Noncentrifuged Autologous Fat Graft Use On The Treatment Of
Lower Extremity Wounds
Abstract:
Background: There are limited number of reports related to the direct
use of non-centrifuged adipose graft in the literature. This preliminary
study aims to present our experience on the efficacy of non-centrifuged
autologous fat graft use in the treatment of lower extremity wounds.
Methods: 16 wounds treated with non-centrifuged autologous fat grafts
were retrospectively analyzed. VAC (vacuum-assisted therapy) or
silver-impregnated dressing was used to reduce wound exudation and
provide a healthy wound bed before fat grafting. Autologous fat grafts
were harvested from abdominal or gluteal regions of the patients and
injected into the wound bed and wound environment. Clinical observation
and photograph records were used to follow the wounds.
Results: 12 wounds needed for covering with skin graft or flap surgery
whereas 4 healed without surgery. After debridement, the mean wound
surface area was 92.69±62.74 cm2 (125[52-175] cm2 for venous ulcers,
100[25-112] cm2 for diabetic ulcer and 81[42-120] cm2 for
traumatic ulcers). The mean fat injection time was 1.63±0.89, and the
mean fat volume was 26.56±15.33 cc. The mean healing time was
32.56±12.03 days. The wounds were uneventful in the average 12
month-following period.
Conclusion: With the results of our study, it can be said that
non-centrifuged autologous fat grafts can have beneficial effects on the
treatment of chronic challenging wounds when it is present on the wound
site during healing.
Key words: Diabetic foot, Lower extremity, Fat graft, Needle,
Noncentrifuged.
Introduction:
Fat grafting has been a commonly used method in both cosmetic and
reconstructive surgery for a long time. Autologous fat graft has an
easily accessible donor source, and it is a minimally invasive procedure
with low morbidity (1-4). The method has also received a great deal of
attention in tissue engineering over the last years due to its stem cell
content which has differentiation capability to different tissues under
appropriate conditions (5,6).
Diabetic foot ulcer is one of the chronic complications of diabetes and
it is the main risk factor leading to non-traumatic amputation in
diabetic patients. The prevalence of peripheral vascular disease in
diabetic patients is 15-30% (7,8). Diabetes and other chronic
conditions negatively affect all wound healing processes and the
duration and degree of hyperglycemia play a major role in terms of
complications (9,10). The deterioration of the metabolic system leads to
reduced resistance to infections, which often result in amputation. A
healthy wound healing process needs a well-orchestrated integration of
cell migration, cell proliferation, and extracellular matrix deposition.
Whereas, chronic conditions such as diabetes, venous and/or arterial
insufficiency, lead to dysregulation of the cellular and molecular
signals during this process and it can result in inadequate wound
healing and chronic ulcers.
In the literature, there have been lots of reports related to the
chemical and physical pre-manipulated adipose tissue use and it was
generally used in the treatment of chronic scars and burn scars or
cosmetic conditions. Besides, there have been a few papers about the
direct use of non-centrifuged adipose tissue in the treatment of chronic
ulcers in the human subject. In our previous experimental study, adipose
tissue was used centrifuging alone in nerve healing with various
surgical methods and we obtained considerably beneficial effects of fat
grafts when used on nerve healing (5). At this time, autologous adipose
tissue was used without centrifuging in the treatment of lower extremity
wounds and directly applied to the wound bed and environment after
achieved a healthy and suitable wound bed for fat graft take. Thus, the
present study aimed to investigate whether non-centrifuged autologous
fat graft has efficacy on the treatment in various chronic challenging
wounds on the lower extremity.
