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Fat Transfer to the Upper and Lower Extremities in Patients with Raynaud's Phenomenon
- 1. Fat Transfer to the Upper and Lower Extremities in Patients With Raynaud’s Phenomenon – A Novel Therapeutic Modality Lawrence S. Zachary, MD Section of Plastic and Reconstructive Surgery Department of SurgeryNo disclosures
- 2. 2 Raynaud’s Phenomenon Fat Transfer in Raynaud’s
- 3. 3 Raynaud’s Phenomenon PrimaryVasoconstriction Cold attacks Pain Secondary Fibrosis Scarring Contracture Ulceration Autoamputation Fat Transfer in Raynaud’s
- 4. 4Fat Transfer in Raynaud’s Treatment Ca Channel Blockers ARB Protective Measures Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids
- 5. 5Fat Transfer in Raynaud’s Treatment Ca Channel Blockers ARB Protective Measures Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids Invasive Modalities Surgical Sympathectomy Neuro- modulators Fat TransferFat Transfer
- 6. • Clinical improvement – radiation dermatitis, burns • Histological evidence – Sultan, PRS 2011 – Radiation dermatitis murine model fat injection – Regression of hyperpigmentation, ulcers and fibrosis – Improvements in the inflammatory, microvascular, and fibrotic characteristics • Mechanism unclear – Restoration of depleted adipose-derived stem cells? 6Fat Transfer in Raynaud’s Fat Transfer Rationale Raynaud’s - different pathogenesis – similar end effect
- 7. 7Fat Transfer in Raynaud’s Goal as a means to delay progression of Raynaud’s Phenomenon after failure of medical management as a means to delay progression of Raynaud’s Phenomenon after failure of medical management Utilize fat graftingUtilize fat grafting
- 8. • Adaptation of rejuvenation of the hand by fat grafting • Approximately 30 ml of decanted fat • Abdominal depots • Injected via blunt cannulae into the affected extremity 8Fat Transfer in Raynaud’s Technique
- 9. 9Fat Transfer in Raynaud’s Technique 10 ml - dorsum of hand 3 ml - snuff-box 2-3 ml - each dorsal webspace 6 ml - along palmar arch 1 ml - palmar webspaces 2-4 2 ml - first webspace 2 ml - ulnar border of small finger
- 10. 10Fat Transfer in Raynaud’s Technique
- 11. 11 Results Fat Transfer in Raynaud’s Total patients 14 Total extremities 25 Hand 20 Feet 5 Mean follow up 12 months (4-17) Female: Male 13:1 Primary: Secondary 8:6 Average fat injected 23.29 ml (10-30) Concomitant digital sympathectomy 4
- 12. 12 Results Overall improvement 92.5% of patients Pain reduction 85.7% (7 2.6) 1 patient – no change 1 patient – increased pain Cold attacks 78.5% decreased frequency and severity Ulcerations 66% improvement Major complications 0 Minor complications 2 Subsequent neuromodulator 1 Subsequent sympathectomy 1 Fat Transfer in Raynaud’s
- 13. 13Fat Transfer in Raynaud’s
- 14. 14Fat Transfer in Raynaud’s
- 15. 15Fat Transfer in Raynaud’s
- 16. 16Fat Transfer in Raynaud’s
- 17. 17Fat Transfer in Raynaud’s
- 18. 18Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler Normal Moderate Severe
- 19. 19Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler
- 20. 20Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler
- 21. 21Fat Transfer in Raynaud’s Preop Postop 200 150 100 50 Perfusionunits Hand Vascular Perfusion by Laser Doppler ?QMRADASH
- 22. Durable clinical improvement in the majority of treated patients Safe, relatively straightforward Mechanism – to be elucidated (stem cell angiogenesis? padding?) Role in treatment of advanced, refractory Raynaud’s Phenomenon 22 Conclusions Fat Transfer in Raynaud’s
- 23. Thank You
Editor's Notes
- Thank you for allowing me to present here today
- Raynaud’s phenomenon is a common affliction effecting 2% of the adult population, More commonly in woman It results from an imbalance between vasodilation and vasoconstriction
- It can be divided in to primary raynaud, which usually exists in isolation from systemic disease and in which the vasoconstriction results in cold attacks an pain, which can be severe and debilitating Secondary raynauds typically occurs in the setting of autoimmune diseases such as systemic sclerosis (or scleroderma) And manifests in fibrosis, scarring, contractures, ulcerations and even autoamputations Clearly there is a continuum of disease manifestation
- Initial treatment is preventative – with gloves and cold avoidance But many patients progress to require medical treatment with calcium channel blockers and topical nitrates And there is a whole host of other medications aimed at vasodilation and prevention of arterial thrombosis
