I recently reported the most current algorithms for the treatment and prevention of keloids and hypertrophic scars in this Journal (Plast Reconstr Surg. 2010;125:557–568).1 I was pleased to read the kind comments of Dr. Caviggioli et al., who wrote a letter in response to this article.2 I was also interested in his suggestion that the lipostructure technique could be added to the hypertrophic scar treatment algorithm.
Like Dr. Caviggioli et al., I also believe that the structural fat grafting technique that was reported by Dr. Sydney Coleman3 has markedly improved previous fat grafting techniques and has opened up many avenues in aesthetic and reconstructive surgery. As Dr. Caviggioli et al. commented in their letter, adipose-derived stem cells may influence the recipient site by differentiating into endothelial cells or adipocytes, secreting growth factors, or inducing cell-to-cell crosstalk effects. It is thus entirely possible that fat grafting, adipose-derived stem cell transplantation, or other cell therapies could improve the abnormal excessive scarring seen in hypertrophic scars and keloids. However, at present, whereas fat grafting has been shown to be useful for mature scars in terms of correcting their contours and uneven surfaces, it is not yet clear whether it is also suitable for abnormal scarring. For this reason, fat grafting was not included in my algorithm for hypertrophic scar treatment. I look forward to seeing the additional basic research and well-controlled clinical studies that will show clinicians how to most appropriately use fat grafting and cell therapy technologies.
In their letter, as evidence of the success with which hypertrophic scars can be treated with fat grafting, Dr. Caviggioli et al. included a set of before-and-after photographs. However, it should be noted that most of the scar shown in Figure 1, left seems to be composed of mature scarring, and it is difficult to call it a hypertrophic scar, which is defined as a red and elevated scar characterized by prolonged chronic inflammation and excessive collagen deposition. Hypertrophic scars can become mature scars over time, whereas keloids rarely improve naturally. Even if one assumed the scar shown in Figure 1, left still had hypertrophic scarring at its periphery and center, such small and short hypertrophic scars tend to improve naturally, which could explain the apparent improvement seen in these areas after fat grafting (Fig. 1, right). Moreover, the red and elevated areas in the center of the scar did not change after treatment (Fig. 1, right). Thus, on the basis of these photographs, it cannot yet be said that fat grafting successfully treats hypertrophic scars.
There are many therapy choices for “mature scars,” including abrasion lasers, neodymium:yttrium-aluminum-garnet lasers, chemical peeling, surgical abrasions, and surgical resection. I am currently in the process of establishing an algorithm for the treatment of “mature scars” (keloids and hypertrophic scars can be considered as prolonged “immature scars”) and intend to add fat grafting to the list of possible therapies. In the meantime, I hope that well-controlled studies examining the efficacy of fat grafting for keloids and hypertrophic scars will be published in the next few years. If so, I may also be able to include fat grafting and perhaps other techniques to my updated algorithms for the prevention and treatment of keloids and hypertrophic scars.
Rei Ogawa, M.D., Ph.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Nippon Medical School
1-1-5 Sendagi, Bunkyo-ku
Tokyo 113-8603, Japan
1.Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg
2.Caviggioli F, Maione L, Vinci V, Klinger M. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids (Letter). Plast Reconstr Surg
3.Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg
. 2006;118 (3 Suppl):108S–120S.
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