Patients and methods:
In this preliminary study, 16 lower extremity wounds treated with using
non-centrifuged autologous fat graft between 2015-2018 years, were
retrospectively reviewed and data were collected from the patient files
and photographs (Table 1). The wounds continued for at least three
months of high to moderately exudate and required open management to the
secondary intervention were included in the study. An informed consent
form was taken from all patients. The mean age of the patients was
55.88±9.71 years. The etiologies of the wounds were diabetic, venous or
traumatic ulcers. The wounds were debrided and, VAC therapy or
silver-impregnated dressing alone (Silverlon; Cura Surgical, Geneva,
Illinois) was applied to achieve a healthy wound bed for achieving fat
graft take. The wound dressing change was made at 24-48-hour intervals,
and VAC therapy was set at intermittent mode at -80mmHg. If the wound
was smaller than 10cm2 and/or less exudate at the beginning, the
silver-impregnated dressing was used alone to prepare the wound bed for
fat grafting. Silver-impregnated dressing was used in 4 cases. When
wound exudation was considered to reduce and a healthy granulation
tissue started to observe clinically, VAC therapy or silver-impregnated
dressing was stopped, and fat grafting was planned.
Autologous fat grafts were harvested from the abdominal or gluteal
region. After the infiltration of the standard tumescence solution was
performed, tunneling was made with the liposuction cannula (3–5 mm).
The cannula was attached to a syringe to harvest the fat grafts from the
deep subcutaneous tissue. The volume of fat graft depended on the wound
size. An abdominal garment was used for 2 to 4 weeks to minimize
swelling and allow for smooth, controlled adaptation of the elevated
pockets of subcutaneous tissue to the underlying fascia. The fat grafts
were filtered under sterile conditions using a metal sieve and then
washed with 0.9% saline solution to concentrate the fat particles and
separate them from fluids and debris. The purified fat was placed in 10
cc syringes using a sterile spoon. Then, the fat grafts were injected
around the wound bed and surrounding areas approximately 1cm from the
wound edge by 1using 4G blunt single hole cannula or with 2.5cc syringe
so as to stay in contact with the wound site (Figure 1,2). It was taken
account not to tighten the skin edges so as not to cause any skin
necrosis. The amount and frequency of fat graft was determined on
clinical observation of the wounds. Ointment dressing and a plaster cast
were used for the stabilization of fat graft. The wounds were followed
closed for 5-7 days. Patients were received perioperative and
postoperative antibiotics guided by positive culture results and
sensitivities. Dressing changes were made on 10, 14, 21 days. When the
wound shrinkage was observed, the wound was left secondary healing,
whereas, the wounds not showing any shrinkage required skin grafting or
flap.
Case1: The patient applied to our clinic with signs of diabetic foot
ulcers. The wounds were at the left lateral of his left foot, large and
highly exudate. It was considered Wagner grade 3-4. The wound
debridement was made under general anesthesia (Figure 3). The VAC
therapy and debridement period have continued for 13 days (Figure 4).
When debridement and VAC therapy was completed, autologous fat grafting
was planned. The method was performed under general anesthesia and 19cc
fat grafts were injected into the wound site. The wound was followed by
closed dressing for 7 days and it was found to be suitable for skin
graft in this period (Figure 5). However, the patient didn’t accept the
operation, so, he was followed by wet-to-dry wound care. In this period,
the wound was completely healed at 55 days (Figure 6).
Case 2: A 45-year-male patient was admitted to our clinic because of
venous ulcer on his right cruris (Figure 7). First, the wound
debridement was made under spinal anesthesia and the silver-coated
dressing was started for decreasing exudate and reaching a healthy wound
bed. After wound care of 3 days, fat grafting was performed under
general anesthesia. 10cc fat graft was transferred to the wound site in
this operation. 10 days after the application, considerable wound
shrinkage was observed, and this wound was left secondary healing. The
total treatment time was 10 days and the wound completely healed in 16
days (Figure 8).
Case 3: The patient had us malodorous, necrotic, and large traumatic
foot ulcer (Figure 9). After debridement, the wound has been applied VAC
therapy for 7 days. After the VAC therapy, the wound was found suitable
for fat grafting and the procedure was performed 2 times (Figure 10).
VAC therapy has been continued 12 days more. Then, the wound has become
suitable for covering by skin graft. The total treatment period was 53
days (Figure 11).
