|Year : 2018 | Volume
| Issue : 1 | Page : 15-19
Role of autologous fat grafting in burn wounds
M Rahul, Sunil Sharma
Department of Burns and Plastic Surgery, Safdarjung Hospital, New Delhi, India
|Date of Web Publication||11-Mar-2019|
Dr. Sunil Sharma
Ground Floor, L-11B, Rajouri Garden, Delhi - 110 027
Source of Support: None, Conflict of Interest: None
Introduction: The role of autologous fat grafting in burn wound healing was not studied adequately although there are few references in favor of the same. Autologous fat grafting was used in the treatment of burn wounds showing no signs of healing even after 3 weeks of injury. This study was done to study the role of autologous fat grafts in the treatment of burn wounds and to assess outcome in terms of healing or production of granulations suitable for skin grafting.
Materials and Methods: The study was conducted in a tertiary burn care center. It was a prospective case–control study. The study was done on 30 cases and 30 controls. Burn wounds of duration >21 days with size <40 cm2 were selected for the study. The study group underwent wound debridement followed by autologous fat grafting, whereas controls underwent wound debridement only. The results were assessed on day 3, 6, 10, and 14. Chi-squared test was used; P < 0.05 was statistically significant.
Results: Statistically significant differences were noted in the early appearance of healthy granulation tissue, epithelialization from margins, and reduction in size of the wounds, leading to early healing. All patients in the study group developed healthy granulations by day 3, whereas only 6.7% of the control group developed healthy granulations. All the cases among the study group showed epithelisation from margins on day 6, whereas only 3.3% of the controls showed epithelialization from margins. On day 14, 10% of cases in the study group were healed with statistically significant reduction in size of the wounds compared to those on the control group.
Discussion: The cases undergoing autologous fat grafting showed significantly improved healing with respect to faster appearance of healthy granulations, epithelialization from margins, and thereby reduction of wound surface area and healing, proving the usefulness of autologous fat grafting in burn wounds. The autologous nature of fat grafts is remarkable considering the solution to the longing problem found inside the body itself.
Keywords: Autologous fat grafting, burns, wounds
|How to cite this article:|
Rahul M, Sharma S. Role of autologous fat grafting in burn wounds. Indian J Burns 2018;26:15-9
| Introduction|| |
India with over a billion people has an estimated annual burn incidence of 6–7 million. With less than adequate capabilities to measure burn depth, surgeons have had difficulty implementing proper treatment protocols for deep partial-thickness burns. With the number of people with burn injuries increasing, there remains a need for improvement in the treatment of burn injuries. Many techniques have been employed to reduce the resultant morbidity following burns. These techniques include collagen dressings, negative pressure wound therapy, and autologous fat grafting. Given the autologous nature of fat in addition to its availability and ease of manipulation, surgeons have been intrigued by the use of fat for surgical interventions in the setting of burns. Studies done so far with the fat grafting in burn wounds suggested a favorable outcome with regard to the time taken for healing, and also practically, no hypertrophic scars were seen. However, the studies were not having either controls or adequate sample size.
| Materials and Methods|| |
The study was conducted in the Department of Burns and Plastic Surgery of a tertiary care burns center from November 2016 to May 2018, a period of 18 months, in patients of age group 18–60 years without any comorbidities having burn wounds. The burn wounds of size <40 cm2, showing no signs of healing even after 3 weeks of injury, were selected for the study. Sixty patients satisfying the above criteria were selected for the study, and they were divided into study group and controls. Ethical clearance was obtained from the Institutional Ethical Committee. Written informed consent was taken from all patients. Controls underwent wound debridement alone, whereas the study group underwent wound debridement followed by autologous fat grafting.
Fat was harvested in a completely sterile technique. Fat (1.6–2 ml/10 cm2) was injected around and beneath the wound, and nonadhesive dressing was done. The outcome was assessed based on the time taken for healing or the production of healthy granulations making the wound feasible for skin grafting. The results were assessed under the headings size of the wounds, presence of granulations, and epithelialization from margins on the postoperative days 3, 6, 10, and 14.
