Fat grafting provides a reliable modality with expanding usefulness in reconstructive plastic surgery. Owing to its mechanical and theorized regenerative properties, adipose tissue can improve scar qualities and scar related symptoms when grafted adjacent to or within a scar. In this article, the literature describing the effect of fat grafting on various types of scars, current scientific understanding of fat grafting for scars, and our current approach to the management of problematic burn scars are reviewed.
Key points
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An increasing volume of literature supports fat grafting for the treatment of problematic scars.
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Transferred adipose tissue provides a mechanical effect and a putative regenerative environment that improves scar qualities and scar related symptoms.
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Fat grafting may improve symptoms in patients with refractory neuropathic pain in burn scars.
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With the expanding role of autologous fat grafts, regulatory issues surrounding its use must be considered continuously.
Introduction
Free autologous fat transfer was first described in 1893 when Franz Neuber reported the harvest of fat from a patient’s arm to fill a defect in the cheek cause by tuberculosis of the maxilla. Eugene Hollander was the first to report the use a needle and syringe to transfer fat into the face of a patient with lipoatrophy in 1912. Over the remainder of the 20th century, multiple reports emerged on the use of fat grafting as a soft tissue filler; however, these uses were associated with substantial variability in results. It was not until Sydney Coleman described a strict protocol for harvesting and injecting fat that results became more reliable. As a result, the popularity of fat grafting surged and its clinical applications diversified.
In 2007, Rigotti and colleagues described the use of autologous fat grafts to treat radiation-induced skin lesions, and showed that autologous fat grafts have the ability to improve local tissue environment in humans. They proposed that regeneration occurred owing to adipose-derived stem cells within the lipoaspirate. The usefulness of fat grafting continued to expand, and lipotransfer became recognized as a versatile medium possessing valuable mechanical and regenerative properties.
Reports began to emerge investigating the role of fat grafting for treating various types of scars, with promising results. In 2008, Klinger and colleagues published a case series of 3 patients with burns to the face who underwent fat grafting and had improvement in scar quality. Additional reports described fat grafting to various traumatic, surgical, and burn scars with improvement in scar qualities.
Many investigators noted that scar-related pain improved after fat grafting, which has led to recent interest in the use of fat grafting to treat painful scars. Fat grafting has been shown to improve symptoms in patients with painful surgical scars, traumatic scars, and postmastectomy pain syndrome. In 2016, we investigated the possible role of lipotransfer in treating neuropathic pain in burn scars and showed that adipose tissue can be safely grafted into burn scars and may improve symptoms in patients with refractory neuropathic pain after burn injury. A prospective study is currently underway to quantify the improvement in pain and quality of life that is observed after fat grafting in patients with chronic neuropathic burn scar pain.
In this article, we review the current literature on fat grafting for scars, discuss the physiology of fat grafting as it relates to management of problematic scars, present our approach for the use of fat grafting to manage painful burn scars, and elaborate on current regulatory issues surrounding autologous fat grafting.
Introduction
Free autologous fat transfer was first described in 1893 when Franz Neuber reported the harvest of fat from a patient’s arm to fill a defect in the cheek cause by tuberculosis of the maxilla. Eugene Hollander was the first to report the use a needle and syringe to transfer fat into the face of a patient with lipoatrophy in 1912. Over the remainder of the 20th century, multiple reports emerged on the use of fat grafting as a soft tissue filler; however, these uses were associated with substantial variability in results. It was not until Sydney Coleman described a strict protocol for harvesting and injecting fat that results became more reliable. As a result, the popularity of fat grafting surged and its clinical applications diversified.
In 2007, Rigotti and colleagues described the use of autologous fat grafts to treat radiation-induced skin lesions, and showed that autologous fat grafts have the ability to improve local tissue environment in humans. They proposed that regeneration occurred owing to adipose-derived stem cells within the lipoaspirate. The usefulness of fat grafting continued to expand, and lipotransfer became recognized as a versatile medium possessing valuable mechanical and regenerative properties.
Reports began to emerge investigating the role of fat grafting for treating various types of scars, with promising results. In 2008, Klinger and colleagues published a case series of 3 patients with burns to the face who underwent fat grafting and had improvement in scar quality. Additional reports described fat grafting to various traumatic, surgical, and burn scars with improvement in scar qualities.
Many investigators noted that scar-related pain improved after fat grafting, which has led to recent interest in the use of fat grafting to treat painful scars. Fat grafting has been shown to improve symptoms in patients with painful surgical scars, traumatic scars, and postmastectomy pain syndrome. In 2016, we investigated the possible role of lipotransfer in treating neuropathic pain in burn scars and showed that adipose tissue can be safely grafted into burn scars and may improve symptoms in patients with refractory neuropathic pain after burn injury. A prospective study is currently underway to quantify the improvement in pain and quality of life that is observed after fat grafting in patients with chronic neuropathic burn scar pain.
In this article, we review the current literature on fat grafting for scars, discuss the physiology of fat grafting as it relates to management of problematic scars, present our approach for the use of fat grafting to manage painful burn scars, and elaborate on current regulatory issues surrounding autologous fat grafting.
