Plastic and Reconstructive Surgery • January 2015 circumstances with fat injection technique. In our hands, use of this technique did not prove safe and reliable. DOI: 10.1097/PRS.0000000000000814
Leonidas Pavlidis, Stamatis Sapountzis, Georgia Alexandra Spyropoulou, Efterpi Demiri,
M.D., M.D., M.D., M.D.,
Ph.D. Ph.D. Ph.D. Ph.D.
Aristotle University of Thessaloniki Thessaloniki, Greece Correspondence to Dr. Pavlidis Aristotle University of Thessaloniki Mikroulea 25 55132 Thessaloniki, Greece [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Bank J, Fuller SM, Henry GI, Zachary LS. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2014;133:1109–1118. 2. Abergel RP, David LM. Aging hands: A technique of hand rejuvenation by laser resurfacing and autologous fat transfer. J Dermatol Surg Oncol. 1989;15:725–728. 3. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg. 2002;110:1731–1744; discussion 1745. 4. Giunta RE, Eder M, Machens HG, Muller DF, Kovacs L. Structural fat grafting for rejuvenation of the dorsum of the hand. Handchir Mikrochir Plast Chir. 2010;42:143–147. 5. Ozkaya O, Egemen O, Barutça SA, Akan M. Long-term clinical outcomes of fat grafting by low-pressure aspiration and slow centrifugation (Lopasce technique) for different indications. J Plast Surg Hand Surg. 2013;47:394–398.
Reply: Fat Grafting to the Hand in Patients with Raynaud Phenomenon: A Novel Therapeutic Modality Sir:
Thank you for granting us the opportunity to contribute to the discussion on the topic of fat injection to the hands of patients with Raynaud phenomenon. In response to our article1 describing the technique and results published in the May of 2014 edition of Plastic and Reconstructive Surgery, Pavlidis et al. describe a case of an 84-year-old woman with a history of scleroderma that presented with 10-digit ischemia. Subsequent to fat injection, the patient suffered necrosis of 10 digits, requiring surgical débridement. Although we are disheartened by this unfortunate outcome, and appreciate Pavlidis et al.’s cautionary words, several points should be expounded on regarding the case description before far-reaching conclusions can be drawn. First, the precise technique of the
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injection performed in this case is unclear. We concede that it is unlikely that minor differences in technique affect the outcome. However, we do believe that certain factors are important to clarify. The authors do not indicate whether they adhered to the methods we described. In what positions and planes was the fat injected? Was the fat injected with force? Was it injected on withdrawal of the cannula? Were blunt cannulas used for injection? What size cannulas were used? Was epinephrine used in the tumescent solution, and if so, at what concentration? Was the fat filtered after harvest or simply left to decant? Were local anesthetics and epinephrine used in the hands? Simple decanting may cause retention of epinephrine in the injected material, which may be critically detrimental in peripheral vasculopathy, particularly during an ischemic crisis. Second, and more importantly, the indication seemingly applied in this case extends beyond what we may have chosen in the management of this patient. Our study population required an inclusion criterion of medically diagnosed Raynaud phenomenon. We presume that the patient presented had Raynaud phenomenon, although this is not clearly stated in the case report. The description of nasal tip necrosis along with 10-digit necrosis at 36 hours after fat grafting warrants questioning whether an undiagnosed systemic disorder was present before grafting. It is difficult to ascertain whether this outcome was a progression of an underlying process manifesting with peripheral ischemia, or whether the fat injection caused a systemic reaction by an unknown mechanism. One putative explanation may be inadvertent intravascular injection leading to fat embolism, which emphasizes the significance of technical nuances required for safe fat grafting. We take this opportunity to highlight our proviso that we would not perform this procedure during an acute ischemic crisis (which may have occurred in this case, as evidenced by the reported need for hospitalization). Fat transfer to the hands is not a new procedure, but the unknown factors still outnumber the known. Undertaking a change in practice should be done under optimal conditions, after eliminating confounders and excluding other causes of multidigit ischemia. In this particular case, attempts at ischemia reversal were performed before fat grafting. We do not see fat transfer as a reliable means of treating acute ischemic digits. Grafting fat in patients with Raynaud phenomenon stemmed from benefits observed in fibrotic irradiated tissue. The ensuing clinical improvement of the intermittent ischemia of Raynaud phenomenon is a serendipitous outcome that we are still unable to explain. Since submitting our manuscript in June of 2013, we have performed fat grafting to more than a dozen hands and feet of patients with Raynaud phenomenon, with outcomes similar to those reported previously. We welcome further correspondence regarding our technique and indications.
Volume 135, Number 1 • Letters DOI: 10.1097/PRS.0000000000000789
Jonathan Bank, M.D. Lawrence S. Zachary, M.D. Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center Chicago, Ill. Correspondence to Dr. Zachary Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center 5841 South Maryland Avenue Chicago, Ill. 60637 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Bank J, Fuller SM, Henry GI, Zachary LS. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2014;133:1109–1118.
