Fat Transfer to the Upper and Lower Extremities in Patients with Raynaud's Phenomenon - A Novel Therapeutic Modality
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Dr. Lawrence S. Zachary of the University of Illinois at Chicago discussed fat transfer as a treatment for Raynaud's patients.
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Fat Transfer to the Upper and Lower Extremities in Patients with Raynaud's Phenomenon - A Novel Therapeutic Modality
- 1. Fat Transfer to the Upper and Lower Extremities in Patients With Raynaud’s Phenomenon – A Novel Therapeutic Modality Jonathan Bank, MD, Sam A. Fuller, MD Ginard I. Henry, MD, Lawrence S. Zachary, MD Section of Plastic and Reconstructive Surgery Department of SurgeryNo disclosures
- 2. Fat Transfer to the Upper and Lower Extremities in Patients With Raynaud’s Phenomenon – A Novel Therapeutic Modality Jonathan Bank, MD, Sam A. Fuller, MD Ginard I. Henry, MD, Lawrence S. Zachary, MD Section of Plastic and Reconstructive Surgery Department of Surgery
- 3. 3 Raynaud’s Phenomenon Vasodilation Vasoconstriction Fat Transfer in Raynaud’s
- 4. 4 Raynaud’s Phenomenon PrimaryVasoconstriction Cold attacks Pain Secondary Fibrosis Scarring Contracture Ulceration Autoamputation Fat Transfer in Raynaud’s
- 5. 5Fat Transfer in Raynaud’s Treatment Ca Channel Blockers ARB Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids
- 6. 6Fat Transfer in Raynaud’s Treatment Ca Channel Blockers ARB Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids Invasive Modalities Surgical Sympathectomy Neuro- modulators Fat Transfer
- 7. • 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? 7Fat Transfer in Raynaud’s Fat Transfer Rationale Raynaud’s - different pathogenesis – similar end effect
- 8. 8Fat Transfer in Raynaud’s Goal as a means to delay progression of Raynaud’s Phenomenon after failure of medical management Utilize fat grafting
- 9. • 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 9Fat Transfer in Raynaud’s Technique
- 10. 10Fat 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
- 11. 11Fat Transfer in Raynaud’s Technique
- 12. 12 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
- 13. 13 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
- 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
- 19. 19Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler Normal Moderate Severe
- 20. 20Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler
- 21. 21Fat Transfer in Raynaud’s Hand Vascular Perfusion by Laser Doppler
- 22. 22Fat Transfer in Raynaud’s Preop Postop 200 150 100 50 Perfusionunits Hand Vascular Perfusion by Laser Doppler QMRADASH
- 23. 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 23 Conclusions Fat Transfer in Raynaud’s
Editor's Notes
- Thank you for allowing me to present here today
- The work I will discuss is really an innovation of larryzachary123
- Raynaud’s phenomenon is a common affliction effecting 2% of the adult population, More commonly in womanIt results from an imbalance between vasodilation and vasoconstriction
- It can be divided in to primary raynaud, which usually exists in isolation from systemic diseaseand in which the vasoconstriction results in cold attacks an pain, which can be severe and debilitatingSecondary raynauds typically occurs in the setting of autoimmune diseases such as systemic sclerosis (or scleroderma)And manifests in fibrosis, scarring, contractures, ulcerations and even autoamputationsClearly there is a continuum of disease manifestation
- Initial treatment is preventative – with gloves and cold avoidanceBut many patients progress to require medical treatment with calcium channel blockers and topical nitratesAnd 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 symptomsAnd 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 settingAnother 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 trainingand my not be long-lived with the regrowth of the stripped adventitiaThe 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 reconstructionA published study from a murine model shower regression of hyperpigmentation, ulcers and fibrosisWith histological correlatesHowever, the mechanism is unknown, and thought to be related to repletion of adipose derived stems cells into the injured tissueRecognizing 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 graftingAs 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 graftingAnd 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 follows10 cc dorsum of the hand3 ml in the snuff box2-3 in each dorsal webspace6 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 patientsOr 25 extremitiesMainly in the handsWith a mean follow up of one yearMost of the patients severe females with primary raynaudsThe average amount of fat was about 23 ccAnd four had concomitant single digit sympathectomy for critical ischemia
- All in all – We some some levelof improvement in the vast majority of our patientsPrimary in pain reliefAlthou one patient reported no changeAnd would stated her pain was actually worseIn the patients that had ulcerations – two thirds were much improved or healedTwo 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 obserationsAnd we are are still working out how to utilize this technologyAnd are in the process of using other objective measure sucha s the DASH score whch grades functionAs well as quantitative MRA for a better assessment of tissue perfusion and longevity of the far grafts5 showed LD improvement – 4/5 improved clinically, but the impovement was not sig in the LD5 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 patientsIt appears to be safe and relatively straightforwardThe precise mechanism has yet to be elucidated – and perhaps has to do with neoangiogenesis and decreased scar promoted by stem cellsAlthough 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 digitsSo we think that there is definitely a role for fat transfer in advanced, refractory raynauds phenomenonAnd look forward to collaborating with other surgeons on this project