Fat grafting: an adjunct in management of chronic leg ulcers
DOI:
https://doi.org/10.18203/2349-2902.isj20230266Keywords:
CLU, ADSC, GF, VASAbstract
Chronic leg ulcers (CLU’s) are one of the most challenging medical conditions, mostly resistant to conventional therapy. Several treatment modalities are present but none have become standard of care. Autologous fat contains adipose derived stem cells (ADSC’s) which is believed to have abundant growth factors (GF’s) required for its regenerative and reparative properties. Our observational study was conducted to see the feasibility and efficacy of fat grafting in management of CLUs with complete wound healing as final outcome. 14 patients with CLUs (any etiology, >3 months and multiple ulcers were counted as individual cases if >3 cm apart) were included with coagulopathies, uncontrolled diabetes mellitus (Hba1c>9 mmol/mol) being the exclusions. Fat was harvested using standard Coleman’s technique. Study was conducted from December 2015 to December 2017 in tertiary care hospital and patients were followed up for next 24 months. All cases were evaluated clinically. Average age of wounds before intervention was 33.34 months, average wound size 16.46 cm2 and 4.9 cc of average fat was transferred underneath the ulcer. 11 out of 14 wounds healed completely within average 27.4 days and final outcome was not achieved in 3. Pain assessed using visual analogue scale (VAS) in immediate post operative period till 48 hours (telephonically). Patients were evaluated at 1 week, 1 month, 3 months and 6 months after procedure for pattern of wound healing and related complications. Fat grafting is easy, safe, effective and a minimally invasive OPD procedure with short recovery time for managing CLUs.
References
Werdin F, Tenenhaus M and Rennekampff HO. Chronic wound care. Lancet. 2008;372:1860-2.
Crovetti G, Martinelli G, Issi M, Barone M, Guiz-zardi M, Campanati B, Moroni M and Carabelli A. Platelet gel for healing cutaneous chronic wounds. Transfus Apher Sci. 2004;30:145-51.
Simka M, Majewski E. The social and eco¬nomic burden of venous leg ulcers: focus on the role of micronized purified flavonoid frac¬tion adjuvant therapy. Am J Clin Dermatol. 2003;4:573-81.
Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-29.
Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelmann RF. Impaired wound healing. Clin Dermatol. 2007;25(1):19-25.
Agale S. Chronic leg ulcers: epidemiology, aetiopathogenesis, and management. Ulcers. 2013;2013
Olin JW, Beusterien KM, Childs MB, Seavey C, McHugh L, Griffiths RI. Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study. Vasc Med. 1999;4(1):1-7.
Psychosocial aspects in patients with chronic leg ulcers. WOUNDS. 2017.
Rogers LC, Bevilacqua NJ and Armstrong DG. The use of marrow-derived stem cells to accel¬erate healing in chronic wounds. Int Wound J. 2008;5:20-5.
Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118:108S-20S.
Naderi N, Combellack EJ, Griffin M. The regenerative role of adipose-derived stem cells (ADSC) in plastic and reconstructive surgery. Int Wound J. 2017;14(1):112-24.
Planat-Benard V, Silvestre JS, Cousin B. Plasticity of human adipose lineage cells toward endothelial cells: physiological and therapeutic perspectives. Circulation. 2004;109:656-63.
Piccolo NS, Piccolo MS, Piccolo MT. Fat grafting for treatment of burns, burn scars, and other difficult wounds. Clin Plast Surg. 2015;42:263-83.
Toyserkani NM, Christensen ML, Sheikh SP, Sørensen JA. Adipose-derived stem cells: new treatment for wound healing? Ann Plast Surg. 2015;75(1):117-23.
Delay E, Garson S, Tousson G, Sinna R. Fat injection to the breast: technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360-76.
Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg. 2000;26:1159-66.
Eto H, Kato H, Suga H. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg. 2012;129(5):1081-92.
Yu NZ, Huang JZ, Zhang H. A systemic review of autologous fat grafting survival rate and related severe complications. Chin Med J (Engl). 2015;128(9):1245-51.
Kruschewsky LES, de Mello-filho FV, Dos Santos AC. Autologous fat graft absorption in unilateral paralyzed canine vocal folds. Laryngoscope. 2007;117(1):96-100.
