I recently came across an article in the Journal of Plastic and Reconstructive Surgery from the July 2011 issue by the author Hovius et al describing a novel technique that is added to percutaneous aponeurotomy for the treatment of Dupuytren’s contracture. Dupuytren’s contracure is something I have talked about recently on my blog and it draws a great deal of interest whenever I talk about it because it is such an unusual disease in many ways. We understand so little about it and there is no specific cause for it other than genetics predisposition that seems to activated my microtrauma (golfing, hammering, gripping a lot).
The fingers start curling down at a certain point in a person’s life and they cannot be extended. This usually happens after 65-70 years of age, but not always, and the mainstay of treatment has been invasive (surgical) means that breakup the scar tissue in the hand or what is known as fascia. (Although recently there has been a medical treatment used which uses enzymes to break down the diseased fascia called Xiaflex…but that’s for another blog entry!) This break up of the fascia is done through a variety of methods some of which are extensive and will require a long surgical excision and some which are less invasive. One is called percutaneous aponeurotomy and this basically entails placing a sharp needle through the skin and breaking up the fascia under the skin without actually making an incision in the skin.
It is not a particularly effective technique over the long-term and there is high recurrence rate,which means that the fingers curl back rather quickly, though I have certainly used it in patients with some success, especially those that cannot tolerate surgery. However, in this article, the additional use of fat grafting ,which is typically something that is done by plastic surgeons for facial rejuvenation, is used to treat Dupuytren’s contracture and appears to reduce recurrence especially after percutaneous needle aponeurotomy.
The results seem pretty good (at least the ones that they show). Physiologically, though, it makes sense because Dupuytren’s contracture is associated with a loss of subcutaneous fat as a result of the disease process, so it makes sense to replace that fat through fat grafting. Fat grafting also helps soften the skin in the area of the Dupuytren’s contracture which is often very firm and fibrotic as well.
Having the fat graft spread out throughout the fascia may also help lead to a decreased risk of a recurrence because the fibers cannot reattach because the fat is physically blocking the fascial fibers from reattaching.
Finally, fat grafting is a rich source of stem cells and growth factors which can improve tissue quality in general and has been used in all sorts of procedures to help with the quality of the skin and the tissue in general especially after radiation damage for cancer treatment or chronic ulceration as a result of trauma and/or scar tissue. I have certainly used fat grafting in the face for rejuvenation as well as breast tissue for correction of deformities and improve contour.
All-in-all, it is a very interesting article and it is something that I will certainly consider performing on a patient who would be a good candidate and would be interested in going ahead with the procedure.