Case 4: A 55-year-female diabetic patient was admitted to our clinic
with signs and symptoms of diabetic foot ulcer on her left foot at the
first toe to the level of the metatarsophalangeal joint. The wound
debridement was made under spinal anesthesia and VAC therapy was applied
(Figure 12). VAC therapy has been continued for 10 days. When the wound
exudation was clinically observed get less, fat graft was planned. A
single fat application of 10cc was made and then, the wound was covered
by skin graft (Figure 13). The total healing time was 28 days.
Statistical analysis
Quantitative data were obtained regarding the arithmetic mean, standard
deviation or frequency, percentage. One-way analysis of variance (ANOVA)
test was used to compare quantitative variables among groups. A p-value
<0.05 was considered significant. Analyses were performed
using SPSS 19 (IBM SPSS Statistics 19, SPSS inc., an IBM Co., Somers,
NY).
Results:
Tables 2 and 3 show the distribution of quantitative and qualitative
variables according to wound etiologies. 4 cases were venous ulcer, 10
cases were diabetic ulcers and 2 were traumatic. All wounds were applied
vacuum-assisted therapy or silver-impregnated dressing alone so as to
reduce exudation and provide a healthy wound bed before fat grafting. A
healthy granulation tissue formation was generally started to observe by
day 5. At the commencement, the mean wound surface area was 92.69±62.74
cm2. The measurement for venous ulcers was 125[52-175] cm2,
100[25-112] cm2 for diabetic ulcer and 81[42-120] cm2 for
traumatic ulcers. Total healing time was 23.5[13-31.5] days
34.5[23-35] days and 45.5[38-53] days, respectively. The fat
injection was made 1[1-1.5] time for venous ulcers, 1.5[1-2]
times for diabetic ulcers and 2[1-3] times for traumatic ulcers. The
mean fat volume used was 20[10-30] cc, 20[19-30] cc, and
50[50-50] cc, respectively. Seven wounds required applying fat graft
one more time. According to fat injection, mean fat volume and mean
treatment time, statistically significant difference was not found
between the measurements. 12 wounds required using a skin graft or flap
surgery to cover and 4 were left secondary healing. Cross-leg flap was
used for one diabetic heel ulcer because these wounds were at the
weight-bearing area. The following period was averaged 12 months and the
patients were uneventful in this period.
Discussion:
In chronic wounds, the use of adipose tissue has become very popular due
to its regenerative capacity and its stem cell content and a great
promise in tissue engineering and reconstructive surgery over the last
years (5). The stem cells secrete various growth factors and cytokines
named paracrine function. Experimental and previous clinical studies
have shown that transplantation of autologous mesenchymal stem cells
into ischemic limbs could promote collateral vessel formation and
angiogenesis (11-16). Stem cells have also enormous potential for skin
tissue regeneration, as the cells can both regenerate lost tissue and
promote wound repair through paracrine coordination of their actions
(5). Thus, the rationale of the present study was to investigate whether
adipose tissue could aid the cutaneous wound healing process owing to
its rich stem cell content in various acute and chronic wounds. This
study describes our clinical outcomes on the treatment of lower
extremity wounds with directly using the non-centrifuged fat graft.
In clinical practice, centrifugation is routinely made in 3000 rpm for 3
minutes during various fat grafts uses. Centrifugation is introduced to
concentrate adipocytes and separate them from substances that may
degrade adipocytes, such as blood cells, proteases, and lipases, and
establish a better environment for tissue viability, although there is
no consensus on the latter (17). A recent study by Conde-Green et al.
compared the influence of the three most used fat-processing techniques
(i.e., decantation, washing, and centrifugation) on the viability and
number of adipocytes and mesenchymal stem cells in the aspirated fat
(18). They conclude that washing is the best processing method for
adipose tissue grafting, as it maintains adipocyte integrity and number,
clears the fat with most blood contaminations, and has a greater number
of endothelial cells and mesenchymal stem cells. Asilian et al, no
significant difference was found between the two fat-processing methods
(19). Similarly, in a different study, transplantation of
non-centrifuged adipose tissue was found to have more active
pre-adipocytes which could possibly lead to better potential chances of
survival and even de novo development of fat (20). In the present study,
the non-centrifuged autologous fat graft was applied to the wound edge,
wound bed and environment. And, we observed better results compared to
our previous observation and experiments for similarly wounds as it was
used without centrifuging.