Karacaoglu E, Kizilkaya E, Cermik Hl. The role of recipient sites in fat-graft survival: experimental study. Ann Plast Surg. 2005;55(1):63-8.
Cherubino M, Rubin JP, Miljkovic N, Kelmendi-Doko A, Marra KG. Adipose derived stem cells for wound healing applications. Ann Plast Surg. 2011;66(2):210-5.
Escandon J, Vivas AC, Tang J, Rowland KJ, Kirsner RS. High mortality in patients with chronic wounds. Wound Repair Regen. 2011;19(4):526-8.
Renner R, Gebhardt C, Simon JC, Seikowski K. Changes in quality of life for patients with chronic venous insufficiency, present or healed leg ulcers. J Dtsch Dermatol Ges. 2009;7(11):953-61.
Global report on diabetes 2016. Geneva: World Health Organisation. 2016. Available at: https://www.who.int/publications/i/item/9789241565257. Accessed on 3 June 2022.
Phillips CJ, Humphreys I, Fletcher J, Harding K, Chamberlain G, Macey S. Estimating the costs associated with the management of patients with chronic wounds using linked routine data. Int Wound J. 2016;13:1193-7.
Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;49(2):106-16.
Kern S, Eichler H, Stoeve J, Klüter H, Bieback K. Comparative analysis of mesenchymal stem cells from bone marrow, umbilical cord blood, or adipose tissue. Stem Cells. 2006;24(5):1294-301.
Bertozzi N, Simonacci F, Grieco MP, Grignaffini E, Raposio E. The biological and clinical basis for the use of adipose-derived stem cells in the field of wound healing. Ann Med Surg. 2017;20:41-8.
Hassan WU, Greiser U, Wang W. Role of adipose-derived stem cells in wound healing. Wound Repair Regen. 2014;22(3):313-25.
Tierney EP, Kouba DJ, Hanke CW. Safety of tumescent and laser-assisted liposuction: review of the literature. J Drugs Dermatol. 2011;10(12):1363-9.
Sharma RK, John JR. Role of stem cells in the management of chronic wounds. Indian J Plast Surg. 2012;45(2):237-43.
Bourin P, Bunnell BA, Casteilla L. Stromal cells from the adipose tissue derived stromal vascular fraction and culture expanded adipose tissue derived stromal/stem cells: a joint statement of the International Federation for Adipose Therapeutics and Science (IFATS) and the International Society for Cellular Therapy (ISCT). Cytotherapy. 2013;15(6):641-8.
Riis S, Zachar V, Boucher S, Vemuri MC, Pennisi CP, Fink T. Critical steps in the isolation and expansion of adipose-derived stem cells for translational therapy. Expert Rev Mol Med. 2015;17:e11.
Caviggioli F, Klinger FV, Valeriano C, Guido KM. Treatment of Chronic Posttraumatic Leg Injury Using Autologous Fat Graft. Case Rep Med. 2012;648683:10.1155/2012/648683.
Zuk PA, Zhu M, Mizuno H. Multilineage cells from human adipose tissue: implications for cell-based therapies. Tissue Engineering. 2001;7(2):211-8.
Gimble JM, Nuttall ME. Bone and fat: old questions, new insights. Endocrine. 2004;23(2-3):183-8.
Li HX, Luo X, Liu RX, Yang YJ, Yang GS. Roles of Wnt/β-catenin signaling in adipogenic differentiation potential of adipose-derived mesenchymal stem cells. Molecular Cellular Endocrinol. 2008;291(1-2):116-24.
Tiˇgli RS, Ghosh S, Laha MM. Comparative chondrogenesis of human cell sources in 3D scaffolds. J Tissue Engineering Regenerative Med. 2009;3(5):348-60.
Lin J, Lindsey ML, Zhu B, Agrawal CM, Bailey SR. Effects of surface-modified scaffolds on the growth and differentiation of mouse adipose-derived stromal cells. J Tissue Engineering Regenerative Med. 2007;1(3):211-7.
Smith OJ, Leigh R, Kanapathy M. Fat grafting and platelet-rich plasma for the treatment of diabetic foot ulcers: A feasibility-randomised controlled trial. Int Wound J. 2020;17:1578-94.