The data of study subjects and the outcome were statistically analyzed on the basis of percentages, and the appropriate statistical tests were applied using the latest version of SPSS software (SPSS Inc. Chicago, US). P <0.05 was considered statistically significant.
| Results|| |
Sixty percent of the study group participants belonged to the 18–30 years of age group, and 56.7% of the controls belonged to the same age group. About 66.7% of the study group participants were males and 76.7% of the controls were males comprising 71.6% of the total study population. About 36.7% of the cases had a size of 35–40 cm2 preoperatively, followed by 33.3% of wounds of size 25–30 cm2. About 26.7% of controls had size 25–30 cm2, followed by 20% each of wounds of size 20–25 cm2 and 35–40 cm2 [Table 1]. About 93.3% of the study group had unhealthy granulations, and all the controls had unhealthy granulations in the preoperative state. None of the wounds had any evidence of epithelialization from margins in the preoperative state [Figure 1].
|Figure 1: Day 0 (preoperative status of wound, showing slough and unhealthy granulation tissues)|
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There was no change in size of the wound on day 3 from the preoperative stage of the wounds. All the study group cases who had unhealthy granulations in the preoperative stage turned healthy on day 3 following wound debridement and fat injection [Figure 2], whereas only 6.7% of the controls developed healthy granulations following wound debridement alone, P value which came as <0.001 which is significant. Only 6.7% of study group cases showed evidence of epithelialization from margins on day 3, whereas none of the controls showed features of epithelialization. The difference was not statistically significant (P > 0.05).
|Figure 2: Day 3 (wound size remaining the same with appearance of healthy granulation tissue)|
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On day 6, the size of the wounds started reducing in the cases, whereas the controls remained the same [Figure 3]. All the study group cases had healthy granulations, whereas in controls, 73.3% of them developed healthy granulations; P value came as 0.002 which suggests a significant difference. All the study group cases showed epithelialization from the margins, whereas only 3.3%, i.e., only one out of the 30 controls showed epithelialization. P value came to <0.001 which is significant.
|Figure 3: Day 6 (wound size starting to decrease with presence of epithelialization from margins)|
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On day 10, it was noticed that no patients had wounds with size 35–40 cm2 [Table 2]. On day 14, no study group cases had a size more than 30 cm2 and 10% of the wounds got healed, whereas 43.3% of controls had a size more than 30 cm2, showing a statistically significant difference [Table 3]. All the study group cases and controls had healthy granulations by day 14, but only 76% of the controls had epithelialization from margins, the difference being statistically significant. images of a representative case and control shown from [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].
|Figure 4: Day 10 (decrease in size of wound with progressing margin of epithelialization from all sides)|
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|Figure 5: Day 14 (significant reduction in size of the wound with progressing margin of epithelialization without any wound contraction)|
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|Figure 6: Control day 0 image after debridement on right lateral chest wall 7 cm × 5.5 cm in maximum dimension|
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|Figure 8: Control day 6 after debridement (showing formation of biofilm)|
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|Figure 9: Control day 10 after debridement, with unhealthy granulation, and thick biofilm formation|
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The absolute value of wound sizes over the study period were analyzed, plotted on a graph, and independent t-test applied [Figure 10]. It showed a significant difference in the wound size between cases and controls, proving the benefit and efficacy of autologous fat grafting on burn wounds.
| Discussion|| |
Eugene Hollander was the first to document the use of fat in surgical enhancement in 1912 when he used this technique in patients presenting with lipoatrophy of the face. In the past few years, greater emphasis has been placed on the use of adipose tissue as a regenerative medium, the discovery that adipose-derived stem cells reside within the stromal vascular sections of a fat graft. Many studies have shown that the proangiogenic capabilities of the vascular section of the stromal fat graft are comparable even to bone marrow-derived stem cells.,,, The stromal vascular fraction of processed fat grafts contained multipotent stem cells that expressed adipogenic, osteogenic, and chondrogenic genes. They had also been shown to play a role in skin regeneration by forming tissue consisting of hypodermis, dermis, and epidermis. It was this regenerative capacity that is of particular interest in burn wound therapy.
Adipose-derived stem cells, which we are introducing through fat injection, have also been shown to play a role in skin regeneration by forming tissue consisting of hypodermis, dermis, and epidermis. On day 6, the size of the wounds started reducing in the cases because of epithelisation, whereas the controls remained the same. All the cases had healthy granulations, whereas the controls 73.3% of them developed healthy granulations. The early production of granulation tissue which was seen in the study group was thought to be due to increased production of growth factors, cytokines released by the adipose-derived stem cells.