Vascularization of the Dorsal Base of the Second Metacarpal Bone: Implications for a Reverse Second Dorsal Metacarpal Artery Flap Sir:
W
e would like to congratulate the authors for their excellent report describing the vascularization of the base of the second metacarpal bone for use as a proximally based vascularized bone flap.1 Their descriptions offer a reconstructive option for a range of carpal and metacarpal bony defects, supplied in an anterograde fashion by the second dorsal metacarpal artery. When used as a free flap, these applications are broadened even further, as the authors have described.2 Anatomical studies in the recent literature have also demonstrated the distal communications of the second dorsal metacarpal artery with the palmar vasculature and both dorsal and palmar digital vasculature.3 Although the authors offer clinical applications for the anterograde second dorsal metacarpal artery bone flap, we would like to contribute our experience with the “reverse” second dorsal metacarpal artery bone flap (unreported as yet). To our knowledge, this has not been described previously, but offers the use of the same bony segment for a range of distal bony defects (metacarpal, and each of the index phalanges), and we have used this flap as distal as the distal phalangeal shaft. Such distally based bone flaps have been described in the fifth ray for distal bony defects, but not in the index finger.4 Such a flap is raised initially in the same manner as the authors describe, with identification of the second dorsal
Fig. 1. Second dorsal metacarpal artery identified at the base of the index metacarpal (arrow), during harvest of a distally based reverse second dorsal metacarpal artery bone flap for distal phalangeal reconstruction.
metacarpal artery proximally (Fig. 1), and after preservation of periosteum and a soft-tissue cuff that includes a dorsal vein, the flap can be pivoted as distally as the level of the proximal phalanx for inclusion of the communications with the proper palmar and proper digital arteries. This technique offers broader application of the anatomical findings described in the superb study by Bermel et al. DOI: 10.1097/PRS.0000000000000813
Warren M. Rozen, M.B.B.S., B.Med.Sc., M.D., Ph.D. Tanya L. Katz, M.B.B.S., P.G.Dip.Surg.Anat., B.Sc. David J. Hunter-Smith, F.R.A.C.S., F.A.C.S. Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School) Peninsula Health Frankston, and Department of Surgery Monash University Monash Medical Centre Clayton, Victoria, Australia Correspondence to Dr. Rozen Department of Plastic and Reconstructive Surgery Frankston Hospital Peninsula Health 2 Hastings Road Frankston, Victoria 3199, Australia [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Bermel C, Saalabian AA, Horch RE, et al. Vascularization of the dorsal base of the second metacarpal bone: An anatomical study using C-arm cone beam computed tomography. Plast Reconstr Surg. 2014;134:72e–80e.
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Leonidas Pavlidis, Stamatis Sapountzis, Georgia Alexandra Spyropoulou, Efterpi Demiri,
M.D., M.D., M.D., M.D.,
Ph.D. Ph.D. Ph.D. Ph.D.
Aristotle University of Thessaloniki Thessaloniki, Greece Correspondence to Dr. Pavlidis Aristotle University of Thessaloniki Mikroulea 25 55132 Thessaloniki, Greece [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Bank J, Fuller SM, Henry GI, Zachary LS. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2014;133:1109–1118. 2. Abergel RP, David LM. Aging hands: A technique of hand rejuvenation by laser resurfacing and autologous fat transfer. J Dermatol Surg Oncol. 1989;15:725–728. 3. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg. 2002;110:1731–1744; discussion 1745. 4. Giunta RE, Eder M, Machens HG, Muller DF, Kovacs L. Structural fat grafting for rejuvenation of the dorsum of the hand. Handchir Mikrochir Plast Chir. 2010;42:143–147. 5. Ozkaya O, Egemen O, Barutça SA, Akan M. Long-term clinical outcomes of fat grafting by low-pressure aspiration and slow centrifugation (Lopasce technique) for different indications. J Plast Surg Hand Surg. 2013;47:394–398.
