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Percutaneous Aponeurotomy and Lipofilling: A Regenerative Alternative to Flap Reconstruction?

Khouri, Roger K. M.D.; Smit, Jan Maerten M.D.; Cardoso, Eufemiano M.D.; Pallua, Norbert M.D., Ph.D.; Lantieri, Laurent M.D.; Mathijssen, Irene M. J. M.D., Ph.D.; Khouri, Roger K. Jr. B.S.; Rigotti, Gino M.D.

Plastic and Reconstructive Surgery: November 2013 - Volume 132 - Issue 5 - p 1280–1290
doi: 10.1097/PRS.0b013e3182a4c3a9
Reconstructive: Trunk: Original Articles
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Background: The application of a new approach is presented, percutaneous aponeurotomy and lipofilling, which is a minimally invasive, incisionless alternative to traditional flap reconstructions.

Methods: The restrictive subdermal cicatrix and/or endogenous aponeurosis is punctured, producing staggered nicks. Expansion of the restriction reconstructs the defect and creates a vascularized scaffold with micro-openings that are seeded with lipografts. Wide subcutaneous cuts that lead to macrocavities and subsequent graft failure are avoided. Postoperatively, a splint to hold open the neomatrix/graft construct in its expansive state is applied until the grafts mature. Thirty-one patients underwent one to three operations (average, two) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (n = 9), contour defects of the trunk and breast requiring large-volume fat grafts (n = 8), burn contractures (n = 5), radiation scars (n = 6), and congenital constriction bands (n = 3).

Results: The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range, 20 to 30 percent). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion.

Conclusions: Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its three-dimensional expansion, a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts was developed. Grafting this scaffold applies tissue-engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery.


Boston, Mass.

From Brigham and Women’s Hospital.

Received for publication April 2, 2013; accepted April 30, 2013.

Disclosure: Roger K. Khouri (Sr.), M.D., has an equity interest in the company, Brava, LLC, the manufacturer of the Brava device. None of the other authors has any financial information to disclose.

Roger K. Khouri, Jr., B.S., 478 Bay Lane, Key Biscayne, Fla. 33149,

©2013American Society of Plastic Surgeons