Skin Integrity and Pressure Injuries

Fat Grafting

In recent years a few studies have been completed suggesting that several intrinsic factors can be affected through fat grafting to prevent or reverse the effects of sitting surface pressure. Marangi et al. (2014) in his study of 42 people who showed early signs of pressure injury development, found increased skin and subcutaneous thickness, increased vascularization and increased intact continuous fascia superficialis in the high-risk sitting surface areas following fat grafting to these areas and 3 months post. Currently, there are two studies regarding fat grafting which are specific to the SCI population.

Author Year
Country
Research Design
PEDro Score
Sample Size		 Methods Outcome
Di Caprio et al. 2016
Italy
Pre-post
N=7		 Population: Mean age=38.7 yr; Gender: males=4, females=3; Level of injury: paraplegia; Pressure injury stage: I or II or had previous reconstructive flap surgery and present with areas of dystrophic and unstable scarring and flap showing thinning, atrophy and scar retractions creating risk for new ulcers.
Intervention: Autologous fat injections using fat from participant into areas of risk; avg of 400 cm3 fat was used (range 115-620). Post injection intervention followed standard liposuction practices and preventative antibiotics. Follow-up using ultrasound completed at 2 & 4 weeks and 3,6,12 months post-injection.
Outcomes: Thickness of subcutaneous tissues; Quality and elasticity of tissues; Recurrence of pressure sores.		 1. All participants had general improvements in skin characteristics, with improved elasticity in areas of dystrophic and unstable scarring, increased thickness of subcutaneous fat layer facilitated satisfactory restoration of the anatomical profile and the degree of filling of the weight-bearing areas.
2. Fat grafting resulted in an increase of the subcutaneous layer thickness, which decreased progressively during the postoperative period until stabilizing around 6mo postintervention.
3. At 12 mo post-intervention, the risk of pressure injury recurrence was reduced in all patients.
Previnaire et al. 2016
France
Pre-post
N=10		 Population: Mean age=44.1 +/- 6.8 yr; Gender: males=8, females=2; Level of injury: paraplegia=8, tetraplegia=2; Severity of injury: complete=8, incomplete=2; ASIA classification: A=8, B=2; Time since injury=21.1 +/- 9.4 yr; Pressure injury stage: recurring pressure injuries following unsatisfactory previous surgical flap procedures (mean of 3.2, range of 1-6 surgeries). Braden risk scale: mild risk (score of 15-18) =8, no risk (scores of 19 -23) = 2.
Intervention: Participants at risk of pressure injury recurrence due to unsatisfactory adipose tissue thickness received the Coleman procedure for fat grafting (water-jet assisted liposuction, decantation and reinjection of autologous fat) to a thickness of at least 5 cm in both ischial tuberosity regions and as deemed necessary by the surgeon, in the sacral and trochanteric regions. Follow-up occurred 14 days, 1, 3 and 6 months post grafting.
Outcomes: Pre and post grafting meaures of weight, body mass index, pressure mapping Pressure injury recurrence; Fat wasting; Adipose tissue thickness; Sitting times; self-assessment of Skin quality and Quality of life; Better feeling of positioning; Pelvic Pain.		 1. Three participants developed pressure injuries (2 stage I and 1 stage II) due to longer sitting position (patients’ negligence); no recurrence of stage 3 or 4 during follow up period.
2. Significant improvement of adipose tissue thickness was seen in 7 patients, with 2 patients having significant fat waste, one of whom purposely lost overall body weight for health reasons.
3. Three participants reported longer sitting times, nine participants reported improved skin quality, six participants reported improved quality of life but none reported a decrease, four participants reported a “better feeling of positioning in their wheelchair”, and 3 participants reported decreased pelvic pain.
4. Severity of lesion (Asia A or B) and type of motor neuron lesion (upper or lower) do not seem to influence the outcome.
5. Body mass index seems to play a role in grafting success.

Discussion

Di Caprio et al. (2016) found that using the participants own body fat and injecting it into the high risk areas noted for that participant, resulted in; 1) a decrease in recurrence of the development of pressure injuries, 2) improvements in the characteristics of the tissue in the area and, 3) the anatomical shaping of the area was restored. The participants were followed for 12 months, so the long term effects were not clear. However, this study suggests that fat injections into those high risk areas, may be considered as a preventative strategy for some people when all other strategies have been unsuccessful.

Similarly, participants who had unsuccessful flap surgeries in the study by Previnaire et al. (2016) had success with reducing the recurrence of stage 3 and 4 pressure injuries following fat grafting. This study also suggests that this preventative strategy is an option for those when all other strategies have not been successful. This study also suggests that pressure management strategies continue to be required to manage sitting pressures, as noted with the 2 participants who did not continue with these strategies and developed stage 1 & 2 pressure injuries.

Conclusions

There is level 4 evidence (from two pre-post studies: Di Caprio et al. 2016; Previnaire et al. 2016) showing that fat grafting using the participants’ own body fat may be considered as a prevention strategy for some people when all other prevention strategies have been unsuccessful.

Fat grafting may have potential as a prevention strategy for those people where other strategies have not been successful; ongoing pressure management strategies are still required post grafting.

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