In our study, before fat grafting, the wound debridement was made, and
then, they were treated vacuum-assisted therapy or silver-impregnated
dressing to accelerate reducing exudation and providing a healthy wound
bed for enhancing the fat graft take. In the majority of the wounds, VAC
therapy was preferred, because these wounds were larger and have more
exudates than others. In other wounds, silver-impregnated dressing alone
was used to prepare them for fat grafting. A healthy granulation tissue
formation was generally started to observe by day 5. In a similar study,
the authors used autologous fat graft without centrifuging in chronic
lower extremity wounds and they obtained completely healing in
twenty-two of 25 wounds (9). However, the authors used the fat grafts
for relatively smaller sized wounds compared to those of our study, and
parallel to that, they transferred a smaller amount of fat grafts. Also,
our mean healing time was shorter. VAC therapy was also used after fat
grafting in that study. So, it can be speculated that VAC therapy can
positively affect their results although they suggest that VAC therapy
time of 4-5 days was probably not responsible for the good outcomes. In
the present study, VAC therapy was used before applying the fat grafts.
However, we also had to use VAC with fat in one case. This was because
tissue necrosis was ongoing, and the wound was relatively large and
highly exudated than others. We also used silver-impregnated dressing in
4 wounds relatively smaller than others and less exudated. The
silver-impregnated dressing or VAC therapy has several theoretical
advantages including antimicrobial inhibition and enhancement of soft
tissue granulation (7). So, it can be an explanation of the difference
in mean healing time between two comparable studies.
Various intrinsic factors such as microcirculation, and chronic
diseases, diabetes, and venous insufficiency determine the wound
response to the fat grafts used. After the non-vascularized fat
grafting, the connective tissue or extracellular matrix may be preserved
as a scaffold, and all differentiated cells usually die and are replaced
by those of the next generation derived from tissue-specific stem cells,
depending on the microenvironment (5,6). Besides these intrinsic
factors, the fat graft volume is mainly determined according to the
wound surface area. Therefore, while making a decision about any
therapeutic fat grafts dose or frequency of application, it should be
taken wound etiology and localization into consideration. Hypoxic or
diabetic environment can affect fat graft survival increasing the
mesenchymal and endothelial progenitor cell responses and enhancing the
formation of blood vessels and (21,22). In our study, we generally
observed that the skin surrounding the wounds started to turn into
normal color especially in venous ulcers. It is known that these
pathologic tissue changes in chronic wounds can arise by the
inflammatory process and extensive inflammation plays a major role in
the disruption of the normal healing cascade (23,24). So, it can be
speculated that our clinical observations can be related to the
anti-inflammatory and immunoregulatory function of stem cell content of
adipose tissue graft (25,26,27). We can say that it can be one of the
clinical signs indicating the efficacy of fat grafts on the treatment of
challenging wounds.
Limitation:
In the present study, although traumatic ulcers were relatively smaller
than other wounds, total fat volume, application frequency and total
healing time were found longer in traumatic ulcers. We think that the
number of cases was less to make comparisons and provide a significant
conclusion. Also, the reason for longer treatment time and more fat
volume need in traumatic ulcers might have been due to these ulcers
being complicated wounds. In addition, fat graft volume used in wounds
causing by different etiologies was always not correlated with the
degree of clinical signs and improvement.
Conclusions:
There are limited numbers of papers with the direct use of adipose
tissue grafts in the literature and they are generally related to the
burn scars. In the majority of these reports, the centrifuged fat graft
was used. In this preliminary study, we found that the presence of
non-centrifuged fat graft during wound healing on the wound site could
have beneficial effects. However, more clinically and experimental
studies are needed to provide more comparable, clarifying and optimal
results.
Acknowledgment:
All authors disclose that none of the authors has a financial interest
in any of the products, devices mentioned in this manuscript.
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