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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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Fig. 5.6 (a, b) Scar being treated with dermaroller and laser, respectively; (c) centrifuged fat being delivered to the previously treated scar surface;
(d) petrolatum gauze is placed over the delivered fat and is then covered with dry gauze and a bandage
“piece meal” fashion and with whichever fashion the surgeon prefers, all of the lining tissue must be removed.
Frequent irrigation with saline may be necessary to rid the
wound cavity of debris or fragments of contaminated tissue.
After creating a practically “new” wound, free of debris
and undesired tissue, the most geometrically accepted aps
will be created, aiming at simple advancement—no rotation
aps are usually created, as these may yield larger cavities
and longer suture lines (both unnecessary for this technique).
In very large wounds, when there are cavities extending
away from the open wound, it may be necessary to open
some of the skin and subcutaneous tissue immediately “over”
the cavity, to be able to completely clean the wound—this,
however, is uncommon, and when preformed, aps are also
closed in an opposed advancement fashion.
After creating the aps, the plan is to place enough “suture
lines” (simple suture rows) oriented perpendicularly to the
aps as needed. Starting form the most distal portion of the
cavity, 0 nylon simple sutures are passed progressively using
sutures with 4-cm needles—the needle is removed and both
suture ends are temporarily held with straight Kelly clamps,
until the complete planned suture line is placed.
Centrifuged fat is then laid in deep to the suture line, in
the deeper portion of the cavity and knots are progressively
tightened. As the cavity is closed, additional suture lines are
placed and centrifuged fat is delivered as needed. No Penrose
or suction drains are placed (Fig.5.11).
One should not worry with how much fat should be delivered since as the suture lines are tightened, considering that
they are placed in such a way to leave a minimum of dead
space within the previous and the next suture line, the tying
of the knots will also provide a very constrict, practically a
“virtual” space, while the “extra” fat is extruded—in this
way warranting the survival of the delivered fat, since it will
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Fig. 5.7 (a) A 4-year-old patient previously treated elsewhere after ame burn; (b) Result after two intralesional resections and fat grafting/fat
delivery—please note the absence of intralesional suture line scars
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Fig. 5.8 (a) A teenager boy 3months after ethanol burn and severe hypertrophy on ear lobe; (b–d) almost complete intralesional resection of both
lesions; (e) fat grafting to the undersurface of the suture line; (f) result at 6months
e
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Fig. 5.9 (a) Preoperative view of a 2-year-old boy with severe retrac-
tion of the II and III right ngers after an oven contact burn; (b) centrifuged fat grafting to the undersurface of the scar; (c, d) microneedling
be in contact with live tissue. Extruded fat after each line is
completed may be left in place or cleansed, depending on the
need of visualization to place the next row of sutures and fat
is delivered again as needed and the sutures tied until the
complete approximation of the aps is obtained.
and centrifuged fat delivery to the surface of the scar—this procedure
aiming at “preparing” the future scar release area to “better receive” the
skin graft
clean, new wound. A helpful method is to inject a Methylene
blue solution (1 cc of Methylene blue added to 9 cc of
saline) into the decubitus ulcer cavity helping to dene the
actual ulcer lining—whatever become blue must be
removed.
Very frequently in these patients, the wound will be sev-
5.3.9.1 Special Considerations
In ischial wounds, there frequently is a need to “open” the
wound tract to reach the deepest portion of the wound,
which, of course, must be completely seen, for one to be
able to get rid of all the contaminated lining and to create a
eral years old, since the patient only sees a small opening,
and thinks that it will eventually heal since apparently it is a
small wound—this may complicate the wound, including
with ischial bone colonization, infection, and even possibly
partial bone loss (Fig.5.12).
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Fig. 5.10 (a) Postoperative view after two fat grafting/fat delivery pro-
cedures; (b, c) incision through the scar at the retraction site immediately shows previously grafted fat (with abundant irrigation); fat
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delivery to the surface of the scar; (d) immediate aspect after cavum
plantar skin graft; (e, f) results at 3months
Fig. 5.11 (a) Left trochanteric ulcer on a 36-year-old lady with acute
spinal cord injury (42days after the accident); (b, c) thorough debridement with complete removal of the wound bed; (d) aps are created
bilaterally; (e–h) 0 nylon reverted sutures are placed longitudinally;
centrifuged fat is deposited along each suture line, which are tied
sequentially approximating the entire width of the wound; (i) healed
wound aspect, 6 weeks post healing
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Fig. 5.12 (a) Please note the apparent shallow aspect of this 7-year-old
ischial ulcer; (b) the wound is as deep as the bony surface which has
been debrided (please note arrow showing ischial tuberosity); (c) fat
5.4 Discussion
Fat can easily be grafted practically in any body area. As we
have demonstrated, it can also be generously applied over
microneedled or laser-treated skin, delivering fat directly
within the substance of the skin or the scar. [20–23].
Current (and past) fat grafting literature is rich with different authors indicating different methods of harvesting and
different ways to handle, or enrich, the lipoaspirate, or even
how it is injected, which could inuence the result of each
one specic fat injection procedure. Of course, these scientists and practitioners have also had great success in treating
similar patients.
However, we believe that the Coleman Technique provides a rather standardized method, with a very short learning curve for the surgeon and with an easy to learn routine by
the entire surgical team. When one uses a recognized routine
delivered to the wound and several suture layers provide progressive
closure; (d) aspect of the wound 3months post-cure
such as the Coleman Technique, even when the procedures
are practiced and results presented by different surgeons, this
routine will allow to make these results easier to compare,
since the harvesting and preparation of the fat was done
through this standardized technique and this wellconsolidated method [23, 24].