- Despite all of these options, A portion of these patients develop severe, refractory symptoms And this is where the hand surgeon comes in to play, invoking invasive modalities With injection of neuromodulators such as botulinum toxin – which has shown to be effective, but short lived, and can be an arduous undertaking for the patient and surgeon when done in the clinic setting Another option would be surgical sympathectomy of the hands of affected feet – this is not a trivial undertaking, with inherent procedural risks, and requires somewhat specialized training and my not be long-lived with the regrowth of the stripped adventitia The intervention we propose he today is autologous fat grafting into the affected extremities
- The rationale here stems from the clinical improvement witnessed in radiation dermatitis treated with fat injection, and to a certain extent in burn reconstruction A published study from a murine model shower regression of hyperpigmentation, ulcers and fibrosis With histological correlates However, the mechanism is unknown, and thought to be related to repletion of adipose derived stems cells into the injured tissue Recognizing that the pathophysiology in raynauds is differet, we contend that the end result at the tissue level is similar
- We therefore set out to utilize fat grafting As a means to treat patients with refractory cases of raynauds
- We adapted a technique popularized by coleman for cosmetic rejuvenation of the hand by fat grafting And inject approximately 30 ccs of decanted fat from abdominal sources, Via blunt cannulae into the affcted extremity
- The fat is dispersed subcutaneously and deeper, along the vessels as follows 10 cc dorsum of the hand 3 ml in the snuff box 2-3 in each dorsal webspace 6 cc along the palmar arch, the palmar webspaces and along the digital vessels
- Here you can see the fat being injected while withdrawing the cannula
- Over the past couple of years we performed this procedure on 14 patients Or 25 extremities Mainly in the hands With a mean follow up of one year Most of the patients severe females with primary raynauds The average amount of fat was about 23 cc And four had concomitant single digit sympathectomy for critical ischemia
- All in all – We some some levelof improvement in the vast majority of our patients Primary in pain relief Althou one patient reported no change And would stated her pain was actually worse In the patients that had ulcerations – two thirds were much improved or healed Two patients required further interventions at a 3-6 month interval
- It may be difficult to appreciate the subtle coloration improvement in this case
- But here you can clearly see the healing of several ulcers In the patient with severe scleroderma
- With overall improvement suggested by here wearing her ring again
- An example of fat transfer to the feet
- We attempted to further quantify and monitor this intervention With speckle laser doppler that gives an idea as to the perfusion to the studied area
- And this is an example of a clinically improved patient with a correlating improvement in measured perfusion
- However, not all of our outcomes were as encouraging
- We really had a range of measured responses that did not directly correlate with our clinical obserations And we are are still working out how to utilize this technology And are in the process of using other objective measure sucha s the DASH score whch grades function As well as quantitative MRA for a better assessment of tissue perfusion and longevity of the far grafts 5 showed LD improvement – 4/5 improved clinically, but the impovement was not sig in the LD 5 LD decrease – 4/5 improved symptoms
- In conclusion we found fat transfer in patients with raynauds phenomenon of varying degrees Provides a durable clinical improvement in the majority of treated patients It appears to be safe and relatively straightforward The precise mechanism has yet to be elucidated – and perhaps has to do with neoangiogenesis and decreased scar promoted by stem cells Although I think in the scleroderma patients – even the small amount of fat that survives, Provides a little bit of padding and cushioning to their severely sclerotic digits So we think that there is definitely a role for fat transfer in advanced, refractory raynauds phenomenon And look forward to collaborating with other surgeons on this project