lipoaspirate is centrifuged at 3000 rpm for
3 minutes in a 30-degree-angle centrifuge. T e resulting material will have a top layer of oil, a middle
layer of fat with the stromal vascular fraction (SVF) within at its lower portion, and an aqueous bottom
layer. T e top layer of oil is discarded while the plug is still on the syringe. T e plug is then removed and
the aqueous layer drains out by gravity. T e remaining compound is sequentially injected into insulin
syringes without the plunger, which is then replaced.

295
Chapter 21 • Treatment of Difficult Wounds and Scars With Fat Grafts
Fat Injection
Fig. 21-2
A

B
C

D
Fat is injected through a perforation made with a 6-gauge needle at an acute angle in healthy skin in the
periphery of the wound or scar. A 70 mm long cannula with a .8 mm outside diameter and a . mm
internal diameter, connected to a cc syringe, is inserted through the needle puncture hole and force-
fully driven immediately under the wound bed or the scar. (Patient , A and B, 0.8 cc of fat was injected;
patient , C and D, cc of fat was injected.)

296
Part III • Clinical Applications • Skin
Fig. 21-3
A

B
C

D
E

F
G

H
Fat is injected in a retrograde manner in several passes until the entire area has been covered, through as
many puncture sites as needed around the periphery of the scar or wound. An average of . to .0 cc is
injected per each 0 cm2 area; 5 to 30 passes are necessary to inject a total of cc. In chronic wounds,
fat is also injected under the indurated, “healed” area in the periphery of the remaining wound.14-17
(A through D, 0.3 cc of fat was injected in the ear and cc in the facial scars. E through H, in the same
patient, .5 cc of fat was injected in each wound and 0.8 cc to each wound.)

297
Chapter 21 • reatment o Di icult Wounds and Scars With Fat Gra ts
Fig. 21-4
T is 48-year-old diabetic woman presented with a venous ulcer that she had had or 3 ⁄2 years. T e size
and depth o the erythematous peripherally indurated area was signif cant. A er debridement o the
wound, 8 cc o at was injected under the wound. A needle roller was applied in all directions on the
indurated tissue. T en cc o at was delivered/laid over the indurated area (pretreated with micronee-
dling) and the wound. T is patient eventually had one more similar procedure per ormed 5 days later,
and a skin gra ing 3 days later, with healing occurring within 44 days o treatment.

298
Part III • Clinical Applications • Skin
Fat Delivery
Fig. 21-5
T is 3 -year-old patient was seen days a er a crush injury rom a motorcycle all with an in ected he-
matoma. Drainage and excision o necrotic tissue were per ormed. Fat gra ing ( cc) was per ormed on
day 1 , through the wound, inside the muscle septa and the muscle spaces, and delivered/laid over the
entire wound ( cc). Fat can occasionally be injected through the wound in larger areas or when there
are racture lines, bone-loss voids, or exposed bone. In such cases, at can be targeted to these specif c
areas.