Autologous Fat Grafting in the Upper Extremity: Defining New Indications.

Autologous fat grafting is a commonly used technique in plastic surgery that can also be applied broadly in hand surgery. We present a case series to demonstrate the diverse indications for fat grafting in hand surgery.
Methods: We retrospectively reviewed cases of fat grafting in the upper extremity in 2020. Cases representing a unique application of fat grafting were identified. Patient data, including demographics, diagnoses, preoperative and postoperative assessments, complications, patient satisfaction, and surgical operative reports, were recorded.
Results: Five patients representing distinct indications for autologous fat grafting in the upper extremity were identified. Indications included hand rejuvenation (20.0%), burn/scar management (20.0%), tenolysis (20.0%), revision nerve decompression (20.0%), and carpometacarpal joint arthritis (20.0%). Average patient age was 60.4 years (range, 42-71). Average volume of fat injected was 15.2 ml (range, 1-37 ml). No major complications were noted (0.0%). All patients expressed satisfaction with their overall result with good functional outcomes (100%). Conclusions: Autologous fat grafting can be applied broadly in hand surgery. Indications for fat grafting in hand surgery include hand rejuvenation, burn/scar management, tenolysis, revision nerve decompression, and thumb carpometacarpal arthritis. Hand surgeons can easily incorporate fat grafting into their daily practice. Current literature supports fat grafting as a viable technique in hand surgery with lower-level studies.

Takeaways

Question: What are the indications for fat grafting in the upper extremity?

Findings: We present five cases of fat grafting hand surgery with unique surgical indications.

Meaning: Autologous fat grafting had broad applications in the upper extremity, including hand rejuvenation, burn/scar revision, tenolysis, Dupuytren contracture, peripheral nerve injury, and arthritis.

INTRODUCTION

Autologous fat transfer has various applications for upper extremity surgery. It offers long-term improvements in soft tissue contour and functional motion.[1,2] Harvested fat contains adipose-derived stem cells (ASCs), containing proliferative and multilineage differentiation potential, directly supporting nerve regeneration, angiogenesis, and chondroprotection.[3-6]

We have found fat useful in hand rejuvenation, burn/scar management, tenolysis/contracture, peripheral nerve decompression, and basilar thumb arthritis.[7] We aim to share our clinical experience in unique applications of autologous fat grafting in hand surgery to introduce an effective and easy technique to the larger community of hand surgeons.

METHODS

Cases of autologous fat grafting in the upper extremity by the senior author from 2019 to 2020 were retrospectively reviewed. Cases representing unique indications for the use of fat grafting were selected. We reviewed patient demographics, diagnoses, preoperative and postoperative assessments, complications, patient satisfaction, and operative reports.

RESULTS

Five patients representing five indications for autologous fat grafting in the upper extremity were identified (Table 1). Patient age ranged from 42 to 71 years. Volume of fat injected ranged from 1 to 37 ml. Donor sites included the abdomen, flank, hips, and thighs. No major complications were noted (0.0%). All patients expressed satisfaction and good functional outcomes (100%). Follow-up period after fat grafting ranged from 2 to 36 months.

Table 1.

Patient Demographics and Clinical Characteristics

Case	Age	Indication	Volume of Fat (ml)	Donor Site	Other Treatment	Time to Follow-up (Months)	Satisfaction and Function (1, Worst and 5, Best)	Complication
1	70	Soft tissue atrophy	10	Thighs	None	2	5	No
2	42	Full-thickness burn	20	Abdomen	Full-thickness skin graft, contracture release	36	5	No
3	60	Contracture	8	Abdomen	Tenolysis, central slip reconstruction	3	5	No
4	71	Ulnar neuropathy	37	Abdomen and flank	Decompression and transposition	6	5	No
5	59	Basilar joint arthritis	1	Flank	Synovectomy	2	5	No

Example 1: Rejuvenation

A 70-year-old woman with thumb basilar joint osteoarthritis presented with severe soft tissue atrophy following corticosteroid injection. She underwent 10 ml of fat grafting from her thighs into a 12 cm × 6 cm defect. Her preoperative and postoperative results are shown in Figure 1.

Fig. 1.

Case example 1. A, Preoperative wrist soft tissue atrophy. B, Wrist image 2 months after fat grafting.

Example 2: Scar Management

A 42-year-old man with diffuse full-thickness burn to his right hand and a localized full-thickness burn to his left hand from a bonfire underwent full-thickness skin grafting. After 4 months, he underwent contracture release and fat grafting to the dorsum of his right hand and palmar fingers. His hands are shown before fat grafting and at 3 years postoperatively (Figs. 2–7).

Fig. 2.

Case example 2. A, Preoperative scaring. B, Results 3 years after fat grafting.

Fig. 7.

Intraoperative photograph of case example 5. STT joint visualized by nanoscope after synovectomy.

Case example 3. A, Preoperative fixed contracture of the ring finger and planned incisions. B, Injection of autologous fat following contracture release.

