Treatment of Chronic Posttraumatic Ulcers Using Autologous Fat Graft

Sir: Posttraumatic wounds are very common and often result in retracted, painful scars. Within these scars, some ulcerated areas tend to become chronic, significantly affecting the patient's quality of life. According to our clinical evidence (i.e., significant improvement in texture, color, softness, quality of skin and subcutaneous tissue, functional motility, and pain) and histologic findings (i.e., patterns of new collagen deposition, local hypervascularity, dermal hyperplasia, and regeneration of annexial structures),1–5 we performed scar remodeling by fat grafting in a large series of cases, including posttraumatic scar areas. From January of 2007 to April of 2008, we also treated eight patients with posttraumatic scars, presenting chronic, poorly responsive ulcers within the scar areas. In these patients, we accidentally observed not only the expected improvements, but also the unexpected, complete reepithelialization of the ulcers. All patients underwent only one intervention under continuous intravenous fentanyl infusion associated with local anesthesia. After tumescent infiltration of 100 ml of saline solution, 75 mg of levobupivacaine, 40 mg of mepivacaine, and 0.5 ml of epinephrine 1:1000, liposuction of the subumbilical area by means of a 10-ml syringe was performed. An adipose tissue sample of approximately 10 ml was obtained and processed following Coleman's technique (i.e., centrifuged at 3000 rpm for 5 minutes). A volume of 3 to 10 ml (average, 5.7 ml) was injected using an 18-gauge angiographic needle with a snap-on wing (Cordis, a Johnson & Johnson Company, Roden, The Netherlands) at the dermal-subdermal junction within all the scar area, including the edges and the central region of the ulcer. All patients were followed up at 2 weeks, 1 month, 3 months, 6 months, and 1 year after surgery. The patients (five men and three women) had a mean age of 37.4 years (range, 19 to 58 years). At the first visit, they had undergone medical advanced treatment without improvement for a mean period of 15.4 weeks (range, 12 to 18 weeks). Two weeks after fat grafting, complete reepithelialization was found in all patients. No complications occurred. Patient satisfaction was excellent. At 1-year follow-up examination, the tissue integrity was preserved (Figs. 1 and 2).Fig. 1.: Preoperative view of patient 3, a 52-year-old woman with a chronic ulcer of the knee following a domestic accident.Fig. 2.: Postoperative view of patient 3.The rapid improvement in wound healing and the complete reepithelialization of ulcers within the scar areas suggest that deep biological interactions between transplanted fat and dermal-subdermal structures occur very early. We also found that these results are stable over time. Our research1–5 and other evidence in the literature suggest an active role of adult mesenchymal stem cells from the stromal fraction of harvested fat, but it is uncertain how the molecular components and the surrounding microenvironment are involved in modulating scar remodeling. In conclusion, the treatment of posttraumatic ulcers by fat grafting is yielding encouraging results and, in our opinion, could become suitable in all types of ulcers (i.e., posttraumatic, vascular, and pressure ulcers), as an additional or alternative procedure, with low morbidity. Marco Klinger, M.D. Fabio Caviggioli, M.D. Valeriano Vinci, M.D. André Salval, M.D. Federico Villani, M.D. Cattedra di Chirurgia Plastica Università degli Studi di Milano U.O. Chirurgia Plastica 2 Istituto di Ricovero e Cura a Carattere Scientifico Istituto Clinico Humanitas Rozzano, Milano, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. There was no outside source of funding.