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 & Reconstructive Surgery.
132(5):1280-1290, November 2013.
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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.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
(C)2013American Society of Plastic Surgeons