Postoperative photographs of case example 3. Active extension at 5 months postoperative demonstrates sustained improvement compared with initial presentation.

Intraoperative photograph of case example 4. A, Intraoperative findings of severe neuritis of the ulnar nerve at the cubital tunnel. B, Neurolysis of the ulnar nerve is complete.

Preoperative photographs of case example 5. A, Preoperative radiograph demonstrating moderate osteoarthritis of the thumb CMC joint. B, Autologous fat is mixed with PRP in preparation for injection into the CMC joint.

Example 3: Tenolysis

A 60-year-old man presenting with a fixed proximal interphalangeal (PIP) joint flexion contracture of 110 degrees was treated with tenolysis through a lateral incision. Eight ml of fat was harvested from the abdomen and injected overlying the tendons. At 5-month follow-up, he achieved full passive range of motion.

Example 4: Nerve Decompression

A 71-year-old woman with recurring right ulnar nerve neuropathy at the elbow presented following two decompressions. She reported constant pain and progressive tingling. She underwent revision neurolysis at the cubital tunnel with adipofascial transposition. Thirty-seven ml of fat was harvested from her abdomen and flank and injected overlying the ulnar nerve. She reported relief of her pain at 6 weeks postoperatively, which continued through her 6-month follow-up.

Example 5: Basilar Joint Arthritis

A 59-year-old woman with symptomatic thumb CMC joint arthritis presented with minimal radiographic changes. Arthroscopy of the scaphotrapezial joint showed mild synovitis without cartilage degeneration. The CMC joint had extensive synovitis and chondral degeneration. Arthroscopic CMC synovectomy was performed, and 1 ml of fat harvested from the flanks was injected into the joint. At 2 months postoperatively, she had full thumb range of motion and minimal pain. [See figure, Supplemental Digital Content 1, which displays intraoperative case example 5. The images show carpometacarpal (CMC) joint before (a), during (b), and after synovectomy (c), and during insertion of fat (d), http://links.lww.com/PRSGO/C129.]

DISCUSSION

We have found fat grafting to be safe based on our lack of major complications and universally high patient satisfaction; however, this small case series lacks a control group. Each case represents a unique application of fat grafting, and, in most cases, fat grafting was utilized in addition to standard treatments such as tenolysis or nerve decompression. Although we showcase the many uses of fat grafting, recent literature provides specifics of fat grafting for each unique application.

Zhou et al[8] demonstrated a high patient satisfaction rate of 94.1% in their targeted approach to restore volume and improve pigmentation to the dorsum of the hand. Fat grafting of the superficial compartments allowed for the decreased visibility of tendons and veins. In the deep lamella, fat grafting addresses interosseous atrophy. The middle lamella, containing nerves and veins, should be avoided to prevent injury.[8-10]

Burn and injury to the hand can result in scar contracture, adhesions, and unstable skin, leading to reduced range of motion and function.[11-13] Fat grafting aids in regeneration of injured tissues through ASCs and facilitates gliding planes. Byrne et al[13] describe fat grafting in 13 patients who gained statistically significant improvements in total active movement, Michigan Hand Outcome Questionnaire, and Patient Observer Scar Assessment Scale.

Autologous fat has been described to reduce recurrence of tendon adhesions from trauma of immobilization.[14-15] This is presented in the lower extremity by Colonna et al[12] as two cases of dorsal foot and tendon adhesions treated with tenolysis and fat grafting. They found a reduction in activity-related pain and improved range of motion with recovery of normal ambulation without recurrence at 2 years.[12]

Autologous fat grafting may inhibit scar formation over peripheral nerves through anti-inflammatory and angiogenic properties.[16-19] In cases of nerve compression, the grafted fat prevents reformation of entrapping scar tissue.[16] Krzesniak et al[16] reported 10 patients who underwent autologous fat transfer in secondary carpal tunnel release. Patients universally reported resolution of night pain. By the Boston carpal tunnel questionnaire, they demonstrated significant improvements in the functional and sensory severity scores.[16]

Osteoarthritic change at the thumb CMC joint may be treated with autologous fat grafting, offering a less invasive treatment than trapeziectomy.[20-21] The therapeutic relief may result from the regenerative effect of transplanted ASCs or a volume effect to cushion the diseased joint.[22]‚[23] Herold et al[20] published their series of 50 patients undergoing fat grafting for stage II–IV osteoarthritis. At 1 year, they found patients with stage II and III disease to have significant improvement in pain, DASH, grip, and pinch strength, but not for stage IV disease.[20]

CONCLUSIONS

Autologous fat grafting is used in the treatment of hand rejuvenation, burn/scar contracture, peripheral nerve pathology, tendon adhesion and contracture, and thumb CMC arthritis. The literature and our case series demonstrate fat grafting’s versatility, efficacy, and safety. Further research is needed to better understand the therapeutic mechanisms and improve the collective level of evidence represented in the literature.