As the technique of blunt cannula insertion optimizes the
release of scar retraction, this may also play a part in the
analgesic effect of this treatment method. This nding is
related in published evidence which supports current theories of mesenchymal stem cell’s regenerative and antiinammatory properties responsible for scar healing.
We have been using the Coleman Technique for more
than a decade now and one of the most pleasant surprises
with fat grafting, when we started to use this procedure as a
routine, was the presence of very little hypertrophy as a routine result of the procedure. Minimal or practically no bro-
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sis is the routine outcome and these such results are very
frequent. This a common nding in wounds treated with fat
grafting, regardless of intermediate coverage with skin grafting or if left to heal spontaneously (Fig.5.13).
This will be also true when treating the patient that comes
to us already with a scar, or was treated acutely by us and
developed signicant hypertrophic scarring. Fat grafting on
itself, when used in scars, will similarly (as when treating
acute wounds) yield a most satisfactory result in relation to
diminishing brosis, be it on the surface (skin scar) or in the
deep tissues such as post-traumatic brosis in injuries to the
hand and distal forearm, like post-electrical burn scarring
around tendons and nerves. The effect appears to be cumulative, as proportionally more improvement is perceived after
the fat grafting procedure is repeated, at 6–8weeks intervals
and so on. This improvement could be related to the number
of injections and/or the time elapsed post-injection, since
there are denite, progressive, and cumulative changes after
repeat injections (Figs.5.14 and 5.15).
Fat injection aimed at improving scars most likely brings
improvements through mesenchymal cells and numerous
growth factors contained in the lipoaspirate which contribute
to the skin and scar remodeling. In the patients with scars
which were treated by this technique, one of the main related
improvements was the increase in elasticity and malleability
of the scar tissue, as well as for its signicant decrease in
volume and thickness. This could be partially due to the
marked increase in the number of elastic bers, easily perceived microscopically in post-injection scar samples, in
consequence of these injections.
Fig. 5.13 (a) Areas of deep second- and third-degree burns on a hot clothing press working accident; (b) aspect after tangential excision; (c, d)
aspect 6months after “spontaneous” cure (no skin grafting)—fully functional hand—no tendon adhesions
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Fig. 5.14 (a, b) The same patient as in Fig.5.4, 3weeks after healing, when a repeat fat grafting procedure was performed; (c, d) aspect 3months
after healing
Fat grafting/fat delivery has become a routine treatment in our Service for these patients. As surgeons we
notice almost immediate changes, but a moste rewarding
situation is that the patients also noticed the same. These
ndings also appear very obviously across the time range
of scar evolution and maturation, even at post-matured
scar phases, when fat grafting and fat delivery continue to
act on diminishing brosis (completely matured hypertrophic scarring). As mentioned before, these effects are
even more impressive (and appear to be cumulative)
(Fig.5.16).
Another fact to consider is the psychological burden of a
sequela, or a chronic wound, regardless of the patient age.
And consequently, the emotional difculties that a patient or
his or her family may have to go through to decide when and
how to take care of the deformity.
The results of fat grafting/grafting are even more impressive on keloid-like hypertrophic scars which may appear
after (ame or other) burns to the ears. Most unfortunately,
these are relatively common accidents in our community. In
the past, we would make these children go through months
and months of clinical treatment. Very frequently, these
patients would not wear pressure garments and inserts effectively, usually resulting in a frustrated attempt to control
hypertrophy. We have now been able to remove the scar completely in one single surgical act, when centrifuged fat is
grafted under the suture line as well as delivered over it.
Figure5.17 shows a typical long-term result.
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Fig. 5.15 (a, c) A 3-year-old boy 6months after an oil burn to the left foot; (b, d) aspect 4weeks after the third fat grafting procedure
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Fig. 5.16 (a–e) A 53-year-old lady 4years post-acid (unknown) burn
to the face, on previous “aesthetic” treatment by a local dermatologist;
(f–j) results after three fat grafting/fat delivery procedures to the
affected areas on chin, nasolabial sulci, perioral area, and dorsum of the
Chronic wounds may cause even more damage due to
the difculties in wound care which will then perpetrate the
disease, causing severe physical as well as emotional
damage.
In decubiti, mostly on very large sacral wounds, although
one may consider technically difcult to advance local aps,
one usually will be surprised how “forgiving” the buttock is
in relation to “allowing” local tissue advancement (Fig.5.18).
When the wound is very large, repeat procedures will be
performed. The initial procedure will diminish the size of the
wound, advancing a ap on each side, and anchoring it to the
nose (results 15months after originally seen, 3 months after the last
procedure; patient lives 200km away, so procedures were performed at
3months intervals)
deep tissues, suture line after suture line, with centrifuged fat
added in every suture line, before tying the suture knots. The
objective is the complete closure, and every time the patient
is brought back to the OR, the wound is treated similarly,
until complete closure is obtained. Procedures can be a one
side or both sides procedures and can be repeated as early as
1week on contralateral sides or as early as 2weeks when
advancing both sides. On the “last” procedure, aps will be
anchored to the deep tissues as well as to themselves, completing the closure, always tying the suture knots over centrifuged fat deposited layer by layer (Fig.5.19).
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Fig. 5.17 (a, c) A 3-year-old girl post-ame burn with severe bilateral ear keloid-like hypertrophy; (b–d)– 3years post almost complete scar
resection and centrifuged fat injection under the suture line—single procedure—please note the complete absence of hypertrophy
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