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Use of Lipomodeling to Forearm Residuum to Assist Fitting of Below-Elbow Prosthesis

Bavikatte, Ganesh MBBS, MD, MRCP (UK), MRCP (London); Kulkarni, Jai MA, FRCP, FRCS; Choukairi, Fouzia BSc, MBBch; Lees, Vivien MD, FRCS(Plast)

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JPO Journal of Prosthetics and Orthotics: January 2012 - Volume 24 - Issue 1 - p 50-51
doi: 10.1097/JPO.0b013e3182438b30
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Lipomodeling or fat grafting is a technique whereby fat is harvested from one part of the body and is transferred to another in order to correct a deficiency or relative deficiency in the subcutaneous fat layer. The technique was originally developed for use in aesthetic surgery and has been refined in those applications.1 Lately, the range of indications has been extended to include a variety of reconstructive applications.24

Congenital absence of the forelimb can be ameliorated by use of a prosthetic device. Regular prosthetic wear can be associated with skin and musculoskeletal problems. When the residual limb is short, the bone may overgrow and develop soft tissue deficiency. This can cause pain over pressure points, skin ulceration, bursitis, and inability to wear the prosthesis. Temporary discontinuation of prosthetic wear is used to facilitate wound dressing and healing. This inevitably leads to limitation of activity and may lead to the amputee not going to work.

CASE REPORT

A 48-year-old woman with transverse absence of the proximal third of forearm short below elbow residuum has been a long-term patient at our facility. The patient had used a simple one-piece transradial prosthesis from the time of presentation in December 1963. She sustained an accident at work in 1987, which left her with some weakness of left-hand grip, and was subsequently given a cosmetic one-piece artificial arm prosthesis over one sock and small above-elbow cuff. This prosthesis was used successfully until the time of the present complaint. At this time, she recounted pain, swelling, and blistering occurring in a recurrent manner and affecting the wearing of her prosthesis. Examinations performed at this time demonstrated erythema, swelling, and tenderness over the tip of the residual limb with intermittent bursitis and blistering of the skin. Adaptations to the prosthetic sockets and newer types of stump socks and a distal silicone cup were used but did not resolve the problem. Radiographs of the forearm and elbow were obtained. There was no evidence of a treatable bony spur and no evidence of underlying acute or chronic osteomyelitis. Trabecular bone changes with longstanding fusion of the proximal radioulnar joint were noted. A normal brachial artery pulse was noted, using hand-held Doppler.

Following combined review with the multidisciplinary team (rehabilitation doctors, plastic surgeons, prosthetists, and occupational therapists), it was suggested that there was a deficiency in the volume of subcutaneous tissue in the area that was rubbing on the prosthesis. After discussion of various alternatives, fat grafting from the abdominal area to the tip of the residual limb was recommended. Intraoperatively, fat was extracted from the abdominal area using liposuction cannula via a preexisting hysterectomy scar.5 The fat aspirate was centrifuged and loaded into syringes ready for injection. The area to be treated was pretunneled with the injection cannula to create the pocket into which the fat injection would be injected. A total of 20 mL fat were then injected. The operated site healed well with preservation of the injected fat volume suggesting the graft survived (Figures 1, 2). The prosthetic limb was refitted with improved comfort and stability of wear of the prosthesis. The patient expressed her satisfaction with the outcome and has been particularly appreciative of having avoided the more extensive scar pattern and more substantial intervention of the flap-type reconstructions.

Figure 1
Figure 1:
Residual limb, preoperative.
Figure 2
Figure 2:
Residual limb, postoperative.

DISCUSSION

Fat grafting was originally described in 1893 by German physician Franz Neuber who used upper-arm fat for a facial deformity. Shortly after, in 1895, a similar technique was used in a case of breast augmentation. Through the early part of the 20th century, fat grafts were used in attempts to correct a variety of soft tissue and cutaneous defects.6,7 Further scientific developments in this field have allowed plastic, reconstructive, and aesthetic surgeons to offer fat grafting for cosmetic and functional benefits. Since advances have been made in liposuction and lipomodeling techniques, the range of indications for fat grafting has extended.

Fat replacement used for contouring purposes has specific advantages over alternative methods. Fat is an autologous material, readily available, long-lasting, and feels natural. Other autologous material including fascia and dermis have been used in the past to build up soft tissue bulk but are less commonly used today. Flap reconstruction including free tissue transfer is another method. Exogenous materials used for contour correction include collagen, hyaluronic acid, silicone solid polytetrafluoroethylene, sheets of human dermis, and poly-L-lactic acid.8,9 However, the use of most of these substances has met with difficulties, including impermanence, foreign body reaction, unnatural texture, and possible disease transmission. Review of the literature suggests no other reports of the use of lipomodeling used to resolve the problem of the type described in this report in an upper-limb amputee. We would anticipate using this technique again for similar problems.

REFERENCES

1. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S.
2. Lam SM. Fat transfer for the management of soft tissue trauma: the do's and the don'ts. Facial Plast Surg 2010;26:488–493.
3. Sinna R, Delay E, Garson S, et al.. Breast fat grafting (lipomodeling) after extended latissimus dorsi flap breast reconstruction: a preliminary report of 200 consecutive cases. J Plast Reconstr Aesthet Surg 2010;63:1769–1777.
4. Ducic Y. Fat grafting in trauma and reconstructive surgery. Facial Plast Surg Clin North Am 2008;16:409–416, v–vi.
5. Kantanen DJ, Closmann JJ, Rowshan HH. Abdominal fat harvest technique and its uses in maxillofacial surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:367–371.
6. Neuber F. Fettransplantation. Chir Kongr Verhandl Dtsch Ges Chir 1893:22;66.
7. Czerny V. Plastischer Ersatz der Brustdruse durch ein Lipom. Zentralbl Chir 1895;27:72.
8. De Boulle K, Swinberghe S, Engman M, Shoshani D. Lip augmentation and contour correction with a ribose cross-linked collagen dermal filler. J Drugs Dermatol 2009;8(3 Suppl):1–8.
9. Hartzell TL, Taghinia AH, Chang J, et al.. The use of human acellular dermal matrix for the correction of secondary deformities after breast augmentation: results and costs. Plast Reconstr Surg 2010;126:1711–1720.
Keywords:

lipomodelling; fat graft; amputee; prosthesis fit

© 2012 American Academy of Orthotists & Prosthetists