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LETTERS

Fat Grafting According to Coleman for the Treatment of Radial Nerve Neuromas

Vaienti, Luca M.D.; Merle, Michel M.D.; Villani, Federico M.D.; Gazzola, Riccardo M.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 676-678
doi: 10.1097/PRS.0b013e3181df652a
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Sir:

We read with great interest the article by Phulpin et al. regarding the rehabilitation of irradiated neck tissues by autologous fat transplantation.1 In this article, fat grafting is used with brilliant aesthetic and functional results, improving local vascularization, vitality, and quality of tissues. We applied fat transplantation in treating posttraumatic and iatrogenic neuromas affecting the radial nerve, which are a challenging problem because of their chronic and invalidating course. Several surgical techniques have been suggested, including transplantation of the nerve stump into radial bone, brachioradialis muscle, vein, and end-to-side nerve repair.2 Nevertheless, the results of the surgical treatment are poor, being ineffective in up to 67 percent of cases, probably because of surrounding cicatricial adherences causing loss of physiologic nerve excursion, and delayed and reiterated treatments.2

Fat grafting according to Coleman3 has been demonstrated to be effective in the treatment of posttraumatic adherences, tissue atrophy, and peripheral neuralgias; improvement of local vascularization; and reduction of inflammatory status.4 For these reasons, we decided to use fat grafting in recurrent radial nerve neuromas in two patients.

A 22-year-old patient had a forearm trauma 6 months previously and came to our attention for radial posttraumatic neuroma treated with resection at 2 and 4 months after the trauma. The latter patient, a 47-year-old woman, displayed a third recurrence 9 months after surgical treatment for de Quervain tenosynovitis. Both patients underwent a desensitization program unsuccessfully. The visual analogue scale score was 81 percent and 75 percent, respectively, whereas the Tinel sign was highly positive on the scar in both patients. The Disabilities of the Arm, Shoulder and Hand score was 55.14 percent in the former patient and 52.94 percent in the latter patient.

Under general anesthesia, the neuroma was isolated and resected (Fig. 1, above). The nerve was dissected proximally on 2.5 cm. A traction stitch was applied on the perineurium of the stump (Fig. 1, center). The nerve was then pulled through a 3-mm cutaneous incision 2 cm proximal to the previous incision (Fig. 1, below). After tumescent infiltration, liposuction of the subumbilical area was performed. A volume of adipose tissue, processed according to Coleman's technique, of 12 and 15 ml, respectively, was injected into the subcutaneous layers around the nerve stump from approximately 3 cm proximal and 1 cm distal to the first incision (Fig. 2, above). During the entire procedure, gentle traction was applied to the nerve stump, which was sectioned after fat grafting at the cutaneous exit level (Fig. 2, below).

Fig. 1.
Fig. 1.:
(Above) The neuroma of the radial nerve was isolated. (Center) After resection of the neuroma, a 5-0 nylon stitch was applied on the perineurium. A 3-mm incision was made proximal to the previous incision. (Below) The nerve was pulled through the new proximal incision.
Fig. 2.
Fig. 2.:
(Above) A volume of 12 and 15 ml was injected into the subcutaneous layer to create a complete envelope around the nerve stump, extending from approximately 5 cm proximal and 1 cm distal to the main incision. (Below) Gentle traction was applied on the nerve stump and then the nerve was sectioned at the cutaneous exit level. Because of relief of the nerve tension, the nerve, which was previously dissected, naturally retracted into its new fat envelope.

After 7 and 5 months of follow-up, respectively, after the postoperative program of desensitization, neither clinical recurrence nor complications were observed. The scar was eutrophic and the Tinel sign was negative in both patients. The postoperative visual analogue scale score was 7 percent and 11 percent, respectively, with a clear improvement in quality of life.

The results achieved using fat grafting are satisfactory. In our opinion, the fat graft created a protecting envelope around the nerve, reducing the compression of the nerve, allowing paraphysiologic excursion of the free stump,5 probably improving local vascularization. This procedure is suitable in such cases as an option because of its safety and effectiveness.

DISCLOSURE

No funding for this work was received from any organization.

Luca Vaienti, M.D.

Plastic Surgery Department

Università degli Studi di Milano

Policlinico San Donato

Milan, Italy

Michel Merle, M.D.

Federico Villani, M.D.

Institute Européen de la Main

Hopital Kirchberg

Luxembourg, Belgium

Riccardo Gazzola, M.D.

Plastic Surgery Department

Università degli Studi di Milano

Policlinico San Donato

Milan, Italy

REFERENCES

1. Phulpin B, Gangloff P, Tran N, Bravetti P, Merlin JL, Dolivet G. Rehabilitation of irradiated head and neck tissues by autologous fat transplantation. Plast Reconstr Surg. 2009;123:1187–1197.
2. Stokvis A, Henk Coert J, van Neck JW. Insufficient pain relief after surgical neuroma treatment: Prognostic factors and central sensitisation. J Plast Reconstr Aesthet Surg (in press).
3. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S–120S.
4. Klinger M, Gaetani P, Villani F, Klinger F, Rodriguez y Baena R, Levi D. Anatomical variations of the occipital nerves: Implications for the treatment of chronic headaches. Plast Reconstr Surg. 2009;124:1727–1728.
5. Wilgis EF, Murphy R. The significance of longitudinal excursion in peripheral nerves. Hand Clin. 1986;2:761–766.

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