Butler, PEM

Griffin, MF

Jeon, FHK

Langridge, B

Ruston, J

English

UCL Discovery

1Clinical and Experimental Rheumatology 2020Letters to the EditorsAutologous fat grafting for plantar fat-pad atrophy in systemic sclerosisSirs,Plantar fat-pad atrophy is a progressive and disabling condition that commonly occurs LQ V\VWHPLF VFOHURVLV 66F 7KH ÀEURWLFcounterpart of the disease gives rise to sub-cutaneous atrophy of the foot including the plantar fat-pads (1), which are specialised compartments of fat globules providing shock absorption over the metatarsal heads and heel to facilitate their weight-bearing function (2). Fat-pad atrophy precipitates foot pain that can limit mobilisation and ac-tivities of daily living, impacting work and ÀQDQFLDO LQFRPHZLWK VLJQLÀFDQW SV\FKR-logical morbidity (3). Autologous fat graft-ing (AFG) is gaining popularity as a meth-od of soft tissue reconstruction as it offers a minimally invasive procedure that utilises the patients’ own tissue reserves (4). There are only limited reports on its use for plan-tar fat-pad atrophy (3, 5-6). We describe our technique and experience of using AFG in SSc patients with plantar fat-pad atrophy.We performed AFG using the technique described by Coleman (7). Fat was har-vested predominantly from the abdomen or thighs using a cannula connected to a 10ml syringe. The lipoaspirate was centrifuged at 3000 rpm for 3 minutes. The proximal portion consisting of free oil and blood was discarded, and the remaining portion com-prised of adipose cells was injected into the base of the metatarsal heads or heels using a blunt cannula connected to a 1ml syringe (Fig. 1). Post-operatively patients were in-structed to be partial weight bearing for two weeks. Patients were followed-up in the outpatients clinic at 6 weeks to 3 months.Nine female patients were treated with 18 fat grafting procedures between Novem-ber 2009 and November 2019. All patients had a diagnosis of SSc and presented with symptoms of plantar fat pad atrophy that was being managed conservatively. Aver-age age at surgery was 60±7.90 years. Fat was harvested from the abdomen (89%) or thighs (11%) and transferred to one (67%) or both feet (33%). A mean volume of 4.22±1.93ml was injected per foot in each procedure. Patients underwent an average of 2 procedures (range 1-3) in total over 34.5±14.10 months, with an average of 23±14.7 months between each procedure. Post-operatively patients reported a global improvement in pain and mobility at 3 to 6 months. Three patients went on to have other surgical procedures but ceased to re-quire further fat grafting.Management of plantar fat-pad atrophy largely involves the use of external cush-ioning devices or orthotics to alleviate pedal pressures, but there is risk of adjacent tissue breakdown and a requirement for rig-LGFRPSOLDQFH6\QWKHWLFÀOOHUVVXFKDVliquid silicone are prone to migration with recurrence of symptoms and have an added risk of foreign body response (3). Surgi-cal reconstruction using local or distant ÁDSVFRQIHUVJUHDWHUPRUELGLW\WKDQEHQHÀWin this context, and skin grafts are unsuit-able for weight bearing (8). Fat grafting offers a novel therapeutic approach using autologous tissue to restore plantar fat-pad volume. In addition it contains adipose-derived stem cells (ADSCs) with regenera-tive potential (4). AFG has been reported to VLJQLÀFDQWO\ LPSURYH IRRWSDLQ LQSDWLHQWVwith plantar fat-pad atrophy (3, 6). An on-going and persistent improvement in pain and function was reported at 24 months post-op despite apparent resorption of the fat graft and return of soft-tissue thickness back to baseline in less than 6 months (6). A further study from the same group showed that pedal dermal thickness increased by 6 months that persisted at 24 months (5), giv-ing plausible explanation to the improve-ment in symptoms. The consequences of plantar foot atrophy FDQEHVLJQLÀFDQWDQGGLVDEOLQJ)DWWUDQV-fer offers a treatment modality that is safe and minimally invasive. It is hypothesised that the regenerative effect of adipose stem cells serves to increase pedal dermal thick-ness contributing to improvement in symp-toms despite reabsorption of fat.F.H.K. JEON1, MBBS, MScB. LANGRIDGE1,2, MBBS, MAJ. RUSTON2, MBBS, MRCSM.F. GRIFFIN1,2, MBChB, MSc, MRes, MRCS, PhDP.E.M. BUTLER1,2, MD, FRCSI, FRCS, FRCS(Plast)1Division of Surgery and Interventional Science, University College London; 2Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK.Please address correspondence to: Faith H.K. Jeon,Division of Surgery and Interventional Science, Royal Free Hospital, Pond Street, London NW3 2QG, UK.E-mail: h.jeon@outlook.com© Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2020.Competing interests: none declared.References  1. ALCACER-PITARCH B, BUCH MH, GRAY J et al.: Pressure and pain In Systemic sclerosis/Sclero-derma - an evaluation of a simple intervention (PI-SCES): Randomised controlled trial protocol. BMC Musculoskelet Disord 2012; 13: 11.  2. DALAL S, WIDGEROW A, EVANS G: The plantar fat pad and the diabetic foot – a review. Int Wound J 2015; 12: 636-40.  3. GUSENOFF JA, MITCHELL RT, JEONG K, WU-KICH DK, GUSENOFF BR: Autologous Fat Graft-ing for Pedal Fat Pad Atrophy: A Prospective Ran-domized Clinical Trial. Plast Reconstr Surg 2016; 138: 1099-108.  4. GRIFFIN MF, ALMADORI A, BUTLER PE: Use of Lipotransfer in Scleroderma. Aesthet Surg J 2017; 37: S33-7.  5. FARBER SE, MINTEER D, GUSENOFF BR, GUSE-NOFF JA 7KH ,QÁXHQFH RI )DW *UDIWLQJ RQ 6NLQQuality in Cosmetic Foot Grafting: A Randomized, Cross-Over Clinical Trial. Aesthet Surg J 2019; 39: 405-12.  6. MINTEER DM, GUSENOFF BR, GUSENOFF JA: Fat Grafting for Pedal Fat Pad Atrophy in a 2-Year, Prospective, Randomized, Crossover, Single-Center Clinical Trial. Plast Reconstr Surg 2018; 142: 862e-871e.  7. COLEMAN SR: Structural Fat Grafting: More Than a Permanent Filler. Plast Reconstr Surg 2006; 118: 108S-20S.  8. NICOLETTI G, BRENTA F, JABER O, LABERINTI E, FAGA A/LSRÀOOLQJIRUIXQFWLRQDOUHFRQVWUXFWLRQof the sole of the foot. Foot (Edinb) 2014; 24; 21-7.Fig. 1. Fat is injected to the base of the metatarsal heads as marked.

Autologous fat grafting for plantar fat-pad atrophy in systemic sclerosis

https://discovery.ucl.ac.uk/10097750/1/AFGplantar.pdf

Autologous fat grafting for plantar fat-pad atrophy in systemic sclerosis

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