The reduction in wound size can either be due to the wound contraction or epithelialization from the margins. In our study, it was assumed to be more due to the epithelialization, due to early appearance of epithelialization from wound margins which were visible on the wounds as a bluish hue, from day 6 onward. The wounds got healed by advancing margin of epithelialization rather than wound contraction. This seems to be the remarkable advantage of use of fat grafting in burn wounds giving faster healing with rapid epithelialization which may help in reducing the incidence of contractures.
Piccolo et al. described their experience using fat grafting in acute and subacute burn wounds and burn scars. They treated 240 patients who presented with burn, vascular, or traumatic injuries. The authors reported subjective improvements in wound healing, fibrosis, and scar suppleness. This study was large, with adequate follow-up, but lacked statistical analysis and controls.
Keck et al., in 2013, did a study where adipocyte-derived stem cells isolated from debrided burn skin were used on acute burns. The results showed improved skin graft take. However, sample size was only three. Histology showed debrided burn fat comparable to abdominal fat adipose tissue detected in reconstructed areas. It was then a novel therapeutic technique with potential for patients with large burn surface area. The drawbacks were lack of controls and the small sample size.
Loder et al., Karimi et al., and Atalay et al. conducted murine studies in 2014 using the regenerative potential of fat in burn wounds. All of them suggested chances of improved wound healing with the use of fat.,,
Fat grafting resulted in more rapid revascularization and reepithelialization at the burn site, as measured by laser Doppler flow, CD31 staining, and chemical markers of angiogenesis. In turn, this resulted in decreased fibrosis as measured by Sirius red staining and chemical markers as per the study done by Sultan et al. in 2012 on 20 wild mice.
Ours was a study using cases compared with results on controls, proving statistically significant improvement in the production of healthy granulation tissue, epithelialization from margins, and thereby reduction in wound surface area, thereby wound healing at a greater pace in cases compared to the controls, validating the usefulness of autologous fat grafts for the treatment of burn wounds.
| Conclusion|| |
Autologous fat grafting can be used as an effective tool in the treatment of burn wounds, especially smaller ones, showing no signs toward healing. The study needs to be done on larger wounds also on a larger population to confirm and expand his spectrum of usage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta JL, Makhija LK, Bajaj SP. National programme for prevention of burn injuries. Indian J Plast Surg 2010;43:S6-10.
] [Full text]
Zuk PA, Zhu M, Ashjian P, De Ugarte DA, Huang JI, Mizuno H, et al.
Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell 2002;13:4279-95.
Piccolo NS, Piccolo MS, Piccolo MT. Fat grafting for treatment of burns, burn scars, and other difficult wounds. Clin Plast Surg 2015;42:263-83.
Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118:108S-20S.
De Ugarte DA, Morizono K, Elbarbary A, Alfonso Z, Zuk PA, Zhu M, et al.
Comparison of multi-lineage cells from human adipose tissue and bone marrow. Cells Tissues Organs 2003;174:101-9.
Rydén M, Dicker A, Götherström C, Aström G, Tammik C, Arner P, et al.
Functional characterization of human mesenchymal stem cell-derived adipocytes. Biochem Biophys Res Commun 2003;311:391-7.
Gimble J, Guilak F. Adipose-derived adult stem cells: Isolation, characterization, and differentiation potential. Cytotherapy 2003;5:362-9.
Rigotti G, Marchi A, Galiè M, Baroni G, Benati D, Krampera M, et al.
Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007;119:1409-22.
Trottier V, Marceau-Fortier G, Germain L, Vincent C, Fradette J. IFATS collection: Using human adipose-derived stem/stromal cells for the production of new skin substitutes. Stem Cells 2008;26:2713-23.
Loder S, Peterson JR, Agarwal S, Eboda O, Brownley C, DeLaRosa S, et al.
Wound healing after thermal injury is improved by fat and adipose-derived stem cell isografts. J Burn Care Res 2015;36:70-6.
Karimi H, Soudmand A, Orouji Z, Taghiabadi E, Mousavi SJ. Burn wound healing with injection of adipose-derived stem cells: A mouse model study. Ann Burns Fire Disasters 2014;27:44-9.
Atalay S, Coruh A, Deniz K. Stromal vascular fraction improves deep partial thickness burn wound healing. Burns 2014;40:1375-83.
Sultan SM, Stern CS, Allen RJ Jr., Thanik VD, Chang CC, Nguyen PD, et al.
Human fat grafting alleviates radiation skin damage in a murine model. Plast Reconstr Surg 2011;128:363-72.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]