Reply: Fat Grafting to the Hand in Patients with Raynaud Phenomenon: A Novel Therapeutic Modality Sir:
Thank you for granting us the opportunity to contribute to the discussion on the topic of fat injection to the hands of patients with Raynaud phenomenon. In response to our article1 describing the technique and results published in the May of 2014 edition of Plastic and Reconstructive Surgery, Pavlidis et al. describe a case of an 84-year-old woman with a history of scleroderma that presented with 10-digit ischemia. Subsequent to fat injection, the patient suffered necrosis of 10 digits, requiring surgical débridement. Although we are disheartened by this unfortunate outcome, and appreciate Pavlidis et al.’s cautionary words, several points should be expounded on regarding the case description before far-reaching conclusions can be drawn. First, the precise technique of the
230e
injection performed in this case is unclear. We concede that it is unlikely that minor differences in technique affect the outcome. However, we do believe that certain factors are important to clarify. The authors do not indicate whether they adhered to the methods we described. In what positions and planes was the fat injected? Was the fat injected with force? Was it injected on withdrawal of the cannula? Were blunt cannulas used for injection? What size cannulas were used? Was epinephrine used in the tumescent solution, and if so, at what concentration? Was the fat filtered after harvest or simply left to decant? Were local anesthetics and epinephrine used in the hands? Simple decanting may cause retention of epinephrine in the injected material, which may be critically detrimental in peripheral vasculopathy, particularly during an ischemic crisis. Second, and more importantly, the indication seemingly applied in this case extends beyond what we may have chosen in the management of this patient. Our study population required an inclusion criterion of medically diagnosed Raynaud phenomenon. We presume that the patient presented had Raynaud phenomenon, although this is not clearly stated in the case report. The description of nasal tip necrosis along with 10-digit necrosis at 36 hours after fat grafting warrants questioning whether an undiagnosed systemic disorder was present before grafting. It is difficult to ascertain whether this outcome was a progression of an underlying process manifesting with peripheral ischemia, or whether the fat injection caused a systemic reaction by an unknown mechanism. One putative explanation may be inadvertent intravascular injection leading to fat embolism, which emphasizes the significance of technical nuances required for safe fat grafting. We take this opportunity to highlight our proviso that we would not perform this procedure during an acute ischemic crisis (which may have occurred in this case, as evidenced by the reported need for hospitalization). Fat transfer to the hands is not a new procedure, but the unknown factors still outnumber the known. Undertaking a change in practice should be done under optimal conditions, after eliminating confounders and excluding other causes of multidigit ischemia. In this particular case, attempts at ischemia reversal were performed before fat grafting. We do not see fat transfer as a reliable means of treating acute ischemic digits. Grafting fat in patients with Raynaud phenomenon stemmed from benefits observed in fibrotic irradiated tissue. The ensuing clinical improvement of the intermittent ischemia of Raynaud phenomenon is a serendipitous outcome that we are still unable to explain. Since submitting our manuscript in June of 2013, we have performed fat grafting to more than a dozen hands and feet of patients with Raynaud phenomenon, with outcomes similar to those reported previously. We welcome further correspondence regarding our technique and indications.
Volume 135, Number 1 • Letters DOI: 10.1097/PRS.0000000000000789
Jonathan Bank, M.D. Lawrence S. Zachary, M.D. Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center Chicago, Ill. Correspondence to Dr. Zachary Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center 5841 South Maryland Avenue Chicago, Ill. 60637 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Bank J, Fuller SM, Henry GI, Zachary LS. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2014;133:1109–1118.
Vascularization of the Dorsal Base of the Second Metacarpal Bone: Implications for a Reverse Second Dorsal Metacarpal Artery Flap Sir:
W
e would like to congratulate the authors for their excellent report describing the vascularization of the base of the second metacarpal bone for use as a proximally based vascularized bone flap.1 Their descriptions offer a reconstructive option for a range of carpal and metacarpal bony defects, supplied in an anterograde fashion by the second dorsal metacarpal artery. When used as a free flap, these applications are broadened even further, as the authors have described.2 Anatomical studies in the recent literature have also demonstrated the distal communications of the second dorsal metacarpal artery with the palmar vasculature and both dorsal and palmar digital vasculature.3 Although the authors offer clinical applications for the anterograde second dorsal metacarpal artery bone flap, we would like to contribute our experience with the “reverse” second dorsal metacarpal artery bone flap (unreported as yet). To our knowledge, this has not been described previously, but offers the use of the same bony segment for a range of distal bony defects (metacarpal, and each of the index phalanges), and we have used this flap as distal as the distal phalangeal shaft. Such distally based bone flaps have been described in the fifth ray for distal bony defects, but not in the index finger.4 Such a flap is raised initially in the same manner as the authors describe, with identification of the second dorsal
Fig. 1. Second dorsal metacarpal artery identified at the base of the index metacarpal (arrow), during harvest of a distally based reverse second dorsal metacarpal artery bone flap for distal phalangeal reconstruction.
metacarpal artery proximally (Fig. 1), and after preservation of periosteum and a soft-tissue cuff that includes a dorsal vein, the flap can be pivoted as distally as the level of the proximal phalanx for inclusion of the communications with the proper palmar and proper digital arteries. This technique offers broader application of the anatomical findings described in the superb study by Bermel et al. DOI: 10.1097/PRS.0000000000000813
Warren M. Rozen, M.B.B.S., B.Med.Sc., M.D., Ph.D. Tanya L. Katz, M.B.B.S., P.G.Dip.Surg.Anat., B.Sc. David J. Hunter-Smith, F.R.A.C.S., F.A.C.S. Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School) Peninsula Health Frankston, and Department of Surgery Monash University Monash Medical Centre Clayton, Victoria, Australia Correspondence to Dr. Rozen Department of Plastic and Reconstructive Surgery Frankston Hospital Peninsula Health 2 Hastings Road Frankston, Victoria 3199, Australia [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Bermel C, Saalabian AA, Horch RE, et al. Vascularization of the dorsal base of the second metacarpal bone: An anatomical study using C-arm cone beam computed tomography. Plast Reconstr Surg. 2014;134:72e–80e.
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