Literature review
Over the past decade, there has been an abundance of literature published about fat grafting ( Fig. 1 ). Recognition of the beneficial effects of transferred fat on local tissue has generated interest in fat grafting for problematic scars. Recent systematic literature reviews by Negenborn and colleagues and Condé-Green and colleagues provide a detailed analysis of studies reporting the use of fat grafting for scars, including burn scars, and scar-related conditions. Table 1 provides an updated summary of the literature on fat grafting for scars and scar-related conditions. Case reports, as well as studies that use autologous fat mixed with platelet-rich plasma, enhanced with stromal vascular fraction or similarly manipulated are not included in this review.
| Author | Wound Type | Design | n | Therapy | Processing | Methods | Results | OCEBM |
|---|---|---|---|---|---|---|---|---|
| Sardesai and Moore, 2007 | Scars, not specified | PCS | 14 | AFG | Centrifuge | Cutometer, dermaspectrometer POSAS, VSS | Significant improvement in stiffness, thickness, relief, and pliability. No significant improvement in height, vascularity, pigmentation, pain, pruritis, or irregularity. | III |
| Klinger et al, 2008 | Burn scars | Case series | 3 | AFG | Not specified | Clinical assessment | Improvement in mimic features, skin texture, and thickness. | IV |
| Caviggioli et al, 2010 | Traumatic scars and burns | PCS | 24 | AFG | Centrifuge | Clinical assessment | Improved nipple projection, skin texture, softness, color, and elasticity. Improved patient satisfaction. | IV |
| Caviggioli et al, 2011 | Postmastectomy pain syndrome | RCT | 113 | AFG (72) vs no treatment (41) | Centrifuge | Pain (VAS) | Significant decrease in pain | II |
| Brongo et al, 2012 | Burn scars | Case series | 18 | AFG | Centrifuge | Patient satisfaction questionnaire, digital photographs assessed by surgeons and independent medical observer | Improved satisfaction; better texture, softness, thickness, color, and elasticity. | IV |
| Guisantes et al, 2012 | Traumatic/surgical scars | Case series | 8 | AFG | Centrifuge | Clinical assessment | Improvement in scars in all patient | IV |
| Ulrich et al, 2012 | Painful episiotomy scars | Case series | 20 | AFG | Centrifuge | Pain (VAS, Present Pain Intensity index), sexual function (Sabbatsberg Sexual Self-Rating Scale) | Significant decrease in pain and improvement in sexual function. | IV |
| Bruno et al, 2013 | Burn scars | Case control | 93 | AFG (split scar study) | Centrifuge | VSS, patient questionnaires, double-blind clinical assessment | Improved scar qualities. | III |
| Khouri et al, 2013 | Burn scars | Case series | 5 | AFG | Centrifuge | Clinical assessment | Softened scar, improved mobility, and texture. | IV |
| Klinger et al, 2013 | Burn, traumatic, surgical scars | PCS/case control | 694 | AFG (split scar study in 20 patients) | Centrifuge | Clinical assessment, POSAS and durometer in 20 patients | Functional and aesthetic improvement in all scars, decreased scar hardness. | III |
| Mazzola et al, 2013 | Tracheostomy scar | Case series | 10 | AFG | Centrifuge | Clinical assessment | Aesthetic and functional improvement in all patients. | IV |
| Gentile et al, 2014 | Burn scars | PCS | 30 | SVF-enhanced AFG (10) vs AFG plus PRP (10) vs AFG (10) | Centrifuge | Preoperative and postoperative photos, clinical evaluation, MRI, US, patient self-evaluation | Improved texture and softness. | III |
| Maione et al, 2014 | Postmastectomy pain syndrome | PCS | 88 | AFG (57) vs control (35) | Centrifuge | Pain (VAS) | Decrease in pain. | III |
| Maione et al, 2014 | Surgical scars | PCS | 36 | AFG | Centrifuge | Durometer, POSAS | Improvement in scar quality, pain, POSAS scores (except itching). Decreased hardness. | III |
| Pallua et al, 2014 | Traumatic/surgical scars | PCS | 26 | AFG | Centrifuge | Preoperative and postoperative photographs, POSAS | Improved scar quality and POSAS. | III |
| Huang et al, 2015 | Painful traumatic scars | RCS | 13 | AFG | Centrifuge | Pain (VAS, NPSI) | Significant decrease in VAS and NPSI score. | III |
| Piccolo et al, 2015 | Traumatic scars and burns | RCS | 87 | AFG | Centrifuge | Clinical assessment | Improvement in all scars | IV |
| Byrne et al, 2016 | Burn scars—Hand | RCS | 13 | AFG | Centrifuge | Grip strength measurement, TAM, the DASH Questionnaire, and MHQ, POSAS | Improvement in TAM measurement. The total score, activity of daily living score and satisfaction score of the MHQ also statistically increased. The changes in function score, work score, and pain score of the MHQ were not significant. Grip strength measurement and DASH score did not show improvement. Improved POSAS. | IV |
| Fredman et al, 2016 | Painful burn scars | RCS | 7 | AFG | Read Head, Puregraft | Patient-Reported Outcomes Measurement Information System | Improvement in scar quality. Six of 7 patients had improvement in neuropathic pain. | IV |
| Jaspers et al, 2017 | Burn, traumatic, surgical scars | PCS | 40 | AFG | Centrifuge | POSAS, Cutometer, Colometer | Improved elasticity, POSAS. No improvement in color. | III |
| Juhl et al, 2016 | Postmastectomy pain syndrome | RCT | 15 | AFG (8 fat grafted, .7 controls) | Centrifuge | Pain (Dolotest, VAS, NPSI), POSAS | Improved pain, health related QOL, scar qualities | II |
| Mende et al, 2016 | Painful finger scars | RCS | 16 | AFG | Centrifuge | Pain (VAS) | Improved pain. | IV |
| Piper et al, 2016 | Axillary web syndrome | Case series | 18 | AFG | Not listed | Clinical assessment | 30° to 40° improvement in range of motion. Decreased or eliminated pain, improved scar qualities. | IV |
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