SLR - March 2022 - Zachary R. Hansen
Reference: Rangaswamy M. Regenerative Wound Healing by Open Grafting of Autologous Fat and PRP-Gel - A New Concept and Potential Alternative to Flaps. Plast Reconstr Surg Glob Open. 2021 Jan 25;9(1)Level of Evidence: IV
Reviewed By: Zachary R. Hansen, DPM
Residency Program: New York Presbyterian Queens – Flushing NY
Podiatric Relevance: Complex, deep wounds with exposed bone can be difficult for foot and ankle surgeons to treat. Plastic surgery methods including flaps and grafts can be utilized in these situations, but these interventions are not without their own morbidity. This study investigates a series of three patients who underwent treatment with a triple layer matrix composed of platelet rich fibrin gel, autologous fat, and collagen matrix. The purpose was to develop a technique to regenerate vascularized tissue in deep wounds that have failed advanced wound care.
Methods: This case series reviews the novel treatment of three patients with complex, deep wounds, two of which had exposed bone. The surgical technique involves harvest of autologous platelet rich fibrin matrix (PRFM) from blood and adipocytes from abdominal liposuction. Wounds were debrided and the wound edges were injected with autologous fat. PRFM was then placed over the wound base with autologous fat layered on top of the PRFM. The top layer consisted of a fat and serum soaked collagen dressing. All patients were treated with Negative Pressure Wound Therapy (NPWT) in conjunction with the triple layer dressing, but NPWT was implemented at varying time-points post-operatively. Peripheral and core biopsies were obtained in Case 3 twenty-eight days after index procedure.
Results: Regeneration of healthy vascularized tissue was seen in all 3 patients. Epithelialization was seen in 7 to 8 weeks in all 3 patients. Peripheral and core biopsies in Case 3 showed advancing epithelium and new vessels forming in the superficial fat at 28 days. Larger vessels, histiocytes, and fibroblasts were seen at the intermediate depth. Well organized collagen bundles with histiocytes and fibroblasts were seen at deeper layers.
Conclusions: This small case series yielded excellent results in all patients. The author developed this technique in response to a challenging case involving a pediatric patient. The subsequent cases were utilized to confirm the success of Case 1. The biologic mechanism was hypothesized to be the result of creating a scaffold of fibrin, extracellular matrix, and intact microvascular fragments that allows growth factors to facilitate neovascularization and cellular proliferation. Overall, this is a very interesting study with a novel technique, however it is limited with its sample size and is the only study known at present that investigates open fat grafting in wound healing. It is also unclear whether or not NPWT played a major role in this study. More studies are necessary to fully understand cellular processes taking place in this study. As for foot and ankle surgeons, the clinical utility is there, but we are limited by the amount of fat able to be harvested due to our scope of practice.